Objective: Two crowding metrics are often used to measure emergency department (ED) crowding: the occupancy rate and the emergency department work index (EDWIN) score. To evaluate these metrics for applicability in our community ED, we sought to measure their correlation with the number of patients who left without being seen (LWBS) and determine if either, or both, correlated with our daily LWBS rate. We hypothesized a statistically significant positive correlation between the number of patients who LWBS and both crowding metrics.

Methods: We performed a retrospective observational study by reviewing data on all patients who LWBS from December 1, 2007, to February 29, 2008. Occupancy rates and EDWIN scores were obtained through our electronic patient tracking board. We identified LWBS status by searching the final disposition entered into our electronic medical record. We measured the correlation between each crowding metric averaged over each 24-hour day and the number of patients who LWBS per 24-hour day using Spearman's rank correlation, and created receiver operator characteristic (ROC) curves to quantify the discriminatory power of occupancy rate and EDWIN score for predicting more than two patients per day who LWBS.

Results: We identified 1,193 patients who LWBS during the study period, including patients who registered but then left the waiting room (733), as well as those who left before: registration (71), triage (75), seeing a physician (260), or final disposition (54). The number of patients who LWBS per day ranged from one to 30, with a mean of 13 and median of 11 (IQR 6 to 19). The daily number of patients who LWBS showed a positive correlation with the average daily occupancy rate (Spearman’s rho = 0.771, p = 0.01) and with average daily EDWIN score (Spearman's rho = 0.67, p< .001). Area under the ROC curve for occupancy rate was .97 (95% CI .93 to 1.0) and for EDWIN score was .94 (95% CI .89 to 1.0).

Conclusion: Average daily occupancy rates and EDWIN scores both correlate positively with, and have excellent discriminatory power for, the number of patients who LWBS in our ED; however, the scale of our EDWIN scores differs from that obtained at other institutions. For studies of crowding, occupancy rate may be the more useful metric due to its ease of calculation. [West J Emerg Med. 2010; 11(4):324-328.]

Despite its widespread use in North America and many other parts of the world, the safety of etomidate as an induction agent for rapid sequence intubation in septic patients is still debated. In this article, we evaluate the current literature on etomidate, review its clinical history, and discuss the controversy regarding its use, especially in sepsis. We address eight questions: (i) When did concern over the safety of etomidate first arise? (ii) What is the mechanism by which etomidate is thought to affect the adrenal axis? (iii) How has adrenal insufficiency in relation to etomidate use been defined or identified in the literature? (iv) What is the evidence that single dose etomidate is associated with subsequent adrenal-cortisol dysfunction? (v) What is the clinical significance of adrenal insufficiency or dysfunction associated with single dose etomidate, and where are the data that support or refute the contention that single-dose etomidate is associated with increased mortality or important post emergency department (ED) clinical outcomes? (vi) How should etomidate’s effects in septic patients best be measured? (vii) What are alternative induction agents and what are the advantages and disadvantages of these agents relative to etomidate? (viii) What future work is needed to further clarify the characteristics of etomidate as it is currently used in patients with sepsis? We conclude that the observational nature of almost all available data suggesting adverse outcomes from etomidate does not support abandoning its use for rapid sequence induction. However, because we see a need to balance theoretical harms and benefits in the presence of data supporting the non-inferiority of alternative agents without similar theoretical risks associated with them, we suggest that the burden of proof to support continued widespread use may rest with the proponents of etomidate. We further suggest that practitioners become familiar with the use of more than one agent while awaiting further definitive data. [West J Emerg Med. 2010; 11(2):161-172.]

Introduction: Emergency department (ED) crowding has been shown to negatively impact patient outcomes. Few studies have addressed the effect of ED crowding on patient satisfaction. Our objective was to evaluate the impact of ED crowding on patient satisfaction in patients discharged from the ED.

Methods: We measured patient satisfaction using Press-Ganey surveys returned by patients that visited our ED between August 1, 2007 and March 31, 2008. We recorded all mean satisfaction scores and obtained mean ED occupancy rate, mean EDWIN score and hospital diversion status over each 8-hour shift from data archived in our electronic tracking board. Univariate and multivariate logistic regression analysis was calculated to determine the effect of ED crowding and hospital diversion status on the odds of achieving a mean satisfaction score ≥85, which was the patient satisfaction goal set forth by our ED administration.

Results: A total of 1591 surveys were returned over the study period. Mean satisfaction score was 77.6 (SD±16) and mean occupancy rate was 1.23 (SD±0.31). The likelihood of failure to meet patient satisfaction goals was associated with an increase in average ED occupancy rate (OR 0.32, 95% CI 0.17 to 0.59, P<0.001) and an increase in EDWIN score (OR 0.05, 95% CI 0.004 to 0.55, P=0.015). Hospital diversion resulted in lower mean satisfaction scores, but this was not statistically significant (OR 0.62, 95% CI 0.36 to 1.05). In multivariable analysis controlling for hospital diversion status and time of shift, ED occupancy rate remained a significant predictor of failure to meet patient satisfaction goals (OR 0.34, 95% CI 0.18 to 0.66, P=0.001).

Conclusions: Increased crowding, as measured by ED occupancy rate and EDWIN score, was significantly associated with reduced patient satisfaction. Although causative attribution was limited, our study suggested yet another negative impact resulting from ED crowding. [West J Emerg Med.2013;14(1):11-15.]

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