Introduction: Timeliness has been considered as a key domain in quality of emergency department (ED) care and delay in care providing is influential determinants of patient’s outcomes. The present study, aimed to evaluate the determinants of prolonged ED length of stay (LOS).
Methods: In this cross-sectional study, using adopted version of the latest form for external evaluation and accreditation of EDs introduced by Iranian Ministry of Health, determinants of prolonged LOS were evaluated in the ED of an educational Hospital. Using SPSS 11, multivariate binary logistic regression was applied to estimate adjusted odds ratios (OR) for determining factors associated with prolonged LOS.
Results: 162 (10.2%) cases with prolonged LOS were detected. Based on univariate analysis, female gender (OR: 1.42, 95% CI: 1.14-1.75, p = 0.001), older age (OR: 1.05, 95% CI: 1.02-1.08, p < 0.0001), admission on evening shifts (OR: 4.0; 95% CI: 1.84-8.68, p < 0.001), triage level I (OR: 1.76, 95% CI: 1.21-2.57, p = 0.003), lack of insurance support (OR: 1.56, 95% CI: 1.12-2.19, p = 0.010), higher number of ordered para-clinical tests (OR: 1.23, 95% CI: 1.11-1.37, p = 0.016), and disposition time > 6 hours (OR, 0.13, p < 0.0001), were significant risk factors of prolonged LOS.
Conclusion: Older age, lack of insurance support, disposition time > 6 hours due to complexity of patients’ complaint, and the necessity of repeated para-clinical measures were the most important reasons for failed provision of timely services. From the view point of ED personnel, a small part of prolonged LOS in ED was concerned with defective ED workflow, while, the most important cause of such delays was the delayed response of the consultancy services.
Higginson I. Emergency department crowding. Emergency medicine journal. 2012;29(6):437-43.
Hoot NR, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Annals of emergency medicine. 2008;52(2):126-36. e1.
Pines JM, Mullins PM, Cooper JK, Feng LB, Roth KE. National trends in emergency department use, care patterns, and quality of care of older adults in the United States. Journal of the American Geriatrics Society. 2013;61(1):12-7.
Pines JM, Hollander JE. Emergency department crowding is associated with poor care for patients with severe pain. Annals of emergency medicine. 2008;51(1):1-5.
Reid PP, Compton WD, Grossman JH, Fanjiang G. Building a better delivery system: a new engineering/health care partnership: National Academies Press; 2005.
Mason S, Weber EJ, Coster J, Freeman J, Locker T. Time patients spend in the emergency department: England's 4-hour rule—a case of hitting the target but missing the point? Annals of emergency medicine. 2012;59(5):341-9.
Dinh M, Walker A, Parameswaran A, Enright N. Evaluating the quality of care delivered by an emergency department fast track unit with both nurse practitioners and doctors. Australasian Emergency Nursing Journal. 2012;15(4):188-94.
Hallas P, Ekelund U, Bjørnsen LP, Brabrand M. Hoping for a domino effect: a new specialty in Sweden is a breath of fresh air for the development of Scandinavian emergency medicine. Scandinavian journal of trauma, resuscitation and emergency medicine. 2013;21(1):1.
Göransson KE, Ehrenberg A, Ehnfors M. Triage in emergency departments: national survey. Journal of clinical nursing. 2005;14(9):1067-74.
Noroozian M. The elderly population in iran: an ever growing concern in the health system. Iranian journal of psychiatry and behavioral sciences. 2012;6(2):1-6.
Mohammad A, Kor EM, Mahmoodi M. The Effect of Time-to-Provider, Left-without-Treatment and Length-of-Stay on Patient Satisfaction in Training Hospitals’ Emergency Department, Iran. Iranian journal of public health. 2015;44(10):1411.
Golaghaie F, Sarmadian H, Rafiie M, Nejat N. A study on waiting time and length of stay of attendants to emergency department of Vali-e-Asr Hospital, Arak-Iran. Arak Medical University Journal. 2008;11(2):74-83.
Clark K, Normile LB. Influence of time-to-interventions for emergency department critical care patients on hospital mortality. Journal of Emergency Nursing. 2007;33(1):6-13.
Vermeulen MJ, Guttmann A, Stukel TA, Kachra A, Sivilotti ML, Rowe BH, et al. Are reductions in emergency department length of stay associated with improvements in quality of care? A difference-in-differences analysis. BMJ quality & safety. 2015:bmjqs-2015-004189.
Liew D, Liew D, Kennedy MP. Emergency department length of stay independently predicts excess inpatient length of stay. Medical Journal of Australia. 2003;179(10):524-7.
Molavi-Vardajani H, Haghdoost AA, Shahravan A, Rad M. Cleansing and preparation of data for statistical analysis: A step necessary in oral health sciences research. Journal of Oral Health and Oral Epidemiology. 2016;5(4).
Kleinbaum DG, Kupper LL, Nizam A, Rosenberg ES. Applied regression analysis and other multivariable methods: Nelson Education; 2013.
Jones P, Schimanski K. The four hour target to reduce emergency department ‘waiting time’: a systematic review of clinical outcomes. Emergency Medicine Australasia. 2010;22(5):391-8.
Bortnick AE, Epps KC, Selzer F, Anwaruddin S, Marroquin OC, Srinivas V, et al. Five-year follow-up of patients treated for coronary artery disease in the face of an increasing burden of co-morbidity and disease complexity (from the NHLBI Dynamic Registry). The American journal of cardiology. 2014;113(4):573-9.
Nejhad ZH, Vardanjani HM, Abolhasani F, Hadipour M, Sheikhzadeh K. Relative effect of socio-economic status on the health-related quality of life in type 2 diabetic patients in Iran. Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2013;7(4):187-90.
Penson DF, Stoddard ML, Pasta DJ, Lubeck DP, Flanders SC, Litwin MS. The association between socioeconomic status, health insurance coverage, and quality of life in men with prostate cancer. Journal of clinical epidemiology. 2001;54(4):350-8.
Morey JC, Simon R, Jay GD, Wears RL, Salisbury M, Dukes KA, et al. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Health services research. 2002;37(6):1553-81.
Hashemi B, Baratloo A, Forouzafar MM, Motamedi M, Tarkhorani M. Patient satisfaction before and after executing health sector evolution plan. Iranian Journal of Emergency Medicine. 2015;2(3):127-33.
Naughton C, Drennan J, Treacy P, Fealy G, Kilkenny M, Johnson F, et al. The role of health and non-health-related factors in repeat emergency department visits in an elderly urban population. Emergency medicine journal. 2010;27(9):683-7.
Moss JE, Flower CL, Houghton LM, Moss DL, Nielsen DA, Taylor DM. A multidisciplinary Care Coordination Team improves emergency department discharge planning practice. Medical Journal of Australia. 2002;177(8):435-9.