Use of the SONET Score to Evaluate High Volume Emergency Department Overcrowding: A Prospective Derivation and Validation Study

Hao Wang, Richard D Robinson, John S Garrett, Kellie Bunch, Charles A Huggins, Katherine Watson, Joni Daniels, Brett Banks, James P D'Etienne, Nestor R Zenarosa, Hao Wang, Richard D Robinson, John S Garrett, Kellie Bunch, Charles A Huggins, Katherine Watson, Joni Daniels, Brett Banks, James P D'Etienne, Nestor R Zenarosa

Abstract

Background. The accuracy and utility of current Emergency Department (ED) crowding estimation tools remain uncertain in EDs with high annual volumes. We aimed at deriving a more accurate tool to evaluate overcrowding in a high volume ED setting and determine the association between ED overcrowding and patient care outcomes. Methods. A novel scoring tool (SONET: Severely overcrowded-Overcrowded-Not overcrowded Estimation Tool) was developed and validated in two EDs with both annual volumes exceeding 100,000. Patient care outcomes including the number of left without being seen (LWBS) patients, average length of ED stay, ED 72-hour returns, and mortality were compared under the different crowding statuses. Results. The total number of ED patients, the number of mechanically ventilated patients, and patient acuity levels were independent risk factors affecting ED overcrowding. SONET was derived and found to better differentiate severely overcrowded, overcrowded, and not overcrowded statuses with similar results validated externally. In addition, SONET scores correlated with increased length of ED stay, number of LWBS patients, and ED 72-hour returns. Conclusions. SONET might be a better fit to determine high volume ED overcrowding. ED overcrowding negatively impacts patient care operations and often produces poor patient perceptions of standardized care delivery.

Figures

Figure 1
Figure 1
It shows the flow diagram of patient included in the SONET derivation study.
Figure 2
Figure 2
It shows the flow diagram of patients returning to the ED within 72 hours of initial visit during the derivation study period. There were total 440 ED returns in which 276 patients were discharged at their first ED visit. 66.3% (183/276) presented within 72 hours of their initial ED visit with the same complaint or one directly related to the initial one. Of these 9.8% (18/183) were admitted to hospital at their second ED visit. Follow-up of these patients in hospital showed no significant worsening of their outcomes.

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