title: The referral and complete evaluation time study.
abstract: BACKGROUND
  It has been suggested that inefficiency in the delivery of care in emergency departments (EDs) may contribute to their overcrowding. Specifically the duplication of work by the on take teams of the assessment already performed by the ED doctor has been identified as a possible contributor to prolonged waits for a hospital bed for those requiring admission. Anything that prolongs an individual patient's processing time will contribute to overcrowding.
  
  
  METHODS
  This observational study was performed using a database of all patient attendances to examine the timeliness of the delivery of care to patients requiring admission through the ED and specifically to examine the impact of the referral process on the total time spent in the ED.
  
  
  RESULTS
  Between August 2006 and February 2007, 6973 (25.4%) patients were referred to the on take teams and admitted. The mean total time in the ED for the 4092 (58.7%) medical patients was 21 h 16 min (standard deviation 12 h 24 min) as compared with 14 h 28 min (standard deviation 10 h 46 min) for the 2852 (40.9%) surgical admissions (P<0.001). The referral process accounted for an average of 16.6% of the patient journey through the ED while access block accounted for an average of 59.6%.
  
  
  CONCLUSIONS
  The overwhelming reason for prolonged waits and overcrowding in Irish EDs is not the duplication of work inherent in the referral process but it is because of a lack of acute hospital capacity.
authors.affiliation: Departments of aEmergency bInformation Technology cNephrology, Beaumont Hospital, Dublin, Ireland. peadargilligan@beaumont.ie
authors.forename: Peadar
authors.initials: P
authors.lastname: Gilligan
authors.forename: Stephen
authors.initials: S
authors.lastname: Winder
authors.forename: Navin
authors.initials: N
authors.lastname: Ramphul
authors.forename: Patrick
authors.initials: P
authors.lastname: O'kelly
mesh_terms: D000368:Aged; D016208:Databases, Factual / Q000706:statistics & numerical data; D003695:Delivery of Health Care / Q000706:statistics & numerical data*; D017598:Efficiency, Organizational / Q000706:statistics & numerical data; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006301:Health Services Needs and Demand / Q000706:statistics & numerical data*; D006801:Humans; D007494:Ireland; D008875:Middle Aged; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D018709:Statistics, Nonparametric; D013995:Time; D017748:Time Management; D014218:Triage / Q000706:statistics & numerical data; D014850:Waiting Lists