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Three Part Question

In [pediatric emergency departments], does [overcrowding] cause a [delay in care, or increase chances of adverse outcomes]?

Clinical Scenario

A 7-year-old female with a history of atopic dermatitis presents to a pediatric emergency department for wheezing and increased work of breathing. The department is full with many hall beds currently occupied by patients. You put in orders to administer 4 puffs of albuterol and a dose of dexamethasone. You notice that 45 minutes later the medications have not been given and when you reassess the patient she is in more respiratory distress. Crowding in the emergency department seemed to play a role in the adverse turn of events for the patient.

Search Strategy

Medline 1966-07/24 using PubMed, Cochrane Library (2024), and Embase
[(pediatric emergency department [All Fields] AND (overcrowding.mp OR crowding.mp)] Limit to English language

Search Outcome

98 studies were identified; 7 clinical trials addressed the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Doan Q, et al June 2019 Canada	All children visiting 8 Canadian pediatric emergency departments across 4 provinces between 2010 and 2014	Retrospective cohort study	Association between mean ED length of stay and hospital admission within 7 days	A positive association between crowding and hospital admission within 7 days (0.8%–1.5%)	Retrospective design and use of administrative databases, which depend on the accuracy of entered data and are limited in detail. Data used was old and varied in availability across provinces.
Gorski JK, et al. October 2021 USA	Data from the ED of a quaternary care children's hospital and trauma center during the 14-month study period to demonstrate the relationship between patients who leave without being seen (LWBS) risk and overcrowding.	Retrospective observational study	Relationship between patient LWBS risk and each crowding score	The odds ratio for LWBS risk was 1.30 (95% CI 1.27–1.33) per 10-point increase in overcrowding score	Unable to include chief complaint information as a factor in this analysis; retrospective; limited generalizability due to the single study nature.
			Relationship between patient LWBS risk and occupancy rate	Patients were 1.23 times more likely to LWBS per 10% increase in occupancy rate
Sills MR, et al. March 2011 USA	927 patients aged 2 to 21 years treated for acute asthma at a children's hospital ED.	Retrospective observational study	Timeliness quality measures versus crowding	Patients were 52% to 74% less likely to receive timely care when crowding measure was at the 75th rather than at the 25th percentile (P<0.05).	Performed at one emergency department; retrospective; may have been confounded by inadequate adjustment for severity of illness; possible discrepancies between the electronic medical record event time and the actual event time
			Effectiveness quality measures versus crowding	Patients were 9% to 14% less likely to receive effective care when crowding measure was at the 75th rather than at the 25th percentile (P<0.05).
Timm NL, et al September 2008 USA	Pediatric ED boarding time and daily census were determined each day from July 2003 to July 2007.	Retrospective observational study	Mean length of stay (LOS)	For every 50 patients seen above the average daily volume of 250, LOS increased 14.8 minutes	Data collection from one institution; retrospective; ED boarding time was distributed over a 24-hour period and did not specifically determine impact during busy or slow times of the day; other aspects of quality of care, including safety, which were not evaluated.
			Time to triage	For every 50 patients seen above the average daily volume of 250, time to triage increased 6.6 minutes
			Time to physician	For every 50 patients seen above the average daily volume of 250, time to physician increased 18.2 minutes
			Patient elopement during a 24-hour period	For every 50 patients seen above the average daily volume of 250, number of patient elopements increased by three
Chan M, et al. September 2017 Canada	All patient visits to the BCCH PED from January 2008 and December 2012 for 21 years of age and younger were included for analysis.	Retrospective cohort study	Association between hospital admission versus PED crowding	Positive association between crowding and the odds of being admitted to the hospital (odds ratio 2.1)	Retrospective study design; limited generalizability; imperfect measures of PED crowding; hospitalization as an outcome measure does not discriminate between admissions related to the patient’s underlying condition and those that may result from deterioration of delayed ED care or errors associated with a crowded PED environment.
			Association between PICU admission versus PED crowding	Positive association between crowding and the odds of being admitted to the PICU (odds ratio 8.9))
Kappy B, et al March 2024 USA	PED patients admitted to non-psychiatric services, broken into four periods: pre-COVID-19, early pandemic, COVID-19 variants, and non-COVID respiratory viruses.	Retrospective observational study	Median PED boarding time	significantly increased from Period I (acute: 2.4 h; critical: 3.0 h) to Period II (acute: 3.0 h, critical: 4.0 h) to Period III (acute: 4.4 h, critical: 6.6 h) to Period IV (acute: 6.2 h; critical: 9.5 h).	Single institution; retrospective design; analysis of return visit and readmission did not consider that children may have presented to outside EDs following their discharge from hospital.
			Boarding time survival analysis	as boarding time increased, hospital LOS increased for acute admissions and decreased for critical admissions
			Boarding time versus patient safety events	PED boarding times were significantly associated with higher odds of any filed safety report
Menon NVB, et al August 2021 India	17,463 children beyond neonatal age attending the 22-bedded emergency were prospectively enrolled from February to December, 2019.	Prospective observational study	Correlation between unfavorable ED outcomes and new admissions	Positive correlation (P<0.001)	The effect of socioeconomic status, duration of illness, and disease specific factors were not evaluated
			Correlation between unfavorable ED outcomes and bed occupancy rate	Positive correlation (P<0.001)
			Correlation between unfavorable ED outcomes and number of boarders	Positive correlation (P<0.0001)

Comment(s)

Pediatric emergency department (PED) overcrowding occurs when the need for emergency services outstrips available resources in the ED. Boarding patients in the PED when there is a lack of staffed inpatient beds is believed to be the primary contributor to ED overcrowding. Studies demonstrate a correlation between ED overcrowding and inpatient mortality, delayed time to medication administration, increased medical errors and patients leaving without receiving care. The American Academy of Pediatrics (AAP) 2023 policy statement on PED crowding proposes several solutions to improve the care of children and mitigate the effects of crowding on patients and care providers.

Clinical Bottom Line

Pediatric ED overcrowding threatens patient safety, increases medical errors, decreases patient satisfaction, prolongs length of stay, and jeopardizes the ability of the health care system to effectively care for children.

References

1. Doan Q, Wong H, Meckler G, Johnson D, Stang A, Dixon A, Sawyer S, Principi T, Kam AJ, Joubert G, Gravel J, Jabbour M, Guttmann A. The impact of pediatric emergency department crowding on patient and health care system outcomes: a multicentre cohort study. CMAJ 2019 Jun 10;191(23):E627-E635
2. Gorski JK, Arnold TS, Usiak H, Showalter CD. Crowding is the strongest predictor of left without being seen risk in a pediatric emergency department Am J Emerg Med 2021 Oct;48:73-78
3. Sills MR, Fairclough D, Ranade D, Kahn MG. Emergency department crowding is associated with decreased quality of care for children with acute asthma. Ann Emerg Med. 2011 Mar;57(3):191-200.e1-7
4. Timm NL, Ho ML, Luria JW Pediatric emergency department overcrowding and impact on patient flow outcomes. Acad Emerg Med. 2008 Sep;15(9):832-7.
5. Chan M, Meckler G, Doan Q. Paediatric emergency department overcrowding and adverse patient outcomes. Paediatr Child Health 2017 Oct;22(7):377-381.
6. Kappy B, Berkowitz D, Isbey S, Breslin K, McKinley K. Characteristics and patient impact of boarding in the pediatric emergency department, 2018-2022. Am J Emerg Med 2024 Mar;77:139-146.
7. Menon NVB, Jayashree M, Nallasamy K, Angurana SK, Bansal A. Utilization and Overcrowding in a High-Volume Tertiary Level Pediatric Emergency Department. Indian Pediatr. 2021 Aug 15;58(8):723-725.