The impact of pediatric emergency department crowding on patient and health care system outcomes: a multicentre cohort study

Abstract

Background: Emergency department overcrowding has been associated with increased odds of hospital admission and mortality after discharge from the emergency department in predominantly adult cohorts. The objective of this study was to evaluate the association between crowding and the odds of several adverse outcomes among children seen at a pediatric emergency department.

Methods: We conducted a retrospective cohort study involving all children visiting 8 Canadian pediatric emergency departments across 4 provinces between 2010 and 2014. We analyzed the association between mean departmental length of stay for each index visit and hospital admission within 7 days or death within 14 days of emergency department discharge, as well as hospital admission at index visit and return visits within 7 days, using mixed-effects logistic regression modelling.

Results: A total of 1 931 465 index visits occurred across study sites over the 5-year period, with little variation in index visit hospital admission or median length of stay. Hospital admission within 7 days of discharge and 14-day mortality were low across provinces (0.8%-1.5% and < 10 per 100 000 visits, respectively), and their association with mean departmental length of stay varied by triage categories and across sites but was not significant. There were increased odds of hospital admission at the index visit with increasing departmental crowding among visits triaged to Canadian Triage and Acuity Scale (CTAS) score 1-2 (odds ratios [ORs] ranged from 1.01 to 1.08) and return visits among patients with a CTAS score of 4-5 discharged at the index visit at some sites (ORs ranged from 1.00 to 1.06).

Interpretation: Emergency department crowding was not significantly associated with hospital admission within 7 days of the emergency department visit or mortality in children. However, it was associated with increased hospital admission at the index visit for the sickest children, and with return visits to the emergency department for those less sick.

Figure 1:

Crude rate of outcomes by mean departmental length of stay (LOS) in the 8 hours before index arrival. Note: CTAS = Canadian Triage and Acuity Scale.

Figure 2:

Odds of hospital admission within 7 days or mortality within 14 days of discharge from the pediatric emergency department, by triage acuity, with increasing departmental mean length of stay in the 8 hours before arrival. Note: CI = confidence interval, CTAS = Canadian Triage and Acuity Scale.

Figure 3:

Odds of hospital admission at index visit to the pediatric emergency department with increasing departmental mean length of stay in the 8 hours before arrival. Note: CI = confidence interval, CTAS = Canadian Triage and Acuity Scale.

Figure 4:

Odds of returning to the pediatric emergency department within 7 days of discharge with increasing departmental mean length of stay in the 8 hours before arrival. Note: CI = confidence interval, CTAS = Canadian Triage and Acuity Scale.