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ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 6-10

Do trauma patients have to wait longer in emergency department?


Department of General Surgery, Medical College, Umm Al-Qura University, Makkah, Saudi Arabia

Date of Web Publication27-Feb-2018

Correspondence Address:
Dr. Khaled Albazli
Medical College, Umm Al-Qura University, Makkah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_20_17

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  Abstract 

Introduction: Trauma is a major health problem in Saudi Arabia and the number one cause of mortality. Tremendous effort is needed to improve the quality of care to decrease the burden of this health problem on national hospitals. To be able to establish a new trauma system, we need to have a better insight into the current level of care and practice. This study aims to shed light on trauma patients presenting to the largest emergency department (ED) in Makkah, Saudi Arabia, and determine the length of stay (LOS) for all trauma patients.
Methodology: During the 31-day study period, 1984 trauma visits in Alnoor Specialist Hospital in Makkah have been analyzed. The LOS of all the patients presented to ED is calculated and then compared to the LOS of all nontrauma patients.
Results: The analysis showed a significant increase in LOS of trauma patients. Several factors have been identified as the major causes of prolonged stay. A priceless insight of the current care provided to trauma patients is described in this study. Further efforts should be focused on the need of advanced trauma care to improve patient's care.

Keywords: Emergency department, length of stay, Makkah, Saudi Arabia, trauma


How to cite this article:
Bukhari H, Albazli K, Almaslmani S, Najjar F, Sulaimani N, Al-Maghrabi H. Do trauma patients have to wait longer in emergency department?. Saudi Surg J 2018;6:6-10

How to cite this URL:
Bukhari H, Albazli K, Almaslmani S, Najjar F, Sulaimani N, Al-Maghrabi H. Do trauma patients have to wait longer in emergency department?. Saudi Surg J [serial online] 2018 [cited 2018 Oct 15];6:6-10. Available from: http://www.saudisurgj.org/text.asp?2018/6/1/6/226227


  Introduction Top


It is well known that emergency department (ED) is one of the busiest services in health-care system. It carries the responsibility of providing care for a wide range of cases, which vary from simple complaint to life-threatening conditions. Thus, it is crucial to ensure that a high quality of care is provided to patients to manage all cases effectively and efficiently.

Patient flow and overcrowding of EDs create a major challenge for health-care professionals to provide an exceptional level of care beyond patients' satisfaction. Several factors are known to contribute to the satisfaction of patients in ED, and the most important one is waiting time, which is proportionally related to poor patient satisfaction.[1]

ED of Al Noor Specialist Hospital (NSH) is a vital center that provides health-care services for millions of patients throughout the year, especially during the season of Umrah (almost through the whole year) and Hajj (annual Islamic pilgrimage to Makkah), which makes it a great concern for hospital staff members and stakeholders to ensure a high quality of services provided to patients. Moreover, NSH is the main emergency center in Makkah city and covers a large nearby regions. Although there is no dedicated trauma center in this hospital, NSH is considered as the main referral center for trauma patients in Saudi Arabia where trauma is the number one killer.[2] There is no published data evaluating the ED response and factors affecting the length of stay (LOS) of trauma patients in NSH. It is also not clear yet whether trauma patients have longer LOS compared to nontrauma patients or not.

The aim of this study is to compare the ED response and LOS between trauma patients and nontrauma ED visits. The analysis will focus mainly on factors affecting LOS for trauma patients.


  Methodology Top


Setting

This study was conducted in the ED of NSH, the main tertiary care center in Makkah, Saudi Arabia. The ED receives over 200,000 patients a year and was staffed by one medical or surgical consultant physician with few numbers of specialists and residents. There were no ED-certified consultants or residents practicing in the department. Pediatric and obstetric and gynecology emergency rooms were excluded. This study received ethical approval from Umm Al-Qura University Research Board.

Data collection

This study had two phases:

Phase one was analysis of waiting time in ED. The flow of every single patient who attended the ED between the midnight of January 1 until the midnight of January 31, 2013, was monitored and manually recorded for a continuous 744-h period of study. Age, gender, registration time, initial triage level, triage assessment time, arrival area, door-to-nurse time, door-to-doctor time, medical decision time (discharge versus admission), time of physical disposition, use of laboratory and/or radiology services, and asking for specialty consultation services were all recorded for each patient seen during the study period.

Phase two was conducting a comparison between the LOS for trauma patients who attended trauma area and the LOS of patients who attended other ED areas. It was based on the result of an article published by Bukhari et al., looking at the factors that prolong LOS of all patients in the ED of NSH.[3]

Time intervals

Two predefined time intervals were determined and calculated for each patient. The time intervals were: (1) from registration to physician assessment and (2) from ED entry until the patient actually left the ED (admission or discharged). Admitted patients were not considered to have departed from the ED until they physically left the ED to the hospital inpatient ward or another patient care facility. The two main time intervals were determined for each patient based on The Canadian Triage and Acuity Scale level (CTAS I-V)[4] and arrival area (trauma, resuscitation, observation, and triage).

Data analysis

Data were recorded on standard study form and then entered into SPSS spreadsheet (SPSS version 21, IBM corporation, Somers, NY, USA). Patient demographics, triage levels, arrival area, time intervals, and several variable relationships were described using descriptive statistics. Multivariate analysis and multiple linear regression analysis were performed to determine how various patient characteristics and ED service processes influenced LOS of trauma patients. These factors included the following: laboratory time, final decision time to time of physical response to the final decision, consultation time, critical care versus noncritical care patients, door-to-final decision time, radiology time, doctor-to-consultation time, doctor-to-radiology time, doctor-to-laboratory time, and door-to-doctor time. The regression model had LOS in hours as a dependent variable and several independent variables were used for the model. These included initial triage level, time to initial assessment by physician, use of laboratory tests, use of diagnostic imaging (plain X-ray, computed tomography, or ultrasound), and specialty service consultation. SPSS statistical software (SPSS version 21) was used to perform the regression analysis and to compare between ED trauma LOS and other ED departments' LOS.


  Results Top


During the 31-day study period, 1984 patients have been registered in the ED trauma area. Of these, 263 patient charts (13.26%) were excluded from the analysis because of incomplete documentation of LOS per triage level. The mean age of study trauma patients was 22.28 years (standard deviation [STD] = 18.48 years) and 58.3% were male. The trauma visits represented more than one-fourth of the total ED visits. [Table 1] shows the number of trauma visits and LOS. Patients attended trauma area had the longest total LOS time compared to other ED areas. There is a significant difference between LOS time of trauma area and other ED areas (P< 0.03). [Table 2] shows the differences in waiting time among different ED areas. CTAS has five acuity levels consisting of CTAS I (resuscitation), CTAS II (emergent), CTAS III (urgent), CTAS IV (less urgent), and CTAS V (nonurgent).[4] Trauma patients triaged to Level I had the longest LOS, while those in Level IV had the shortest [Table 3]. About one-third of the trauma patients spent <59 min (36.64%), 44.5% spent 1–3:59 h, 8.06% spent 4–7.59 h, 4.44% spent more than 8 h, and 6.81% missed documented LOS [Table 1].
Table 1: Trauma visits and total length of stay

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Table 2: Length of stay per arrival area

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Table 3: Length of stay per Canadian Triage and Acuity Scale level

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Among the total analyzed visits to ED trauma, 1085 patients had radiological study requested, 109 laboratory tests requested, and 406 consultations requested. Among the requested services in ED trauma, laboratory results had a longer waiting time than radiology and consultation arrival. Nearly 23.9% of laboratory results had a waiting time more than 1 h compared to 4.8% and 8.4% for radiology results and consultation arrival, respectively [Table 4]. The complete regression model yielded an r2 = 0.421 (F = 2.577, P < 0.04). Multivariate analysis was used to examine the influences of explanatory variables on waiting times of trauma patients. The time of arrival to time of physical discharge (i.e. total LOS) was considered the dependent variable. The results showed that laboratory time, final decision time to time of physical response to the final decision, and consultation time were significantly associated with LOS (P< 0.01) [Table 5].
Table 4: Length of stay per Canadian Triage and Acuity Scale level for sub intervals

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Table 5: Trauma cases' waiting time for selected emergency department services

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  Discussion Top


According to latest information from the World Health Organization and Centers for Disease Control and Prevention, more than nine people die every minute from trauma and violence.[5] The trauma area of the ED is a vital spot. LOS is a very important key performance indicator of quality in the ED. This study focuses on time analysis for trauma patients to identify and quantify factors that prolong EDLOS and compare it to other ED visits. The CTAS is a useful tool to help the ED in categorizing patients according to the severity of their injuries and their need for prompt care. Our study shows that nurses' and physicians' response times were very fast for about 100% assessment rate for Level I injured patients. This finding supports the results published by Bukhari et al.[3] The initial assessment was rapid to most critically ill patients (Level I), which meets the CTAS objectives.[3],[4] This is expected because those patients require immediate care and lifesaving procedure due to their critical situation.

The study by Bukhari et al. at NSH showed a total of 10,226 patients registered in the ED. Among all ED visits, 1984 (25.8%) were admitted to trauma area. The mean age of all ED patients was 37.93 years, while trauma patients were younger with a mean age of 22.8 years. Regarding the duration of stay in the ED for all types of patients, 9.42% of patients were admitted in <59 min, 42.77% were admitted in <4 h, 21.36% were admitted between 4 and 8 h, and 26.45% after 8 h from arrival to the ED. The mean EDLOS was 3 h and 2 min for all patients (including trauma patients) compared to mean EDLOS of 1 h and 32 min for only trauma patients (STD: 2.50 h). This variation is expected due to the wide range of cases including trauma and nontrauma patients in their study. In fact, our study shows that patients of Level IV spent the longest time in the ED [Table 3], which could be explained by their minor injuries and the longer time needed for their investigation and consultation (less priority).

Majority of the ED visits in this study were in CTAS Levels III, IV, and V. As this hospital is the main tertiary care center in Makkah, it receives various types of cases of different age groups and variable degree of injuries ranging from simple fractures, soft-tissue injuries, and burns to severely traumatized patients with life-threatening injuries. Careful assessment and management will lead to significant impact on patient's outcome and improve waiting time. Many factors contributed to prolonged LOS, for example, laboratory time, door-to-doctor time, final decision time to time of physical response to the final decision, and consultation time were the most important factors leading to prolonged LOS [Table 6]. This emphasizes the fact that trauma patients need more workup than nontrauma ED patients, although prompt but appropriate management is paramount.
Table 6: Multivariate analysis of factors affecting waiting times for trauma cases, with waiting time as the dependent variable

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A pervious study was conducted in Taipei, Taiwan, at Mackay Memorial Hospital, which showed that most of their elderly patients with a variable degree of triage level had a prolonged time of stay compared to those who were seen by senior physicians of the same age group.[6] Among the 400 patients, the mean length of ED stay was 118.3 min and the mean age was 33.3 years.[6] Our study had 1984 patients of mean age of 22.28 years and mean LOS of 1.32 h. Another study was done in Geelong, Victoria, Australia, at Geelong Hospital that showed that their patients complaining of musculoskeletal problems seen by primary practitioner with physiotherapy service had improved waiting times and LOS.[7] Nearly 91% of patients who went home were discharged within 4 h.[7] In comparison to our study, 80.69% of patients were discharged within 4 h.

Factors associated with prolonged LOS includes: Waiting time for laboratory and radiology results as well as consultation waiting time. Laboratory results had a waiting time more than 1 h compared to radiology results and consultation arrival.

The increased number of critically ill trauma patients raises the concern for an urgent establishment of Level I trauma center in the area. It has been shown in a previous study conducted in Saudi Arabia that trauma patients have a high mortality rate compared to large trauma centers in the United States of America.[8] Implementation of a Level III trauma center in a rural community in the USA has been shown to have a shorter LOS and lower mortality rate.[8],[9]

Limitations

Analysis of patients admitted to trauma area showed that patients are younger than other patients in different ED areas with higher frequency of motor vehicle accidents among our study population during the 1-month period. This might notreflect the real incidence, and longer study period is needed to get better insights on other factors that could affect LOS. Incomplete documentations of chief complaints for many trauma visits made the cause–effect analysis difficult. Moreover, it is not clear if the type of transportation for trauma patient (self-transported, by ambulance, or helicopter) had an effect on LOS as it is not documented.


  Conclusion Top


Our study aimed to estimate the total LOS and factors affecting it for trauma patients in the ED according to the CTAS classification. Number of trauma visits represent 25.8% of the total visits to ED. LOS was <4 h for 80.69% of trauma visits, approximately half of them (36.64%) had to wait for <1 h. Only 12.5% of patients had to wait for more than 4 h (8.06% spent 4–7.59 h and 4.44% of the patients spent more than 8 h).

LOS plays an important role in the quality of service delivered to all cases of ED and more importantly to trauma cases. LOS is affected by several factors, mainly laboratory, radiological, and consultation times. The frequent trauma visits and high number of critically injured patients transferred to NSH should encourage stakeholders to establish at least one Level I trauma center and several Level II trauma centers in Makkah city to serve millions of residents and visitors.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Locker T, Mason S, Wardrope J, Walters S. Targets and moving goal posts: Changes in waiting times in a UK emergency department. Emerg Med J 2005;22:710-4.  Back to cited text no. 1
[PUBMED]    
2.
Ansari S, Akhdar F, Mandoorah M, Moutaery K. Causes and effects of road traffic accidents in Saudi Arabia. Public Health 2000;114:37-9.  Back to cited text no. 2
    
3.
Bukhari H, Albazli K, Almaslmani S, Attiah A, Bukhary E, Najjar F, et al. Analysis of waiting time in emergency department of Al-Noor Specialist Hospital, Makkah, Saudi Arabia. Open J Emerg Med 2014;2:67.  Back to cited text no. 3
    
4.
Beveridge R, Clarke B, Janes L, Savage N, Thompson J, Dodd G. Canadian emergency department triage and acuity scale: Implementation guidelines. Can J Emerg Med 1999;1 Suppl 3:S1-24.  Back to cited text no. 4
    
5.
World Health Organization. The Injury Chart Book: A Graphical Overview of the Global Burden of Injuries. Geneva: World Health Organization, Department of Injuries and Violence Prevention, Noncommunicable Disease and Mental Health Cluster; 2002.  Back to cited text no. 5
    
6.
Chang WH, Huang CH, Tsai CH. Survey of elderly trauma patients with prolonged emergency departments stays. IJG 2008;2:215-21.  Back to cited text no. 6
    
7.
Gill SD, Stella J. Implementation and performance evaluation of an emergency department primary practitioner physiotherapy service for patients with musculoskeletal conditions. Emerg Med Australas 2013;25:558-64.  Back to cited text no. 7
    
8.
Alghnam S, Palta M, Hamedani A, Remington P, Alkelya M, Albedah K, et al. In-hospital mortality among patients injured in motor vehicle crashes in a Saudi Arabian hospital relative to large US trauma centers. Inj Epidemiol 2014;1:21.  Back to cited text no. 8
    
9.
National Emergency Departments Advisory Group. A Quality Framework and Suite of Quality Measures for the Emergency Department Phase of Acute Patient Care in New Zealand. Wellington: Ministry of Health; 2014.  Back to cited text no. 9
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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