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• An answer to the dilemma whether emergency department length of stay improves quality of care?
  Jill D Van Acker
  Published on: 22 September 2015
• Length of stay as a marker of quality?
  Tess Alexandra Baker
  Published on: 15 September 2015

• Published on: 22 September 2015

  An answer to the dilemma whether emergency department length of stay improves quality of care?

  • Jill D Van Acker, Anaesthetist

  Dear Editor,

  I commend Vermeulen et al for addressing a fundamental question: Is ED length of stay (ED LOS), a globally used key performance indicator, actually associated with improvement in quality of care[1]?

  Vermeulen et al set out to compare whether patients presenting with one of three acute conditions (high acuity asthma, upper arm/forearm/shoulder fracture and acute myocardial infarct) at hosp...

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  Dear Editor,

  I commend Vermeulen et al for addressing a fundamental question: Is ED length of stay (ED LOS), a globally used key performance indicator, actually associated with improvement in quality of care[1]?

  Vermeulen et al set out to compare whether patients presenting with one of three acute conditions (high acuity asthma, upper arm/forearm/shoulder fracture and acute myocardial infarct) at hospitals with reduced ED LOS following the introduction of the Ontario Emergency Room Wait time strategy were also likely to experience improvements in other measures of quality of care; i.e. is evidence based treatment more likely given and if so, is it done in a timely fashion [1]?

  Interestingly, the study did not reveal an association between reduced ED LOS and improvement of other quality indicators, surprisingly not even for measures involving timely delivery of care [1]. Nevertheless, they did find that shift-level crowding is inversely associated with quality indicators related to timeliness of care: timeliness of reperfusion in AMI, splinting and analgesia in adult patients with fractures and steroid, bronchodilator within 60 minutes of presentation with acute asthma[1]. This supports prior studies reporting a correlation between ED crowding and increased short-term or in patient mortality [2, 3] and failure to administer timely care [4]. In my view, this study confirms that both quality initiatives and assessment of quality of care ought to be multidimensional and not focussed on one quality indicator. The association with shift-level crowding emphasises that we must concentrate on mapping trends in ED crowding over time to allow for appropriate ED staffing and institute systems that aid efficiency while assuring safety during those times. This may prove to be a more effective system to improve overall quality of care that encompasses safety, efficiency, timeliness and patient centredness [5] rather than focussing on reducing ED LOS in isolation, which appears to be a poor measure of quality of care[1]. Furthermore, reducing ED LOS equals time pressure, a known major contributing factor to error in human performance, which is likely to predominantly affect the diagnosis and treatment in complex patients due to performance degradation[6]. Finally, though it seems obvious that reduced ED LOS improves patient satisfaction, if it is associated with abrupt staff and contributes to human error[6], this is unlikely to be the case. I applaud Vermeulen et al for highlighting the critical issue with using one-dimensional measures to assess quality of healthcare.

  Word count: 394.

  References.

  1. Vermeulen, M.J., et al., Are reductions in emergency department length of stay associated with improvements in quality of care? A difference-in-differences analysis. BMJ Qual Saf, 2015. 2. Guttmann, A., M.J. Schull, and M.J. Vermeulen, Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ, 2011. 342. 3. Sun, B., R. Hsia, and R. Weiss, Effect of emergency department crowding on outcomes of admitted patients. Ann Emerg Med, 2013. 61: p. 605-611. 4. Pines, J., J. Hollander, and A. Localio, 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: p. 873-878. 5. Pronovost, P., et al., How can clinicians measure safety and quality in acute care? Lancet, 2004. 363: p. 1061-1067. 6. Suzuki, T., T.L. Von Thaden, and W. Geibel Influence of time pressure on aircraft maintenance errors. 2008.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 15 September 2015

  Length of stay as a marker of quality?

  • Tess Alexandra Baker, Physiotherapist

  Dear Editor,

  Vermeulen et al [1] provides further insight into the effect of emergency department (ED) crowding and length of stay (LOS) on several quality indicators. This piece of work not only adds to the body of literature which suggests ED crowding delays timeliness of interventions, but importantly highlights that government initiatives targeting LOS alone are not enough to enhance other aspects of true, q...

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  Dear Editor,

  Vermeulen et al [1] provides further insight into the effect of emergency department (ED) crowding and length of stay (LOS) on several quality indicators. This piece of work not only adds to the body of literature which suggests ED crowding delays timeliness of interventions, but importantly highlights that government initiatives targeting LOS alone are not enough to enhance other aspects of true, quality care delivery.

  Donabedian [2] originally explored the various dimensions of quality, using a measurement framework recognising structural, procedural and outcome indicators. These have since been refined by various authors but are widely recognised to include efficacy, access, efficiency, safety, equitability, appropriateness and acceptability - the full spectrum of which must be considered when assessing the quality of care in emergency departments and hospitals.

  Like the Ontario ER Wait Time Strategy, Australia has adopted a National Emergency Access Target (NEAT) as a way of addressing crowding, patient flow and access to emergency care. Overcrowding and prolonged LOS in ED for admitted patients is certainly associated with poorer outcomes, and the introduction of a 4-hour rule can reduce hospital mortality [3].

  As is well demonstrated by Vermeulen et al, LOS targets measure when you arrive and when you leave ED - nothing in between. While seen as a quality access target, it in no way measures what actually happens within this time gap. Extended wait times for medical assessment and intervention have been associated with higher mortality rates and hospital admissions [4], but this only looks at one part of the patient's overall emergency experience. So although it is acknowledged that access is important, having LOS targets may also create unintended, negative consequences. ED doctors have less time to spend with complex patients, potentially resulting in diagnostic error and avoidable admissions. The results of this study show a lack of improvement in most quality indicators measured, suggesting that perhaps purely targeting LOS can in fact compromise effectiveness. The push to get patients through the system faster has also resulted in sick patients being transferred to ill-equipped medical assessment units - this I have experienced first-hand.

  Quality of care is of upmost importance but is complex and difficult to measure. Performance indicators such as NEAT are easily monitored but are, at best, only surrogate markers of quality. As Vermeulen highlights, strategies aimed at reducing ED LOS do not necessarily result in improvements to the other dimensions of excellent care provision. Whilst no detrimental effects to safety are demonstrated in this research, other measures such as adverse events, medication errors or changes in hospital admission rates were not captured to support this conclusion.

  LOS targets may have been an appropriate first step to tackle the issue of crowding, but there is now a need to look deeper into the quality of care being delivered in our ED's. Interestingly, the UK has lowered its performance threshold on the 4 hour rule, now placing emphasis on a number of other quality indicators [5]. Quality of patient care must be prioritised while ensuring access is maintained. This requires more sophisticated measurements of the quality of emergency medical care.

  Tess Baker

  References: 1. Vermeulen MJ, Guttmann A, Stukel TA, Kachra A, Sivilotti M, Rowe BH et al. Are reductions in emergency department length of stay associated with improvements in quality of care? A difference-in-difference analysis. BMJ Qual Saf 2015;0:1-10

  2. Donabedian A. The quality of care. How can it be assessed? JAMA 1988; 260(12):1743-1748

  3. 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. MJA 2006, 184;208- 212

  4. Guttmann A, Schull MJ, Vermeulen MJ, Stukel TA. Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ 2011;342:D2983

  5. Department of Health. Accident and emergency provisional quality indicators [internet] UK: Department of Health; August 2010 [cited 2015 Sept 7]. Available from https://www.gov.uk/government/news/accident-and- emergency-provisional-quality-indicators

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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