Investigating Indicators of Waiting Time and Length of Stay in Emergency Departments

Early Identification and Referral of Patients With Diabetic Foot Complications in the Emergency Department

BACKGROUND

Prolonged length of stay (LOS) in the emergency department (ED) and lack of post-ED follow-up pose a risk of worsening infection and amputation among patients with diabetic foot complications.

LOCAL PROBLEM

Excessive ED LOS posed a risk of delayed foot care, and triage providers underutilized post-ED telehealth referrals.

INTERVENTIONS

A graphic icon on the ED dashboard, nurse-initiated order set, and staff education were implemented.

METHODS

A pre-/postimplementation design was used. Outcomes included usage of the graphic icon and order set, ED LOS, and telehealth referrals.

RESULTS

Use of the graphic icon and order sets significantly increased ( P < .001). The rate of telehealth referrals upon discharge also increased but was not significant ( P = .086). Interestingly, LOS increased after the intervention.

CONCLUSION

Using the graphic icon and order set can streamline patient referral to telehealth care. Various factors lead to an extended LOS.

Identifying the Main Bottlenecks in the Workflow of Saudi Arabian Emergency Departments (EDs)

Background: Crowded emergency departments (EDs) adversely affect patient care and healthcare efficiency, leading to prolonged wait times, delayed treatments, and increased medical errors. This issue also diminishes patient satisfaction and disrupts hospital operations. In Saudi Arabia, ED overcrowding impacts response times and staff morale, highlighting the need for efficient patient flow processes to ensure timely and effective care. Objectives: The aim of this study is to identify the main bottlenecks in the workflow of Saudi Arabian EDs from patient arrival to disposition. Design: A retrospective quantitative study analyzed data from 753 patients across multiple hospitals in Saudi Arabia's EDs to identify workflow bottlenecks. Using SPSS and AMOS for data analysis, various statistical methods, including ANOVA and structural equation modeling (SEM), were employed to evaluate key performance metrics and their influence on the total length of stay (LOS). Results: The Doctor to Decision Time is the most significant bottleneck, followed by the Triage to Doctor Time. CTAS3 and CTAS4 categories experience the most significant delays across multiple stages. In addition, the default model in AMOS 29 shows an excellent fit, indicating that reducing delays in Decision to Disposition Time (estimate = 0.840) and Doctor to Decision Time (estimate = 0.442) is crucial for improving the total LOS in the ED. Conclusion: This study identifies significant inefficiencies in the ED workflow in Saudi Arabia, particularly in the Doctor to Decision Time and Triage to Doctor Time stages, and recommends streamlining consultation protocols, enhancing medication delivery, expediting lab and radiology services, and increasing staffing to improve operational efficiency and patient outcomes. Faster bed turnover reduces Decision to Disposition Time and frees up ED beds. Adequate staffing improves triage, evaluation times, and care quality. Well-trained nurses enhance patient interactions and reduce delays. Standardized guidelines ensure timely treatment. Effective communication and teamwork improve patient flow and reduce bottlenecks.

Analysis of factors influencing length of stay in the emergency department in public hospital, Padang, Indonesia

Background

Extending the time patients spend in the emergency department (ED) not only diminishes the quality of care but also heightens the potential for harm and adversely impacts patient satisfaction. However, there exists a dearth of accessible information regarding the length of stay (LOS) in emergency departments and the factors associated with it in Indonesia. This study aims to analyze the factors that influence the LOS of patients in the emergency department of a public hospital in Padang, Indonesia.

Methods

This research design is a cross-sectional approach. The sample was patients who visited the ED in a tertiary public hospital in Padang (n = 328). The data collected from the medical records included length of stay, mode of arrival, case type, triage scale, diagnostic examination, specialist consultation needs, and needs for admission. Data analysis was performed using the chi-square statistical test and binary logistic regression.

Results

The percentage of patients with LOS > 6 h in the emergency department was 29 %. There was a significant relationship between the triage scale, diagnostic tests, and the need for hospitalization with LOS (p < 0.05). The results of the multivariate analysis showed that the case type and the need for admission to hospitalization influence 12.4 % of LOS in ED.

Conclusion

This study enriches our comprehension of the variables exerting the most substantial impact on the average duration of stay in the emergency department of a hospital in Indonesia. The findings will assist policymakers in crafting enduring strategies to optimize patient flow in the emergency department.

Prolonged length of stay and associated factors among emergency department patients in Ethiopia: systematic review and meta-analysis

BACKGROUND

The duration between a patient's arrival at the Emergency Department (ED) and their actual departure, known as the Emergency Department Length of Stay (EDLOS), can have significant implications for a patient's health. In Ethiopia, various studies have investigated EDLOS, but a comprehensive nationwide pooled prevalence of prolonged EDLOS, which varies across different locations, is currently lacking. Therefore, the objective of this systematic review and meta-analysis is to provide nationally representative pooled prevalence of prolonged EDLOS and identify associated factors.

METHODS

In this study, we conducted a comprehensive systematic review and meta-analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist. We conducted a thorough search of numerous international databases, including PubMed/Medline, SCOPUS, Web of Science, and Google Scholar. The primary outcome was the prevalence of prolonged EDLOS. The secondary outcome was factors affecting the EDLOS. Random-effects model was used to since there was high heterogeneity. We also conducted subgroup analysis and meta-regression to investigate heterogeneity within the included studies. To assess publication bias, we used Egger's regression test and funnel plots. All statistical analyses were performed using STATA version 17.0 software to ensure accurate and reliable findings.

RESULT

We have identified eight articles that met our inclusion criteria with a total sample size of 8,612 participants. The findings of this systematic review and meta-analysis indicate that the pooled estimate for the prevalence of prolonged EDLOS is 63.67% (95% CI = 45.18, 82.16, I2 = 99.56%, P = 0.0001). The study identified several significant factors associated with prolonged EDLOS, including patients admitted to overcrowded emergency departments (OR = 5.25, 95% CI = 1.77, 15.58), delays in receiving laboratory findings (OR = 3.12, 95% CI = 2.16, 4.49), and delays in receiving radiological results (OR = 3.00, 95% CI = 2.16, 4.16).

CONCLUSION

In this review, the EDLOS was found to be very high. Overcrowding, delays in laboratory test findings, and delays in radiology test results make up the factors that have a statistically significant association with prolonged EDLOS. Given the high prevalence of prolonged EDLOS in this review, stakeholders should work to increase the timeliness of ED services in Ethiopia by proper disposition of non-emergency palliative patients to the appropriate destination, and implementing point-of-care testing and imaging.

Obstacles and Challenges Affecting Quality Indicators in a Complex Tertiary Emergency Center

Introduction

Hospital performance is significantly affected by external factors (political and economic) rather than internal factors (effectiveness and efficiency). Emergency department (ED) overcrowding is a significant issue for emergency care services globally, characterized by a rising number of visits and persistent unsolved issues, resulting in increased challenges faced by ED staff and decreased patient satisfaction. This study aimed to explore the obstacles and challenges that cause variation in ED quality indicators (QIs) based on five domains: infrastructure, population, workflow, workforce, and administration.

Methods

A tertiary emergency center in Saudi Arabia administered a questionnaire with standardized measures to 180 nurses, using a cross-sectional descriptive design.

Results

Most nurses (75.5%) believed that crowded waiting rooms in the ED were the most influential factor affecting QIs. Many other challenges were identified, including bed capacity, triage area/workflow, increased volume during peak periods, demand for nonemergency visits, staff and shortages. Significant differences in nurses' responses were found on the basis of education level (for infrastructure only, p = 0.004), specialty (for nursing administration only, p = 0.052), and ED experience (for all variables, p = 0.008-0.039).

Conclusion

The analysis uncovered various critical aspects of infrastructure, workflow, population, workforce, and nursing administration that have a major effect on patient flow in the ED. Comprehending these aspects will greatly affect the quality measures of ED performance and assist policymakers in formulating strategic plans to enhance ED performance. Therefore, successful implementation and optimization of ED resources depend greatly on considering the right decision variables and resource restrictions.

Length of stay and associated factors among pediatric patients in the pediatric emergency unit of the Tikur Anbessa specialized hospital, Addis Ababa, Ethiopia

BACKGROUND

Length of stay in the emergency department is used as a quality indicator to gauge the overall efficiency of emergency care. The performance measure was used to evaluate the quality of care provided in the emergency department.

OBJECTIVE

To assess the length of stay and associated factors among pediatric patients admitted to the pediatric emergency unit of Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia.

METHODS

An institution-based prospective cross-sectional study design was employed. A systematic random sampling technique was used to select the study participants. Data were collected via semi-structured, interviewer-administered questionnaires and chart reviews. Analysis was performed via the Statistical Package for Social Science software version 27. Binary logistic regression analysis was conducted to identify variables associated with the length of stay. The study was conducted in the Pediatric Emergency Unit of Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia, from March 15 to April 15, 2023.

RESULTS

A total of 268 patients participated in the study, with a response rate of 97.81%. The majority of the participants were male (157, 58.6%), with a median age of 3 years. The study revealed that 180 participants (67.2%) experienced a prolonged length of stay. The variables significantly associated with prolonged length of stay included residency (AOR = 2.04, CI: 1.03, 4.025), triage category (AOR = 3.25, CI: 1.08, 5.974), number of investigations (AOR = 2.381, CI: 1.038, 5.462), and waiting for imaging (AOR = 4.230, CI: 1.638, 10.93).

CONCLUSION

Many pediatric patients stayed in the emergency room for more than 24 h because of factors such as residency, triage category, number of investigations, and the need for imaging. To address this, we recommend streamlining triage processes, increasing imaging resources, providing additional staff training, developing integrated care pathways, and advocating for policy changes to increase emergency room efficiency and improve patient outcomes.

Characteristics of paediatric injuries as predictors of 24-hour disposition from the Emergency Department of a teaching hospital in Southwestern Uganda

Background

Paediatric injuries are among the leading causes of morbidity and mortality globally, especially in low- and middle-income countries. We aimed to characterize paediatric injuries as predictors of disposition from Mbarara Regional Referral Hospital Emergency Department (ED) Southwestern Uganda.

Methods

This was a prospective cohort study done from 12th December 2022 to 31st March 2023. We described the characteristics of injuries sustained by children and evaluated the predictors of 24-hour disposition from the ED using logistic regression.

Results

Of the 160 children followed up, 64.4% were male with a median age of 7 years, brought in with road traffic accidents (RTAs) (40.6%) and falls (35.6%) as the commonest mechanism of injury. Over half of the patients were triaged as yellow (urgent); polytrauma and head injuries were the top injury patterns. The majority (45.6%) of the children were admitted to the inpatient surgical ward. Only 1.9% and 5.0% ended up in intensive care unit (ICU) and died (to mortuary), respectively. The median time to disposition was 8 h and 14% stayed in the ED beyond 24-hours. Patients who needed more intensive initial treatment, including additional medications or interventions, were significantly more likely to be admitted to the ward (AOR= 5.3, 95%CI: 2.0-13.0, p <0.01).

Conclusion

Paediatric injuries were caused mainly by RTAs and presenting with polytrauma and head injuries. Most patients were disposed of to the inpatient surgical ward within 24 h with severe KTS and initial management being strongest predictors of admission. These findings can be used to tailor quick risk stratification and decision-making tools and improve ED disposition of paediatric injuries in Low- and Middle- income countries.

Overcoming challenges in nursing disaster preparedness and response: an umbrella review

Disaster nursing plays a vital role in addressing the health needs of vulnerable populations affected by large scale emergencies. However, disaster nursing faces numerous challenges, including preparedness, logistics, education, ethics, recovery and legalities. To enhance healthcare system effectiveness during crises, it is essential to overcome these issues. This umbrella review, conducted using the Joanna Briggs Institute (JBI) methodology, synthesizes data from 24 studies to identify key strategies for improving disaster nursing. The review highlights nine key themes: Education and Training, Research and Development, Policy and Organizational Support, Technological Advancements, Psychological Preparedness and Support, Assessment and Evaluation, Role-Specific Preparedness, Interprofessional Collaboration and Cultural Competence, and Ethics and Decision-Making. The review emphasizes the importance of education, technological advancements, psychological support, and interprofessional collaboration in bolstering disaster nursing preparedness and response efforts. These elements are crucial for enhancing patient outcomes during emergencies and contributing to a more resilient healthcare system. This comprehensive analysis provides valuable insights into the various aspects essential for enhancing disaster nursing. By implementing evidence-based strategies within these nine themes, the nursing profession can enhance its capacity to effectively manage and respond to the complex needs of disaster-affected populations, ultimately improving patient care and outcomes during emergencies.

Strategies to Measure and Improve Emergency Department Performance: A Review

Emergency Departments (EDs) globally face escalating challenges such as overcrowding, resource limitations, and increased patient demand. This study aims to identify and analyze strategies to enhance the structural performance of EDs, with a focus on reducing overcrowding, optimizing resource allocation, and improving patient outcomes. Through a comprehensive review of the literature and observational studies, the research highlights the effectiveness of various approaches, including triage optimization, dynamic staffing, technological integration, and strategic resource management. Key findings indicate that tailored strategies, such as implementing advanced triage protocols and leveraging telemedicine, can significantly reduce wait times and enhance patient throughput. Furthermore, evidence suggests that dynamic staffing models and the integration of cutting-edge diagnostic tools contribute to operational efficiency and improved quality of care. These strategies, when combined, offer a multifaceted solution to the complex challenges faced by EDs, promising better patient care and satisfaction. The study underscores the need for a comprehensive approach, incorporating both organizational and technological innovations, to address the evolving needs of emergency healthcare.

The pattern of emergency department length of stay in Saudi Arabia: an epidemiological Nationwide analyses of secondary surveillance data

Background

Emergency department length of stay is a vital performance indicator for quality and efficiency in healthcare. This research aimed to evaluate the length of stay patterns in emergency departments across Saudi Arabia and to identify predictors for extended stays. The study used secondary data from the Ministry of Health's Ada'a program.

Methods

Using a retrospective approach, the study examined data from the Ada'a program on emergency department length of stay from September 2019 to December 2021. These data covered 1,572,296 emergency department visits from all regions of Saudi Arabia. Variables analyzed included quality indicators, year of visit, shift time, hospital type, and data entry method. The analysis was conducted using multiple linear regression.

Results

The study found that the median length of stay was 61 min, with significant differences among related predictors. All associations were significant with a value of p of less than 0.001. Compared to 2019, the length of stay was notably shorter by 28.5% in 2020 and by 44.2% in 2021. Evening and night shifts had a shorter length of stay by 5.9 and 7.8%, respectively, compared to the morning shift. Length of stay was lower in winter, summer, and fall compared to spring. Patients in levels I and II of the Canadian Triage and Acuity Scales had longer stays than those in level III, with those in level I reaching an increase of 20.5% in length of stay. Clustered hospitals had a longer length of stay compared to the non-clustered ones. Pediatric hospitals had a 15.3% shorter stay compared to general hospitals. Hospitals with data entered automatically had a 14.0% longer length of stay than those entered manually. Patients admitted to the hospital had a considerably longer length of stay, which was 54.7% longer compared to non-admitted patients. Deceased patients had a 20.5% longer length of stay than patients discharged alive.

Conclusion

Data at the national level identified several predictors of prolonged emergency department length of stay in Saudi Arabia, including shift time, season, severity level, and hospital type. These results underline the necessity of continuous monitoring and improvement efforts in emergency departments, in line with policy initiatives aiming to enhance patient outcomes in Saudi Arabia.

A study of factors affecting the length of hospital stay (LOS) of COVID-19 patients: A qualitative evidence in Iranian hospital

BACKGROUND

The present study aimed to identify the administrators' and physicians' experiences and viewpoints about the factors affecting the length of stay (LOS) of COVID-19 patients and provide valid operational evidence.

MATERIALS AND METHODS

The current study was carried out qualitatively and phenomenologically on experts, officials, and administrators of hospitals in 2021. Purposeful sampling was performed with the maximum diversity. To achieve a comprehensive view, snowball sampling was conducted. Twenty-one experts in the field of healthcare and emerging diseases participated in this study. Semi-structured interviews were used to collect the data. The study sites were universities of medical sciences and hospitals of the Ministry of Health of Iran. The interview questions included questions about the factors affecting the LOS and strategies for controlling the LOS of COVID-19 patients in infectious units. Text analysis was performed through the content analysis method in MAXQDA-10 software.

RESULTS

Based on the experts' viewpoints, several factors affected the LOS in COVID-19 patients. These factors were divided into five clinical, preclinical, economic, social, and management subcategories. The proposed solutions included policy solutions (supportive policies, development of home care services, training and culture building, and establishment of clinical guidelines) and operational solutions (drug management, promotion of equipment and facilities, telehealth or telemedicine services, and promotion of clinical and support processes).

CONCLUSION

One of the main tasks of hospital administrators is identifying the factors affecting the reduction of LOS. Among these factors, clinical and management factors in the hospital are more important and need more planning and attention by hospital officials.

Parents' knowledge of emergency management of avulsed permanent teeth in children and adolescents in the State of Qatar: a questionnaire cross-sectional study

PURPOSE

To elucidate the level of parental knowledge in Qatar regarding the management of avulsed teeth.

METHODS

A self-administered questionnaire was completed by 400 parents attending their children's routine dental appointments. The questionnaire comprised of items on sociodemographics, parents' prior knowledge on management of avulsion, parents' willingness to replant avulsed teeth at the site of injury, and parents' opinion as to the best format for future parental education on the management of dental trauma. Univariate and multivariate logistic regressions were employed to assess the association between sociodemographic status and knowledge in the management of avulsion.

RESULTS

The overall mean score of parents' knowledge was (23%). Only 23.3% (n = 93) of parents thought that it was possible to reinsert an avulsed permanent tooth. Out of those, only 12.9% (n = 12) indicated willingness to reinsert the tooth back into its socket, while 48.4% (n = 49) indicated that an avulsed tooth should be stored using physiological media. Less than one third (27.8%) indicated that they would seek professional help within 30 min. Males were less likely to give favourable answers when compared to females (OR = 0.43, 95% CI = 0.22-0.84). Age groups "31-40" years and "41-50" years were more likely to give favourable answers when compared to 20-30 years age group (OR = 2.8, 95% CI = 1.05-8.0and OR = 3.8, 95% CI = 1.3-11.48; respectively).

CONCLUSION

This study highlights critical deficiencies in parental knowledge on the management of tooth avulsion and the need to improve parents' knowledge by developing easily accessible onsite emergency management tools.

Prolonged length of stay and its associated factors at adult emergency department in amhara region comprehensive specialized hospitals, northwest Ethiopia

Background

Prolonged length of stay at the emergency department interferes with the main goal of emergency care and results in adverse patient outcomes like nosocomial infection, dissatisfaction, morbidity, and mortality. Despite this, little is known about the length of stay and the factors that influence it in Ethiopia’s emergency department.

Methods

An institution-based cross-sectional study was conducted on 495 patients admitted at Amhara region comprehensive specialized hospitals emergency department from May 14 to June 15/2022. A systematic random sampling was employed to select study participants. A pretested structured interview-based questionnaire was used to collect data by using Kobo toolbox software. SPSS version 25 was used for data analysis. Bi-variable logistic regression analysis was carried out to select variables with P-value < 0.25. The significance of association was interpreted using an Adjusted Odds Ratio with a 95% confidence interval. Variables with P-value < 0.05 in the multivariable logistic regression analysis were inferred to be significantly associated with length of stay.

Result

Out of 512 enrolled participants, 495 were participated with a response rate of 96.7%. The prevalence of prolonged length of stay in the adult emergency department was 46.5% (95%CI: 42.1, 51.1). Lack of insurance (AOR: 2.11; 95% CI: 1.22, 3.65), non-communicative presentation (AOR: 1.98; 95% CI: 1.07, 3.68), delayed consultation (AOR: 9.5; 95% CI: 5.00, 18.03), overcrowding (AOR: 4.98; 95% CI: 2.13, 11.68), and shift change experience (AOR: 3.67; 95% CI: 1.30, 10.37) were significantly associated with prolonged length of stay.

Conclusion

The result of this study is found to be high based on Ethiopian target emergency department patient length of stay. Lack of insurance, presentation without communication, delayed consultation, overcrowding, and shift change experience were significant factors for prolonged emergency department length of stay. Therefore, interventions like expansion of organizational setup are needed to decrease the length of stay to an acceptable level.