الفهرس 
Emergency departmentOnly 14 pages are availabe for public view
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Abstract
The Emergency Department (ED) has become one of the main entrances to hospitals for a large number of patients and often provides the first impression of the patient from the hospital. Studies have indicated that overcrowding in the ED is an important global problem that may reduce the quality of patients care, and that a small number of patients who need to enter the hospital wards may stay in the ED for more than four hours. There is no benefit from keeping patients beyond this time in the ED. Patient satisfaction is an indicator of the quality of care provided by the ED.
This study aims to:
1. Measure overcrowding in the ED
2. Measure the waiting times that patients experience in the ED
3. Measure emergency department patient satisfaction
4. Identify relationship between overcrowding, waiting times, and patient satisfaction in the ED.
The study was conducted at the ED of Al Hawari general hospital; a 505-bed general hospital in Benghazi, Libya operated by the Ministry of Health. It is a cross sectional, descriptive study that included observation, and interviewing of patients as well as physicians and nurses.
The systematic random sampling technique was used to select patients that were proportionally allocated to visit rate in the three shifts. A total of 390 patients were observed, and data were collected about 384 hours.
Observation was used to record the timing of services provided for ED patients from arrival till discharge or admission. Each patient was followed throughout his stay at the ED. Specifically the following times were noted: arrival time, time of completion of registration, time of entry to emergency department treatment area, time physician started attending the patient, and time of admission or discharge from emergency department.
An ED overcrowding observation sheet was used during each observation shift, to collect information for calculation of ED overcrowding. During each hour, at a randomly selected point the following was noted: total number of patients in ED, number of patients in waiting room, number of patients being treated, number of patients waiting admission, number of physicians, and number of nurses. Physicians and nurses were interviewed hourly to obtain their opinion on the level of overcrowding in the ED.
A structured interview schedule was used to collect data about the level of patient’s satisfaction with different aspects of ED services, with special reference to satisfaction with waiting times and communication with providers.
The study revealed the following findings:
A) ED overcrowding
Overcrowding measurements were high in the morning and evening shifts, ED occupancy being 188.61±46.78 in the evening shifts and 149.17±53.29 in morning shifts, respectively.
No statistically significant difference was detected for overcrowding between Sundays and Thursdays by all overcrowding measures used.
The correlation between ED occupancy, EDWIN score, physicians’ opinion and nurses’ opinion is statistically significant. Correlation between staff opinion and ED occupancy is higher than between staff opinion and EDWIN score.
B) Waiting time intervals
The total time spend in the ED by all patients was within the recommended time intervals of not exceeding four hours, and more than 95% of them left ED in less than two hours.
Around 90% of patients were attended by a physician in less than fifteen minutes.
The TAT for lab. investigations was the longest waiting time, with a mean of 56.43±36.29 minutes.
There were no significant differences in waiting time by patient characteristics or day and shift of arrival with few exceptions.
Cases that left without being seen a doctor and left before completing the treatment constituted 3.8% and 3.1% of the study sample. They experienced the shortest ED LOS, with a mean of 33.89 ± 28.39 minutes.
Less urgent and non-urgent cases constituted 35.5% and 44.8% of cases, respectively, the latter experiencing the shortest ED LOS, with a mean of 38.26 ± 26.065 minutes.
C) ED patients’ satisfaction
As much as 95% of patients described waiting time from arrival to be shown to exam room as expected, and 90% described waiting time from entering exam room to be seen by physician as expected; with correlation between actual and estimated waiting times being statistically significant.
Satisfaction was lowest with the advice about caring about self at home and follow-up medical care, followed by and the chance to ask question given to him/ her by the doctor/nurse, and time with doctors and nurses to discuss things fully, with mean scores of 2.87 ± 1.211, 3.51 ± 1.099, and 3.54± 1.055, respectively.
The present study did not identify any statistically significant differences in the level of patient satisfaction by different patient variables (sex, age, acuity level) as well as arrival day, and arrival shift).
No statistically significant correlation was detected between the total satisfaction score and two overcrowding measures, namely EDWIN score and ED occupancy, as well as the waiting time from entering exam room until seen by physician and total ED length of stay.
Accordingly, the following recommendations were suggested:
1. Reducing the inappropriate demand on the ED caused by non-urgent and less-urgent cases to solve the problem of ED overcrowding in the evening and morning shifts. This may be approached through:
a. Investigating the reasons for patients’ seeking non-urgent care at the hospital’s ED instead of primary care and implementing solutions that address identified problems.
b. Adoption of one of the triage acuity systems and its implementation in the ED after well defining of the different categories and conducting training programs for the personnel. This will help to identify less urgent cases and at the same time provide more expedient care to the more acute cases.
c. Nursing practitioners should be trained to transfer appropriate cases of ED of the hospital through the triage process. Counseling for non-urgent cases to seek care at primary care facilities should be emphasized.
2. Developing and implementing an ED information system that continuously monitors ED crowding using real-time hourly occupancy, preferably by a computerized system. ED occupancy provides an advantage over more complex compound measures of ED crowding. The ED computerized system should also monitor waiting times for individual cases to detect cases that exceed recommended times. Turnaround times for investigations should also be monitored.
3. Conducting training programs for the ED personnel to develop attitude and skills related to communication with the patient, with special emphasis on explanation of the medical conditions and follow-up discharge instructions.
4. Conducting periodic ED patients’ satisfaction survey to reveal the weak areas from patients’ perspective.