Till Örebro universitet

Background: Emergency departments (EDs) must balance timely care, safety, and resource utilization. Emergency department length of stay (EDLOS) is widely used as a proxy for ED performance, yet it primarily reflects elapsed time whose clinical meaningfulness depends on patient case-mix and context. Aim: The overall aim was to develop a deeper understanding of patient flow in Swedish EDs, with particular focus on process determinants of EDLOS and on patient groups at greatest risk of poor outcomes. Methods: Four studies were undertaken. Study I was a concept analysis of “long EDLOS”. Study II was a retrospective observational study of 222,047 ED visits from two hospitals, estimating the impact of input-, throughput and output factors on EDLOS. Study III examined high‑frequency ED users (HEDU) at a university hospital (121,403 visits), assessing prevalence, costs, and process outcomes. Study IV linked national registries across 5,049,641 ED visits from 15 sites (2015–2023) to analyse associations between EDLOS and adverse outcomes. Results: Long EDLOS is often used as a proxy for other phenomena. Throughput processes were the dominant factors impacting EDLOS. HEDU comprised 6.1% of patients but accounted for 22.4% of visits and a disproportionate share of costs. In Study IV, absolute EDLOS displayed a non‑linear association with mortality, with elevated risk at very short stays. Patients with non‑specific complaints were vulnerable to extended EDLOS. Conclusions: EDLOS is a useful metric, but when dichotomized, blunt and imprecise. Patient flow in the ED is not necessarily a reflection of levels of crowding and access block. Deviations from the expected EDLOS — whether longer or shorter — better predict adverse out-comes than absolute duration, highlighting the need for contextualised patient-centred performance metrics.

Background: Prolonged emergency department length of stay (EDLOS) is a worldwide issue associated with increased mortality, decreased patient satisfaction and poor quality of care. The factors influencing EDLOS have not been comprehensively studied in the context of Swedish EDs. This study's objective is to determine the input-, throughput- and output factors associated with EDLOS, at two urban EDs in Sweden.

Methods: Data was collected from two hospitals. All patient visits during the two-year study period were included. Patients who left without being seen by a physician were excluded. The explanatory factors included patient characteristics, medical data, and hospital bed occupancy data. Multi-variable linear regression analysis was used to test the associations between the factors and EDLOS.

Results: The top contributors to prolonged EDLOS were diagnostic imaging, which added between 64 and 149 min of EDLOS, diagnostic testing at central laboratory (53-99 min), followed by intra-ED zone transfer (46-94 min). Arriving during crowding or being admitted during high hospital bed occupancy had a significant but relatively small absolute effect on the outcome.

Conclusions: Throughput factors had far greater impact on EDLOS than both input- and output factors. Adapting strategies to the structural and procedural characteristics of each setting may enhance the effectiveness of improvement efforts.

Clinical trial number: Not applicable.

BACKGROUND: There is little research on high frequency emergency department users (HEDU) in Sweden. We aim to determine the prevalence and costs of HEDU compared to non-HEDU at Örebro University Hospital (ÖUH). Additionally, we will determine the factors and outcomes associated with being a HEDU.

METHODS: This was a retrospective, observational cohort study of ED patients presenting to ÖUH, Sweden between 2018-19. Analyses used electronic registry, ambulance, and cost data. The definition for HEDU was ≥4 visits/year. HEDUs were categorized further into Repeat, High and Super HEDU with 4-7, 8-18 and ≥19 visits/year, respectively. We used multivariable logistic regression to determine the adjusted odds ratios for factors and outcomes between HEDU and non-HEDU.

FINDINGS: Of all ÖUH ED patients, 6.1% were HEDU and accounted for 22.4% of ED visits and associated costs. Compared to the mean cost of non-HEDU, the Repeat, High and Super HEDU were more costly by factors of 4, 8 and 27, respectively. The HEDUs were more likely to be male, self-referred, present with abdominal pain, arrive by ambulance, at night and from the Örebro municipal region. Super HEDU were more likely to be of adult age and assigned lower acuity scores. HEDU were more likely to be directed to the surgical zone, less likely to receive radiologic imaging or achieve a 4-hr time target. In contrast to the Repeat and High HEDU, Super HEDU were less likely to be admitted, but more likely to leave without being seen.

CONCLUSION: ÖUH has a HEDU population with associated factors and outcomes. They account for a substantial proportion of ED costs compared to non-HEDU.

Introduction: Emergency Department (ED) Length of stay (LOS) has been associated with poor patient outcomes, which has led to the implementation of time targets designed to keep EDLOS below a specific limit. The cut-offs defining long EDLOS varies across settings and seem to be arbitrarily chosen. This study aimed to clarify the meaning of long EDLOS.

Methods: A concept analysis using the Walker and Avant approach was conducted. It included a literature search aiming to identify all uses of the concept, resulting in a set of defining attributes and a way of measuring the concept empirically.

Results: Long EDLOS was primarily used as proxy for other phenomena, e.g. boarding or crowding. The definitions had cut-offs ranging between 4 and 48 h. The attributes defining long EDLOS was waiting, a crowded ED environment and an inefficient organization.

Discussion: Time targets are probably more suitable when directed towards and tailored for specific sub-groups of the ED population.