The association between emergency department crowding and the disposition of patients with transient ischemic attack or minor stroke

Background — Emergency department (ED) crowding has been associated with adverse events, including short-term death and hospitalization among discharged patients. The mechanisms are poorly understood, but may include altered physician decision-making about ED discharge of higher-risk patients. One example is patients with transient ischemic attack (TIA) and minor stroke, who are at high risk of subsequent stroke. While hospitalization is frequently recommended, little consensus exists on which patients require admission.

Objectives — The authors sought to determine the association of ED crowding with the disposition of patients with minor stroke or TIA.

Methods — This was a retrospective cohort study of prospectively collected data from the Registry of the Canadian Stroke Network at 12 EDs in Ontario, Canada, between 2003 and 2008, linked to administrative health databases. A hierarchical logistic regression model was used to determine the association between crowding at the time the patient was seen in the ED (defined as mean ED length of stay) and patient disposition (admission/discharge), after adjusting for patient and hospital-level variables.

Results — The study cohort included 9,759 patients (4,607 with TIA and 5,152 with minor stroke); 49.5% were discharged from the ED. The mean (±SD) age of study patients was 70.78 (±13.40) years, with 52.9% being male, 37.3% arriving by emergency medical services, and 92.3% triaged as emergent or urgent. Greater severity of ED crowding was associated with a lower likelihood of discharge, regardless of ED size.

Conclusions — These results suggest that crowding may influence clinical decision-making in the disposition of patients with TIA or minor stroke and that, as crowding worsens, the likelihood of hospitalization increases.