title: What are we waiting for? Factors influencing completion times in an academic and peripheral emergency department.
abstract: BACKGROUND
  A long completion time in the Emergency Department (ED) is associated with higher morbidity and in-hospital mortality. A completion time of more than four hours is a frequently used cut-off point. Mostly, older and sicker patients exceed a completion time of four hours on the ED. The primary aim was to examine which factors currently contribute to overcrowding and a time to completion of more than four hours on the EDs of two different hospitals, namely: the VU Medical Center (VUmc), an academic level 1 trauma centre and the St. Antonius Hospital, a large community hospital in Nieuwegein. In addition, we compared the differences between these hospitals.
  
  
  METHODS
  In this observational study, the time steps in the process of diagnosing and treatment of all patients visiting the EDs of the two hospitals were measured for four weeks. Patients triaged as Emergency Severity Index (ESI) category 2/3 or Manchester Triage System (MTS) orange/yellow were followed more closely and prospectively by researchers for detailed information in the same period from 12.00-23.00 hrs.
  
  
  RESULTS
  In the VUmc, 89% of the patients had a completion time of less than four hours. The average completion time (n = 2262) was 2:10 hours, (median 1:51 hours, range: 0:05-12:08). In the St. Antonius Hospital, 77% of patients had a completion time shorter than four hours (n = 1656). The average completion time in hours was 2:49 (n = 1655, median 2:34, range: 0:08-11:04). In the VUmc, a larger percentage of ESI 1, 2 and 3 patients did not achieve the 4-hour target (14%, 20% and 19%) compared with ESI 4 and 5 patients (2.7% and 0%), p < 0.001. At the St. Antonius Hospital, a greater percentage of orange and yellow categorised patients exceeded four hours on the ED (32% and 28%) compared with red (8%) and green/blue (13%), p < 0.001. For both hospitals there was a significant dependency between exceeding four hours on the ED and the following: whether a consultation was performed (p < 0.001), the number of radiology tests performed (p < 0.001), and an age above 65 years.
  
  
  CONCLUSIONS
  Factors leading to ED stagnation were similar in both hospitals, namely old age, treatment by more than one speciality and undergoing radiological tests. Uniform remedial measures should be taken on a nationwide level to deal with these factors to reduce stagnation in the EDs.
authors: Departments of Internal Medicine, Section Acute Medicine, VU University Medical Centre, Amsterdam, the Netherlands.
authors: I L
authors: IL
authors: Vegting
authors: N
authors: N
authors: Alam
authors: K
authors: K
authors: Ghanes
authors: O
authors: O
authors: Jouini
authors: F
authors: F
authors: Mulder
authors: M
authors: M
authors: Vreeburg
authors: T
authors: T
authors: Biesheuvel
authors: J
authors: J
authors: van Bokhorst
authors: P
authors: P
authors: Go
authors: M H H
authors: MH
authors: Kramer
authors: G M
authors: GM
authors: Koole
authors: P W B
authors: PW
authors: Nanayakkara
mesh_terms: D000046:Academic Medical Centers / Q000706:statistics & numerical data*; D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D006764:Hospitals, Community / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data*; D008875:Middle Aged; D011446:Prospective Studies; D011859:Radiography; D012017:Referral and Consultation; D012720:Severity of Illness Index; D013997:Time Factors; D014218:Triage / Q000706:statistics & numerical data*; D055815:Young Adult