The effect of crowding on access and quality in an academic ED.

BACKGROUND: Emergency department crowding has the potential to cause undesirable outcomes. We evaluated ED access and provider and patient assessments of quality.
METHODS: This multimethod study, done in an urban academic ED, included descriptive analysis of administrative records, paired physician and nurse provider surveys, and pre- or postpatient surveys regarding expectations and experiences. Our outcomes were rates and characteristics of patients who left without being seen (LWBS), provider ratings of crowding/compromised care, and patient satisfaction.
RESULTS: During data collection periods, 11743 patients registered, and 9% LWBS. Patients who LWBS tended to be younger than 45 years (relative risk [RR] = 1.7; 95% confidence interval [CI], 1.5-1.9), of nonurgent/stable triage acuity (RR = 3.1; 95% CI, 2.5-3.8), and without insurance (RR = 1.5; 95% CI, 1.3-1.7). Seventy-four percent of all patients had insurance, and 28% were private. Doctors and nurses had 81% agreement (kappa = 0.54) in their assessment of crowded conditions, which were temporally associated with LWBS rates (P < .01). In 47% of 57 shifts, at least 1 provider felt that crowding was compromising quality of care. Of 423 sequential ED waiting room patients approached, 310 (73%) enrolled and 174 (56%) of these completed phone follow-up. On average, patients felt that they should be seen within 1 hour but expected to wait for 2.1 hours. Patient's perceived that wait times on follow-up averaged 3.5 hours, 5+ hours for LWBS patients. Visit satisfaction was inversely related to patient's perceived wait times.
CONCLUSIONS: We find that ED crowding increased LWBS rates and patient satisfaction. Systemwide changes in ED organization will be necessary for the ED to fulfill its role as a safety net provider and meet public health needs during disaster surge capacity.