According to published studies, pain is the most common reason for seeking care in the ED, accounting for up to 78% of visits. Underuse of analgesics is common, especially among pediatric patients. There are many reasons that contribute to this problem, but key themes have emerged as culprits, says Marion R. Sills, MD, MPH. “Studies have found that higher crowding levels appear to delay treatment of pain in adult patients who visit the ED, but little research has been conducted in pediatric populations. The effect of ED crowding on children is growing as a research priority.”

The Pediatric Population & ED  Crowding

For adults, crowding has been associated with decreased quality across all six Institute of Medicine (IOM) quality dimensions: timeliness, effectiveness, equity, patient-centeredness, safety, and efficiency. In an effort to address these dimensions in the context of crowding in ED pediatric patients, Dr. Sills and colleagues conducted a study involving children with acute long-bone fracture-related pain who visited an ED (see also, ED Crowding: The Impact on Child Asthma Care). “Extremity fractures are among the most common reasons children seek ED care, resulting in 850,000 ED visits nationwide each year,” adds Dr. Sills. “These fractures can be especially painful for children.”

The study by Dr. Sills and colleagues, which was published in the December 2011 issue of Academic Emergency Medicine, measured the association between ED crowding and the quality of pain management for children with long-bone fractures. The objective was explored in three of the IOM’s six dimensions of quality: effectiveness, timeliness, and equity. The research team measured the dose-response effect of ED crowding on quality by comparing quality across crowding percentiles.

ED Crowding Affects Delivery of Care

In their analysis, the study team found that children were 4% to 47% less likely to receive pain treatment within 1 hour of the patient’s arrival when the ED was very crowded (at the 90th percentile) than when it was less crowded (at the 10th percentile). The researchers also found that children were 3% to 17% less likely to receive pain management that was indicated (based on their pain score) in these crowded conditions. “Importantly, we also observed a threshold effect,” Dr. Sills says (Figure). “For three of the associations we analyzed, quality declined steeply between the 75th and 90th crowding percentiles. As the crowding levels rose above a certain threshold, quality of care decreased. Our investigation further confirms that crowded EDs are impacting the delivery of care on many levels.” (see also, A New Look at Leaving Without Being Seen in EDs)

According to the data, timeliness and effectiveness of pain score administration was least affected by crowding, while opioid timeliness was most affected. “This is logical considering the stepwise nature of the processes of managing pain,” says Dr. Sills. The more steps that are required in the process, the more opportunities there are for crowding to delay or deter later processes in the sequence. For example, opioid administration requires attending physicians to order and nurses to give the medication, whereas in many hospitals, certain non-opioids can be ordered and given by the same nurse.

Mitigation Efforts Are Needed to Reduce ED Crowding

Dr. Sills says that the relationship between ED crowding and pain treatment was expected for several reasons. “When EDs become increasingly busy, staff may be less responsive to the needs of individual patients,” she says. “As a result, patients have a higher likelihood of non-treatment and delays in treatment. Furthermore, delays can occur when attending physicians are the only ones permitted to provide certain pain medications. These problems are hampering many EDs throughout the country that care for children with fracture-related pain.”

Efforts to mitigate ED crowding may reduce the underuse of analgesics in children with acute fractures, says Dr. Sills. “Hiring more staff can help, but this is an expensive approach and may not be feasible. Leveraging the capabilities of the current staff may be preferable. To best leverage staff from a systems standpoint, policy makers and ED leadership can use continuous quality improvement techniques to implement and measure the impact of interventions, such as order sets to allow nurses to provide pain management and computer- or phone-based alerts to call attention to undertreated pain.”

A Problem Worth Addressing

Research has consistently shown that crowding is a serious issue for EDs nationwide and that the phenomenon is caused by a variety of factors, including use of the ED for non-urgent medical care and federal policies that require EDs to treat all who present for care. “On a policy level, we need to increase the priority of fighting crowding problems in EDs to benefit both adults and children,” says Dr. Sills, “including creating incentives for patients to seek care for non-urgent complaints at their own doctor’s office. Such incentives may include improving compensation for primary care providers and establishing patient disincentives for non-urgent use of EDs.”