title: Is emergency department crowding associated with increased "bounceback" admissions?
abstract: OBJECTIVE
  Emergency department (ED) crowding is linked with poor quality of care and worse outcomes, including higher mortality. With the growing emphasis on hospital performance measures, there is additional concern whether inadequate care during crowded periods increases a patient's likelihood of subsequent inpatient admission. We sought to determine if ED crowding during the index visit was associated with these "bounceback" admissions.
  
  
  METHODS
  We used comprehensive, nonpublic, statewide ED and inpatient discharge data from the California Office of Statewide Health Planning and Development from 2007 to identify index outpatient ED visits and bounceback admissions within 7 days. We further used ambulance diversion data collected from California local emergency medical services agencies to identify crowded days using intrahospital daily diversion hour quartiles. Using a hierarchical logistic regression model, we then determined if patients visiting on crowded days were more likely to have a subsequent bounceback admission.
  
  
  RESULTS
  We analyzed 3,368,527 index visits across 202 hospitals, of which 596,471 (17.7%) observations were on crowded days. We found no association between ED crowding and bounceback admissions. This lack of relationship persisted in both a discrete (high/low) model (OR, 1.01; 95% CI, 0.99, 1.02) and a secondary model using ambulance diversion hours as a continuous predictor (OR, 1.00; 95% CI, 1.00, 1.00).
  
  
  CONCLUSIONS
  Crowding as measured by ambulance diversion does not have an association with hospitalization within 7 days of an ED visit discharge. Therefore, bounceback admission may be a poor measure of delayed or worsened quality of care due to crowding.
authors.affiliation: *Department of Emergency Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco †VA Palo Alto Health Care System, Center for Healthcare Evaluation, Menlo Park ‡Department of Biostatistics, UCLA Fielding School of Public Health §Department of Medicine ∥Department of Medicine, Division of Geriatrics, University of California, Los Angeles, Los Angeles, CA ¶Department of Emergency Medicine, Oregon Health and Science University, Portland, OR.
authors.forename: Renee Y
authors.initials: RY
authors.lastname: Hsia
authors.forename: Steven M
authors.initials: SM
authors.lastname: Asch
authors.forename: Robert E
authors.initials: RE
authors.lastname: Weiss
authors.forename: David
authors.initials: D
authors.lastname: Zingmond
authors.forename: Gelareh
authors.initials: G
authors.lastname: Gabayan
authors.forename: Li-Jung
authors.initials: LJ
authors.lastname: Liang
authors.forename: Weijuan
authors.initials: W
authors.lastname: Han
authors.forename: Heather
authors.initials: H
authors.lastname: McCreath
authors.forename: Benjamin C
authors.initials: BC
authors.lastname: Sun
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D064422:Ambulance Diversion / Q000706:statistics & numerical data*; D002140:California; D003441:Crowding; D003625:Data Collection; D003627:Data Interpretation, Statistical; D004636:Emergency Service, Hospital / Q000592:standards / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission / Q000706:statistics & numerical data*; D011787:Quality of Health Care; D012959:Socioeconomic Factors; D016896:Treatment Outcome; D055815:Young Adult
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