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The effects of emergency department overcrowding on admitted patient outcomes

a systematic review protocol

Santos, Eduardo; Cardoso, Daniela; Queirós, Paulo; Cunha, Madalena; Rodrigues, Manuel; Apóstolo, João

JBI Database of Systematic Reviews and Implementation Reports: May 2016 - Volume 14 - Issue 5 - p 96–102
doi: 10.11124/JBISRIR-2016-002562
SYSTEMATIC REVIEW PROTOCOLS
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Review question/objective: The objective of this review is to identify the effects of emergency department (ED) overcrowding on admitted patient outcomes.

More specifically, the questions are: does ED overcrowding increase the admitted patient's mortality? Does ED overcrowding increase the admitted patient's hospital length-of-stay? Does ED overcrowding increase the delay in door-to-needle time to treatment (time to antibiotic, time to thrombolysis and time to analgesic)?

1Health Sciences Research Unit: Nursing, Nursing School of Coimbra, The Portugal Centre for Evidence-based Practice: a Collaborating Centre of the Joanna Briggs Institute, Coimbra, Portugal

2Emergency Department: Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal

3Centre of Studies in Education, Health and Technology – Research and Development Unit, Coimbra, Portugal

Correspondence: Eduardo Santos, ejf.santos87@gmail.com

There is no conflict of interest in this project.

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Background

Overcrowding in the emergency department (ED) has become an increasingly significant public health problem in the last decade1 and is described as the most serious problem that affects the reliability of healthcare systems worldwide.2–4

For many authors, ED overcrowding is defined as a situation where the demand for emergency services exceeds the ability to provide quality care within appropriate time frames.4–7 However, it is a consequence of simultaneous increasing demand for health care and a deficit in available hospital beds, for example during mass casualty incidents, but also in other situations causing a shortage of hospital beds.1,6 In this regard, overcrowding is the product of several hospital internal and external factors, and the most relevant are the insufficient access to hospital beds, and shortage of ED nursing and physician staff.1

The etiology of crowding is believed to be multifactorial, with several elements contributing to its cause: a decrease in hospital capacity, an increase in closures of a significant number of EDs, an increase in ED patient volumes, a shortage of nursing staff, an increase in the complexity of patient management and the inability to transfer patients from the ED to inpatient units.7

This reality is intensified because several studies have clearly demonstrated that overcrowding can lead to patients’ unwanted outcomes waiting for care: adverse events (overcrowding leads to increased medical errors), increased morbidity and mortality,8–11 prolonged length-of-stay,12 delay in door-to-needle time to treatment,7,13–17 reduced patient and staff satisfaction18 and an overall inferior health care.1

Although EDs are being closely scrutinized for their ability to meet quality benchmarks, the impact of their volume is often not recognized. In fact, demonstrating a relationship between volume and quality of care is important in bringing resources to bear in solving the crowding issue, as well as improving the ability to meet quality benchmarks.15 In the meanwhile, patient suffering, prolonged wait times, deteriorating levels of service and the ability to retain experienced staff in an ED are all ill effects of this ongoing problem.2–5 Despite increased political, administrative and public awareness, ED overcrowding situations continue to rise in frequency and severity.5

It should be noted that hospital administrative units must realize that overcrowding is not solely an ED problem, and governments must realize that this is a public health crisis and allocate resources accordingly because it is a serious patient-safety issue. However, allocation of resources and reimbursement rates do not reflect this.1

A preliminary search of the JBI Database of Systematic Reviews and Implementation Reports, the Cochrane Database of Systematic Reviews, Prospero, CINAHL and Medline revealed that there are currently no systematic reviews (neither published nor in progress) on the effects of ED overcrowding on outcomes of admitted patients. There are several literature reviews about this issue; however, they present relevant methodological limitations such as non-existence of two reviewers independently searching studies and grading each article for the strength of the evidence, risk-of-bias, too restricted inclusion criteria (e.g. only English language), lack of search in grey literature and single database searched.3,4,19

Therefore, it is necessary to perform a systematic review to determine the effects of ED overcrowding on outcomes of admitted patients, which involves an intense critical analysis based on scientific evidence because it affects the performance on measures of quality of care. For that reason, it is possible that EDs may need to revise their operations to meet the growing challenge of delivering time-sensitive treatments for trauma, sepsis, stroke and acute coronary syndrome patients.

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Inclusion criteria

Types of participants

This review will consider studies that include adult patients, aged 18 years or more' in ED settings only.

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Types of exposure

This review will consider studies that evaluate the exposure of admitted patients to ED overcrowding.

Overcrowding in the ED is defined as “a situation in which the demand for emergency services exceeds the ability of an ED (ED) to provide quality care within appropriate time frames”.5(p.1)

We will exclude overcrowding related to disasters/catastrophies.

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Comparator

This review will consider studies that compare adult patients in overcrowded ED units versus not crowded ED units. Studies without comparator will also be included.

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Outcomes

This review will consider studies that include the following outcome measures:

  • Primary outcome – mortality
  • Secondary outcomes – hospital length-of-stay, time to antibiotic, time to thrombolysis and time to analgesic.
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Types of studies

This review will consider epidemiological study designs and prospective and retrospective cohort studies, before and after studies, case-control studies and analytical cross-sectional studies for inclusion.

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Search strategy

The search strategy aims at finding both published and unpublished studies. A three-step search strategy will be used in this review. An initial limited search of MEDLINE and CINAHL will be undertaken, followed by an analysis of text words in the titles and abstracts, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional studies. Studies published in Portuguese, English and Spanish will be considered for inclusion in this review. Studies published from 1989 (this was the year ED crowding was first described20,21 and first studies started to appear according to our preliminary database search) will be considered for inclusion in this review. Studies in another language or date of publication will be excluded.

The databases to be searched include:

  • MedicLatina
  • CINAHL Complete
  • MEDLINE Complete
  • Cochrane Central Register of Controlled Trials
  • Scielo – Scientific Electronic Library Online

The search for unpublished studies will include:

  • ProQuest – Nursing and Allied Health Source Dissertations
  • Banco de teses da CAPES (http://www.capes.gov.br)
  • RCAAP – Repositório Científico de Acesso Aberto de Portugal
  • OpenGrey – System for Information on Grey Literature in Europe

Initial keywords to be used will be: emergenc*, critical care, crowd*, occupancy, capacity, congest*, mortality, length of stay, time to treatment.

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Assessment of methodological quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

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Data extraction

Data will be extracted from papers included in the review independently by two reviewers, using the standardized data extraction tool from the JBI-MAStARI (Appendix II). Data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. For missing information or to clarify unclear data, the authors of primary studies will be contacted. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

A draft charting table was developed at the protocol stage to record the key information on which type of data we expect to find and how we intend to evaluate them; however, this may be further refined for use for at the review stage. Some key information that may be charted is as follows: author(s); year of publication; setting (country); study methods; aim/purpose; intervention/types of exposures; effect of ED crowding on main outcomes (mortality incidence proportion, hospital length-of-stay, time to antibiotic, time to thrombolysis, time to analgesic) and conclusions.

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Data synthesis

Quantitative data will, where possible, be pooled in statistical meta-analysis using the JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for dichotomous data), weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for outcome analysis. Heterogeneity will be statistically assessed using the standard Chi-square and also explored using subgroup analyses on the basis of different quantitative study designs and types of participants, included in this review. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation.

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Appendix I: Appraisal instruments

MAStARI appraisal instrument

Figure

Figure

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Appendix II: Data extraction instruments

MAStARI data extraction instrument

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Figure

Figure

Figure

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References

1. Di Somma S, Paladino L, Vaughan L, Lalle I, Magrini L, Magnanti M. Overcrowding in emergency department: an international issue. Intern Emerg Med 2015; 10 2:171–175.
2. Hoot NR, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med 2008; 52 2:126–136.
3. Bernstein SL, Aronsky D, Duseja R, Epstein S, Handel D, Hwang U, et al. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med 2009; 16 1:1–10.
4. Johnson KD, Winkelman C. The effect of emergency department crowding on patient outcomes: a literature review. Adv Emerg Nurs J 2011; 33 1:39–54.
5. Affleck A, Parks P, Drummond A, Rowe BH, Ovens HJ. Emergency department overcrowding and access block. CJEM 201; 15 6:359–370.
6. Sun BC, Hsia RY, Weiss RE, Zingmond D, Liang LJ, Han W, et al. Effect of emergency department crowding on outcomes of admitted patients. Ann Emerg Med 2013; 61 6:605–611.
7. Tekwani KL, Kerem Y, Mistry CD, Sayger BM, Kulstad EB. Emergency department crowding is associated with reduced satisfaction scores in patients discharged from the emergency department. West J Emerg Med 2013; 14 1:11–15.
8. Miro O, Antonio MT, Jimenez S, De Dios A, Sánchez M, Borrás A, et al. Decreased health care quality associated with emergency department overcrowding. Eur J Emerg Med 1999; 6 2:105–107.
9. Richardson DB. Increase in patient mortality at 10 days associated with emergency department overcrowding. Med J Aust 2006; 184 5:213–216.
10. Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR, Jelinek GA. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust 2006; 184 5:208–212.
11. Chalfin DB, Trzeciak S, Likourezos A, Baumann BM, Dellinger RP. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med 2007; 35 6:1477–1483.
12. Liew D, Liew D, Kennedy MP. Emergency department length of stay independently predicts excess inpatient length of stay. Med J Aust 2003; 179 10:524–526.
13. Schull MJ, Morrison LJ, Vermeulen M, Redelmeier DA. Emergency department overcrowding and ambulance transport delays for patients with chest pain. CMAJ 2003; 168 3:277–283.
14. Schull MJ, Vermeulen M, Slaughter G, Morrison L, Daly P. Emergency department crowding and thrombolysis delays in acute myocardial infarction. Ann Emerg Med 2004; 44 6:577–585.
15. Fee C, Weber EJ, Maak CA, Bacchetti P. Effect of emergency department crowding on time to antibiotics in patients admitted with community-acquired pneumonia. Ann Emerg Med 2007; 50 5:501–509.
16. Pines JM, Localio AR, Hollander JE, Baxt WG, Lee H, Phillips C, et al. The impact of emergency department crowding measures on time to antibiotics for patients with community-acquired pneumonia. Ann Emerg Med 2007; 50 5:510–516.
17. Pines JM, Hollander JE. Emergency department crowding is associated with poor pain care for patients with severe pain. Ann Emerg Med 2008; 51 1:1–5.
18. Pines JM, Hollander JE, Localio AR, Metlay JP. The association between emergency department crowding and hospital performance on antibiotic timing for pneumonia and percutaneous intervention for myocardial infarction. Acad Emerg Med 2006; 13 8:873–878.
19. Carter EJ, Pouch SM, Larson EL. The relationship between emergency department crowding and patient outcomes: a systematic review. J Nurs Scholarsh 2014; 46 2:106–115.
20. Dickinson G. Emergency department overcrowding. CMAJ 1989; 140 3:270–271.
21. Gallagher EJ, Lynn SG. The etiology of medical gridlock: causes of emergency department overcrowding in New York City. J Emerg Med 1990; 8 6:785–790.
Keywords:

Critical care; crowding; emergency medical services; outcome assessment (health care); patient safety

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