title: Emergency department crowding is associated with decreased quality of analgesia delivery for children with pain related to acute, isolated, long-bone fractures.
abstract: OBJECTIVE
  The authors sought to determine which quality measures of analgesia delivery are most influenced by emergency department (ED) crowding for pediatric patients with long-bone fractures.
  
  
  METHODS
  This cross-sectional, retrospective study included patients 0-21 years seen for acute, isolated long-bone fractures, November 2007 to October 2008, at a children's hospital ED. Nine quality measures were studied: six were based on the timeliness (1-hour receipt) and effectiveness (receipt/nonreceipt) of three fracture-related processes: pain score, any analgesic, and opioid analgesic administration. Three equity measures were also tested: language, identified primary care provider (PCP), and insurance. The primary independent variable was a crowding measure: ED occupancy. Models were adjusted for age, language, insurance, identified PCP, triage level, ambulance arrival, and time of day. The adjusted risk of each timeliness or effectiveness quality measure was measured at five percentiles of crowding and compared to the risk at the 10th and 90th percentiles. The role of equity measures as moderators of the crowding-quality models was tested.
  
  
  RESULTS
  The study population included 1,229 patients. Timeliness and effectiveness quality measures showed an inverse association with crowding-an effect not moderated by equity measures. Patients were 4% to 47% less likely to receive timely care and were 3% to 17% less likely to receive effective care when each crowding measure was at the 90th than at the 10th percentile (p < 0.05). For three of the six quality measures, quality declined steeply between the 75th and 90th crowding percentiles.
  
  
  CONCLUSIONS
  Crowding is associated with decreased timeliness and effectiveness, but not equity, of analgesia delivery for children with fracture-related pain.
authors.affiliation: Department of Pediatrics, Children's Outcomes Research Program, University of Colorado School of Medicine, Aurora, USA. sills.marion@tchden.org
authors.forename: Marion R
authors.initials: MR
authors.lastname: Sills
authors.forename: Diane L
authors.initials: DL
authors.lastname: Fairclough
authors.forename: Daksha
authors.initials: D
authors.lastname: Ranade
authors.forename: Michael S
authors.initials: MS
authors.lastname: Mitchell
authors.forename: Michael G
authors.initials: MG
authors.lastname: Kahn
mesh_terms: D000208:Acute Disease; D000698:Analgesia / Q000592:standards / Q000706:statistics & numerical data*; D000701:Analgesics, Opioid / Q000008:administration & dosage; D002648:Child; D002675:Child, Preschool; D016001:Confidence Intervals; D003430:Cross-Sectional Studies; D003441:Crowding; D016208:Databases, Factual; D004632:Emergency Medical Services / Q000706:statistics & numerical data*; D005260:Female; D050723:Fractures, Bone / Q000150:complications / Q000000981:diagnostic imaging / Q000628:therapy; D006801:Humans; D007223:Infant; D015601:Injury Severity Score; D008297:Male; D020380:Needs Assessment; D010146:Pain / Q000188:drug therapy* / Q000209:etiology; D059408:Pain Management / Q000639:trends; D010147:Pain Measurement; D011787:Quality of Health Care; D011859:Radiography; D018570:Risk Assessment; D013997:Time Factors
chemical_list: D000701:Analgesics, Opioid