This study analyzed emergency department (ED) overcrowding and length of stay at a hospital in Kuwait. A team observed 22 patients over 12 hours and mapped their journeys in the ED. They found that more than one-fifth of patients had long ED lengths of stay, with most of their time spent waiting rather than receiving direct care. Mapping one patient's 8.5 hour stay revealed that 78% of the time was spent waiting with no added value. The primary cause of overcrowding and prolonged stays was found to be "access block" due to lack of available inpatient beds, which was most severe every Sunday. The study concludes that accounting staff should be provided all week and discharge rounds conducted on weekends to address

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1 Nov 2013 - 31 Jan 2014
ED Overcrowding: A Global Concern Reaching Us
Hossam Elamir,
[1,2]
Abeer G. Dossokey,
[1]
Amal T. Mohamed,
[1]
& Lea Martinez
[1]
[1] Department of Quality and Accreditation, Mubarak Al-Kabeer Hospital, MOH
[2] MSc in Healthcare Management, Royal College of Surgeons in Ireland
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0:38 0:10 0:15 0:35 0:10 0:45 1:40 0:00 0:40 0:10 4:53
0:13 0:05 1:00 0:05 1:00 4:25 6:43
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0:30 0:05 2:25 0:25 0:40 0:10 2:05 7:50
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I. Background
Emergency Department (ED) overcrowding (OC) is defined as a situation where the
demand for services exceeds the capacity of the department to provide them in a high
quality and timely manner.
[1]
EDOC is associated with increased ED Length of Stay
(LOS) of some patients beyond the accepted limit that varies from above 4 hours in UK
to above 8 hours in Australia.
[2]
Both –EDOC and increased EDLOS- are key global
issues for more than 20 years, as they have serious clinical, quality, safety and
financial repercussions.
[1,2]
ED staff of the general hospitals in Kuwait and ED patients
are reporting a progressively increased EDLOS and EDOC. No measurements have
been done to assess the situation. On Sunday 26/1/2014, there were 33 patients
waiting to be shifted to inpatient after they had been admitted. According to Heads of
Emergency and Medical Department, this was a recurrent problem manifested every
Sunday of Nov., Dec., 2013 and Jan., 2014. Moreover, it was reported many times to
have patients in ED setting on wheelchairs or lying in trolleys (Fig. 1).
Out of those 22 observed patients (Fig. 2), 10 patients stayed less than 5 hours in the
ED (the greens), 7 patients stayed between 5 to 7 hours (the yellows) and 5
patients stayed more than 7 hours (the reds). Two patients stayed more than 12 hours
and this was retrieved from patient records and ED staff observation records.
A multidisciplinary team was formed to map the patient journey in ED. The team
selected a day from 7 am till 7 pm to collect data and calculate wait times. ED nurses
were requested to observe and register timing of the steps using a data collection
form. During that 12 hour period, 22 patients were observed. The selection was based
on Willoughby et al.’s
[3]
strategy to overcome the infeasibility of documenting all ED
visits, so only the apparently more acute patients were observed.
Fig. 1: The Overcrowded ED Room
Fig. 4: No of Daily Discharges from Medical Wards (1/11/2013 - 31/1/2014)
Fig. 2: Waits Time and Length of Stay in ED
Fig. 3: Patient Wasted Time in Waits Compared to Services Time
III. Conclusions
IV. References
II. Case Summary
a. Mapping of 8:25 hrs patient stay in ED observation
b. Aggregation of non-value added waits (white) vs. added-value services (coloured).
Further mapping of case number (8) revealed that around 78% of the total time of the
patient at the observation room was waits, with no value added (Fig. 3).
Moreover, the team listed the possible causes of ED overcrowding and increased ED
LOS, where the most important cause was admission blockage due to unavailability
of inpatient beds.
[1]
The team retrieved the number of daily discharges from Medical
department to find out a very peculiar cyclic pattern of daily discharges (Fig. 4). Every
week there were two peaks for discharges, Sundays and Thursdays which are before
and after weekends. This is why the ED is congested with waiting to be admitted
patients every Sunday.
We would like to acknowledge the help provided by Prof. Jane Griffiths,
Director of Nursing, Rashid hospital , Dubai Health Authority
For further information contact: Dr. Hossam Elamir,
Head of Quality & Accreditation Department, MKH, MOH, Kuwait
Mobile: 00965-65198442 - E mail: dr_hossam_elamir@hotmail.com
Linkedin URL: kw.linkedin.com/pub/hossam-elamir/b2/97b/296
1. Affleck A, Parks P, Drummond A, Rowe BH, Ovens HJ. Emergency department overcrowding and
access block. CJEM. 013;15(6):359–70.
2. Horwitz LI, Green J, Bradley EH. US Emergency Department Performance on Wait Time and
Length of Visit. Annals of Emergency Medicine. 2010;55(2):133–41.
3. Willoughby KA, Chan BTB, Strenger M. Achieving wait time reduction in the emergency
department. Leadership in Health Services. 2010 Oct 5;23(4):304–19.
This 12 hour observation revealed alarming signs. More than one fifth of the sample
(22%) had long EDLOS and most of the time spent was waits, and Access Block to
inpatient wards was the primary cause of prolonged EDLOS and EDOC every Sunday.
This variation in practice should be corrected by providing Accounting department staff
all through the week and discharge rounds in weekends. A national-wide measurement
project should be considered to define the exact problem volume, its impact and
identify its causes. Setting ED performance indicators for clinical and service times
together with the whole EDLOS might be helpful to track progression.
[2]
V. Acknowledgement & Contacts