Abstract
IntroductionThe mean emergency department (ED) length of stay (LOS) is considered a measure of crowding. This paper measures the association between LOS and factors that potentially contribute to LOS measured over consecutive shifts in the ED: shift 1 (7:00 am to 3:00 pm), shift 2 (3:00 pm to 11:00 pm), and shift 3 (11:00 pm to 7:00 am).MethodsSetting: University, inner-city teaching hospital. Patients: 91,643 adult ED patients between October 12, 2005 and April 30, 2007. Design: For each shift, we measured the numbers of (1) ED nurses on duty, (2) discharges, (3) discharges on the previous shift, (4) resuscitation cases, (5) admissions, (6) intensive care unit (ICU) admissions, and (7) LOS on the previous shift. For each 24-hour period, we measured the (1) number of elective surgical admissions and (2) hospital occupancy. We used autoregressive integrated moving average time series analysis to retrospectively measure the association between LOS and the covariates.ResultsFor all 3 shifts, LOS in minutes increased by 1.08 (95% confidence interval 0.68, 1.50) for every additional 1% increase in hospital occupancy. For every additional admission from the ED, LOS in minutes increased by 3.88 (2.81, 4.95) on shift 1, 2.88 (1.54, 3.14) on shift 2, and 4.91 (2.29, 7.53) on shift 3. LOS in minutes increased 14.27 (2.01, 26.52) when 3 or more patients were admitted to the ICU on shift 1. The numbers of nurses, ED discharges on the previous shift, resuscitation cases, and elective surgical admissions were not associated with LOS on any shift.ConclusionKey factors associated with LOS include hospital occupancy and the number of hospital admissions that originate in the ED. This particularly applies to ED patients who are admitted to the ICU.
Highlights
The mean emergency department (ED) length of stay (LOS) is considered a measure of crowding
For each 8-hour shift, we measured the numbers of [1] ED nurses on duty; [2] ED discharges defined as patients leaving the ED whether admitted, transferred to another facility, or discharged; [3] ED discharges on the previous shift; [4] resuscitation cases; [5] admissions, ie patients seen in the ED who are subsequently admitted to an inpatient unit; and [6] intensive care unit (ICU) admissions, ie patients seen in the ED who are subsequently admitted to the ICU
Our study focused on the association between LOS and throughput and output factors related to the conceptual model of ED crowding
Summary
Per patient measured from the patient’s arrival to departure has been promoted as a surrogate indicator of crowding in the absence of a standard or universal definition It is frequently considered a key process indicator for performance improvement and clinical and operational efficiency.. Asplin et al developed an inputthroughput-output conceptual model of ED crowding which forms the basis for our selection of factors for study.3 Input factors, such as the number of unscheduled ambulatory care ED visits and emergency medical services transports, cannot be controlled except by diverting ambulances away from the ED. The expediency of the departure process from the ED is an important output factor and the number of discharged patients per shift (ED discharges) leaving for home, an inpatient bed, or for another facility was incorporated as a covariate in the study
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