Factors Affecting Length of Stay in Patients Referred to Emergency Department in Bandar Abbas, Iran

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Background
The increase in demand for emergency services causes overcrowding in emergency departments in America, Europe, and Asia (1). The overcrowding in emergency departments has been a challenge all over the world (2) and has been investigated by the Institute of Medicine as a public health crisis (3). Overcrowding decreases the efficient capacity for the management and treatment of the patients referred to emergency departments (4). Previous studies reported that overcrowding, prolonged waiting times, and protracted lengths of stay increase the proportion of patients who leave without being examined by a physician (5,6). Understanding the factors contributing to the emergency department process times and patient care delays is essential for improving the patient care efficiency of emergency departments. Length of stay in emergency departments influences overcrowding in emergency departments and is a key factor for monitoring the performance in emergency departments (7). It was reported that length of stay in emergency departments was related to the rates of hospital admission, 10-day mortality, and dissatisfaction (8). Patients who spent more than 4 hours in emergency departments exhibited lower satisfaction compared with those who spent less time (9). A study investigated the direct factor affecting emergency department length of stay known as "access block", which refers to the situation in which patients who need an emergency hospital admission remain more than 8 hours in the emergency department due to a lack of access to appropriate hospital inpatient beds (10). Another study found that 7.7% of 11 906 patients experienced access block, and the mean length of stay was 4.9 days in those who experienced access block compared with 4.1 days in those who were in noblock group (11). Studies have reported that the increase in testing, consultation, radiology studies, and provision of less substantial treatment contribute to an increase in emergency department length of stay (12)(13)(14). Disease and acuity factors such as higher triage level, certain presenting symptoms, or delayed pain alleviation are related to the increase in emergency department length of stay (15). Some demographic characteristics (e.g., age and ethnicity) and the presence of junior residents or medical students are related to longer length of stay in emergency department (16)(17)(18)(19). Several studies have explored this subject, but no study has been conducted to investigate the parameters in Bandar Abbas, Iran. As such, this study contributes to the factors affecting length of stay in patients referred to emergency department in Bandar Abbas, Iran.

Materials and Methods
A retrospective cross-sectional study was conducted in the Department of Emergency of Shahid Mohammadi in Bandar Abbas from December 2018 and February 2019. A total of 234 eligible patients were randomly selected from patients referred to Department of Emergency of Shahid Mohammadi, Bandar Abbas, Iran. All the patients who referred to the emergency department with complete history and documents were included in the study, while exclusion criteria included the patients with incomplete documents and history and lack of consent for participation in the study as well as the patients who were transferred from hospital. To randomize, 120 patients were systematically selected in December, and other patients were selected in February. Demographic characteristics, including gender, age, reason for coming to the emergency, arrival type, and triage level were recorded. Time sets included entry to medicine specialist visit, specialist visit to order time, entry to lab/imaging assays, entry to other specialist consultants, and entry to final decision time. Entry time was considered as zero time. The data were collected using a checklist and the recorded data for the patients. Other unregistered data were collected from nurses and shift supervisors. The times were recorded based on the medical and nursing reports. Finally, the data were analyzed through independent samples t tests, ANOVA, and Mann-Whitney U test using SPSS software (version 23).

Results
The results showed that times for entry to medicine specialist visit, specialist visit to order time, entry to lab/ imaging assays, entry to other specialist consultants, and entry to final decision time were 14.83 ± 0.445 minutes, 6.29 ± 0.275 minutes, 1.97 ± 0.068 hours, 2.37 ± 0.171 hours, and 2.69 ± 0.096 hours, respectively. The results for times based on gender are presented in Table 1. The results did not reveal any significant differences in both genders for entry to medicine specialist visit (P = 0.978), specialist visit to order time (P = 0.725), entry to lab/imaging assays (P = 0.657), entry to other specialist consultants (P = 0.312), and entry to final decision time (P = 0.543).
According to Table 2, there were no significant differences for all age groups (P > 0.05), but time for entry to lab/imaging assays was significantly lower in patients under 40 years of age (P = 0.001).
The times based on disease types are illustrated in Table 3. The results indicated that specialist visit to order time (P = 0.001), entry to lab/imaging assays (P = 0.003), and entry to final decision time (P = 0.013) were   The times based on triage levels are shown in Table  4. The results showed that entry to specialist visit time (P = 0.001), entry to lab/imaging assays time (P = 0.0212) and entry to final decision time (P = 0.004) were significantly lower in the patients with lower levels of triage.
The results for the times based on to be acute are shown in Table 5. The results did not show significant difference for to be acute and sub-acute (P > 0.05).

Discussion
The current study was conducted to assess factors affecting length of stay in patients referred to emergency department in Bandar Abbas, Iran. The results indicated no significant difference in both genders, and they were similar to those reported in previous studies (20,21). Conversely, a study reported significant differences for genders regarding length of stay in emergency department (1). The differences might be attributed to regional differences and cultural factors.
Similarly, the results revealed no significant difference for all age groups, but entry time to lab/imaging assays was significantly lower in patients under 40 years of age. Other studies have also reported significant differences regarding age in emergency departments for length of stay (1,(22)(23). Age is a factor related with the increase in emergency department length of stay across different nations (13,15,24,25). Older patients spent more time for lab/imaging assays owing to their communication skills and conditions.
The results also showed that time for specialist visit to order time, entry to lab/imaging assays, and entry to final decision time were significantly shorter in the patients with cardiac diseases. A study reported that the mean for emergency department length of stay was 3.9 days in patients diagnosed with cardiac who experienced access block compared to 5.6 days in cardiac patients who did not experience access block (11). Kılıçaslan et al (27) reported that the most common symptoms at the time of present at the emergency department were various cardiac symptoms, fatigue, general poor health, pain, and faulted consciousness (26). The most common specialties are cardiology, neurology, and internal medicine, but internal medicine consultations occurred most frequently (27).
Moreover, the results indicated that entry to specialist visit, entry to lab/imaging, and final decision time were significantly lower in the patients with levels 1-3. It was reported that triage level has a significant effect on emergency department length of stay. Patients in intermediate triage level of 5, spent the longest times for nurse and physician assessment and emergency department lengths of stay (28). Triage level was frequently mentioned in relation to length of stay even in the departments with different triage systems (24,29).

Conclusion
Overall, age and gender did not have significant effects on lengths of stay in emergency department; however, disease and triage level had significant effects on length of stay. Triage levels are contributing factors for emergency department lengths of stay, and these factors can be used for decreasing lengths of stay in emergency department.

Authors' Contribution
All authors read and approved the final manuscript, and all made the same contribution to the presentation of the idea and writing the manuscript.

Conflict of Interests
All the authors declared no conflict of interests.