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Emergency Department Crowding Is Associated With Decreased Quality of Care for Children

Sills, Marion R. MD, MPH*†‡; Fairclough, Diane DrPH‡§; Ranade, Daksha MSPH, MBA*∥; Kahn, Michael G. MD, PhD*∥¶

doi: 10.1097/PEC.0b013e31822c1382
Original Articles

Objective: We sought to determine which of several simple indicators of emergency department crowding are most predictive of quality of care in 2 pediatric disease models: acute asthma and pain associated with long-bone fractures.

Methods: We performed a retrospective, cross-sectional study of patients 2 to 21 years old seen for acute asthma and patients 0 to 21 years old seen for acute, isolated long-bone fractures from November 1, 2007, to October 31, 2008, at a single, academic children's hospital emergency department. The main outcome measures were quality measures based on 3 asthma care-related processes-asthma score, β-agonist, and corticosteroid-and 2 fracture-related processes-analgesic and opioid analgesic. Good quality care was defined as receipt of an indicated process within 1 hour of arrival. Poor quality care was defined as nonreceipt or delayed receipt of an indicated process. Nine crowding measures were assigned based on conditions at each patient's arrival. We calculated the adjusted risk of receiving good quality care for each quality measure at 5 percentiles of crowding for each crowding measure.

Results: The asthma population included 927 patients, and the fracture population included 1229 patients. Among the 5 quality measures, we found rates of good quality care ranging from 23% to 64%. In adjusted models, we found an inverse association between crowding and quality. The 2 crowding measures with a consistently inverse association with the 5 quality measures across both populations were total patient-care hours and number arriving in prior 6 hours. Across the 10 models combining 1 of 2 key crowding variables with 1 of 5 quality measures, patients in the 2 populations were 0.40 (95% confidence interval, 0.27-0.55) to 0.78 (confidence interval, 0.71-0.85) times as likely to receive the indicated care process within 1 hour when each crowding measure was at the 75th than at the 25th percentile.

Conclusions: Two measures of ED crowding are consistently associated with lower-quality asthma- and fracture-specific care in the ED for pediatric patients.

From the *Department of Pediatrics, University of Colorado Denver School of Medicine; †Division of Emergency Medicine, The Children's Hospital-Denver; ‡Children's Outcomes Research Program, University of Colorado School of Medicine; §Department of Biometrics, Colorado School of Public Health; ∥Department of Clinical Informatics, The Children's Hospital Colorado; and ¶Colorado Clinical and Translational Sciences Institute, Aurora, CO.

Disclosure: The authors declare no conflict of interest.

Reprints: Marion R. Sills, MD, MPH, Department of Pediatrics, University of Colorado School of Medicine, 13123 E 16th Ave, B251, Aurora, CO 80045 (e-mail:

Drs Sills and Fairclough and Ms. Ranade received support from the Agency for Healthcare Research and Quality (5R03HS016418), the American Lung Association (SB-35832-N), the Riggs Family Health Policy Grant from the American College of Emergency Physicians, and the Children's Hospital Research Institute. Dr Kahn was supported by NIH/NCRR Colorado CTSI Grant Number UL1 RR025780.

© 2011 Lippincott Williams & Wilkins, Inc.