Organizational factors affecting length of stay in the emergency department: initial observational study

High LOS may lead to crucial expenditures and may have implications on patient safety. Using prospective observational methods for data collection and an Ishikawa fishbone diagram for data examination, our study identified several factors associated with ED LOS.

Nurse and physician handover in shift changes appear to be among the chief factors with significant influence on ED LOS. In a study that examined handover in change of shifts in ED [14], researchers noted that one of the main considerations that distinguishes ED from other health services is the handover involved in the change of shifts. The content and needs related to this handover vary from patient to patient, and the incoming physician needs to develop the coordination of care for the patients, all of whom may have different and unrelated medical case scenarios and, thus, very different needs. This is in contrast to what occurs with most cross-coverage handovers in other hospital wards, in which most of the patients have similar medical case scenarios and lower clinical status changes and acuity. The incoming physicians in other hospital wards are most often familiar with the patients’ needs [14].

Another study [15] emphasized the complexity of ED handover in which standardization was very low, patient flow was unpredictable and varied, and the likelihood of the incoming provider having to interact with the case being handed over was very high. This is in contrast to inpatient wards where the handover is often more similar than different. Problematic handover at change of shift may have critical consequences causing delays in medical diagnosis, prolonged hospital LOS, and higher probability of adverse events in the ED [16].

Previous studies have shown that 84 % of treatment delays are later judged to be due to miscommunication; of these, 62 % are continuum-of-care issues associated with shift changes [17]. In our study, problems in continuum-of-care were found to affect ED LOS in another form, mainly among the admitted patients group. The process—from deciding to admit a patent until the patient was actually transferred from the ED to an inpatient hospital ward—took 43 % (233 min.) of the total ED LOS of admitted patients. Analysis of the admitting process using Ishikawa diagram [see Fig. 4] revealed several possible explanations to the prolonged waiting times, one of them being deficient communication. For example, when a decision to admit a patient to another hospital ward was made, the ED physician called the receiving inpatient physician to approve the decision. When the physician arrived in the ED, he examined the patient and his/her medical records and in some cases decided to request more diagnostic tests or medical examinations before approving admission. This took additional time, and the patient often had to go to other hospital units to have the tests and then return to the ED. The loop of calling the physician from the admitting department began again and often with a different receiving inpatient physician responding, who lacked the knowledge regarding the patient’s health condition (due to miscommunication) and thus requested more diagnostic tests be done and so on.

The literature suggests that lack of continuum-of-care in the process of patient admissions is derived from deficient communication among medical staff [18], and in our study, we found that it is associated with, and may have led to, prolonged ED LOS. Continuity of patient care is based on the effective transfer of information between medical staff members. A study [19] that examined the handoff process between ED medical staff and Intensive Care unit (ICU) medical staff revealed that there was no structured and consistent approach to how handovers actually occurred, and nurses from both ED and ICU lacked clarity as to when the actual handover process began. Nurses from both settings recognized the importance of the information given and received during handover and deemed it to have an important role in influencing the quality and continuity of care.

In a study examining the perceptions of ED physicians and hospitalizing physicians regarding handoff communication of patients transferred from ED to inpatient settings [20], researchers found that physicians perceived handoff communication as characterized by ambiguity about patients’ conditions and treatment. They found that poor communication practices and conflicting communication expectations presented barriers that exacerbated physicians’ information ambiguity. They noted that ED physicians and receiving inpatient physicians had different expectations about handoffs and those expectations influenced their interactions in ways that could result in communication breakdowns. Hospitalizing physicians expect ED physicians to produce definitive diagnoses, and admissions are delayed until confirmatory test results are provided, whereas emergency physicians might believe that their professional opinions are being questioned.

At the organizational level, prolonged ED LOS is often associated with hospital occupancy rate. Previous studies have demonstrated the effect of hospital overcrowding on ED overcrowding [21‐23]. One of these studies [23] found that daily ED LOS for admitted patients increased 18 min when there was an absolute increase in hospital occupancy of 10 %. The ED LOS appeared to increase extensively when hospital occupancy exceeded a threshold of 90 %. Another study [24] revealed that crowding was associated with substantial delays in ED LOS across the four ED sites it examined. Moreover, crowding prolonged the ED LOS of high-acuity patients. In addition, researchers noted output factors, such as the number of patients admitted and the inpatient medicine occupancy rate, that were associated with significant delays in ED care. These findings, which support those in our study, showed that ED LOS was highest among two of the receiving inpatient departments (orthopedic and internal medicine departments), both of which are characterized by very high occupancy rates.

There are several limitations of the study regards external validity and generalizability. First, we analyzed a small number of ED visits in a limited period. Second, we focused on a single ED in Israel, which possibly functions differently from other EDs in Israel and elsewhere. The hospital participated in our study is a community hospital with limited capacity of admission beds. As a result, the standard route of emergency admission in the hospital studied is for an ED physician to ask an in-hospital consultant to see the patient and consider admission. It is possible that there is an association between the limited capacity of admission beds and the amount of diagnostic tests required by the receiving inpatient physicians before deciding to admit the patient. However the limited capacity of admission beds, cannot explain the association between prolonged ED LOS and shift changes found in our study. Thus, the relevance of deficient communication and lack of continuum-of-care to ED LOS is probably not limited to community hospitals with insufficient bed supply and/or hospitals where the physicians from the admitting departments have a substantial say in the process and timing of the admission decision.

Concerning the findings that showed prolonged LOS for patients who experienced a shift change, it is possible that the long stay itself leads patients to span the shift change, rather than the opposite. We cannot determine a cause and effect relationship between shift change and prolonged LOS, but the prolonged LOS for patients who experienced a shift change shown in our study emphasize the complexity of handover in shift change. In addition, we lack the data regarding the clinical characteristics and acuity of health status of the observed patients that may explain the differences in ED LOS, which were attributed to organizational factors.

Our study results demonstrate the complex multifaceted characteristics of prolonged ED LOS. The potential effects are numerous and severe. Strategies to reduce this LOS may save costs associated with inpatient care, as well as ED costs, and they may prevent patient morbidity and mortality related to prolonged LOS [9]. Therefore, using Lean tools is recommended as it can identify targets for improving the efficiency of healthcare services. Lean tools seeks to reconfigure organizational processes to reduce waste and enhance productivity based on the application of specialized analytical techniques along with creating a culture of continuous improvement [25]. According to the NHS Institute for Innovation and Improvement (NHSIII) the application of Lean principles in healthcare, should remove duplicate processes and unnecessary procedures such as: recording patient details in multiple places, excessive waiting for staff, and uncoordinated, variable discharge processes resulting in a longer length of stay [26].

Organizational factors such as occupancy rate and handover management in shift exchange as well as miscommunication and lack of continuum-of-care, were found to be associated wtih ED LOS as can be concluded from the study results. Therefore, improvement interventions should take into account those types of factors in order to achieve valuable contributions to reducing this time. We believe our study contributes to a broader overview of this problem and to a better understanding of its causes.

Future study may help to assess whether a causal link exists between predictor variables and ED LOS using qualitative methods, and consequently, develop and evaluate data-based interventions to reduce ED LOS.