SUMMARY

The aim of this study was to conduct an in-depth analysis to identify the root causes of an
ED length of stay (ED-LOS) of more than six hours. A root cause analysis was conducted using the
PRISMA-method for patients with an ED-LOS > 6 hours, excluding children and critical care room
presentations and there were 269 root causes identified. Crowding in Emergency department
negatively affects the quality and efficiency of ED care. ED crowding is associated with adverse
patient outcomes including increased mortality delays in diagnosis, treatment and hospital
admission which results in increased hospital length of stay (LOS). One of the most commonly
reported factors responsible for ED crowding is hospital bed shortage other reported factors are
delays in consultations, radiology, laboratory and treatment by multiple specialties. An
observational record review study focusing on patients visiting the ED of the VU University
Medical Center (VUMC) during one busy week in the winter (January 2017) was utilized in the
study. During the study period there were eight residents in emergency medicine, including four
fellows of emergency medicine and four non-trainees working in shifts. Relevant data was
gathered through the Electronic Patient Record (EPR). For every patient visiting the ED during the
study week, basic data was collected from the EPR by two investigators (BR, LV) using a uniform
data collection form that was specifically designed for this study. The basic data involved age,
gender, date and time of arrival, date and time of ED discharge, discharge destination, triage,
number of consultations and the starting and ending specialty. Direct and indirect causes of an
ED-LOS > 6 hours were retrieved by posing the question why the incident, in this case the ED-LOS
> 6 hours, has happened. PRISMA-analysis also ended when the underlying causes were not
related to hospital practices or to any other matters related to hospitalization. Root causes were
classified using the Eindhoven Classification Model (ECM). Main categories of the factors
affecting ED-LOS was Technical and examples of technical category are technical failure in the
lab, the blood test had to be done again which resulted in a long ED-LOS. Secondly, was
Organizational in which they concluded that it showed the most number of root cause, under
organizational were Patient had to remain in the ED for many hours because the patient could

not be admitted due to shortage of available beds in the hospital.
 Another specialty was called
to see the patient and it took more than four hours before the decision for admission was made
by the resident and the supervisors of this specialty. Because of the crowding in the ED, it takes
the ED doctor a long time (1.5hrs) before she can see the patient. Within the organization it is
common practice that the patient is sometimes first assessed by a medical student, after that by
medical resident and finally by a medical specialist. This causes delays. Third is human and under
human were, there is a changing policy and treatment plan initiated for a patient by a second
supervisor in the surgical department. A patient has to wait a long time before the consulting
medical resident came to see the patient because the ED doctor was late with the consultation

request.
 Long duration before discharge because the IV catheter of the patient still had to be

removed. The patient remains in the ED longer than needed because the ED doctor took a long
time to make the treatment plan. And lastly was patient in which examples of these were patient

needed reassurance before discharge which took extra time.
 It took a long time before the

private transport of the patient arrived. The patient had very complex problems which resulted
in many additional diagnostic tests.

IMPLICATIONS
In nursing education, they could integrate this in the organization and management
subject, they should emphasize to students the need for collaboration with the other health
members especially because in the study they found out that assessment of the patient is
frequently redundant due to the number of personnel inside the ER. Also, the use of computer
in the hospital is I think the best thing that is in the ER right except for the medical personnel
because with the use of the computer the work is very fast comparing before and the need for
teaching this in students like in their computer laboratory class instead of typing and Microsoft
word they should teach the students how to use or encode data in the hospital so that they could
also experience doing those things.
While in terms of research I think that they failed to compare the type of hospitals
attending to ER cases and the length of stay on both hospitals and also there is also the need to
study on the things that would create a more efficient environment for the ER patients in which
it would also improve the quality of care given at the same time the quickness of the service in
the emergency department.
As for the nursing practice this journal would help in looking at the organization of the
hospital and how the ER is functioning in which they would need to adopt to changes especially
to the number of people attending to the patient because in the journal they noticed that Within
the organization it is common practice that the patient is sometimes first assessed by a medical
student, after that by medical resident and finally by a medical specialist. This causes delays. Also,
Patient had to remain in the ED for many hours because the patient could not be admitted due
to shortage of available beds in the hospital which was very evident during our duty because of
the bed shortage and sometimes even in a private institution the shortage of staff taking into
consideration that we are a training hospital what more if there are no students helping I think
the work would be more longer.

SUPPORTING JOURNAL
 A model to predict length of stay in a hospital emergency department and enable
planning for non-critical patient’s admission.

Introduction: The progressive growth of aging, increased life expectancy and greater
number of chronic diseases contributes significantly on the growing demand
of emergency medical care, and thus on Emergency Departments (ED) saturation. This is
one of the most important problems for the management of the healthcare system
worldwide, because it requires a substantial amount of human and material resources,
which unfortunately are often scarce and too limited. Saturation of ED
causes long waiting times at different stages along the service, and a
total length of stay of patients in the service (LoS) high above the desirable, causing
discontent among them, and a degradation in the quality of care received. It's a fact that
saturation of the ED service is mostly due to admission of patients with lower acuity level.
These patients represent a high percentage of the admitted patients and most of them
are non-critical patients. If some information or recommendation system about the
current state of the service was available to these patients, they could decide the moment
to go to the ED, to avoid long waiting time in the service. We propose a prediction model
of patient's LoS in the service, using an ED simulator as a sensor of the real system. The
information obtained from the analysis of the data from simulation will enable the
possibility of planning admission of non-critical patients into the service. Simulation also
will show the effectiveness of the model.

Method: We assume the availability of a "self-triage and recommendation system",

accessible to emergency department' potential patients. This will be the way to inform
patients about the current state of the service, and also the platform to obtain all the
necessary information required to make an adequate recommendation to the
patient, e.g., its acuity level, age or possible chronic disease, among other. The hypothesis
of our proposal is that this system can modify the current pattern of incoming of low
acuity patients into the service, depending on the decision of these potential patients,
users of the recommendation system. Moreover, we have developed an ED simulator,
based on an Agent-Based Modeling (ABM) design of the system, in collaboration with the
Hospital de Sabadell. The simulator includes patients, admissions staff, triage nurses,
assistant nurses, doctors and radiology technicians as agents. The actions and interactions
between the involved agents at each process step result in changes of state of the agents,
which ultimately result in the global operation of the system. Each simulated scenario is
identified by a sanitary staff configuration and a specific input of patients into the service,
and the output of the simulation brings data concerning the number of attended patients,
attention time, and waiting time for each patient in all phases in the service. We will use
the simulator as a sensor of the real system to measure the LoS of patients, by modifying
the input parameters concerning the way the patients enter the service, according to the
different options of decision made by potential patients using the "self-triage and
recommendation system".
Progress report: We have defined the model and we are working in the design of the
experimental phase. Some preliminary results have been found. Discussion: We have
defined an analytcal model to determine the theoretical throughput of a particular
sanitary staff configuration, that is, the number of patients it can take care per unit time
given its composition, which is a reference to measure the performance of the system.
The proposed model will be efficient to the extent that the "self-triage and
recommendation system" is effective on the entry of patients, so that patients input curve
gets flatter and approaches the value corresponding to the maximum capacity of the
system, and so system performance is improved. It will be necessary to know the
minimum percentage of potential patients that should take into account the information
provided, to improve system efficiency. We will use the simulation as a tool to test the
effectiveness of the prediction model proposed.

Conclusions: The integrated care model tries to improve quality of care, optimize the
quality perception about the attention paid to population, and contribute to the
sustainability of the current system, ensuring better use of available resources. Our
proposal aims to improve the ED service, which is the main entrance of patients in the
healthcare system, in relation to access, quality, user satisfaction and efficiency, thus
contributing to integrated care goals.

Reference:

Bruballa, E., Wong, A., Epelde, F., Rexachs, D., & Luque, E. (2016). A model to predict
length of stay in a hospital emergency department and enable planning for non-critical
patients admission. International Journal of Integrated Care (IJIC), 16(6), 1–2.
https://doi.org/10.5334/ijic.2967

Driesen, B. E. J. M., van Riet, B. H. G., Verkerk, L., Bonjer, H. J., Merten, H., & Nanayakkara,
P. W. B. (2018). Long length of stay at the emergency department is mostly caused by
 organisational factors outside the influence of the emergency department: A root cause
analysis. PLoS ONE, 13(9), 1–15. https://doi.org/10.1371/journal.pone.0202751

Saint Louis University

School of Nursing

JOURNAL SHARING
Long length of stay at the emergency department
is mostly caused by organisational factors outside
the influence of the emergency department: A root
cause analysis

SUBMITTED BY:
AGULLANA, NICOLE F.