title: Organizational factors affecting length of stay in the emergency department: initial observational study.
abstract: BACKGROUND
  Length of stay (LOS) is considered a key measure of emergency department throughput, and from the perspective of the patient, it is perceived as a measure of healthcare service quality. Prolonged LOS can be caused by various internal and external factors. This study examined LOS in the emergency department and explored the main factors that influence LOS and cause delay in patient care.
  
  
  METHODS
  Observations of 105 patients were performed over a 3-month period at the emergency room of a community urban hospital. Observers monitored patients from the moment of entrance to the department until discharge or admission to another hospital ward.
  
  
  RESULTS
  Analysis revealed a general average total emergency department LOS of 438 min. Significant differences in average LOS were found between admitted patients (Mean = 544 min, SD = 323 min) and discharged patients (Mean = 291 min, SD = 286 min). In addition, nurse and physician change of shifts and admissions to hospital wards were found to be significant factors associated with LOS. Using an Ishikawa causal diagram, we explored various latent organizational factors that may prolong this time.
  
  
  CONCLUSIONS
  The study identified several factors that are associated with high average emergency department LOS. High LOS may lead to increases in expenditures and may have implications for patient safety, whereas certain organizational changes, communication improvement, and time management may have a positive effect on it. Interdisciplinary methods can be used to explore factors causing prolonged emergency department LOS and contribute to a better understanding of them.
authors.affiliation: Department of Public Health, School of Health Sciences, Ashkelon Academic College, Ashkelon, Israel.
authors.forename: Osnat
authors.initials: O
authors.lastname: Bashkin
authors.affiliation: Department of Emergency Medicine, Hadassah Medical Center-Mt. Scopus, Jerusalem, Israel.
authors.forename: Sigalit
authors.initials: S
authors.lastname: Caspi
authors.affiliation: Department of Industrial Engineering & Management, Azrieli College of Engineering, Jerusalem, Israel.
authors.forename: Rachel
authors.initials: R
authors.lastname: Haligoa
authors.affiliation: Department of Industrial Engineering & Management, Azrieli College of Engineering, Jerusalem, Israel.
authors.forename: Sari
authors.initials: S
authors.lastname: Mizrahi
authors.affiliation: Department of Emergency Medicine, Hadassah Medical Center-Mt. Scopus, Jerusalem, Israel.
authors.forename: Ruth
authors.initials: R
authors.lastname: Stalnikowicz
keywords: Emergency department; Ishikawa causal diagram; Length of stay; Organizational factors