Extended Abstract
Background
Hospital Emergency Departments (EDs) are considered a miniature version of the entire hospital in terms of management. This makes the ED the only ward in the hospital that is overcrowded. Boarding in the ED refers to the retention of patients in the ED, often in hallways or EDs, while they wait for a bed. The risks can include increased medical errors, decreased quality of care, increased rates of patients discharged against medical advice, increased mortality, and burnout of the ward's medical staff. Retention of patients in the ED indicates hospital-wide capacity shortages and overcrowding. This study is among the first in Iran to comprehensively assess the relationship between ED boarding time and short-term patient outcomes using empirical hospital data. The study, conducted at Imam Reza Hospital- the largest provincial referral center-shows that internal medicine cases, especially those needing admission to infectious disease wards, greatly extend ED stays and highlight capacity issues across the hospital.
This study investigated the status of patients awaiting admission after assignment, including the relationship between ED time indicators, patient characteristics, the departments required for admission in this hospital, and primary outcomes in the ED.
Methods
This descriptive cross-sectional study was conducted in the ED of Imam Reza Hospital in Tabriz between July and December 2024. The inclusion criteria for the study included patients who were assigned to be hospitalized. The patient's lack of consent to participate in the study and incomplete documentation of the patient's file were among the exclusion criteria. The sample size was 400 patients, and the sampling method was a census based on the inclusion and exclusion criteria until the final sample size was reached. This study was approved by the Ethics Committee of Tabriz University of Medical Sciences with the code IR.TBZMED.REC.1403.252 on 24.06.2024
The variables collected included demographic findings of patients, including age and gender, working shift type when patient referral, triage level, method of referral, type of disease, initial diagnosis of the disease, ward required for hospitalization, outcome of patients in the ED, and the total number of referrals per day on the days under study. Emergency time indicators were calculated and recorded for patients, including the time needed from admission to assignment, the time required until leaving the ED, and the total time the patient stayed in the ED. Time indicators were recorded as hours: minutes. The relationship between time indices, the type of inpatient department required for patient hospitalization, and the final ED outcome was analyzed.
The data were entered into the SPSS-24 statistical software. The Kruskal-Wallis test was used to compare quantitative variables in the study groups. The Pearson correlation test was used to evaluate the correlation between quantitative variables of the study. In all cases, a p-value less than 0.05 will be considered significant.
Results
This study was conducted on 400 boarding patients at Imam Reza Hospital ED in Tabriz, Iran. The mean age of the patients was 59.37±18.44 years. In terms of gender, 250 patients (62.5%) were male. In terms of time of visit, the most visited time was the night shift (49%). The average number of patients visiting the ED in a day was 280.96±23.01. The highest triage level of patients based on ESI was level 2 (78%). The internal disease group was the most common type of disease in the studied patients (83.8%). The most common initial diagnosis of boarding patients was respiratory failure (24%). Regarding the hospitalization ward necessary for the patients, 276 individuals required admission to the internal ward. Regarding patient outcomes in the ED, most patients (87.8%) were admitted to the ward, and just five (1.3%) died in the ED during the study.
To assess the relationship between the number of ED visitors in a day and the bed-day occupancy rate, with the timing of patients' attendance in the ED including the time from admission to assignment, the time from assignment to discharge, and the total time of stay in the emergency department, the Spearman correlation test was used. The test results showed no statistically significant relationship between the number of ED visitors in a day and time indices with a P value of 0.944, 0.061, and 0.057, respectively. However, there is a statistically significant relationship between the bed occupancy rate per day and time indices with a P-value of 0.011, 0.007, and 0.001, respectively.
The Kruskal-Wallis test was used to evaluate the relationship between time indices and the type of disease (internal, emergency, and trauma), the required hospitalization ward, and the patient's outcome in the ED. There is a statistically significant relationship between the type of disease and the required hospitalization ward and all-time indices (P-value ≤ 0.001). In the variable of disease type, the time indices of internal diseases are higher than the others. In the variable of required hospitalization, the time indices of the infectious ward are higher than the other wards, so the median total time of stay of patients in the emergency department, if hospitalization in the infectious department is required, is 36 hours and 30 minutes.
Conclusion
Over 83% of boarding patients belonged to the internal disease category, with respiratory failure being the most common initial diagnosis. The longest ED stays were observed among patients requiring infectious disease admission, with a median stay of 36 hours and 30 minutes. No statistically significant association was found between ED length of stay and patient mortality or discharge outcome, despite high congestion. A significant correlation was observed between inpatient bed occupancy rates and longer ED stays (P-value <0.01), highlighting systemic throughput bottlenecks.
In our study, the percentage of the internal disease group awaiting hospitalization was higher (69%). The percentage of patients who died in our study was 1.3% and the percentage of patients awaiting hospitalization in the intensive care unit was 11.3%. Our study found no association between patient outcome in the ED and length of stay.
The number of cases waiting for admission to the ED was higher among the patients in the internal disease group, so necessary measures should be taken to control the entrance to the ED and also to safely and quickly discharge hospitalized patients to reduce the number of cases waiting for admission to the ED. Future studies are recommended to evaluate the cost incurred by the hospital due to the stay of these patients in the ED and the workload imposed on the ED medical staff. The length of stay of assigned patients in the internal disease group in the emergency room is higher than that of other assigned patients. Among the internal disease group patients, the length of stay of patients in the infectious disease group is higher than that of other cases. No relationship was observed between the length of stay and the outcome of the patients. There is a statistically significant relationship between the bed occupancy percent of the inpatient wards and the length of stay of patients in the emergency department.
Practical Implications of Research
The findings call for urgent measures to improve patient flow by enhancing discharge planning, increasing inpatient bed availability, especially in internal and infectious disease wards, and optimizing emergency room throughput. This study provides a data-driven foundation for healthcare administrators and policymakers to mitigate ED overcrowding and enhance system efficiency without compromising patient safety.