Emergency Department Crowding Is Associated With Poor Care for Patients With Severe Pain

doi:10.1016/j.annemergmed.2007.07.008

Annals of Emergency Medicine

Volume 51, Issue 1, January 2008, Pages 1-5

Presented at the Society for Academic Emergency Medicine National Assembly, May 2007, Chicago, IL.

https://doi.org/10.1016/j.annemergmed.2007.07.008 Get rights and content

Study objective

We study the impact of emergency department (ED) crowding on delays in treatment and nontreatment for patients with severe pain.

Methods

We performed a retrospective cohort study of all patients presenting with severe pain to an inner-city, teaching ED during 17 months. Poor care was defined by 3 outcomes: not receiving treatment with pain medication while in the ED, a delay (>1 hour) from triage to first pain medication, and a delay (>1 hour) from room placement to first pain medication. Three validated crowding measures were assigned to each patient at triage. Logistic regression was used to test the association between crowding and outcomes.

Results

In 13,758 patients with severe pain, the mean age was 39 years (SD 16 years), 73% were black, and 64% were female patients. Half (49%) of the patients received pain medication. Of those treated, 3,965 (59%) experienced delays in treatment from triage and 1,319 (20%) experienced delays from time of room placement. After controlling for factors associated with the ED treatment of pain (race, sex, severity, and older age), nontreatment was independently associated with waiting room number (odds ratio [OR] 1.03 for each additional waiting patient; 95% confidence interval [CI] 1.02 to 1.03) and occupancy rate (OR 1.01 for each 10% increase in occupancy; 95% CI 0.99 to 1.04). Increasing waiting room number and occupancy rate also independently predicted delays in pain medication from triage (OR 1.05 for each waiting patient, 95% CI 1.04 to 1.06; OR 1.18 for each 10% increase in occupancy; 95% CI 1.15 to 1.21) and delay in pain medication from room placement (OR 1.02 for each waiting patient, 95% CI 1.01 to 1.03; OR 1.06 for each 10% increase in occupancy, 95% CI 1.04 to 1.08).

Conclusion

ED crowding is associated with poor quality of care in patients with severe pain, with respect to total lack of treatment and delay until treatment.

Introduction

Acute pain is one of the most common reasons for seeking emergency care. According to the 2004 National Hospital Ambulatory Medical Care Survey data, approximately 32% of emergency department (ED) patients presented with either moderate or severe pain.¹ However, oligoanalgesia, which is defined as the undertreatment of pain, is common in EDs.2, 3, 4, 5, 6 Factors associated with oligoanalgesia include older age, ethnicity, provider perceptions of a patient’s pain, concern about drug-seeking behavior, and reluctance to mask symptoms to ensure an accurate diagnosis.7, 8, 9, 10, 11, 12, 13, 14, 15, 16 In the era of ED crowding,17, 18, 19 another potential reason for oligoanalgesia may be that providers are too busy to appropriately assess and treat ED patients with painful conditions. A recent study demonstrated that older adults with hip fracture are less likely to receive analgesia and more likely to experience delays in analgesia at high levels of ED census.²⁰ However, to our knowledge, there have been no studies reporting the impact of ED crowding on a general sample of ED patients with severe pain.

We sought to study the impact of ED crowding on both treatment and delays in treatment in a broad cohort of ED patients who presented at triage with a complaint of severe pain. We hypothesized that when the ED is crowded, patients will experience both failure to receive treatment and delays in treatment for pain.

Section snippets

Study Design and Setting

We performed a retrospective study of all ED patients 18 years of age and older who presented at triage with a complaint of severe pain from April 1, 2005, to September 30, 2006. The study was performed in a large, adult, urban, tertiary care ED with 55,000 annual ED visits. The ED has 25 treatment rooms, 15 hallway treatment spaces, a separate 8-bed fast track, and an attached 3-bed trauma bay.

Data Collection and Processing

We identified all ED patients who reported severe pain (defined as 9 or 10 of 10 on the pain scale)

Results

Throughout the study period, 13,758 patients reported severe pain at ED triage. The median waiting room time was 28 minutes (IQR 8 to 72 minutes). A total of 6,746 (49%) patients received pain medication while in the ED. Of those, 4,052 (60%) were treated with narcotic analgesia. Of the patients who were treated, the median time from triage to administration of first pain medication was 74 minutes (IQR 34 to 142 minutes) and median time from room placement until first pain medication was 23

Limitations

There are a number of limitations in this study. The largest limitation is that it is a retrospective study, and like other studies on the treatment of pain in the ED, although pain score was measured, patient desire for pain medication and reasons for nontreatment or delays in treatment were not directly measured. We did not include any reassessment of pain and measured patients’ subjective pain at only 1 point (triage). Because pain can change over time without any intervention, this may have

Discussion

We detected a significant association between measures of ED crowding and oligoanalgesia as defined by delays in treatment and nontreatment with pain medications in a general population of ED patients reporting severe pain at triage. These findings were robust in multivariable analysis after adjusting for other known risk factors for oligoanalgesia. The assessment and treatment of pain is an important outcome in emergency care and a significant quality issue. Many studies have reported that

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High sensitivity cardiac troponins (hs-cTn) allow earlier identification and exclusion of acute myocardial infarction. We determined if transitioning from contemporary to high sensitivity troponin T (hs-cTnT) would reduce ED length of stay in chest pain (CP) patients.
We conducted a pragmatic, prospective, before and after study of implementing a hs-cTnT by reviewing the electronic health records in all adult ED patients presenting to a large, suburban academic medical center during the 3 months before and after transitioning from a 4th generation troponin to a 5th generation hs-cTnT (Elecsys® Troponin T-high sensitive, Roche Diagnostics, Indianapolis, IN).
There were 1431 and 1437 CP patients before and after the intervention. Mean (SD) age was 51.5 (18) yrs. and 54.3% were female. The median (IQR) ED LOS for chest pain patients directly discharged to home was 6.2 (4.7–8.4) and 5.3 (4.0–7.2) hours before and after introducing hs-cTn respectively; difference 47 min (95%CI, 35–59); P < 0.001. The median (IQR) ED LOS for chest pain patients admitted to the hospital was 9.5 (6.6–13.8) and 8.1 (5.7–11.2) hours before and after introducing hs-cTn respectively; difference 77 min (95%CI, 35–121); P < 0.001. Overall admission rates (22 vs 21% both before and after) did not change during the study. The rates of computed tomography coronary angiography before and after the intervention were 21 and 20.4% respectively. The rates of invasive coronary angiography before and after the intervention were 5.8 and 5.6% respectively.
Transitioning to a hs-cTnT is associated with a clinically relevant and statistically significant reduction in ED LOS for both discharged and admitted patients with and without CP with no increase in admission or coronary angiography rates.
Emergency Department Volume, Severity, and Crowding Since the Onset of the Coronavirus Disease 2019 Pandemic
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We describe emergency department (ED) visit volume, illness severity, and crowding metrics from the onset of the coronavirus disease 2019 (COVID-19) pandemic through mid-2022.
We tabulated monthly data from 14 million ED visits on ED volumes and measures of illness severity and crowding from March 2020 through August 2022 compared with the same months in 2019 in 111 EDs staffed by a national ED practice group in 18 states.
Average monthly ED volumes fell in the early pandemic, partially recovered in 2022, but remained below 2019 levels (915 per ED in 2019 to 826.6 in 2022 for admitted patients; 3,026.9 to 2,478.5 for discharged patients). The proportion of visits assessed as critical care increased from 7.9% in 2019 to 11.0% in 2022, whereas the number of visits decreased (318,802 to 264,350). Visits billed as 99285 (the highest-acuity Evaluation and Management code for noncritical care visits) increased from 35.4% of visits in 2019 to 40.0% in 2022, whereas the number of visits decreased (1,434,454 to 952,422). Median and median of 90th percentile length of stay for admitted patients rose 32% (5.2 to 6.9 hours) and 47% (11.7 to 17.4 hours) in 2022 versus 2019. Patients leaving without treatment rose 86% (2.9% to 5.4%). For admitted psychiatric patients, the 90th percentile length of stay increased from 20 hours to more than 1 day.
ED visit volumes fell early in the pandemic and have only partly recovered. Despite lower volumes, ED crowding has increased. This issue is magnified in psychiatric patients.
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This prospective observational study will enrol ∼1500 patients at ∼20 U.S. Emergency Departments. After informed consent, adults (>21 years of age) with suspected ACS, and no prior enrollment in this study, will provide a fingerstick and venous blood sample within 2 h of ED presentation, >2 to ≤4 h, and >4 to ≤9 h (max. blood draw = 60 mL). HEART and EDACS scores will be prospectively documented. Patients without the first blood draw may be enrolled if the second draw was obtained. Capillary and venous whole blood will undergo Atellica VTLi assay testing, with remaining venous sample processed to plasma and run. All results will be blinded to the clinical care team. Site operators will undergo a 3-day familiarization period. Quality control testing will be performed daily. At 30 ± 3 days, patient mortality status, major adverse cardiac events, and rehospitalizations will be determined. A clinical endpoint adjudication committee, blinded to hs-cTnI VTLi result, will define the final diagnosis. Sensitivity, specificity, and predictive values will describe the assay performance.
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Patients with a higher triage pain level were significantly more likely to receive analgesia (4–6: OR = 1.85; 95% CI = 1.2–2.84, 7–9: OR = 3.36; 95% CI = 2.18–5.17, 10: OR = 10.78; 95% CI = 6.38–18.23) and at least one opioid (4–6: OR = 2.88; 95% CI = 1.13–7.34, 7–9: OR = 4.36; 95% CI = 1.73–11.01, 10: OR = 6.23; 95% CI = 2.42–16.09). Male gender was associated with a significantly lower likelihood of receiving analgesia (OR = 0.74; 95% CI = 0.61–0.9), but a significantly greater likelihood of receiving at least one opioid given that they received any pain medication (OR = 1.87; 95% CI = 1.41–2.48). Patients aged 25–64 years old were significantly more likely to receive at least one opioid if they received any pain medication (25–44: OR = 1.47; 95% CI = 1.08–2.02, 45–64: OR = 1.78; 95% CI = 1.15–2.76). Presentation to the ED on Sundays was associated with lower rates of opioid treatment (OR = 0.63; 95% CI = 0.42–0.94).
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Almost half of patients with appendicitis didn't receive analgesia, with most of those treated receiving only non-opioid analgesia. Older age and Sunday presentations were associated with less opioid treatment. Patients who received analgesia waited longer for imaging, stayed longer in the ED, and had a longer hospitalization.
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: Supervising editors: Debra E. Houry, MD, MPH; Michael L. Callaham, MD.

: Author contributions: JMP was responsible for data collection and article preparation. JMP and JEH were responsible for study design, data analysis, and final article preparation. JEH was responsible for study supervision. JMP had full access to the data in this study and was responsible for the integrity of the data and the accuracy of the data analysis. JMP takes responsibility for the paper as a whole.

: Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that may create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Jesse M. Pines, MD, MBA, is supported by the 2006-7 Riggs Family/Health Policy Grant from the American College of Emergency Physicians.

: Reprints not available from the authors.

: Publication dates: Available online October 25, 2007.

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Health policy and clinical practice/original researchEmergency Department Crowding Is Associated With Poor Care for Patients With Severe Pain

Study objective

Methods

Results

Conclusion

Introduction

Section snippets

Study Design and Setting

Data Collection and Processing

Results

Limitations

Discussion

Am J Emerg Med

Ann Emerg Med

Ann Emerg Med

Am J Emerg Med

Ann Emerg Med

Am J Emerg Med

J Pain

J Emerg Nurs

Am J Emerg Med

Ann Emerg Med

Ann Emerg Med

Emerg Med Clin North Am

Ann Emerg Med

Health policy and clinical practice/original research
Emergency Department Crowding Is Associated With Poor Care for Patients With Severe Pain