JIMMA UNIVERSITY INSTITUTE OF HEALTH

Determining Length of Stay and Its Associated Factors in the Emergency

Department of Karat Primary Hospital, Konso, SNNPRS, Ethiopia.

A thesis submitted to Jimma University, Institute of Health, Faculty of Public

Health, Department of Health Economics, Management and Policy, for Partial
Fulfillment of the requirements for the degree of Master of Health Care and
Hospital Administration.

BY: ARARSO GARO, (B-PHARM)

A Advisors:

1. Mr. Negalign Berhanu

2. Mr. Melaku Haile

May/2017

Jimma, ETHIOPIA

i
Determining Length of Stay and its Associated Factors in the Emergency
Department of Karat Primary Hospital, Konso, SNNPR, Ethiopia

A thesis submitted to Jimma University, Institute of Health; Faculty of

Public Health, Department of Health Economics, Management and Policy,
for partial fulfillment of the requirements for the Master of Health Care
and Hospital Administration.

BY: ARARSO GARO, (B-PHARM)

ADVISORS:
1. Mr. Negalign Birhanu
2. Mr. Melaku Haile

May/2017

Jimma, ETHIOPIA

ii
 Abstract
Background፤ The emergency department is an important part of a hospital as this department is one of the
points of hospital entrance for patients, a place where life threatening and serious problems are dealt with.
Prolonged ED length of stay is not only a cause but also a result of emergency department crowding,
yielding a vicious cycle. The emergency department length of stay has significant correlation with factors
that contribute to overcrowding in the emergency department. The objective of this study was to determine
length of stay of patients and its contributing factors in the emergency department of karat primary hospital.
Method: Facility based cross-sectional study was employed to collect data from 297 patients. The study
used systematic random sampling by observing the natural journey of every third patient from time of
arrival to exit from emergency department in which first comer was the first to be observed at the beginning
of data collection. Data was analyzed using SPSS version 20.0. Bi-variate analysis was done and variables
with p-value less than 0.25 were included in multiple logistic regressions analysis.
Result: The mean length of stay of Karat primary hospital emergency department was found to be 311.4
(SD=256.2) minutes which is 5.2 (SD=4.27) hours. Boarding ( AOR=4.4 CI (2.4, 8.0)), the treatment
service within the emergency department (( AOR= 5, CI(2.7, 9.4)), radiology service (( AOR= 5.91, CI (3.1,
11.2)) and laboratory test (( AOR= 3.2, CI (1.76-5.98)) significantly affected the emergency department
length of stay of Karat primary hospital.

Conclusion and Recommendation

The emergency department length of stay in Karat primary hospital was found to be long. The main factors
that contributed to the prolonged stay in the hospital were then analyzed and treatment service within the
emergency department, radiology tests, boarding and laboratory tests were finally found to be the most
significant factors that contributed to this prolonged length of stay.

Karat primary hospital management has to improve emergency department service by investing on ways to
identify reasons and ways to reduce boarding time, the laboratory waiting time, has to work hard on ways to
fasten the emergency department treatment services and radiologic investigations so as to improve the
standard of care in the department.

Finally since this research identified factors that contributed to the overall length of stay but did not deeply
searched for the reasons of delay of the main factors, other researchers are recommended to do so.

Key words:-waiting time, radiology tests, and emergency department length of stay, boarding, laboratory
test, treatment service and referrals waiting for ambulance.

iii
 List of Tables
Table 1: Distribution of Emergency cases by socio-demographic characteristics, age, sex, marital status,
religion, Mode of arrival and the first attending health professional in ED of Karat primary hospital, from
March 12-Aprill 27/2017
Table 2: Socio demographic associated with EDLOS of Karat primary hospital, from March 12-Aprill
27/2017
Table 3: Potential factors associated with the ED LOS of Karat primary hospital, from March 12-Aprill
27/2017
Table 4: Multivariate Analysis of factors associated with EDLOS of Karat primary hospital, from March 12-
Aprill 27/2017

iv
List of Figure

Fig1. Patient flow path way in Ethiopian hospitals emergency departments, FDRE MOH, AA, Ethiopia,
2008

Fig 2. Conceptual framework of determining length of stay and its associated factors in emergency
department of Karat Primary Hospital, from March 12-Aprill 27/2017

Fig3. Distribution of Emergency case frequencies by type of cases presenting to ED of Karat primary
hospital, from March 12-Aprill 27/2017

v
List of Abbreviations

AFI: Acute febrile illness

AHA: American Hospital Association
ALOS: Average length of Stay
CCO: Chief Clinical Officer
CEO: Chief Executive Officer
COPD: Chronic obstructive pulmonary diseases
DC: Data Collector
ED: Emergency Department
ED LOS: Emergency Department Length of stay
EHRIG: Ethiopian Hospitals Reform Implementation Guideline
EHSTG: Ethiopian Hospitals Services transformation guideline
KPH: Karat Primary Hospital
KPI: Key Performance Indicator
MHA: Master of Health Care and Hospital Administration
PFA: Patient Flow Analysis
PFCA: Patient Flow Challenges Assessment
PTB: pulmonary Tuberculosis
PI: Principal Investigator
SAPZ: Segen Area peoples Zone
SD: Standard deviation
SMT: senior management team

vi
Acknowledgments

Above all it is a great pleasure and an honor to me to elucidate my deep hearted indebtedness and my great
gratitude to my advisors, Mr. Negalign Berhanu (PHD candidate) and Mr. Melaku Haile (BSC, MPH) who
have devoted their invaluable time while providing honest and valuable guidance and constructive advice.

My appreciation goes to Jimma University, Institute of Public Health and Medical sciences; Department of
Health Economics, Management and Policy.

Finally I would like to gratefully recognize the data collectors, the hospital emergency department staff and
the hospital senior management team as a whole for their valuable cooperation and support during the data
collection process.

Table of Content

vii
Contents Page
Abstract………………………………………………………………………………………………………………......................................I
List of Tables………………………………………………………………………………………………………………………………………… II
List of Figure…………………………………………………………………………………………………………………………………………III
Abbreviations and Acronyms…………………………………………………………………………………………………………………IV
Acknowledgements ……………………………………………………………………………………………………………………………..V
Table of contents………………………………………………………………………………………………………………………………….VI
I. Introduction………………………………………………………………………………………………………………………………………….1
1.1 Statement of the problem……………………………………………………………………………………………………………………2
1.2 Significance of the study …………………………………………………………………………………………………………………..3
II. Literature review…………………………………………………………………………………………………………………………………4
III. Objective ..............................................................................................................................................11
2.1 General objective …………………………………………………………………………………………………………………………… 11
2.1 Specific objectives……………………………………………………………………………………………………………………………11
IV. Methods………………………………………………………………………………………………………………………………….………12
4.1 Study Area……………………………………………………………………………………………………………………………………….12
4.2 Study design…………………………………………………………………………………………………………………………………….13
4.3 Source population…………………………………………………………………………………………………………………………….13
4.4 Study population …………………………………………………………………………………………………………………………….13
4.5 Inclusion and exclusion criteria……………………………………………………………………………………………..…………13
4.6 Sample size………………………………………………………………………………………………………………………………………13
4.7 Sampling procedure…………………………………………………………………………………………………………………..…… 15
4.8 Data collection procedures ………………………………………………………………………………………………………………15
4.9 Study Variables ………………………………………………………………………………………………………………………………16
4.10 Operational definitions. …………………………………………………………………………………………………………………16
4.11 Data Analysis Procedures………………………………………………………………………………………………………………17
4.12 Data quality management………………………………………………………………………………………………………………17
4.13 Ethical considerations…………………………………………………………………………………………………………………….18
4.14 Dissemination of the results ………………………………………………………………………………………………….………18
5 Result ………………….…………………………………………………………………………………………………………………………..…19
6. Discussion………………………………………………………………………………………………………………………………..…………27
7. Conclusion and recommendation………………………………………………………………………………………………………30.
Reference……………………………………………………………………………………………………………………………………….………31
Annexes…………………………………………………………………………………………………………………………………………………..34

viii
 CHAPTER ONE

1. Introduction
1.1 Back ground

The emergency department length of stay (EDLOS) is measured from first arrival of patient to
ED until the patient exits from ED. The ED is an important part of a hospital as this department
is the point of hospital entrance for patients, a place where life threatening and serious problems
are dealt with. Patient flow analysis consists of two aspects, flow mapping which is mapping
what actually happens in the current process in the department and cycle time measurement that
actually computes the waiting times at each point of patient journey which enable investigators
to gain a complete picture of patient journey and identify the factors that contribute to delay in
patient flow in the emergency departments. As the result suitable strategic plans can be designed
to tackle the problems of unnecessary delays in the emergency departments (1).The latter aspect
of patient flow analysis is specifically applied in this study.

The mean ED length of stay is considered a measure of crowding. ED mean LOS (length of stay)
per patient measured from the patient's arrival to departure has been promoted as a surrogate
indicator of crowding in the absence of a standard or universal definition. It is also frequently
considered a key process indicator for performance improvement and clinical and operational
efficiency (2).

Properly designed and implemented hospital based emergency medical care services will reduce
patient emergency triage and treatment times, increase provider efficiency and staff and client
satisfaction as well as improve overall quality of care. Increasing emergency department (ED)
volume and concomitantly ED crowding represents a major problem for health care systems
worldwide. The situation when demand for emergency services outstrips available resources can
be caused by multiple factors. These can generally be considered to be a combination of input,
throughput and output components of ED crowding (3-4).

1
The ED LOS has significant correlation with factors that contribute to overcrowding in the
emergency department. (5).

In ED the time is considered a significant tool to measure the quality as this waiting time can
affect the outcomes of patient situation and satisfaction, as well the problem of long waiting time
can also indicate a poorly resourced, poorly managed and/or poorly co-ordinate department (5).

A number of studies have discussed the adverse impacts of ED crowding, which include
prolonged waiting times, increased complications, and increased mortality. Previous literature
has also demonstrated that prolonged ED length of stay (LOS) is not only a cause but also a
result of ED crowding, yielding a vicious cycle Therefore, it is worthwhile to elucidate the
factors associated with ED LOS in order to alleviate ED crowding and improve quality of care.
Many factors are responsible for ED LOS. Recent studies have shown that increased testing,
consultation, radiology studies, and provision of less substantial treatment cause a significant
increase in ED LOS (26).

The objective of this study was to determine the mean LOS in ED of KPH (Karat Primary
Hospital) and identifying major factors that contributed to the LOS.

2
 1.2. Statement of the problem
Health care facilities worldwide face the challenge of providing high-quality care while
struggling with large patient volumes and process inefficiencies in EDs (2).

Increasing ED volume and concomitantly ED crowding represents a major problem for health
care systems worldwide. The situation when demand for emergency services outstrips available
resources can be caused by multiple factors (3).

A number of studies highlighted factors associated with access block and overcrowding in
emergency departments. They can be categorized in to three phases; namely input (number of
non emergency patients in ED and waiting in triage area), throughput (laboratory tests,
radiological examinations, and the time taken on the decision to admit) and outcome (number of
boarders) (4-6).

The ED LOS has significant correlation with factors that contribute to overcrowding in the
emergency department. Delay in any step of patient flow in emergency department will play an
important role in the development of overcrowding, since it contributes to prolonged stay of
patients in the emergency department (7-13).

In South Africa, Public sector Emergency Departments are under enormous pressure with large
patient numbers, understaffing, poor resources and patients have to wait long time in most
hospitals decreasing waiting time in hospital Emergency Departments in South Africa is one of
the preoccupations of the National Department of Health (14).

Likewise there was apparently visible overcrowding and congestion of people around the ED in
Karat Primary Hospital, but the mean EDLOS as well as its main possible related factors were
not actually known based on scientific evidence.

Furthermore, to the best of the researcher’s knowledge, there is no any published article
regarding patient flow analysis in Ethiopia. Studies done elsewhere might not be done in a
similar context, either. Therefore determining ED LOS and its associated factors in the Karat
primary hospital emergency department is apposite.

3
 1.3. Significance of the study
The findings of this study could serve as baseline for further monitoring of the changes in quality
of service and also provides evidence for hospital management and staff that are engaging in
improving quality of ED services by indicating targeted areas of intervention.

Understanding patient flow in the emergency department in terms of length of stay could help
program managers and decision makers to devise effective health care strategy and operational
plan for the betterment of service.

Therefore the benefits of this research are that it will lead to improvements in patient care at ED
by reducing waiting times since the areas of contributing factors for potential Delayance in the
ED were identified and clear recommendations were given to both the hospital SMT (senior
management team) and the emergency case team members. The hospital can use the results of
this study to improve treatment services, laboratory test services and the way to reduce boarding
in the ED. Even the ED service leaders can use the result of the study so as to improve services
via reducing length of stay in the department. Moreover, this study also initiates further research
in the area.

4
 CHAPTER B TWO

2. Literature review

Emergency patient flow/pathway

Properly designed and implemented hospital based emergency medical care services will reduce
patient emergency triage and treatment times, increase provider efficiency and staff and client
satisfaction as well as improve overall quality of care. Increasing ED volume and concomitantly
ED crowding represents a major problem for health care systems worldwide. The situation when
demand for emergency services outstrips available resources can be caused by multiple factors.
These can generally be considered to be a combination of input, throughput and output
components of ED crowding. Patients entering the hospital through the separate ED entrance, via
ambulance, from the reception desk or those referred to the ED from Central Triage should
undergo Emergency Triage. If further investigations and/or treatments are required following
triage, these should be provided by the Emergency Case Team. Patients that are not classified as
emergency cases should be referred to Central Triage (3).

5
Fig1. Patient flow path way in Ethiopian hospitals emergency departments, FDRE MOH,AA,
Ethiopia,2008 (3)

Emergency Department Length of stay (EDLOS)

Increasing ED volume and concomitantly ED crowding represents a major problem for health
care systems worldwide. The situation when demand for emergency services outstrips available
resources can be caused by multiple factors. The ED LOS is measured from the first arrival to
ED until the patient is admitted or discharged from the ED (4).

6
The ED LOS is measured from the first contact in triage until the patient is admitted or
discharged from the ED. Several studies have identified the role in each step of the patient
journey through the ED and correlated this with an increased in mean of ED LOS. Long waits at
triage is one of the factors that contribute to slow patient flow in the emergency department.
Prolonged time to admit decision results in increased length of stay in ED. An increase in an ED
waiting time therefore results in increased patient length of stay in the ED (5).

In a study done in Kintampo Municipal Hospital in Ghana, the overall total median visit time
from arrival to disposition was 5.2 hours (interquartile range [IQR] = 4.1–6.2 hours; mean = 5.1
hours, SD = 1.6). Additionally, median time between arrival and first-provider contact was 4.6 hr
(IQR = 3.4 –5.6 hours; mean= 4.4 hours, SD = 1.6). Longest wait times were between arrival and
registration (median= 2.3 hours, IQR = 1.4–3.2 hours; mean= 2.2 hours, SD= 1.3) and between
history taking and first-provider contact (median = 1.4 hours, IQR = 0.7–2.1; mean = 1.5 hours,
SD = 1.1). Other long delays were noted between registration and triage, and between l aboratory
testing and processing for treatment at the ED (6).

Another research conducted in two different hospitals namely: the VU Medical Center (VUmc),
an academic level 1 trauma centre run and the St. Antonius Hospital, a large community hospital
in Nieuwegein, Netherlands, in 2015, it was found that 89% of the patients in VUmc had a
completion time 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
(n=1655) was 2:49 (median 2:34, range: 0:08 – 11:04) (7).

In Singapore, the patient length of stay in the ED was variable. The majority of EDs (77%)
reported an average length of stay of between 1 and 6 hour. No ED reported an average length of
stay of over 6 hour (7). For the 7604 patient visits analyzed in Saudi Arabia, Emergency
Department of Al-Noor Specialist Hospital, the mean ED LOS was 3.02 hour (SD = 5.03 hour).
About half of the patients spent less than 59 minutes (44%), 32.6% spent 1 to 3:59 hour, 15.2%
spent 4 to 7:59 hour, and 8.2% of the patients spent more than 8 hours (8).

7
According to study conducted in ED of Saint Rita’s Hospital of South Africa in 2010, the total
EDLOS was 397 minutes which was about 6.6hours(14).

In general the internationally recommended benchmark ED LOS range in minutes is 120-

240.Likewise the recommended time for Waite to triage, time for the triage processing,
Laboratory turnaround time, Radiology turnaround time and boarding time are 0, 10, 30-40, 20-
30,and 24 all in minutes respectively(9).

Factors contributing to disruption of patient flow in emergency department

The ED LOS has significant correlation with factors that contribute to overcrowding in the ED.
Delay in any step of patient flow in ED will play an important role in the development of
overcrowding, since it contributes to prolonged stay of patients in the ED (5).

A number of studies highlighted factors associated with access block and overcrowding in EDs.
They also identified the role in each step of the patient journey through the ED and correlated
this with an increased in mean of ED LOS. Long waits at triage is one of the factors that
contribute to slow patient flow in the ED. Prolonged time to admission decision results in
increased LOS in ED. An increase in an ED waiting time therefore results in increased patient
LOS in the ED (6).
Socio-demographic factors

According to the study conducted in Teledo university Medical center ED in USA, entitled
“Emergency Department Length of Stay: Accuracy of Patient Estimates” in 2012, there was no
statistically significant difference detected between male (−7 minutes (IQR −26, 14)) and female
(−8 minutes (IQR −31, 12)) estimations of their LOS compared to their actual total LOS. For age
also, there was no statistically significant difference detected between patients under age 60 (−8
minutes (IQR −29, 12)) and those older than 60 (−5 minutes (IQR −16, 8). In this study, there
was no statistically significant difference between gender, age, education and other socio-
demographic characteristics (10).

8
 Laboratory tests
The other factor that determines ED progression is the throughput phase. Two studies that
recently investigated patient flow have shown that laboratory blood tests significantly impede
patient flow during the throughput phase (13).

Turnaround time (TAT) is one of the most noticeable signs of laboratory service and is often
used as a key performance indicator of laboratory performance and a 90% completion time of
<60 minutes for common laboratory tests is suggested as an initial goal for acceptable TAT (14).
According Multihospital Longitudinal Study conducted in New south Wales and Australia
entitled “The Effect of Laboratory Testing on Emergency Department Length of Stay, 2015“, an
average ED waiting time was 5.57 hours. Regression analysis showed that each minute of
increased laboratory turnaround time increased ED LOS by 7 minutes. They found that as the
number of laboratory test order episodes increased, so did the duration of patient ED LOS
(p < 0.0001). For every five additional tests ordered per test order episode, the median ED LOS
increased by 10 minutes (2.9%, p < 0.0001); each 30-minute increase in TAT was, on average,
associated with a 5.1% (17 minutes; p < 0.0001) increase in ED LOS, after adjustment for other
factors (14).

A research conducted in ED of a teaching hospital in Iran in 2016 showed that the mean total
laboratory turnaround time of all tests ranged from 1.3 to 3.1 hour (15).

Radiology service waiting time

The measurement of turnaround times is the most commonly adopted performance metric to
gauge the success of radiology service today. Prolonged radiological examinations waiting times
also considered as factors that significantly impede patient flow during the throughput phase
(16).

Research has cited laboratory and radiology delays as one of the causes of increased waiting time
in EDs. Delays from these two services have been included in the list of “Bottleneck” culprits in
EDs (17).

9
 Boarding
The other factor that previous studies reported as a significant determinant of ED LOS is
boarding. Prolonged time to admission decision results in increased LOS in ED. According to

Study conducted on the topic “Prolonged length of stay in the Emergency department in high-
acuty patients at a Chinese tertiary hospital,, it was found that patients with a boarding time of
more than two hours are associated with prolonged ED LOS (18). In a study conducted by Khare
in 2009, it was demonstrated that decreasing boarding time without adding more beds in the ED
can reduce LOS from 240 to 218 minutes (19). Another study conducted by other scholars,
namely Bair and Powell found that delay associated with boarding is one of the most significant
factors associated with prolonged EDLOS (20).

Consultation service
A study conducted at two tertiary Canadian EDs on the impact of consultation on length of stay
in tertiary care emergency departments, in 2013; found that consultation time contributes
significantly to ED LOS. The study was entitled “The impact of consultation on length of stay in
tertiary care emergency departments, and concluded that consultation time contributes
significantly to ED LOS. According to this study, median time from for consultation accounted
for approximately 28% of the total median LOS in admitted patients compared to 46% for
discharged patients. Consultation time accounted for 33% and 54% of the LOS for admitted and
discharged patients, respectively (21).

This paper measures the association between LOS and factors that potentially contribute to LOS
measured over consecutive shifts in the ED of KPH.

10
 CONCEPTUAL FRAMEWORK OF THE STUDY

Treatment Boarding

Laboratory tests

ED LOS Socio-
demographic
Radiologic tests Characteristic
s

Referral waiting
Consultation
for ambulance

Fig2. Conceptual frame work of determining length of stay and its associated factors in the
Emergency Department of Karat Primary Hospital, Konso, SNNPR, Ethiopia, 2017.

11
 CHAPTER THREE

Objective

3.1 General objective

To determine EDLOS and its associated factors in karat primary hospital Emergency department,
Konso Woreda, Segen Area peoples Zone, SNNPRS, April/ 2017

3.2. Specific objectives

1. To determine the overall average length of stay in the ED of Karat primary hospital
Emergency department, Konso Woreda, Segen Area peoples Zone, SNNPRS, April/
2017.
2. To identify factors that have significant contributions to the LOS in Karat primary
hospital Emergency department, Konso Woreda, Segen Area peoples Zone, SNNPRS,
April/ 2017.

12
 CHAPTER FOUR

3. Methods
4.1 . Study Area and period

Konso is one of the Woredas in Segen Area Peoples Zone, Southern Nations and Nationalities
and People’s Regional State which is 595 Kms from the capital of the country and 365kms away
from Hawasa, the capital of the region. The people of Konso are named Konsita, as the name
originated from the name of the Woreda. The language is Konsigna. The population lives in 41
traditional rural towns locally known as Paleewwa and two modern small towns of which Karat
is the capital of the Woreda (22).

The population of Konsita is estimated to be 269,119of which 131,668 males and rest are
females (23).

Karat primary hospital is the only hospital in the woreda. On the top of the organizational chart
of the hospital is the governing board which is led by the chief zonal superintendent and the
hospital chief executive officer (CEO). The structure then divided in to two broad areas called
the clinical and non clinical service directors. The clinical service of the hospital is directed by
the chief clinical officer (CCO) who monitors the clinical services being provided by the
outpatient which in turn is directed by the outpatient service director, the service being provided
by the inpatient service department directed by the inpatient service director and the other broad
service area in the hospital, emergence service area, led by the Emergency service director.
There are also other service areas that are nominated as case teams which include the pharmacy
case team, laboratory case team, Delivery case team, OR case team and Medical record room
that are directly accountable to the CCO. There is also environmental health department directly
accountable to the CCO (23).

On the other hand the non clinical part of the organizational chart includes the laundry case team,
the meal preparation case team, the housekeeping case team, the guards’ case team, and the
gardeners’ case team who are accountable to the facility manager and the finance and
procurement case team, the ethics office, the internal auditor the, human resource management,
the human resource records and statistics office all are accountable to the non-clinical service
director who in turn is directly accountable to the CEO (23).

13
Among the major service areas of the hospital, Emergency department is the central and is given
an attention by the senior management so as to improve service quality. There are 4 nurses, 5
Health officers and on general practitioner regularly assigned in the ED serving an average daily
patient flow of 30 patients (23).

The data collection procedure started on March 12 and completed on April27/2017 G.C, until
when the predetermined representative was reached.

4.2. Study design

Facility based cross-sectional study design using quantitative method of data collection was
employed to gather fundamental information about those factors contributing to the LOS in the
ED of the hospital.

4.3. Source population

All emergency patients visiting the hospital ED during the data collection period.

4.4. Study population

 Selected patients in the source population who visited the ED during the study period
(April/2017)
4.5 Inclusion and exclusion criteria
4.5.1. Exclusion criteria
 Patients triaged at central triage but are sent to ED because time spent at central triage is
out of this study.
4.5.2. Inclusion Criteria
 Patient triaged at emergency triage room
4.6 Sample size

By considering p=50%, the following formula was used to calculate sample size for single
population proportion and making the following specific assumptions 95% confidence interval;
Zα/2=1.96 and 5% margin of error (d=0.05), the sample size was calculated as follows:

14
 :

n = (1.96)2 (0.5)(0.5)
(0.05)2
n = 3.84x0.25
0.0025
n =0. 96/0.0025=384
But since monthly average of emergency room attendance is 920(25) to mean the source
population N is finite and less than 10,000; the sample size will be adjusted using the formula;
n= n0/ (1+n0/N)
n=n0/ (1+384/920)
n=384/ (1+0.42)
n=384/1.42
n=270
By adding 10% , of this sample size; i.e 10% of 270which is
10/100 x 270=27; a total of 270+27=297 was the final sample size determined.
4.7 Sampling procedure
In the process of selecting study participants that represented the population so as to make
inference about the population, this study used the systematic sampling technique by observing
the natural journey of every third patient from time of arrival to exit from the ED either via
discharge or admission to the ward. The first comer every day at the beginning of data collection
has been the first to be observed. This was made on the first day of the data collection period
when the first patient to be included in the study was identified by lottery method and is made to
include every third patient since the average daily patient flow of ED was 30 and 10 study
participants have planned to be observed every day (i.e K= 30/10=3, the first by lottery and then
every third patient to observe at least 10 patients per 24 hours).

15
4.8 Data collection procedures

Observational method of data collection was used and the data collectors were expected to
collect the data only by registering the arrival and exit times of the emergency patient to and
from the ED with few interviews about the demographic data from the patients or otherwise from
care givers if the patient is a child or unconscious that cannot communicate. The data therefore
was collected using the data collection tool by trained health professionals from Gidole primary
hospital ED. The recruited health professionals collected the data using a data collecting tool
(annex 5) which was adopted from a research done in Indonesian ED of a major teaching
hospital(1). The patients were also observed and registered for the need for consultation,
laboratory tests, radiology test, boarding if patient was to be admitted.

Every day, six data collectors were assigned in such a way that a group of two observers
collected data with eight hours intervals shift until the number of patients to be observed per day
reaches. The data collection started early in the morning from 8:00 AM and continued over 24hrs
in such a way that the first group collected the data from 8:00 AM to 4:00 P.M, the next group
from 2:00 P.M to 10:00 P.M and the last group collected from 10: 00 P.M to 8:00AM.

Every day while the data collectors observed patients, were supervised by the trained and
recruited supervisor where every morning all the six data collectors were have meeting with the
supervisor so as to report if they faced any problem in the preceding day of data collection and
then have been submitting the filled data collection tool.

The data collectors were then being provided with new data collection tool every morning by the
supervisor. The supervisor has been submitting the filled data to the principal investigator every
week on Monday and then has been receiving new tools for a week. Since all data collectors
have had mobile phone, no any other watches. At the point of starting data collection, every data
collector has been making his/her stopwatch on and offs it exactly at the time patient leaves the
ED there by registering the final time. The data collectors simply have been following the tool
by registering the start and end time and finally they were subtracting the initial time from the
exit time so as to come up on the LOS of each individual in hours and minutes.

16
The time measurement format used was the one that measures time over 24hours i.e it was a
24hours format. At the beginning, every data collector was given a pen and a pencil to fill the
tools.

4.9. Study Variables

4.9.1 Dependant Variable
 Emergency department length of stay (ED LOS)
4.9.2. Independent variable

 The Sociodemographic characteristics (age, sex, religion…)

 Laboratory tests
 Radiology tests
 ED consultation
 Type of emergency patient (AFI, COPD, Diarrhea with dehydration, traffic accident…)
 Boarding
 Referral waiting for ambulance
 Treatment service within ED

4.10. Operational definitions

The following defined terms were used throughout this paper.
 ED LOS: The primary outcome for this study which was the measure time in minute from
the moment of patient arrival until discharged or, if admitted, until the time the patient left
the ED that latter used to compute the mean length of stay in the department.
 Arrival time:-the first recorded time of contact between the patient and emergency triage
nurse/Health officer/doctor.
 Boarding patient: - patient who remains in the ED after he/she has been admitted, but has
not been yet transferred to an inpatient unit.
 Triage time:-is the time from when the patient arrives in the ED to when the emergency
triage nurse/Health officer/doctor completes triage assessment and determines the patients
triage category.

17
 An emergency patient: is a patient suffering from medical, surgical or any other health
related condition that are sudden and, at the time, unexpected and requires immediate
medical treatment and/or an operation.
 An Emergency department: is a unit where the emergency patient is served.
 Referrals waiting for Ambulance: - Referred patients waiting for ambulance to leave the
hospital ED and transported to other higher health institution.
 Treatment time:- The measure of time the patient enters ED just after triage until the
responsible health professional decides admission, discharge or referral during when
emergency treatment is being provided.
 Consultation service time: The time from when the first attending health professional
decided for consultation by the higher special professional, General practitioner in the case of
KPH, to the time when the consultant doctor completes and handovers the patient back to the
attending professional.
 Left ED- The time at which an admitted or transferred patient physically leaves the Emergency
Department treatment area.

4.11 Data Analysis Procedures

Data was checked and cleaned for completeness and accuracy every day after data collection by
the supervisor and every week by the principal investigator and finally after the completion of
data collection it was entered into SPSS version 20. First, descriptive analysis of the
demographic data was conducted and then the mean length of stay computed over which the
contributing factors were analyzed.. Secondly, bivariate analysis was done and variables with p-
value less than 0.25 were included in multiple logistic regressions analysis

Based on the internationally recommended mean ED LOS, 240minutes (9), using this mean as a
cut of point, LOS of less than or equal to 240minutes was taken as a normal range and the one
greater than this internationally recommended benchmark taken as an abnormal range. Each
covariate of ED LOS was then compared over these categories or ranges by their odds ratio
within 95% confidence intervals.

4.12 Data quality management

18
The data collecting tool once developed in English, data collectors were oriented on the data
collection process and pre-testing of the tool was made at Gidole Primary hospital ED on 15 (i.e
5% of sample population) patients before the actual data collection. Each collected data has been
checked on spot during the data collection period. A stop watch standard was used by every data
collector to control the starting and end time of each patient.

4.13 Ethical considerations

Ethical clearance was obtained from the concerned body of the university, the Institutional
Review Board; Permission for the study was then obtained from Segen Area peoples zonal
Health Department and Karat Primary Hospital before the actual data collection. The clients and
concerned staff were informed on the objectives of the study, benefits and requested for consent.
The data was collected in a way to ensure confidentiality of the study participants. Information
which explains the study purposes, benefit, methods was indicated on the data collection tool to
ensure informed consent of the patients to be involved in the study.

In addition to the consent of the clients, the care providers were also informed on the objectives
of the study, procedure, purpose and benefits and requested for consent.

19
 CHAPTER FIVE
Results

5.1 Socio-demographic characteristics

During the 45-day study period, 297 (with 100% response rate) patients were observed in the ED
and all of them were included in the analysis where the age of the patients ranged between a
month to -90 years with a mean age of 28.6 years with SD + 19.11.. From the total of 297
patients included in the study, 51.15 were females and the rest were males. The majority of the
patients observed were married, 172 (57.9%) followed by those who were single (30.3%). The
total number of the protestant religion followers is more than half of the total clients, 63.3%
followed by orthodox which accounts for 23.3% of the study population. The most common
arrival mode is public transport. Ambulance was the second most common arrival mode. On foot
transport is the smallest in proportion, with only four patients (1.3%). Health officer was the
most predominantly first contact serving professional who evaluated and managed 232
emergency patients (78.1%). Clinical Nurses saw the least number of the emergency patients
(only 4.7%) of the total study participants (Table 1).

20
Table1. Distribution of Emergency cases by socio-demographic characteristics, age, sex,
marital status, religion, Mode of arrival and the first attending health professional in ED of Karat
primary hospital, from March 12-Aprill 27/2017
Variable
Age category in years Frequency Percent
0-14 60 20.2
15-64 219 73.7
>=65 18 6.1
Total 297 100
Sex
Male 143 48.15
Female 154 51.85
Total 297 100
Marital status
Single 90 30.3
Married 172 57.9
Widowed 22 7.4
Divorced 13 4.4
Total 297 100
Religion
Protestant 188 63.3
Orthodox 70 23.6
Muslim 20 6.7
Others 19 6.4
Total 297 100
Mode of Arrival to ED
Public transport 251 84.5
Ambulance 42 14.1
On foot 4 1.3
Total 297 100
First attending health professional
Health officer 232 78.1
General Practitioner 51 17.2
Clinical Nurse 14 4.7
Total 297 100
The following figure describes the type of patient cases involved in this study. The majority of
the patients were presented with Acute febrile illness, AFI (85, 28.6%), followed by Chronic
obstructive pulmonary disorders, COPD (51, 17.2%), diarrhea with dehydration (43, 14.5%) and
21
traffic accident (38, 12.8%). The rest of the type of cases all together account only for 26.9% of
cases.

90

80

70

60
Frequency

50
85
40

30
50
42
20 38
31
10 21
9
5 4 3 3 3
0 1 1 1

Ttype of emergency case

Fig3. Distribution of Emergency cases by type in Karat primary hospital, from March 12-Aprill
27/2017
The Mean ED LOS of KPH

The mean ED LOS of KPH was finally found to be 311.4 minute which is 5.2 hours which is one
hour longer than the internationally recommended mean, 4houurs. Among the total sampled
population, 153(51.5%) were served within the internationally recommended mean length of
stay, 240minutes, and the rest 144 (48.5%) stayed in the department for more this recommended
benchmark.

22
 Bivariate analysis
Table 2: Socio demographic associated with EDLOS of Karat primary hospital, from March 12-
Aprill 27/2017

Variables EDLOS COR(95%CI) Sig

Normal range, n(%) Abnormal

range
Sex
Male 74 (51.7%) 69(48.3%) 0.9 (0.65, 1.61) 0.916
Female 79 (51.3%) 75(48.7%) 1
Age in years
0-14 36 (60%) 24 (40%) 1.5 (1.2, 2.61) 0.052*
15-65 111 (50.7%) 108(49.3) 2.0 (1,9) 0.164*
>=65 6(33.3%) 12(66.7%) 1
Marital status
Single 41 (45.6%) 49 (54.4%) 0.53 (0.15, 1.9) 0.321
Married 96 (55.8%) 76(44.2%) 1.35 (1.2,1.4) 0.092*
Widowed 12 (54.5%) 10 (45.5%) 1.37 (1.3,1.6) 0.178*
Divorced 4 (30.8%) 9 (69.2%) 1 11
Religion
Protestant 98 (52.1%) 90 (47.9%) 1.3 (0.47, 3.3) 0.632
Orthodox 33(47.1%) 37(52.9%) 1.5 (0.55, 4.3) 0.406
Muslim 11 (55%) 9 (45%) 1.13 (0.32,4) 0.855
Others 11 (57.9%) 8 (42.1) 1 1
Mode of Arrival
Public transport 128(51%) 123 (49%) 0.96 (0.13,6.9) 0.968
Ambulance 23 (54.8%) 19 (45.2%) 0.82 (0.11, 6.4) 0.826
Others 2 (50%) 2 (50%) 1 1
First Attending health professional
Health officer 117(50.4%) 115 (49.6%) 1.8 (0.58, 5.4) 0.319
General practitioner 27 (52.9%) 24 (47.1%) 1.6 (0.47, 5.4) 0.452
Clinical Nurse 9 (64.3%) 5 (35.7%) 1

23
 The table above showed that among the socio- demographic characteristics age from 15-65 (p-
value =0.164) and from marital status, Married (p-value=0.092) and Widowed (p-value=0.178)
had fulfill the multivariable analysis criteria (P. value below 0.25) and hence became candidates
for the latter analysis. All others were found to have not been statistically significant.

Table 3: potential factors associated with the ED LOS of Karat primary hospital, from March
12-Aprill 27/2017

Factors of EDLOS EDLOS COR(95%CI) P.value

Normal range, n(%) Abnormal

range
Laboratory test
No 104(57.1%) 78(42.9) 1 1
Yes 35 (41.2%) 50 (58.8)% 1.8(1.12, 2.3) 0.015**
Consultation service
No 125(54.6) 104(45.4) 1
Yes 28(41.2) 40(58.8) 0.33 (0.1, 3.1) 0.353
Radiology service
No 126 (62.4) 76 (3.6) 1 1
Yes 27 (28.4) 68 (71.6) 4.2 (2.5, 7.1) 0.001**
Treatment service in the ED (time in minutes)
<120minutes 127(62.9) 75(37.1) 1 1
>=120minutes 26(27.4) 69(72.6) 4.5(2.6, 7.7) 0.000****
Boarding
No 120 (60.3) 79(39.7) 1 1
Yes 33(33.7) 65(66.3) 3 (1.8, 4.9) 0.000****
Referral waiting for ambulance
No 143(55.0) 117(45.0) 1 1
Yes 10 (27.0) 27 (73.0) 0.3(0.2, 2.1) 0.402
Key; *** for p-value<0.005, ** for p Value=0.005, * for 0.005<p-value<0.05

The table clearly illustrates the association between the ED LOS and the factors that contribute
for the hospital ED. Except consultation service (P=0.353, 95%CI (0.1, 3.1)) and Referral
waiting for ambulance (p=0.402, and 95%CI (0.2, 2.1), all other listed variables fulfilled the
multivariable candidate selecting criteria and the majority affected the LOS significantly.

24
 Multivariable analysis
Table 4: Multivariable Analysis of factors associated with EDLOS of Karat primary hospital,
from March 12-Aprill 27/2017 G.C

Variable EDLOS in minutes COR AOR (95%CI) Sig

Normal Abnormal
Range Range
Age of the patient
36 24 1.22 (0.62, 4.42) 0.580
0-14 1.5
111 108 2.9 (0.7, 11.9) 0.160
15-65 3
6 12 1
>065 1
Marital status
41 49 0.775
Single 0.53 0.82 (0.2,3.2)
96 76 0.699
Married 0.35 0.77 (0.2, 3)
12 10 0.342
Widowed 0.37 0.43 (0.08, 2.4)
Divorced 4 9 1 1
Boarding
No 120 79 1 1
Yes 33 65 3 4.4 (2.4, 8.0) 0.000***
Radiologic tests
No 126 76 1
Yes 27 68 4.2 5.91 (3.1, 11.2) 0.001***
Laboratory tests
104 78 1
No 1
35 50 3.2 (1.76, 5.98) 0.000
Yes 1.8
Treatment service
<120 minutes 127 75 1 1
>=120 minutes 26 69 4.5 5(2.7,9.4) .004**

25
 CHAPTER SIX
Discussion

Emergency Department Length of stay, the ED LOS

The Mean EDLOS of Karat primary hospital was found to be 5.2 hours, higher than the result of
the study done in Saudi Arabia which was 3.2hours (5) but was exactly similar to a study done in
Kintampo Municipal Hospital in Ghana, where the overall total median and mean visit time from
arrival to disposition were found to be 5.2 hours and 5.1 hours respectively (6) but was found to
be greater than the average EDLOS in Netherlands which was found to be only 2.1 hours (7).
But when it is compared with the mean EDLOS of Singapore which was less than 6 hours (8) it
was found to be similar. The mean was found to be higher than the maximum international
standard benchmark for EDLOS which is 4hours (9).The discrepancy might be due low attention
given to the EDs in our country as compared to other countries around the world. Even no single
published article was found to be conducted concerning the issue as to the best of the
researchers’ knowledge.

The result of the study showed that the EDLOS in karat primary hospital is prolonged enough
that identification of the factors associated with the stay and hence planning to tackle with the
primarily influencing factors is of paramount importance.

1. The factors that contributed to the ED LOS in karat primary hospital

The finding of this study showed that boarding (P=0.000), Radiology tests (P=0.001), laboratory
tests (p=0.000) and treatment in the emergency department (p=0.004) significantly associated
with ED LOS as displayed on multivariate analysis result (Table 5). Even though the Bivariate
analysis showed that age and marital status were to be further analyzed by multivariable analysis,
the latter analysis finally removed them and hence these two variables no more affected the
EDLOS of Karat primary hospital because there was no statistically significant difference
detected between patients under age 14 years (P=0.580, 95% CI(0.62,4.42)),15-65 years (P=
0.160, 95%CI (0.7, 11.9) and above age 65 years . This was comparable to a study conducted
in Toledo university Medical center ED in USA which concluded that there was no statistically
significant difference detected between patients under age 60 (−8 minutes (IQR −29, 12)) and

26
those older than 60 (−5 minutes (IQR −16, 8). In this study, there was no statistically significant
difference between gender, age, education and other socio-demographic characteristics (10).

A. Boarding
Boarding, the waiting time for bed availability, which is measured when the emergency
department physician decides for admitting the patient to ward and requests an inpatient bed to
when the patient is moved from the emergency department to its assigned ward bed was found to
be one potential factor for the prolonged EDLOS in the health facility as those patients who
waited for bed availability stayed about 4 times (95% CI ( (2.4, 8.0), p=0.000) more than those
who were not boarded or admitted. The contribution of boarding time to the LOS is in line with
other studies which reported that delayed inpatient bed availability could make a significant
contribution to prolonged ED LOS. Previous studies reported boarding time as a significant
determinant of ED LOS. It was found that patients with a boarding time of more than two hours
are associated with prolonged ED LOS (18). Another study also demonstrated that decreasing
boarding time without adding more beds in the emergency department can reduce LOS from 240
to 218 minutes (19). The result of this study is hence comparable to the latter study demonstrated
in that out of the 98 admitted patients 66.3% (n=65) fall in the abnormal range of the EDLOS
and only 33.7% (n=33) stayed within the normal range and hence decreasing boarding time
potentially decreases the total EDLOS.

B. Laboratory tests
The most significant bottleneck that contributes to a prolonged length of stay in Sanglah hospital
emergency department, a general teaching hospital in Indonesia was found to be the mean
laboratory tests turnaround time compared to other variables like radiology, consultation time
and waiting for bed availability (1). The result of this study similarly showed that laboratory
investigation significantly contributed to the ED LOS in konso, karat hospital.
According to this study, those patients who were ordered for laboratory tests waited in the ED by
about 3 times ((P=0.000, 95%CI (1.76, 5.98) more than those who were not ordered to be tested
at the central laboratory of the hospital. The result of this study was supported by other previous
studies which found that shortening laboratory turnaround time and hence completing the
laboratory tests within short period of time can significantly reduce the EDLOS (14). Even

27
though there is no nationally or internationally published studies showed the relationship
between EDLOS and treatment time /resuscitation time within emergency department
resuscitation room, this study showed that treatment service in the emergency department
significantly contributes to the overall EDLOS. Those patients who are treated for more than 120
minutes, taking 50% percent of the internationally recommended total LOS as a cut of point,
waited in the department 5 times ((P=0.004, 95%CI (2.7,9.6)) more than those who were treated
treatment time shorter than 120 minutes in the resuscitation room of the emergency department.
C. Radiologic tests
According to the finding of this study, after adjusting for other factors, those patients who were
served at radiology department for their radiologic investigations around 6 times (95%CI (3.1,
11.2), P=0.001) more stayed than those who were not ordered for radiologic examinations and
the statistical test hence confirms that this service was significantly associated with the ED LOS.
This is hence comparable to a research that has cited laboratory and radiology delays as one of
the causes of increased waiting time in EDs. Delays from these two services have been included
in the list of “Bottleneck” culprits in EDs (17).

Limitations of the study

The observational prospective study may lead the care providers to give better service than usual
because they are being observed that may have an effect on the result of the study.

The study was also limited to the major services related that are directly related to the emergency
department services, but not dug in to the root causes of the main factors.

Though grouping may help data presentation, notably in tables, considering the impact of
converting continuous data to two groups (dichotomizing), as this is the most common approach
in clinical research, because it greatly simplifies the statistical analysis and leads to easy
interpretation and presentation of results (24), dichotomizing leads to loss of information, so the
statistical power to detect a relation between the variable and patient outcome is reduced. It may
lead to underestimation of the extent of variation in outcome between groups, such as the risk of
some event, and considerable variability may be occurring.

28
 CHAPTER SEVEN

Conclusions and recommendations

7.1 Conclusions
The EDLOS of KPH can be concluded as a prolonged ED LOS since it was found to be greater
than the internationally recommended mean benchmark, 4 hours by more than an hour. The main
factors that contributed to the EDLOS in karat primary hospital were found to be boarding;
consultation service, referrals waiting for ambulance, laboratory tests, radiology tests and
treatment time in the ED resuscitation room since they were found to be the most significantly
contributing factors to the prolonged length of stay in the ED. The result of this study has an
implication of reducing overcrowding on certain service points during taking care of emergency
patients in the hospital.

7.2 Recommendations
 The hospital senior management team has to work hard to find causes of boarding so that
admitted patients leave the ED as sooner as possible.
 The hospital has to find causes of delay of patient at laboratory service area and find ways to
reduce the delay time so that patients will be served as fast as possible keeping the quality of
care ensured.
 The hospital as well as the radiology department have to identify reasons of delay of patients
at radiology department in order to serve patients from emergency patients as sooner as
possible.
 Finally this research identified factors that contributed to the overall length of stay such as
laboratory service, treatment in the ED, boarding and the like but not deeply searched for the
reasons of delay at these service points. This is left for other researchers due to cost and time
constraint.

29
 Annexes

References

1. P. Budiarsana, Description of patient flow in an Indonesian Emergency Department of a

Major teaching hospital, The University of Adelaide, October 2015
2. Niels K, et al, Time Series Analysis of Emergency Department Length of Stay per 8-Hour
Shift, West J, Emer Med, May,2012.
3. Federal Democratic Republic Of Ethiopia Ministry Of Health, Ethiopian Hospital Services
Transformation Guidelines Volume 1, September 2016
4. Juliane Lauks, et al, Medical Team Evaluation: Effect on Emergency Department Waiting
Time and Length of Stay in the emergency department of the University Hospital Basel, an
urban 700-bed tertiary care centre in the north-western region of Switzerland., PLOS, Aprill
2016
5. Hassan Bukhari, et al, Analysis of Waiting Time in Emergency Department of Al-Noor
Specialist Hospital, Makkah, Saudi Arabia, Open Journal of Emergency Medicine, 2014

6. Cinnamon A Dixon, et al, Patient Flow Analysis in Resource-Limited Settings: A Practical

Tutorial and Case Study, Global Health: Science and Practice, March 2015
<WWW.ghspjournal.org>

7. I. Vegting1, What are we waiting for? Factors influencing completion times in an academic
and peripheral emergency department, The Netherlands Journal of Medicine, Feb, 2015.

8. Leana S Wen, et al, National inventory of emergency departments in Singapore, International

Journal of emergency Medicine, 2012.

9. K Banerjea et al, Waiting and interaction times for patients in a developing country accident
and emergency department, Emergency Medical Journal, 2006.
10. Brendan T. et al, Emergency Department Length of Stay: Accuracy of Patient Estimates,
Western Journal of Emergency Medicine, March,2014
11. Houston, et al, Waiting for Triage; Unmeasured time in patient flow; Western Journal of
emergency Medicine volume 16, 2015
12. Melinda Lyons, et al, Factors that affect the flow of patients through triage,Emerge Med J. Fe
2007

30
13. Ling Li, et al, The Effect of Laboratory Testing on Emergency Department Length of Stay: A
Multihospital Longitudinal Study Applying a Cross-classified Random-effect Modeling
Approach, Academic Emergency Medicine, Jan, 2015.

14. Ling Li, et al, Multihospital Longitudinal Study conducted in New south Wales and Australia
entitled “The Effect of Laboratory Testing on Emergency Department Length of Stay: A
Multihospital Longitudinal Study Applying a Cross-classified Random-effect Modeling
Approach, Academic emergency Medicine, 2015“,

15. Hamideh Mahdaviazad, et al, Turnaround Times for Hematology and Chemistry Tests in the
Emergency Department: Experience of a Teaching Hospital in Iran, Shiraz E Medical
Journal, April, 2016.
16. A Sheridan Company, Deliver final reports within contracted TATs, Radisphere, 2011.
17. Cinnamon A Dixon, et al, Patient Flow Analysis in Resource-Limited Settings: A Practical
Tutorial and Case Study, Global Health: Science and Practice, March
2015<WWW.ghspjournal.org>
18. Ye, et al, Prolonged length of stay in the Emergency department in high-acuty patients at a
Chinese tertiary hospital; Emergency Medicine Australasia volume 24,2012
19. Khare, et al, Adding more beds to the emergency department or reducing admitted patients
boarding times which has a more significant influence on emergency department congestion;
Annals of Emergency Medicine volume 53, 2009
20. Bair, et al, The Impact of Inpatient boarding on Emergency department crowding: A discrete-
event Simulation study, in a 42nd ANSS,2009
21. Brick C, et al, The impact of consultation on length of stay in tertiary care emergency
departments, PUB MED, Feb, 2014.
22. Karat primary hospital KPI report, Konso Woreda, SAPZ, SNNPR, 2015/2016.
23. Karat primary hospital strategic plan, Konso Woreda, SAPZ, SNNPR, 2015/2016-2020
24. Douglas G, Altman The cost of dichotomizing continuous variables, Statistics in
Medicine, may 2016.
25. Peter Jones, et al, The four hour target to reduce emergency department ‘waiting time’: A
systematic review of clinical outcomes, Emergency Medicine Australia, sep,2010

31
26. Chaou, et al, Analyzing Factors Affecting Emergency Department Length of Stay Using
a Competing Risk-accelerated Failure Time Model, Medicine፣ April 2016

Questionnair

1. Information Sheet
Greetings
My name is________________
This is to give you information regarding a study designed to determining emergency department length
of stay and its associated factors and hence the quality of care in karat primary hospital, Konso Karat in
collaboration with Jimma University institute of Public health and medical sciences MHA coordinating
office. The aim of the study is to generate evidence on the emergency department length of stay and
factors influencing length of stay in the hospital. The study will have a benefit in the effort to improve the
quality service by the stakeholders and can influence decision makers.

The staff has the right for partial or non participation for the data collection. There is no risk for
participating in the data collection and confidentially of the respondent will be maintained as the name is
not required on the data collecting format.
2. Informed Consent
This is to respectfully requesting you to participate on this study. You can have full control to take time to
understand and decide whether or not to take part on the study. You are also not obliged to answer a
question you don’t want to and you may end the interview at any time you want to.
However, your cooperation and genuine response for the study is highly appreciated. The interview
together with the observation may take minutes to hours to complete the tool.
3. Contact detail of the Investigator
If you want to know more about the study you can contact the principal investigator of the study

32
ArarsoGaro through a mobile phone numbers +251-941-86 60 15, or an e-mail: address of
[email protected].
If you have any question that you want to ask us about the study; you are welcome!

4. Consent Form for the client

Observer: Please provide a paper copy of the Consent Form to the clients and concerned staff and explain
it.
With due understanding of the abovementioned information, I am willing to participate in the study?
(Yes) Check box: ☐=> Proceed (No) Check box: ☐=> Stop
Name of the observer: ______________________ Signature __________ Date __/__/______
Name of the supervisors: ______________________ Signature __________ Date __/__/______

5. Consent Form for the staff

Observer: Please provide a paper copy of the Consent Form to the clients and concerned staff and explain
it.
With due understanding of the abovementioned information, I am willing to participate in the study?
(Yes) Check box: ☐=> Proceed (No) Check box: ☐=> Stop
Name of the observer: ______________________ Signature __________ Date __/__/______
Name of the supervisors: ______________________ Signature __________ Date __/__/______

33
 6. Data collection form

Date----------------------------------

Time---------------------------------
Patient card No--------------------------------
I. Socio demographic Characteristics
1. Age in years
2. Sex: A Male B. Female
3. Educational status: A. Illiterate B. Primary school C. Secondary school

D. High school E. College/University

4. Occupational status: A. Farmer B. Student C. Merchant

O
D. Gov. Employee E. Others,
t Specify------------------------------------
h
5. Marital Status: A. Single e B. Married C. Widowed
Or O Sp
D. Divorced s, E. Others, Specify--------------------------------------
t th eci
hS Ot er fy-
6. Residence: A. Karat townp he B. Rural Kebele
e s, ---
rse rs,O S Ot ---
7. Religion: A. Protestant ci,Sp B. Orthodox C. Muslim
, th p he ---
Sf Specer ec Ot rs, --- Ot
4. Others, specify------------------------------------------------------------------
py ecifs,
ify if he Sp --- he
e -- y---
S
--- y- rs, eci --- rs,
ci-- ----
pe
--- -- Sp fy- --- Sp
34 fy-- ----
ci
--- -- eci --- --- ec
---- ----
fy
--- -- fy- --- --- ify
---- ----
---
--- -- --- --- --- ---
----
---
---- --- -- --- --- --- ---
 II. Observation and time measurement
1. Arrival mode :A. Private transport B. Ambulance C. Public transport
D, Others, Specify; -----------------------
2. Type of arrival; A. Transfer from HC B. Self-Referral
C. Others; Specify; -----------------------------------------
3. Arrival to triage time period/triage waiting time:
I. Arrival time in hrs&min II. Time triage process started
III. Diff in min

4. Triage time period

I. Time triage process started II. Time pt exit from triage room
III. Diff in min

5. ED waiting time period in ED waiting area after triage

I. Time pt exit from triage room II. Time pt enters ED

III. Diff in min

6. First attending medical staff in the ED

A. Clinical Nurse diploma B. BSC nurse C. Health Officer

D. Doctor E. Other, Specify------------------------------------------

7. Time period spent in ED with medical staff in the first contact

I. Time pt enters ED II. Time pt exits from ED

III. Diff in hrs/min

8. Need for consultation by another special professional: A. Yes B. No

If Q no 8 is yes, then fill the following two questions; otherwise jump both.

9. Time period spent b/n end time of first medical staff and consultant arrival

35
 I. Time the first contact medical staff decided for consultation II. Time consultant arrived

III. Diff in hrs/min

10. Time period of consultation

I. Time consultant arrived II. Time consultation completed

III. Diff in hrs/min

11. Is laboratory request ordered? A. Yes B. No

12. If the answer to the above question is yes, then measure the laboratory waiting time:

I. Time of request order II. Time of result return from lab

III. Diff in hrs/min-----------------------------------------------------

13. Time period b/n laboratory result return and contact with responsible ED professional

I. Time result returns from lab II. Time patient find the ED professional

III. Diff in minutes

14. Treatment time:

I. Entrance time to ED room after return from lab II Time treatment completed
III. Diff in minutes

15. Radiology test request: A. Yes B. No

16. If Q no 15 is yes, measure the radiology waiting time.

I. Time of order of radiology II. Time result returns

III. Diff in minutes
17. Time period b/n radiology result return and contact with responsible ED professional

I.Time result return from radiology dep’t

36
 II. Time patient find the ED professional III. Difference in minute

18. Treatment time after radiologic investigations.

I. Entrance time to ED room after the investigation II. Time treatment ended.

III. Diff in min

19. Type of case: A. Traffic accident B. Trauma other than traffic accident

C. Diarrhea with DHN D. AFI E. COPD

F. others, specify, --------------------

20. Final decision made by the attending professional: A. Admission B. Referral

C. Discharged to home

21. If an answer to question number 20 is Admission, measure the boarding time:

I. Time and date of admission: Date-----------------Time---------------

II. Time and date pt left ED: Date--------------time---------------------

III. Diff in hrs-------------

22. If the final decision is referral, what is the measure of referral waiting time?

I. Time and date referral form written: Date-----------------Time-----------

II. Time and date pt left the hospital: Date-----------------Time--------------

III. Diff in min-----------------------------

23. If the final decision is discharge, summarize the ED waiting time

I. Date and time of arrival (refer to Q no 3): Date-------------------- time-------------

II. Date and time of discharge: Date--------------------------- time-----------------------

III. Total time spent in hrs and minutes: -------------hrs------------minutes

Name of data collector: -------------------------------------signature----------------------date---------------

Name of supervisor: -----------------------------------Signature--------------------------Date-----------------

37
ASSURANCE OF PRINCIPAL INVESTIGATOR

The undersigned agrees to accept responsibility for the scientific ethical and technical conduct of
the research project and for provision of required progress reports as per terms and condition of
the institute of health in effect at the time grant is forwarded as the result of this application.

Name of the student: Ararso Garo Tabayo

Date---------------------------------------Signature ------------------------------

Approval of the Advisers

Name of the first adviser: Mr. Negalign Berhanu

Date-----------------------------------------Signature ------------------------------

Name of the second Adviser: Mr. Melaku Haile

Date------------------------------------------Signature ------------------------------

Approval of the examiner

Name of the examiner-------------------------------------------------

Date----------------------------------Signature-------------------------

38
39