title: Emergency department crowding is associated with poor care for patients with severe pain.
abstract: OBJECTIVE
  We study the impact of emergency department (ED) crowding on delays in treatment and nontreatment for patients with severe pain.
  
  
  METHODS
  We performed a retrospective cohort study of all patients presenting with severe pain to an inner-city, teaching ED during 17 months. Poor care was defined by 3 outcomes: not receiving treatment with pain medication while in the ED, a delay (>1 hour) from triage to first pain medication, and a delay (>1 hour) from room placement to first pain medication. Three validated crowding measures were assigned to each patient at triage. Logistic regression was used to test the association between crowding and outcomes.
  
  
  RESULTS
  In 13,758 patients with severe pain, the mean age was 39 years (SD 16 years), 73% were black, and 64% were female patients. Half (49%) of the patients received pain medication. Of those treated, 3,965 (59%) experienced delays in treatment from triage and 1,319 (20%) experienced delays from time of room placement. After controlling for factors associated with the ED treatment of pain (race, sex, severity, and older age), nontreatment was independently associated with waiting room number (odds ratio [OR] 1.03 for each additional waiting patient; 95% confidence interval [CI] 1.02 to 1.03) and occupancy rate (OR 1.01 for each 10% increase in occupancy; 95% CI 0.99 to 1.04). Increasing waiting room number and occupancy rate also independently predicted delays in pain medication from triage (OR 1.05 for each waiting patient, 95% CI 1.04 to 1.06; OR 1.18 for each 10% increase in occupancy; 95% CI 1.15 to 1.21) and delay in pain medication from room placement (OR 1.02 for each waiting patient, 95% CI 1.01 to 1.03; OR 1.06 for each 10% increase in occupancy, 95% CI 1.04 to 1.08).
  
  
  CONCLUSIONS
  ED crowding is associated with poor quality of care in patients with severe pain, with respect to total lack of treatment and delay until treatment.
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: Judd E
authors.initials: JE
authors.lastname: Hollander
mesh_terms: D000328:Adult; D000368:Aged; D000700:Analgesics / Q000627:therapeutic use; D015331:Cohort Studies; D003441:Crowding; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010043:Outcome and Process Assessment, Health Care; D059408:Pain Management; D010147:Pain Measurement; D011787:Quality of Health Care; D012189:Retrospective Studies; D013997:Time Factors
chemical_list: D000700:Analgesics