Emergency Department Crowding in Relation to In-hospital Adverse Medical Events

2014-08-27 03:13:59 | BioPortfolio


Since the report "To Err is Human" by the Institute of Medicine (IOM) in 1999, attention was brought to the general public that adverse events in medicine are common and are one of the leading causes of morbidity and mortality within the United States. The report estimates that 44,000 - 98,000 patients hospitalized in the United States die each year as a result of medical errors.

In spite of the growing patient safety movement worldwide, health care has not become measurably safer. Health care is one of the few risk-prone areas in which public demand limits the use of common-sense safety-enhancing solutions, such as limiting the flow and choosing the type of incoming patients. The latter is especially true for emergency departments (EDs) since they deliver an important public service by providing emergency care 24 hours a day, 365 days per year, without discrimination by social or economic status. One of the key expectations of EDs is the ability to provide immediate access and stabilization for those patients who have an emergency medical condition. However, emergency department (ED) crowding is recognized to be a major, international problem that affects patients and providers. A recent report from the IOM noted that the increasing strain caused by crowding is creating a deficit in quality of emergency care. Crowding has been associated with reduced access to emergency medical services, delays in care for cardiac patients, increased patient mortality, inadequate pain management, increased costs of patient care, and delays in administration of antibiotic therapy.

Several issues remain concerning ED crowding and it's relation to adverse events. First, the existing evidence on adverse event occurrence during ED crowding is largely anecdotal and inconclusive. Secondly, although a few studies showed a relationship between ED crowding and mortality, neither of these examined the causes of excess mortality. Finally, although a significant increase in the average length of hospital stay was shown during ED crowding the reasons for this are open to speculation.

The purpose of this study therefore is to identify six explicit adverse events and mortality for patients who were admitted through ED and to compare these results in relation to ED crowding. This will provide us novel insight into the reasons for the hypothesized increased mortality during ED crowding.


Since "ED crowding" is an unplanned condition, a randomized controlled trial is not possible to assess its impact on adverse patients' outcome. Therefore, a large prospective cohort study, with careful matching and correcting for risk factors is the second best design.

The ED occupancy rate, defined as the ratio of the total number of ED patients to the number of licensed treatment bays per hour, will be used as a measure of ED crowding. The numerator includes all patients in the ED at any point during each study hour, regardless of ED location (including in the waiting room, boarding, hallway location). The denominator, constant per study hour, includes the total number of licensed treatment bays as defined according to the ED's original blueprint but excludes hallway locations. For each hour of the day, the ED occupancy rate will be derived from the ED information system. 104 weeks are divided into 13-week seasonal blocks and nursing shifts starting 23:00, 07:00 and 15:00. The mean ED occupancy rate is calculated for each shift as the sum of the occupancy rates within that shift divided by 8. The top quartile of all mean ED occupancy rates during the cohort period is considered as crowded. In order to match both 'crowded 'and 'not crowded' cohorts, the following data elements are extracted from the hospital information system for each registered patient: demographic data (age, sex, co-morbidities); referral source, surgical or medical admission; time of arrival (including season, month of year, day of week, time of day); triage category; ED and total hospital length of stay; and final admission diagnosis.

Medical records of patients who presented to the ED will be reviewed for the occurrence of six adverse events and mortality up to ten days of their ED stay. The six adverse events are searched through explicit clinical criteria. The reviewer first rates on a scale of 1 to 6 the confidence that medical management caused an adverse event. If the rating is 5 or 6, indicating that the injury is probably or definitely caused by management, the event is considered an adverse event. The same rating score is used to assess the degree of preventability. Hospital mortality will be searched for all patients who presented to the ED at some point in time and died during that hospital stay.

In order to identify an adverse event occurrence hazard ratio of 1.2 with a power of 0.9 during ED crowding, a cohort of 104,000 patients is needed. Therefore, data will be retrieved during a 2 year period during which the reviewer is blinded to the degree of ED crowding in relation to the findings on adverse events. The occurrence of adverse events and mortality will be compared to not crowded shifts, corrected for baseline risk factors. A carefully standardized admission form for registration of relevant information as well as a computerized search tool for screening for adverse events will allow finalizing this study within the foreseen time frame.

Study Design

Observational Model: Cohort, Time Perspective: Prospective


Adverse Effects


Emergency Department, Catholic University Leuven
Vlaams Brabant


Not yet recruiting


Katholieke Universiteit Leuven

Results (where available)

View Results


Published on BioPortfolio: 2014-08-27T03:13:59-0400

Clinical Trials [284 Associated Clinical Trials listed on BioPortfolio]

Evaluation of the Merz Cheek Fullness Assessment Scale in the Treatment of Midface Volume Deficit

Evaluation of the sensitivity of the Merz Cheeks Fullness Assessment Scale (MCFAS) and the clinical relevance of aesthetically pleasing outcomes by detecting changes in cheek appearance af...

National Active Surveillance Network and Pharmacogenomics of Adverse Drug Reactions in Children

The purpose of the study is (1) to identify and collect samples from children who take drugs and have adverse drug reactions AND children who take drugs and do not experience any adverse d...

Study of Adverse Effects Occuring in Patients Receiving an Antibiotic Treatment With Temocillin: Study of Adverse Effects Occuring in Patients Receiving an Antibiotic Treatment With Temocillin

The Temocillin prescription frequency may be increased in order to reduce the use of carbapenems to reduce the progressive increase in carbapenem resistance observed in recent years. The i...

Residual Plasma Concentration of Sorafenib and Adverse Events in CHC

To date, Sorafenib is the only drug therapy to have demonstrated a benefit in overall survival in patients with advanced or metastatic hepatocellular carcinoma. However, this treatment cau...

Adverse Event Scale in Patients With Epilepsy (aEscape) - A European Survey for Physicians With Epilepsy Patients

The purpose of the survey is to explore through a structured interview and patient examination the rate and distribution of neurological and systemic adverse effects related to antiepilept...

PubMed Articles [14306 Associated PubMed Articles listed on BioPortfolio]

Adverse effects of psychotropic drugs : when and how to talk to patients ?

The way the potential adverse effects are presented during the introduction of a new medication in the context of psychiatric care can be decisive for subsequent care. This issue is approached from th...

Adjunct Aripiprazole Reduces Prolactin and Prolactin-Related Adverse Effects in Premenopausal Women With Psychosis: Results From the DAAMSEL Clinical Trial.

Prolactin-related adverse effects contribute to nonadherence and adverse health consequences, particularly in women with severe mental illness. Treating these adverse effects may improve treatment acc...

Level of physicians' awareness of antiepileptic drug adverse effects.

The study aimed to investigate the level of physicians' awareness regarding the adverse effects of antiepileptic drugs (AEDs) that were reported by their patients and to investigate whether these adve...

CBASP as an Inpatient Concept for Treatment-Resistant Chronic Depression: A Pilot Study of the Relationship between Adverse Effects and Treatment Outcome.

Inpatient psychotherapy might trigger adverse effects among others due to short but intensive treatment. Thus, in this pilot study, certain adverse effects of the multidisciplinary inpatient Cognitive...

Adverse effects of proton pump inhibitors: fact or fake news?

The present review summarizes the past year's literature, both clinical and basic science, regarding potential adverse effects of proton pump inhibitors.

Medical and Biotech [MESH] Definitions

Persistent detrimental effects from treatment for a condition. Included are effects from surgery such as POSTOPERATIVE COMPLICATIONS, and from DRUG THERAPY, such as CHEMICALLY INDUCED DISORDERS, or other THERAPEUTICS. Failure to attain a desired outcome from treatment for the condition is not considered an adverse effect.

Disorders that result from the intended use of PHARMACEUTICAL PREPARATIONS. Included in this heading are a broad variety of chemically-induced adverse conditions due to toxicity, DRUG INTERACTIONS, and metabolic effects of pharmaceuticals.

Models connecting initiating events at the cellular and molecular level to population-wide impacts. Computational models may be at levels relating toxicology to adverse effects.

Biphasic dose responses of cells or organisms (including microorganisms) to an exogenous or intrinsic factor, in which the factor induces stimulatory or beneficial effects at low doses and inhibitory or adverse effects at high doses.

Alkaloids with powerful hypotensive effects isolated from American or European Hellebore (Veratrum viride Ait. Liliaceae and Veratrum album L. Liliaceae). They increase cholinergic and decrease adrenergic tone with appropriate side effects and at higher doses depress respiration and produce cardiac arrhythmias; only the ester alkaloids have been used as hypotensive agents in specific instances. They have been generally replaced by drugs with fewer adverse effects.

More From BioPortfolio on "Emergency Department Crowding in Relation to In-hospital Adverse Medical Events"

Quick Search


Relevant Topics

Public Health
Alternative Medicine Cleft Palate Complementary & Alternative Medicine Congenital Diseases Dentistry Ear Nose & Throat Food Safety Geriatrics Healthcare Hearing Medical Devices MRSA Muscular Dyst...

Within medicine, nutrition (the study of food and the effect of its components on the body) has many different roles. Appropriate nutrition can help prevent certain diseases, or treat others. In critically ill patients, artificial feeding by tubes need t...

Searches Linking to this Trial