key: cord-0952399-8b89g3ex authors: Lucero, Anthony; Sokol, Kimberly; Hyun, Jenny; Pan, Luhong; Labha, Joel; Donn, Eric; Kahwaji, Chadi; Miller, Gregg title: Worsening of emergency department length of stay during the COVID‐19 pandemic date: 2021-06-22 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12489 sha: 9b0c0f35e5b6e9cec6909aed35c93590170b6748 doc_id: 952399 cord_uid: 8b89g3ex OBJECTIVE: Our study sought to determine whether there was a change in emergency department (ED) length of stay (LOS) during the coronavirus disease 2019 (COVID‐19) pandemic compared to prior years. METHODS: We performed a retrospective analysis using ED performance data 2018–2020 from 56 EDs across the United States. We used a generalized estimating equation (GEE) model to assess differences in ED LOS for admitted (LOS‐A) and discharged (LOS‐D) patients during the COVID‐19 pandemic period compared to prior years. RESULTS: GEE modeling showed that LOS‐A and LOS‐D were significantly higher during the COVID‐19 period compared to the pre‐COVID‐19 period. LOS‐A during the COVID‐19 period was 10.3% higher compared to the pre‐COVID‐19 time period, which represents a higher geometric mean of 28 minutes. LOS‐D during the COVID‐19 period was 2.8% higher compared to the pre‐COVID‐19 time period, which represents a higher geometric mean of 2 minutes. CONCLUSIONS: ED LOS‐A and LOS‐D were significantly higher in the COVID‐19 period compared to the pre‐COVID‐19 period despite a lower volume of patients in the COVID‐19 period. This has led to a significant stress on the healthcare system as a whole, with emergency departments (EDs) across the country taking the brunt of this stress given the fact that they are on the front line of the healthcare system. 2 It has been shown that the higher the volume of patients seen at an ED, the worse an ED's performance is in terms of length of stay (LOS), 3, 4 which leads to overcrowding. ED overcrowding has a detrimental effect on patient morbidity and mortality in a variety of patient groups and cost to both the patient and the hospital. [5] [6] [7] [8] [9] [10] [11] [12] [13] Therefore, to combat this overcrowding, ED and hospital administrators will typically enact a surge protocol in times of predicted increased volumes, such as a pandemic. 2 However, unlike prior similar pandemics that presented with an initial surge, preliminary research from early in the pandemic actually demonstrated an unexpected steep decrease in ED volumes, 14 with a consequential expected improvement in ED LOS. 15 We presume that this led to confusion on the part of ED staff on how to further prepare their EDs for the current and future similar pandemics. To date, there has been limited research assessing the effects of the current COVID-19 pandemic on ED performance as it relates to LOS. Our study therefore seeks to determine whether there was a significant change in ED LOS since the beginning of the COVID-19 pandemic. Our study hypothesis was that reduced ED volumes seen during the COVID-19 pandemic would be associated with a decrease in LOS for both discharged and admitted patients. We performed a retrospective analysis using ED performance data from 56 EDs across the United States, comparing ED LOS and ED volumes from before and after the first government-mandated shutdowns on March 16, 2020. 16 We hope that these data will help EDs both in continuing to respond to the current pandemic and in future planning for a similar global health crisis. This study was approved by the Arrowhead Regional Medical Cen- Length of stay and ESI assessments were abstracted from hospital electronic medical records for each patient. Upon triaging, each patient is assigned an ESI number for prioritization purposes. Higher acuity patients are assigned an ESI level of "1" and lower acuity patients are assigned an ESI level of "5." Our study used LOS, which the Emergency Department Benchmarking Alliance defines as "the interval from ED arrival to ED departure," because it is a universally recognized metric of ED performance. 17 The goal of the study was to determine whether there was a change in ED LOS during the COVID-19 pandemic time period compared to the previous time period. The primary outcome of this study was ED LOS, as defined by ED LOS for admitted patients (LOS-A) and LOS for discharged patients (LOS-D). Primary data analyses were conducted at the site level, meaning that individual patient data were aggregated at the site level. For analytic purposes, median times for each of the LOS metrics were calculated for each site per day as described previously. The analytic data set contains the site identifier, date of service, patient volume, median LOS-A, median LOS-D, and the percentage of patients in ESI levels 1 through 5 for each day. Using median values at the site level precludes the need for overcleansing of data to remove records because of aberrant low or high outlier values and is indicative of "typical" LOS times. A site must have at least 1 day of data in each of the months of the study time period in order to qualify for inclusion. A total of 56 sites were found to have data for each month of the study period. Analysis to assess significance of differences in LOS times from pre-COVID-19 and COVID-19 times was conducted using generalized estimating equation (GEE) models. GEE modeling was conducted using Python stats models module 0.12.0 (available at http://www.python. org). GEE models are a subset of generalized linear models and are used to adjust standard errors when there is correlation within or between observations. 18 GEE modeling is superior to the ordinary least squares (OLS) approach because it accounts for correlated data and corrects for clustering in the standard errors. The correlated data arise from both individuals clustered within EDs and data clustered longitudinally over time. Analysis of correlated data using OLS methods may result in artificially low variance and low P values. 19 The GEE uses maximum likelihood methods of estimating coefficients through a link function. The correlation or covariance structure must be determined a priori, although estimates are consistent despite incorrect specification. 18 Table 1 ). All ED facilities were from community hospitals. For the LOS-A, the GEE results showed significant, positive relationships for the COVID-19 period, ED encounters, and the percentages of patients who are ESI 1 and 2 ( Table 2 ). This means that the LOS-A For the LOS-D, the GEE results showed significant, positive relationships for the COVID-19 period, ED encounters, and the percentages of patients who are ESI 1, 2, and 3 (Table 3) . Similarly, the LOS-D was significantly higher during the COVID-19 period by 2 minutes (geometric mean) compared to the pre-COVID-19 time period (Figure 2 One limitation of this study is that we were unable to collect any inpatient data from our study hospitals specifically regarding inpatient bed availability and the percentage of inpatient beds occupied by to explain the increase in LOS-A as a function of ED volume. [25] [26] [27] Another limitation is that we were unable to collect data regarding nurse staffing, specifically nursing hours worked as a function of time, number of furloughs, and number of nursing call-offs. Having such data may have been useful in determining if and how much nurse staffing had any correlation with LOS. Lastly, it should be noted that our data comes from only 5 of 10 CMS regions, the majority (68%) of which are from region 9 (San Francisco), which could potentially threaten the external validity of this study. As has been seen in prior literature, our study found a precipitous reduction in ED patient volumes from March 2020 onward when compared to the previous 2 years (Figures 1 and 2 ). 14 Given that ED patient volumes has been shown to increase LOS, 4 LOS. 31 However, despite hospitals and EDs taking these precautions, ED volumes dropped by 40%-60% in March and April of 2020. 14, 21, 32 Third, ED staffing remained at prepandemic levels during those same months, which led to more staff being available to care for fewer patients. 22, 28 As has been shown before by Ramsey et al., 29 there is a direct relationship between ED nurse staffing and LOS; the more nursing hours, the shorter the LOS. As the pandemic continued into May and beyond, LOS-A and LOS-D increased above the levels as expected from the pre-COVID-19 period, and this trend continued for the remainder of 2020 (Figures 1 and 2) . One of the biggest contributing factors to this trend may have been hospital overcrowding due to rising COVID-19 admission rates. Based on data from the HHS and the COVID Tracking Project, the rates of inpatient hospitalization due to COVID-19 rose across the United States in April and May 2020. [25] [26] [27] This has likely contributed to a nationwide reduction in inpatient bed availability, which numerous studies have shown to have the strongest correlation with ED LOS-A 23, 24 ; the less inpatient bed availability, the longer the LOS-A. Changes in the proportion of high versus low acuity ED encounters during the pandemic also may have contributed to an increase in LOS. The GEE showed that an increase in the number of ESI 1 and 2 level encounters was associated with an increase in LOS-D, with an even stronger associated increase with LOS-A (Tables 2 and 3 In summary, ED LOS-A and LOS-D increased during the COVID-19 pandemic when compared to previous years, which is particularly concerning given that ED volumes have dropped by as much as 60% at their nadir. 14,32 A myriad of factors may have ultimately contributed to this finding, many of which are either directly related or done in response to the COVID-19 pandemic. However, it is difficult to draw any direct conclusions about their effect on ED LOS given the retrospective design of this study. No conflicts of interest exist for any of the authors listed. All authors conceived the study. JL obtained institutional review board approval. AL and KS drafted the abstract. AL, KS, and ED drafted the introduction, JH and LP drafted the methods and results sections, and JL and CK drafted the limitations and discussion sections. AL, KS, and GM contributed substantially to its revision. AL takes responsibility for the paper as a whole. Centers for Disease Control and Prevention. 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