National Reporting of Emergency Department Length of Stay
Authors: Charles L. Emerman
Journal: JAMA (2012)

IN THIS ISSUE OF JAMA, FEE AND COLLEAGUES 1 REPORT data from the 2008 National Hospital Ambulatory Medical Care Survey evaluating the ability of emergency departments at safety-net hospitals to comply with parameters for time to disposition for both admitted and discharged patients. Based on analysis of nearly 25 000 patient visits, including 11 065 visits at safety-net hospitals and 13 654 visits to non–safety-net emergency departments, there were no significant differences for compliance with proposed length-of-stay measures for admitted patients (median, 269 minutes vs 281 minutes) or discharged patients (median, 156 minutes vs 148 minutes) for safety-net emergency departments and non–safety-net emergency departments, respectively. However, there were associations between longer emergency department length of stay and several subgroups examined, including patients of nonwhite race, those with lower triage acuity, and type of treating clinician (eg, resident/intern). The question of length of stay as a performance measure is important because of concerns about disparity of care because safety-net hospitals serve a disproportionate share of minority, uninsured, or underinsured patients. The authors indicate that their aim was to evaluate the performance of emergency departments in meeting length of stay criteria. But it is here that concerns among emergency physicians begin. A common mantra among the emergency medicine community is that length of stay is a hospital problem and not an emergency department problem. There is evidence that this is partially true. The modern emergency department faces challenges that exceed those of past years. On the one hand, beneficial improvements in medical knowledge have led to life-saving or life-changing therapies and interventions to treat patients with myocardial infarction, stroke, and trauma, and other acute disease processes. Some treatments are time dependent, leading to pressure on already-busy clinicians to prioritize the care of some complex patients over others. Public disclosure of time to treatment has led to improvements in some of these parameters but at a cost of hurried decision making. The pay for performance measures provide incentives for hospitals to improve services and demand rapid action by their emergency department staff. Yet some of these efforts may have unintended consequences. For instance, the increased use of antibiotics for pulmonary conditions other than pneumonia was hypothesized to have occurred so that clinicians could meet the time-to-treatment performance measure for pneumonia reported to Centers for Medicare & Medicaid Services. Both structural and clinical issues contribute to the complexity of measuring quality in the emergency department. Emergency department visits have continued to increase by an estimated 25% over a 10-year period, along with an estimated 5.6% increase more in 2008, the latest year for which estimates are available. The largest increase in emergency department visits occurred among middle-aged adults and patients insured by Medicaid. At the same time, the number of emergency departments has decreased by 27% over the 20-year period up to 2009. Although the proportion of patients requiring admission has remained stable, the absolute number of patients who require admission has increased, yet the number of staffed inpatient beds decreased by 1.2% from 2004-2009. Among the more challenging patients for whom emergency physicians must find a disposition are those patients with mental health symptoms, who now account for almost 12.5% of all visits. Pressures on throughput come from complex critically ill or injured patients who require extensive testing that is most expeditiously performed out of the emergency department. Additionally, the proposed financial penalties associated with readmissions will lead hospitals to expect greater efforts in the emergency department to avoid placing these patients back on the inpatient units. As noted by Fee et al, efforts in other countries to address emergency department overcrowding and length of stay have had mixed effects. The United Kingdom had failed experiments in reducing volumes through the use of nurse