title: Waiting at the hospital door: a prospective, multicentre assessment of third delay in four tertiary hospitals in India.
abstract: BACKGROUND
  A common framework to assess delays in health-care in countries with low-income and middle-income (LMICs) defines three time periods that add to the interval between onset of symptoms and treatment; the time it takes to receive care after hospital arrival is known as the third delay. Tertiary centres in LMICs are known to be overcrowded and under-capacity, but few studies have formally assessed the third delay. This study aims to quantify the third delay in LMIC tertiary centres and identify contributing factors at the facility level.
  
  
  METHODS
  A prospective multicentre study was conducted from July, 2013, to July, 2014, in four tertiary care hospitals in the three largest cities in India: Mumbai, Delhi, and Kolkata. The time from patient arrival to the time when vital signs were first recorded was used as a proxy for the third delay. This delay was recorded by the research officers for those patients who were directly observed. For the rest of the patients the data were collected from patient records. Qualitative interviews were conducted with a subset of patients exploring reasons for the delay.
  
  
  RESULTS
  Data were collected for 5087 patients (1664 from Delhi, 469 from Mumbai centre-1, 711 from Mumbai centre-2, and 2243 from Kolkatta); median age was 30 years (IQR 20-45), 3944 (78%) were men, 3372 (66%) were transfers from other facilities, and 3424 (67·3%) arrived in an ambulance. Researchers directly observed 1392 (27·4%) patients from arrival to time of vital signs. There were wide variations in delays between groups, transferred versus direct presentation (0 min vs 20 min) and in between hospitals (median time 0·0 min in Mumbai to 1·5 h in Kolkatta) and in groups within each hospital. The reasons for delay were multifactorial: administrative (police case recordings, admission paper registration), logistical (no vacant beds, no physician available), and process-based (investigations before vitals, multiple patients at one time, junior physicians in-charge); process based reasons were the most common (80%).
  
  
  CONCLUSIONS
  Delays in care persist in tertiary centres in LMICs for a variety of reasons. Low-cost but context-specific changes that optimise care processes like prioritisation and transfer protocols could yield major reductions in third delay. Adoption of best practices of the better performing hospitals in the Indian setting will help to improve the trauma quality practices in India.
  
  
  BACKGROUND
  The Laerdal Foundation for Acute Medicine and the Swedish National Board of Health and Welfare.
authors: Lokmanya Tilak Municipal Medical College and General Hospital, General Surgery, Mumbai, Maharashtra, India. Electronic address: drvineetkumar@gmail.com.
authors: Vineet
authors: V
authors: Kumar
authors: Seth G S Medical College and K E M Hospital, Mumbai, India.
authors: Monty
authors: M
authors: Khajanchi
authors: Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.
authors: Nakul P
authors: NP
authors: Raykar
authors: Karolinska Institutet, Stockholm, Sweden.
authors: Martin
authors: M
authors: Gerdin
authors: Bhabha Atomic Research Centre Hospital, Mumbai, India.
authors: Nobhojit
authors: N
authors: Roy