EDs with a higher percentage of patients meeting length-of-stay benchmarks on a given shift had lower rates of adverse events, according to a recent study.1 “This suggests that setting, and meeting, performance targets for ED length of stay is an important intervention to reduce the risk for patients associated with crowding,” says Michael Schull, MSc, MD, the study’s lead author. Schull is an emergency physician and president and CEO of the Institute for Clinical Evaluative Sciences in Toronto, Ontario, Canada.
Researchers found that the risk to patients varied, depending on how crowded a particular shift was. “It wasn’t that there were ‘good’ EDs and ‘bad’ EDs in terms of the risk from crowding,” Schull explains. “We statistically compared patient outcomes from more and less crowded shifts from the same ED.”
If EDs choose a length-of-stay benchmark that’s too short, it could compromise patient safety due to rushed care, Schull notes. “If you pick a benchmark that’s too long, you might not really be reducing crowding enough to reduce the risk it poses to patient care,” he adds.
In a previous study of 122 EDs, the researchers showed that death or hospital admission within seven days of ED discharge was more likely to occur when patients were seen during ED shifts with worse crowding, measured by average ED length of stay of all ED patients seen on the shift.2 Better performance on length-of-stay benchmarks was associated with a 10-45% reduction in the odds of death or admission seven days after ED discharge.
“However, from that study, we could not say whether achieving a particular ED length-of-stay benchmark — such as discharging patients within a certain timeframe — would reduce that risk,” Schull says. To reduce risks, he suggests EPs work with ED and hospital leaders to reduce average ED length of stay on each shift, using benchmarks and targets.
“Efforts to improve quality of care for specific high-risk patients — acute myocardial infarction, stroke, and sepsis — are also important,” Schull notes. “But this may do little to reduce the risks we identified, since those higher-risk patients are rarely discharged.”
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Schull M, et al. Better performance on length-of-stay benchmarks associated with reduced risk following emergency department discharge: An observational cohort study. CJEM 2015;17:253-262.
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Guttmann A, et al. Association between waiting times and short-term mortality and hospital admission after departure from emergency department: Population-based cohort study from Ontario, Canada. BMJ 2011;342:d2983.doi: 10.1136/bmj.d2983.
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Michael Schull, MSc, MD, President/CEO, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada. Phone: (416) 480-6100 ext. 4297. Fax: (416) 480-6048. E-mail: [email protected].
