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      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

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          Abstract

          Background

          Emergency department (ED) crowding is common and associated with increased costs and negative patient outcomes. 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.

          Methods

          An observational retrospective record review study was conducted to analyse the causes for ED-LOS of more than six hours during a one-week period in an academic hospital in the Netherlands. Basic administrative data were collected for all visiting patients. 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.

          Results

          568 patients visited the ED during the selected week (January 2017). Eighty-four patients (15%) had an ED-LOS > 6 hours and a PRISMA-analysis was performed in 74 (88%) of these patients. 269 root causes were identified, 216 (76%) of which were organisational and 53 (22%) patient or disease related. 207 (94%) of the organisational factors were outside the influence of the ED. Descriptive statistics showed a mean number of 2,5 consultations, 59% hospital admissions or transfers and a mean age of 57 years in the ED-LOS > 6 hours group. For the total group, there was a mean number of 1,9 consultations, 29% hospital admissions or transfers and a mean age of 43 years.

          Conclusions

          This study showed that the root causes for an increased ED-LOS were mostly organisational and beyond the control of the ED. These results confirm that interventions addressing the complete acute care chain are needed in order to reduce ED-LOS and crowding in ED’s.

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          Most cited references26

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          Skills, rules, and knowledge; signals, signs, and symbols, and other distinctions in human performance models

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            Human error: models and management

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              International perspectives on emergency department crowding.

              The maturation of emergency medicine (EM) as a specialty has coincided with dramatic increases in emergency department (ED) visit rates, both in the United States and around the world. ED crowding has become a public health problem where periodic supply and demand mismatches in ED and hospital resources cause long waiting times and delays in critical treatments. ED crowding has been associated with several negative clinical outcomes, including higher complication rates and mortality. This article describes emergency care systems and the extent of crowding across 15 countries outside of the United States: Australia, Canada, Denmark, Finland, France, Germany, Hong Kong, India, Iran, Italy, The Netherlands, Saudi Arabia, Catalonia (Spain), Sweden, and the United Kingdom. The authors are local emergency care leaders with knowledge of emergency care in their particular countries. Where available, data are provided about visit patterns in each country; however, for many of these countries, no national data are available on ED visits rates or crowding. For most of the countries included, there is both objective evidence of increases in ED visit rates and ED crowding and also subjective assessments of trends toward higher crowding in the ED. ED crowding appears to be worsening in many countries despite the presence of universal health coverage. Scandinavian countries with robust systems to manage acute care outside the ED do not report crowding is a major problem. The main cause for crowding identified by many authors is the boarding of admitted patients, similar to the United States. Many hospitals in these countries have implemented operational interventions to mitigate crowding in the ED, and some countries have imposed strict limits on ED length of stay (LOS), while others have no clear plan to mitigate crowding. An understanding of the causes and potential solutions implemented in these countries can provide a lens into how to mitigate ED crowding in the United States through health policy interventions and hospital operational changes. © 2011 by the Society for Academic Emergency Medicine.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: SoftwareRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: InvestigationRole: Writing – review & editing
                Role: MethodologyRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: SoftwareRole: SupervisionRole: ValidationRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: MethodologyRole: Project administrationRole: SupervisionRole: ValidationRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                14 September 2018
                2018
                : 13
                : 9
                : e0202751
                Affiliations
                [1 ] Department of Emergency Medicine, VU University Medical Center, Amsterdam, The Netherlands
                [2 ] VU University school of medical sciences, Amsterdam, the Netherlands
                [3 ] Section Acute Medicine, Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
                [4 ] Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
                [5 ] Department of Public and Occupational Health, Amsterdam Public Health research institute, VU University Medical Center, Amsterdam, The Netherlands
                [6 ] Acute Care Network North-West, VU University Medical Center, Amsterdam, The Netherlands
                Iran University of Medical Sciences, ISLAMIC REPUBLIC OF IRAN
                Author notes

                Competing Interests: The authors have declared that no competing interest exist.

                Author information
                http://orcid.org/0000-0002-1555-3682
                Article
                PONE-D-18-06009
                10.1371/journal.pone.0202751
                6138369
                30216348
                a29c638c-36b2-46ce-9e42-7d306f4b8cf1
                © 2018 Driesen et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 24 February 2018
                : 7 August 2018
                Page count
                Figures: 2, Tables: 3, Pages: 15
                Funding
                The authors received no specific funding for this work.
                Categories
                Research Article
                Medicine and Health Sciences
                Critical Care and Emergency Medicine
                Medicine and Health Sciences
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                Surgical and Invasive Medical Procedures
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                All relevant data are within the paper and its Supporting Information file.

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