Time to Disposition Plan and In-Hospital Mortality of General Medical Patients

image from deviant art.comThe one thing that strikes me as I work in Emergency Departments across Australia is that access block is rife. Even after the introduction of the so called National Emergency Access Target (NEAT) or the so called "4 hour rule" which will supposedly magically solve the access block issue, I continue to see patients in trolleys lined up in corridors, as well as queues of ambulances ramped, unable to unload their patients into the emergency department.

We all know the consequences of ED overcrowding for patients. But here is a retrospective study that looks at the effect of speeding up time to disposition plan in a select group of patients - those being admitted to a general medical unit - often elderly patients with complex medical issues.

Background:

A perceived risk of time-limited emergency department (ED) assessment of patients is inadequate workup leading to inappropriate disposition. The aim of this study was to examine the association of time to disposition plan (TDP) on ED length of stay (LOS) and correlate this to mortality.

Methods:

A retrospective review of data collected from ED information systems at three hospitals was conducted between June 2008 and October 2009. Included patients were admitted to a general medical unit. Patients were excluded if admitted to intensive care, coronary care, a cardiac monitored bed or required surgery in first 24 h or had an expected LOS of <48 h. Multivariate regression analysis was used to identify indepen- dent associations with mortality.

Results:

A total of 10 107 patient episodes was analysed, of which 6768 patients (67.0%) had an ED LOS of 8 h. There was significant effect modification by ED LOS in the association of TDP and mortality. In the setting of longer ED LOS, a TDP of <4 h was associated with significantly higher mortality (OR 1.57, 95% CI: 1.28–1.92, P < 0.001), corrected for age, gender and triage category. This association was not significant when ED LOS was <8 h (OR 0.88, 95% CI: 0.60–1.27, P = 0.49).

Conclusions:

In the setting of prolonged ED LOS, completing ED assessment and management within 4 h of presentation was associated with significantly higher mortality. Further prospective studies are required to understand the relationship between rapid decision making in the ED and patient safety. 

Whilst it's hard to draw any concrete conclusions from this retrospective study, the findings spit in the face of NEAT and it's intended purpose of solving the access block issue. Prospective studies are needed in order to define the relationship further between time to disposition plan, and mortality.

Increasing inpatient bed capacity is likely to be a safer, more effective, logical solution to ED overcrowding, and perhaps the focus should be on this, rather than the creation of arbitary performance indicators, that have no evidence of benefit prior to implementation.  

The Association Between Time to Disposition Plan in the Emergency Department and In-Hospital Mortality of General Medical Patients.