title: The impact of emergency department crowding measures on time to antibiotics for patients with community-acquired pneumonia.
abstract: OBJECTIVE
  We seek to determine the impact of emergency department (ED) crowding on delays in antibiotic administration for patients with community-acquired pneumonia.
  
  
  METHODS
  We performed a retrospective cohort study of adult patients admitted with community-acquired pneumonia from January 1, 2003, to April 31, 2005, at a single, urban academic ED. The main outcome was a delay (>4 hours from arrival) or nonreceipt of antibiotics in the ED. Eight ED crowding measures were assigned at triage. Multivariable regression and bootstrapping were used to test the adjusted impact of ED crowding measures of delayed (or no) antibiotics. Predicted probabilities were then calculated to assess the magnitude of the impact of ED crowding on the probability of delayed (or no) antibiotics.
  
  
  RESULTS
  In 694 patients, 44% (95% confidence interval [CI] 40% to 48%) received antibiotics within 4 hours and 92% (95% CI 90% to 94%) received antibiotics in the ED. Increasing levels of ED crowding were associated with delayed (or no) antibiotics, including waiting room number (odds ratio [OR] 1.05 for each additional waiting room patient [95% CI 1.01 to 1.10]) and recent ED length of stay for admitted patients (OR 1.14 for each additional hour [95% CI 1.04 to 1.25]). When the waiting room and recent length of stay were both at the lowest quartiles (ie, not crowded), the predicted probability of delayed (or no) antibiotics within 4 hours was 31% (95% CI 21% to 42%); when both were at the highest quartiles, the predicted probability was 72% (95% CI 61% to 81%).
  
  
  CONCLUSIONS
  ED crowding is associated with delayed and nonreceipt of antibiotics in the ED for patients admitted with community-acquired pneumonia.
authors.affiliation: Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA. pinesjes@uphs.upenn.edu
authors.forename: Jesse M
authors.initials: JM
authors.lastname: Pines
authors.forename: A Russell
authors.initials: AR
authors.lastname: Localio
authors.forename: Judd E
authors.initials: JE
authors.lastname: Hollander
authors.forename: William G
authors.initials: WG
authors.lastname: Baxt
authors.forename: Hoi
authors.initials: H
authors.lastname: Lee
authors.forename: Carolyn
authors.initials: C
authors.lastname: Phillips
authors.forename: Joshua P
authors.initials: JP
authors.lastname: Metlay
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D017714:Community-Acquired Infections / Q000188:drug therapy; D003441:Crowding; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D011014:Pneumonia / Q000188:drug therapy*; D012044:Regression Analysis; D012189:Retrospective Studies; D013997:Time Factors
chemical_list: D000900:Anti-Bacterial Agents