Patient care at crowded ERs affected by nearby hospital closures, openings

The closure of emergency departments (ED) can lead to overcrowded conditions and poorer care for patients at other nearby EDs, according to a study published in the latest issue of Health Affairs.

Conversely, while previous studies have examined emergency department closures and their effects on patient care, the study sponsored by Project HOPE also found the opening of an ED could positively impact conditions at already high-occupancy hospitals that are particularly sensitive to the closures and openings of nearby EDs.

“As a researcher and clinician in this field, the reason we pursued this study was to actually see if our ‘hunch’ about crowding and closures was more anecdotal or actual,” said Renee Hsia, professor of emergency medicine and health policy at the University of California and co-author of the study said in an email to FierceHealthcare. 

She said they were surprised to see the strength of the relationship that ED closures can negatively affect nearby hospitals but also that ED openings can also have a positive impact. "I think we were also surprised in some ways that the relationship was very clear—in other words, ED closures don't affect all bystander hospitals equally; they affect the crowded ones more; and the same goes for ED opening," she said. 

Using data from 2001 through 2013, researchers specifically looked at the outcomes of patients with heart attacks at high-occupancy bystander EDs—those EDs located near a recently opened or closed ED—versus hospitals that were not already at capacity. Heart attacks were chosen because it is a condition that requires immediate attention.

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The researchers came up with three possible outcome models that could come of nearby hospital opening or closures. First, they looked at whether an ED closure or opening could change bystander patient outcomes either negatively or positively. Second, they looked at how ED closures and openings could change the time required for patients to travel for care, which could potentially improve or negatively affect patient outcomes.

Finally, they examined ED closures and openings could change the health distribution of patients who go to the bystander ED.

Results showed that bystander hospital mortality and 30-day readmission rates increased by 2.39 and 2 percentage points, respectively. At the same time, the likelihood of patients receiving percutaneous coronary intervention (PCI) in these hospitals decreased by 2 percentage points. On the flip side, bystander hospitals close to an ED opening resulted in decreased driving times and was associated with an increased likelihood of PCI—a highly successful treatment for heart attacks.

Overall, closures and openings that led to a considerable increase in driving time meant significant changes in the outcome of patients at high-occupancy bystander hospitals, but not at regular occupancy hospitals. Specifically, patients who were admitted to high- occupancy bystander EDs were 4% less likely to receive PCI, 6% more likely to be readmitted within 30 days, and 8% more likely to die within one year.

Patients with heart attacks admitted to bystander EDs that were not at high-occupancy and were close to a recently shuttered ED were 18% less likely to die within one year as compared to a patient who went to a hospital not near an opening or closure hospital.

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“Our findings suggest that these negative effects may worsen, as recent healthcare reforms have been associated with changing risks for the survival of ED,” the study stated.

The data also showed that ED openings near high-occupancy bystander hospitals could relieve patient burden, leading to reductions in 30- and 90-day mortality rates.

“Overall, our findings suggest that high-occupancy hospitals are the most sensitive to nearby ED closures and would benefit from ED openings, while other hospitals may actually absorb extra demand for emergency care after ED closures without significant negative impact on patient outcomes or treatment,” the study concluded.

In addition, these outward repercussions are only significant if a patient’s driving time changes by 30 minutes or more.

Hsia notes that there are two important takeaways from this study. First, the confirmation that the system is intricately connected. She notes that ED closures happen most often in poor and vulnerable communities. But the findings of this research reflect that everyone’s access to quality healthcare is dependent on the ability of others to access quality healthcare as well.

The second takeaway is that this research doesn't just show problems with the U.S. healthcare system, it actually suggests that there is hope for improving it.

“I hope these results don't just sit in a journal but rather that people can make it come to life in ways that ultimately make our healthcare system better for everyone,” she said.