Australasian Emergency Care 26 (2023) 321–325

Contents lists available at ScienceDirect

Australasian Emergency Care

journal homepage: www.elsevier.com/locate/auec

Research paper

Factors that contribute to patient length of stay in the emergency

department: A time in motion observational study ]]
]]]]]]
]]

⁎
Karlie Payne a, Dante Risi b, Anna O’Hare a, Simon Binks a, Kate Curtis a,b,c,d,
a
Emergency Department, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
b
Research Central, Illawarra Shoalhaven Local Health District, NSW, Australia
c
Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, RC Mills Building, The University of Sydney, NSW 2006, Australia
d
George Institute for Global Health, King St, Newtown, NSW, Australia

a r t i cl e i nfo a bstr ac t

Article history: Objectives: Increased Emergency Department length of stay impacts access to emergency care and is as­
Received 23 February 2023 sociated with increased patient morbidity, overcrowding, reduced patient and staff satisfaction. We sought
Received in revised form 2 April 2023 to determine the contributing factors to increased length of stay in our mixed ED.
Accepted 26 April 2023
Methods: A real-time observational study was conducted at Wollongong Hospital over a continuous 72-h
period. Times of intervention, assessment and treatment were recorded by dedicated emergency medical or
Keywords:
nurse observers. The time from triage to each event was calculated and descriptive analyses performed. Free
Emergency care
Treatment delays text comments were analysed using inductive content analysis.
Overcrowding Results: Data were collected on 381 of 389 eligible patients. The largest time delays were experienced by
Length of stay patients who required a CT, specialist review and/or an inpatient bed. Registrars and nurse practitioners
Nursing were the most efficient in reaching a decision to admit or discharge. The time from triage to specialist
Emergency medicine review increased with the number requested (148 min for one, 224 min for two and 285 min for three). The
longest length of stay was experienced by mental health and paediatric patients.
Conclusions: The main delays contributing to ED length of stay were CT imaging and specialist reviews.
Overcrowding in ED need targeted, site-specific interventions.
© 2023 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia.

Introduction patients who do not wait for treatment, increased risk of iatrogen­
esis, higher operating costs and decreased patient satisfaction [7,8].
In 2021–2022 there were around 8.79 million presentations to Furthermore, ED overcrowding has detrimental impacts on staff
Emergency Departments (ED) in Australia, an average annual in­ including increased stress and provider dissatisfaction [9].
crease of 2.3% per year [1]. Demand for emergency care and hospital The causes of ED overcrowding are complex, multifactorial and
admission is at an all-time high. This results in overcrowding. can be grouped as follows. (1) Input: the volume and type of care
Overcrowding in EDs is defined as “where the capacity of a hospital’s presenting to ED, (2) Throughput: the internal delays associated
inpatient services cannot meet patient demand, access block and with ED and (3) Output: the discharge of patients home or admis­
emergency department overcrowding occurs, which the Australasian sion [10].
College for Emergency Medicine considers are critical indicators of
health system dysfunction” [2]. Overcrowding is a serious issue in (1) The volume, complexity and acuity of patients presenting to
ED, with several negative consequences. Australia’s EDs is increasing each year. Between 2017–18 and
The effects of overcrowding include ambulance diversion, re­ 2021–22 the total number of presentations assigned a triage
duced access to emergency care, compromised clinical care, adverse category of Urgent or higher increased by 3% [1] and only 58% of
patient outcomes [3], prolonged inpatient length of stay, increased urgent (cat 3) patients were seen within the recommended
rates of morbidity and mortality [4–6]. Other consequences include 30 min. In 2021–22, the proportion of ED visits completed
within 4 h was 61%, down from 67% in 2020–21% and 71% in
2017–18 [1].
⁎
Correspondence to: Wollongong Hospital Emergency Department, Wollongong, (2) Throughput delays can be related to triage, room placement,
NSW 2500, Australia. initial provider evaluation, diagnostic testing and treatment
E-mail address: [email protected] (K. Curtis).

https://doi.org/10.1016/j.auec.2023.04.002
2588-994X/© 2023 Published by Elsevier Ltd on behalf of College of Emergency Nursing Australasia.
K. Payne, D. Risi, A. O’Hare et al. Australasian Emergency Care 26 (2023) 321–325

while in ED. This includes cohesiveness of care teams, physical Data sources and collection
layout, nurse and physician staffing ratios, efficiency and use of
diagnostic testing, accessibility to medical information, quality The primary source of data was observation. Observation meth­
of documentation and communication and availability of speci­ odology is a systematic approach to analyse and improve work
alty consultation [10]. processes by carefully observing and recording the time and motion
(3) Output delays are primarily related to access block which is the of workers. This methodology is useful to identify and eliminate
principle factor responsible for ED overcrowding and reflects inefficiencies, redundancies and wasted time in a process. A major
hospital and health system performance rather than that of the advantage of the observation methodology is higher fidelity of in­
ED [11]. For example, in a 2021 study, the main determinants in formation regarding specific tasks. This level of detail can help ac­
the reduction in ED overcrowding and access block were asso­ curately identify inefficiencies and result in an overall improvement
ciated with reductions in hospital occupancy and elective sur­ in productivity by generating more robust data [26]. Furthermore,
gery levels [12]. One bed space blocked by an admitted patient observation methodology allows for the identification of potential
for 8 h impairs the assessment of 24 low acuity patients [4] in sources of error or delay, that might not be captured through ret­
part by consuming ED nursing and physician resources. rospective review of times for each item.
Ten ED staff were nominated by ED management, orientated to
With these considerations in mind, numerous initiatives have the data collection process, rostered to a supernumerary eight-hour
explored ways to mitigate overcrowding. The majority focused on ED day, afternoon or night shift. Each shift had two data collectors. ED
productivity, rather than whole of hospital performance. Some ef­ staff were not formally advised of the study, however if staff asked,
fective ED efficiency solutions include nurse-initiated radiology and they were informed that the observers were collecting information
pathology [13–15], paramedic initiated blood collection [16], ED about the department, and no identifiable information about any ED
short stay areas [17], Emergency Nurse practitioners [18], rapid as­ staff were being collected.
sessment zones for low acuity patients [1,19] patient flow managers Patients were identified at triage by one of the data collectors,
[20], senior assessment streaming [21], the availability of ED staff to then tracked real-time through ED. The data collector took manual
transport admitted patients to the ward [22] and acute medical units notes of every step of each patient’s ED journey using a template
[23]. One effective initiative was the 4 h national emergency access adapted from a Whole of Hospital patient flow project conducted at
target (NEAT) [24]. Wollongong in 2016 (see Supplementary material 1). They recorded
NEAT was implemented to reduce ED occupancy times. NEAT patient details, date and time of event and any issues (in the com­
improved some internal ED efficiencies and remains a performance ment section). The events that were recorded included time of
indicator (now called Emergency Treatment Performance - ETP) in triage, registration, first medical officer contact/review, test requests
NSW [24], and is impacted by access block. Aside from inpatient bed and availability (bloods, xray, ultrasound, CT), first specialist review,
availability once a patient is admitted, data are not routinely re­ decision (admit/discharge), beds (requests, allocations, ready),
ported that explain delays to a decision to admit, or why the patient transfer, admit/discharge and details of delays. The full list and fur­
may or may not have met the NEAT target. NEAT data are often in­ ther detail can be found in Supplementary material 1.
complete, analysed retrospectively, and not truly reflective of ED To verify time points secondary sources of data were used; pa­
functionality. For example, although many data are routinely and thology, radiology, staff recall and the electronic medical record. For
reliability time stamped and captured, such as time to CT request example, to verify the time of xray, the timestamp from imaging was
and report availability, other influential time points are not. For collected. To verify the time of blood sample collection, the time of
example, time of; blood collected, request for specialist team con­ pathology receipt in the laboratory was recorded. When the observer
sult, medical assessment, analgesia. These times are either not col­ had not seen when and where a patient had been moved to, clinical
lected, or, dependant on timely clinician data entry in the electronic staff were asked. When beds were allocated, and departure to that
medical record. To enable appropriate selection of interventions to bed, the time entered by the clinical manager in eMR (Firstnet) was
improve ED throughput, sites should identify their own site-specific used, which, locally, is reliable.
causes of delay. Our time in motion study sought to identify and
quantify internal delays to enable selection of interventions most Data management and analysis
likely to result in improvement to ED throughput at Wollongong
Hospital. Data were manually entered into Microsoft excel. The data un­
derwent cleaning, double data entry, and were checked for missing
data by three staff. Data were then de-identified. The time of 0 min
Methods was considered to be the timepoint when the patient was triaged.
Time 0 min was triage. The patient timeline from triage to each
This real-time observational study was conducted from 16th event was calculated subtracting the time of triage from the event.
April 0920hrs to 19th April 0700hrs, 2020 (Thursday – Saturday) at Descriptive analyses were conducted and all results are presented in
Wollongong Hospital Emergency Department (WH ED). This enabled minutes. Normally distributed data are described with mean and
24/7 observation and was based on availability of additional staff to standard deviation, skewed data are described with median and
act in a dedicated data collection role. Wollongong hospital is the interquartile range. Kruskal–Wallis one-way analysis of variance was
Illawarra Shoalhaven’s major referral hospital and the ED is one of used to assess differences in time from triage to event across the five
the busiest in New South Wales with over 70,000 presentations care providers: Intern, Registrar, Junior Medical Officer (JMO), Staff
annually. WH ED is a regional, mixed ED, that treats adults and Specialists (SS) and Nurse Practitioner (NP). Post-hoc analysis was
children. From 2021/2022 WH ED registered 73,217 patients of conducted using the Mann–Whitney U test. Results were Bonferroni
which 68% started treatment within the recommended timeframe corrected for multiple comparisons. The sample was not suitable for
and only 47% left the ED within 4 h. The WH ED has 11 day, 11 inferential statistics. All quantitative and descriptive analyses was
evening, 6 night medical staff, 26 day, 26 evening, 23 night nursing completed using SPSS IBM v27. Free text comments were analysed
and 5 day, 5 evening, 2 night clerical and 3 day, 3 evening, 2 night using inductive content analysis. A content analysis was performed
support staff on per day. The project was deemed a quality project on the textual data based on a three phase the framework by Elo and
(QA-109) and exempt from ethical review, complying with NSW Kyngas [27]. Data was read and reread by the researchers, condensed
Health Guidelines [25]. and coded, looking for frequency, similarity and differences.

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K. Payne, D. Risi, A. O’Hare et al. Australasian Emergency Care 26 (2023) 321–325

Fig. 1. Median and 80th percentile* time from triage to event in the ED.
*80th percentile demonstrated in line with local performance targets. MO = medical officer; NP = nurse practitioner; DTA = decision to admit; CT = computed tomography.

Categories were inductive, based on manifest content using a de­ 63.5). The shortest time was ICU 66.5 min (IQR = 117). This delay to
scriptive approach [28] and reviewed by two researchers. decision making was reflected in the median ED length of stay for
mental health (288.5 min) and paediatric patients (166 min). The
Results time from bed allocation to availability varied by specialty of the
admitting team. The longest times were observed for ICU (58 min,
Data were collected on 97.9% (381/398) of patients who pre­ IQR = 151.5).
sented to WH ED between 0920hrs on the 16th of April and 0700hrs
on the 19th of April 2020. Relationship between time points and ED care provider

Demographics Significant differences were observed between the care providers

from: triage to being seen by a medical or nursing practitioner [(MP/
During the 72-h study period 205 male and 193 female patients NP, H(4) = 10.89, p = .03; triage to specialist one review, H(4) = 10.14,
presented to the ED with a mean age of 41.2 years old (SD = 23.4). p = .04; and, triage to decision to admit, H(4) = 27.46, p < .001]. NPs
There were incomplete data on 17 patients, leaving 381 patients. The were significantly faster than interns in time from triage to review
primary mode of arrival was private car (59%) and Ambulance (41%). by the first specialist, U = 2.00, z = −3.01 (corrected for ties) p = .003].
Most patients were allocated a triage category three (44.8%) and four Further, NPs were significantly faster than registrars, U = 1041.00,
(34.7%), followed by category two (15.8%), five (4.1%) and one (0.6%). z = −4.14, p < .001, JMOs, U = 245.00, z = −5.02, p < .001, lead/SS, U
Almost two thirds of patients were discharged home (62%), followed = 325.50, z = −3.61, p < .001, and interns, U = 65.50, z = −4.47,
by admitted to the ward (28.5%), critical care (5.7%), did not wait p < .001, in reaching a decision to admit or discharge (Fig. 2).
(3.3%) and transferred (0.5%).
The Patient Timeline – Triage The median time from triage to Qualitative findings
decision to admit or discharge was 151 min (IQR = 151 min). The
largest time delays were experienced by patients who required a CT, Free text comments were initially grouped into 18 preliminary
specialist review and/or an inpatient bed (Fig. 1). The median time categories, then refined to eight categories and classified as
from triage to CT request was 61 min (IQR = 133 min), attending CT throughput and output (Table 1). The most common throughput
163 min (IQR = 121.5 min) and a report available 215 min (IQR = delays were waiting test results (for example repeat troponins or
148 min). CTs), specialist team reviews and patient deterioration. Output de­
lays were usually related to bed availability. These findings are re­
Specialist referrals flective of the quantitative data.

Nearly one half of the study sample were referred for specialty Discussion
review (n = 171, 45%). The time spent in ED increased with the
number of specialty reviews requested. If a specialist review was This project tracked patients in real-time through the ED to
required, this referral occurred at 83 min (IQR = 126), and the review identify factors contributing to ED throughput. The most significant
occurred 65 min later (148, IQR 178 min). If a second specialty re­ causes of delays were CT, specialist review and bed availability. Other
view was needed this occurred at 224 min (IQR = 171.75), a third at common delays were waiting to be seen by a health practitioner,
285 min (IQR = 262). ward transfer and specialty review which escalated exponentially
The greatest median time to decision to admit was for Obstetric with more than one review.
and Gynaecology patients (228.5 min, IQR = 115.5), followed by Our findings are concordant with existing literature that de­
mental health (183 min, IQR = 275) and paediatrics (178 min, IQR = monstrated ED length of stay is multi-factorial [4,9,29]. In our study,

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K. Payne, D. Risi, A. O’Hare et al. Australasian Emergency Care 26 (2023) 321–325

Fig. 2. Time from triage to event by treating staff type. Junior Medical Officer (JMO),.
Staff Specialist (SS), Nurse Practitioner (NP), Medical Practitioner (MP). *Significant at.05, **Significant at < 0.001. MO = medical officer; NP = nurse practitioner; DTA = decision to
admit; CT = computed tomography; JMO = Junior medical officer; SS = staff specialist.

awaiting medical imaging and reporting was the cause of the longest Delays in the availability of a ward bed also contributed to in­
delays. This is could simply be a mismatch between supply and creased ED length of stay. This issue is multifactorial with delays in
demands. We know that local demand for Emergency CT is in­ patient discharge due to lack of residential aged care or community
creasing 10% year on year. We cannot comment on the effect of over support, lack of ward beds and ward staff [2]. Since this study was
investigation and unnecessary imaging. It is known that early or­ concluded, our health district has lost residential aged care beds,
dering of imaging by senior doctor after a rapid assessment, reduces resulting in up to 160 inpatients awaiting community placement at
the ordering of unnecessary CTs [14,30]. In contrast to medical one anyone time [32]. This, combined with increased ED activity has
imaging delays, the time to blood collection and results in our study resulted in our ED having some of the worst length of stays in the
was relatively short. This could be explained by an efficient pa­ State [33]. Since the conduct of this study, the NSW Government
thology service, embedding of nurse-initiated blood tests [31], senior commissioned a Parliamentary Enquiry to ED overcrowding and the
rapid assessment and paramedic collection of bloods at the time of Australasian College of Emergency Medicine (ACEM) has released a
intravenous cannula insertion all known to expedite pathology re­ position statement outlining possible solutions informed by a 2022
sults [16]. review by the Sax Institute [34]. These include: a whole of system
Another major contributor to length of stay was referral to spe­ approach comprising system wide change; increasing hospital and
cialty teams. This is consistent with Bashkin et al. three month ob­ alternative health care, matching discharges with daily demand,
servational study of 105 patients which demonstrated having over capacity protocols shared throughout the hospital,
communication between ED and inpatient teams caused significant having time based targets throughout the hospital and extending
delays in admission time [29]. Patients have increasing complex hospital function to 24/7; reducing hospital inpatient bed demand
chronic medical conditions and therapies. When more than one through enhancing hospital in the home, ambulatory care clinics,
specialty review was required, delay increased exponentially. We community based mental health; and creating an evidence base to
found variation between specialties which may reflect junior doctor inform policy development.
availability for ED consults and other responsibilities when on-call Although our study was a unique in that it captured patient flow
and senior specialty support for decision making. Admission policies in real time as well as commentary, there were some limitations.
that contain clear criteria and processes for specific clinical condi­ Data were collected during the first wave of COVID-19, when pre­
tions would assist with selecting the appropriate team initially and sentations and in hospital activity was reduced. Should this be
holding that team accountable to accept admissions. conducted currently, we anticipate the findings to be exacerbated.
Alternatively, the number of admissions in some specialties was

Table 1
Categories of delays through the ED.

Category Exemplar n

Through-put Patient factors Patient deteriorated in ED, patient not being between the flags 8
Emergency delays ED treatment not completed before bed available / Delay in MO seeing patient after picked up from the list / no 4
staff to transfer patients
Waiting test results Labs results like serial troponin or delay in imaging 27
Inpatient team delay Difficulty in inpatient team admission/ Awaiting specialist opinion / Delay in med reg review 14
Communication issues in ED NUM not told of admission 8
Total 56
Output Ward delay Ward not ready/ no bed available/ Covid delays i.e. ward not accepting until swab done 16
Transport delay Awaiting transport for discharge/ awaiting hospital transfer/ awaiting discharge letter 10
Change in disposition Admission vs discharge or change in admission destination 3
Total 29

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K. Payne, D. Risi, A. O’Hare et al. Australasian Emergency Care 26 (2023) 321–325

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