Emergency Department Crowding Is Associated with Decreased Quality of Analgesia Delivery for Children with Pain Related to Acute, Isolated, Long-bone Fractures

Authors

  • Marion R. Sills MD, MPH,

    1. From the Department of Pediatrics (MRS, DR, MGK), Children’s Outcomes Research Program (MRS, DLF), University of Colorado School of Medicine, Aurora, CO; the Division of Emergency Medicine (MRS), Department of Clinical Informatics (DR, MGK), The Children’s Hospital–Denver, Aurora, CO; the Department of Biometrics, Colorado School of Public Health, (DLF) Aurora, CO; Department of Pediatrics, University of Alabama School of Medicine, (MSM) Birmingham, AL; the Division of Emergency Medicine, Children’s Hospital of Alabama, (MSM) Birmingham, AL; and the Colorado Clinical and Translational Sciences Institute (MGK), Aurora, CO.
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  • Diane L. Fairclough DrPH,

    1. From the Department of Pediatrics (MRS, DR, MGK), Children’s Outcomes Research Program (MRS, DLF), University of Colorado School of Medicine, Aurora, CO; the Division of Emergency Medicine (MRS), Department of Clinical Informatics (DR, MGK), The Children’s Hospital–Denver, Aurora, CO; the Department of Biometrics, Colorado School of Public Health, (DLF) Aurora, CO; Department of Pediatrics, University of Alabama School of Medicine, (MSM) Birmingham, AL; the Division of Emergency Medicine, Children’s Hospital of Alabama, (MSM) Birmingham, AL; and the Colorado Clinical and Translational Sciences Institute (MGK), Aurora, CO.
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  • Daksha Ranade MSPH, MBA,

    1. From the Department of Pediatrics (MRS, DR, MGK), Children’s Outcomes Research Program (MRS, DLF), University of Colorado School of Medicine, Aurora, CO; the Division of Emergency Medicine (MRS), Department of Clinical Informatics (DR, MGK), The Children’s Hospital–Denver, Aurora, CO; the Department of Biometrics, Colorado School of Public Health, (DLF) Aurora, CO; Department of Pediatrics, University of Alabama School of Medicine, (MSM) Birmingham, AL; the Division of Emergency Medicine, Children’s Hospital of Alabama, (MSM) Birmingham, AL; and the Colorado Clinical and Translational Sciences Institute (MGK), Aurora, CO.
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  • Michael S. Mitchell MD,

    1. From the Department of Pediatrics (MRS, DR, MGK), Children’s Outcomes Research Program (MRS, DLF), University of Colorado School of Medicine, Aurora, CO; the Division of Emergency Medicine (MRS), Department of Clinical Informatics (DR, MGK), The Children’s Hospital–Denver, Aurora, CO; the Department of Biometrics, Colorado School of Public Health, (DLF) Aurora, CO; Department of Pediatrics, University of Alabama School of Medicine, (MSM) Birmingham, AL; the Division of Emergency Medicine, Children’s Hospital of Alabama, (MSM) Birmingham, AL; and the Colorado Clinical and Translational Sciences Institute (MGK), Aurora, CO.
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  • Michael G. Kahn MD, PhD

    1. From the Department of Pediatrics (MRS, DR, MGK), Children’s Outcomes Research Program (MRS, DLF), University of Colorado School of Medicine, Aurora, CO; the Division of Emergency Medicine (MRS), Department of Clinical Informatics (DR, MGK), The Children’s Hospital–Denver, Aurora, CO; the Department of Biometrics, Colorado School of Public Health, (DLF) Aurora, CO; Department of Pediatrics, University of Alabama School of Medicine, (MSM) Birmingham, AL; the Division of Emergency Medicine, Children’s Hospital of Alabama, (MSM) Birmingham, AL; and the Colorado Clinical and Translational Sciences Institute (MGK), Aurora, CO.
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  • Presented at the Pediatric Academic Societies annual meeting, Honolulu HI, May 2008, and the Pediatric Academic Societies annual meeting, Baltimore MD, May 2009.

  • MRS, DLF, and DR received support from the Agency for Healthcare Research and Quality (5R03HS016418) and the Emergency Medicine Foundation.

  • MRS was supported by the Riggs Family/Health Policy Grant from the American College of Emergency Physicians, Grant 1 R03 HS016418-01A1 from the Agency for Healthcare Research and Quality and by the Children’s Hospital Research Institute.

  • The authors have no relevant financial information or potential conflicts of interest to disclose.

  • Supervising Editor: James W. Fox, MD.

Address for correspondence and reprints: Marion R. Sills, MD, MPH; e-mail: sills.marion@tchden.org.

Abstract

ACADEMIC EMERGENCY MEDICINE 2011; 18:1330–1338 © 2011 by the Society for Academic Emergency Medicine

Abstract

Objectives:  The authors sought to determine which quality measures of analgesia delivery are most influenced by emergency department (ED) crowding for pediatric patients with long-bone fractures.

Methods:  This cross-sectional, retrospective study included patients 0–21 years seen for acute, isolated long-bone fractures, November 2007 to October 2008, at a children’s hospital ED. Nine quality measures were studied: six were based on the timeliness (1-hour receipt) and effectiveness (receipt/nonreceipt) of three fracture-related processes: pain score, any analgesic, and opioid analgesic administration. Three equity measures were also tested: language, identified primary care provider (PCP), and insurance. The primary independent variable was a crowding measure: ED occupancy. Models were adjusted for age, language, insurance, identified PCP, triage level, ambulance arrival, and time of day. The adjusted risk of each timeliness or effectiveness quality measure was measured at five percentiles of crowding and compared to the risk at the 10th and 90th percentiles. The role of equity measures as moderators of the crowding-quality models was tested.

Results:  The study population included 1,229 patients. Timeliness and effectiveness quality measures showed an inverse association with crowding—an effect not moderated by equity measures. Patients were 4% to 47% less likely to receive timely care and were 3% to 17% less likely to receive effective care when each crowding measure was at the 90th than at the 10th percentile (p < 0.05). For three of the six quality measures, quality declined steeply between the 75th and 90th crowding percentiles.

Conclusions:  Crowding is associated with decreased timeliness and effectiveness, but not equity, of analgesia delivery for children with fracture-related pain.

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