Two research letters, commentary examine emergency department timeliness, stays

Bottom Line: Variability exists in emergency department (ED) timeliness based on four variables (hospital size, rural vs. urban, ownership and teaching status) reported to the Centers for Medicare & Medicaid Services for patients discharged from the ED or admitted for inpatient services.

Author: Sidney T. Le, B.A., and Renee Y. Hsia, M.D., M.Sc., of the University of California, San Francisco.

Background: The Centers for Medicare & Medicaid Services made several quality measures of ED timeliness available online to provide a national look at the ability of EDs to provide timely care.

How the Study Was Conducted: The authors examined ED measurements of timely care and looked at whether hospital characteristics or patient populations were associated with poor timeliness of ED care. Their study, which was reported in a research letter, included a sample of 3,692 hospitals, most of them nonteaching, private nonprofit hospitals in urban areas.

Results: For patients ultimately discharged from the ED, the median wait time to see a health care professional was about 30 minutes and the length of stay just over two hours. For patients who were admitted, the median length of stay in the ED was more than four hours, approximately one-third of which was "boarding" (waiting for an inpatient bed). Lengths of stay for patients discharged from the ED were longer at large hospitals (158.2 minutes) than hospitals of other sizes and urban hospitals (149.2 minutes) compared with those in other areas. Public hospitals (149.5 minutes) and major teaching hospitals (172.6 minutes) had the longest length of stays compared with other hospitals based on ownership and teaching status.

Discussion: "Given the variation in hospital ED performance, our results suggest a potential for improvement in ED timelines. However, if these measures are translated into pay-for-performance incentives, the financial pressures faced by larger, urban, major teaching, public hospitals may be exacerbated."

(JAMA Intern Med. Published online September 15, 2014. doi:10.1001/jamainternmed.2014.3431. Available pre-embargo to the media at http://media.jamanetwork.com.)

Editor's Note: This study was supported by an American Heart Association National Clinical Research Program Award. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Bottom Line: Length of stay (LOS) in the ED appears to be associated with rates of inpatient admission.

Author: Emily Carrier, M.D., M.Sci., formerly of Mathematica Policy Research, Princeton, N.J., now of the Centers for Medicare & Medicaid Services, Baltimore, and colleagues.

Background: Hospitals are expected to report their median ED LOS to the Centers for Medicare & Medicaid Services and the data are reported to the public. However, there is concern that in the future maximum LOS intervals may be tied to reimbursements.

How the Study Was Conducted: The authors analyzed a nationally representative sample of 24,879 ED visits to determine whether meeting ED LOS targets was associated with rates of admission. The authors used LOS targets that were four hours for discharged patients and eight hours for admitted patients. They classified hospitals based on whether 90 percent of their visits met LOS targets.

Results: Most visits (51.9 percent) that resulted in admission were to hospitals that met the 8-hour target for 90 percent of admissions, while 22.5 percent of visits resulting in discharge were in hospitals that met the 4-hour target. ED visits to hospitals that met the 8-hour targets for admitted patients had higher odds of inpatient admission (compared to hospitals that met the 4-hour target)

Discussion: "If the pressure of LOS measures encourages otherwise avoidable inpatient admissions, this could increase health care costs and unnecessary hospital-acquired conditions. Policy makers should consider these unintended consequences before adopting ED LOS quality measures."

(JAMA Intern Med. Published online September 15, 2014. doi:10.1001/jamainternmed.2014.3467. Available pre-embargo to the media at http://media.jamanetwork.com.)

Editor's Note: This study was supported by the University of California, San Francisco – Clinical and Translational Science Institute grant from the National Center for Advancing Translational Sciences, National Institutes of Health and by the Robert Wood Johnson Foundation Physician Faculty Scholars Program. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

In a related commentary, Jeremiah D. Schuur, M.D., M.H.S., of Brigham & Women's Hospital and Harvard Medical School, Boston, writes: "When admitted patients are boarded in the ED, the ED's effective size decreases, limiting capacity to care for the next patient."

"The decision by the CMS to publicly report ED waiting times is an important first step. Justice Louis Brandeis said, 'Sunshine is the best disinfectant,'" Schuur notes. "Improving timeliness is a leading quality focus for emergency medicine, but it should not be viewed in isolation. There are cases when a longer ED visit may be in the patient's interest."

"We need to refocus hospitals on the everyday crisis of lengthy ED waiting and boarding time and discourage them from putting the sickest patients at the back of the line. The studies by Le and Hsia and Carrier et al bring important attention to ED and hospital crowding – critical barriers to high quality care of acute medical conditions – and raise important concerns around the use of performance measures," Schuur notes.

(JAMA Intern Med. Published online September 15, 2014. doi:10.1001/jamainternmed.2014.1174. Available pre-embargo to the media at http://media.jamanetwork.com.)

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Media Advisory: To contact research letters' corresponding author Renee Y. Hsia, M.D., M.Sc., call Elizabeth Fernandez at 415-514-1592 or email Elizabeth.Fernandez@UCSF.edu. To contact commentary author Jeremiah D. Schuur, M.D., M.H.S., call Jessica Maki at 617-525-6373 or email JMAKI3@partners.org.

To place an electronic embedded link to this study in your story: Links for these research letters and commentary will be live at the embargo time: http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2014.3431, http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2014.3467 and http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2014.1174.