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Emergency Department overcrowding and increased length of stay: Identifying the causes in a secondary care general hospital
0 20 40 60 80 100
waiting for a vacant in-patient bed: 561.17
Total ED observation room LOS: 1918.95 hrsMajor waste time: 1078.98 hrs
waiting for a
Missed 01:00 02:00 03:00 04:00 05:00 06:00 07:00 08:00 09:00 10:00 11:00 12:00 13:00 14:00 15:00
24 19 18 7 10 4
LOS intervals in hours
Emergency Department overcrowding and increased length of stay:
Identifying the causes in a secondary care general hospital
Hossam Elamir,MSc, TQMD, MBBCh
Department of Quality and Accreditation, MKH, MOH, Kuwait
Institute of Leadership, Royal College of Surgeons in Ireland, Bahrain
The author’s hospital is the only general hospital in the health area.It provides secondary
and some tertiary healthcare services to 880,235 people from 13 residential areas in Kuwait.
The hospital has a total of 734 beds and approximately 3,000 staff in 25 different departments.
Of these,9 are clinical departments,7 provide clinical support services,5 provide non-clinical
support and 4 provide administrative and technical support.Emergency Department (ED) is
amongst the most crucial departments in the hospital.It receives around 1000 patient/day.
ED overcrowding (EDOC) and increased Length of Stay (LOS) are key global issues for more
than 20 years,as they have serious repercussions.
Emergency Department (ED) overcrowding
(OC) is deﬁned as a situation where the demand for services exceeds the capacity of the
department to provide them in a high quality and timely manner,
and associated with
increased ED Length of Stay (LOS) of some patients beyond the accepted limit that varies
from above 4 hours in UK to above 8 hours in Australia.
ED staff of the general hospitals in Kuwait and ED patients are reporting a progressively
increased EDLOS and EDOC (Fig.1).No measurements have been done to assess the situation
The study used direct observation for seven days,starting 26 November to 2 December 2014,
to collect patient ﬂow data (Fig. 2) on ED patients at a governmental hospital in Kuwait.It
calculated wait times and services to identify the major causes of EDOC and increased LOS.
Fig. 1: The Overcrowded ED Room
Fig. 2: High-level ﬂow diagram of ED visit
Fig. 3a: Categorisation of patient visits to ED during 7 days
Fig. 3b: Number of patients in every LOS interval
Fig. 4: Percentage of the aggregated time of the 210 patients
Fig. 5: The aggregated LOS and waiting times in hrs (of LOS > 6 hrs)
I would like to acknowledge the help provided by my colleagues:
Abeer, Amal, Lea, Manar and Rinto, the quality nurses of MKH, MOH, Kuwait
For further information: Mobile: 00965-65198442 - E mail: firstname.lastname@example.org
Linkedin URL: kw.linkedin.com/pub/hossam-elamir/b2/97b/296
1. PACI.(2014).Gender By Nationality and Age and Governorate.Retrieved January 2,2015,from http://stat.paci.gov.kw/
2. Afﬂeck A,Parks P,Drummond A,Rowe BH,Ovens HJ.Emergency department overcrowding and access block.CJEM.
3. Horwitz LI,Green J,Bradley EH.US Emergency Department Performance on Wait Time and Length of Visit.Annals of
Around one third of the ED design capacity was utilized by 12% of the ED patients.The wasted
waiting time represents 56.2% of the aggregated LOS,and access block to inpatient wards
was the primary cause of increased LOS and EDOC.A national-wide measurement project
should be considered to assess the exact problem volume,its impact and test solutions,
which should eliminate the waits before trying to reduce the service time.
VI. Acknowledgement & Contacts
A total number of 6383 patient visits were registered,1750 of them were referred to the ED
observation room.Among these,210 patients stayed more than 6 hours as a total ED visit
time (Fig.3a-b). The aggregated time of the 210 patients was 1918.95 hours (Fig.4).
Total patient visits
during 7 days
Patients who didn't
go to observation
Patients who went
Patients who deserve to
be seen in observation
Patients with cold
Patients who stayed
less than 6 hrs
Patients who stayed
more than 6 hrs
Patient Arrival Triage Doctor room
Further analysis revealed that they spent 1078.98 hours as major wasted waiting time.(Waiting for
a vacant in-patient bed) constituted 52% of that time,(waiting for a consultation reply) constituted
13.3% and (waiting for a radiology request to be executed) constituted 13.29% (Fig.5).
Total calculated ED time
(by design capacity)
(35 beds X 7 days)=
245 bed days
Aggregated LOS time of
observation room visits that
deserve to be observed
(1434 patients)= 221.53 days
Aggregated time of
+6 hrs LOS patients
(210 patients)= 79.95 days
the 210 patients
who stayed more
than 6 hrs each
All other patients
who stayed less
than 6 hrs each