Time Within the Acute Care Chain: How Long Have Medical Emergency Department Patients Spent

All adult ED patients in the province of Limburg will be included in a 72 hour time frame. Students were present at the EDs 24 hours to include all these patients. Patient data were gathered from medical records (including hospital file, referral letters and EMS notes) using a Case Report Form (CRF) and from a questionnaire filled out by the patient. Data were collected on demographic variables, including sex, age, highest level of education, living situation and the presence of roommates. Furthermore, information regarding the ACC and Time spent in the ACC (TACC) was collected.

The entire ACC was divided into four phases: the pre-referral phase, the referral phase, the ED phase and the post ED phase. In each phase several variables were collected.

Pre-referral phase The pre-referral phase started with the onset of complaints this disease period up to the referring contact. The following variables of this phase were collected: the symptom duration in days calculated from the day of onset of symptoms until ED visit, number of prior contacts with a healthcare provider and prescribed medication this disease period before ED visit. A prior contact with a healthcare provider was defined as a contact within this disease period, regarding the same complaint, and before the contact during which the patient was referred to the ED.

Referral phase The referral phase started with the moment of referral until arrival at the ED. The following variables of this phase were collected: time and date of referral contact, referring health care provider (GP, EMS, medical specialist, nursing home doctor, other or self-referral), prehospital triage urgency (EMS and GCP), and mode of transportation to the ED (own transport or by EMS). Prehospital triage urgency levels (for GPC and EMS) are determined using the Netherlands Triage Standard (NTS), which categorizes patients from U1 (life threatening, immediate action required) up to U5 (advice, a physical examination can wait until the next day) (16). If necessary, an ambulance is subsequently dispatched according to these urgency levels.

ED phase The ED phase started with arrival at the ED until hospital discharge, including 30-day follow-up. The following variables of this phase were collected at the ED: referred specialty (the specialty to which the patient has been referred), treating specialty (the specialty that eventually treated/discharged/admitted the patient), triage urgency level (MTS (17)), presenting symptoms, the number of patients with a presumptive prespecified complex condition, ED work up, and arrival and departure time in the ED to calculate the length of stay (LOS).

The EDs in this study use the Manchester Triage System (MTS) as a triage system, which categorises patients into five levels of urgency (17). Immediate (red) patients are to be evaluated immediately, whereas non-urgent (blue) patients are allowed to wait for 240 minutes prior to evaluation. In this study we combined red and orange triage urgencies as 'highly urgent' (evaluation within 10 minutes maximum), and yellow, green and blue as 'urgent' (evaluation within 60-240 minutes). Presenting symptoms were categorized into 18 groups after discussion with the researchers: minor trauma, abdominal pain, dyspnoea, general malaise, fever, extremity complaints (e.g. arthritis), neurological complaints, syncope/palpitations, skin symptoms, urological complaints, complaints after treatment, allergic reaction, hypertension, minor oncological complaints (e.g. rash), chest pain, ENT problem, intoxication, and other. Prespecified complex conditions were defined as patients presenting with the presumptive diagnosis of a stroke, myocardial infarction, aortic syndrome or major trauma.

The ED work up was defined as simple when ED work-up included lab tests, electrocardiogram and X-ray and was defined complex when included CT, ultrasound, lumbar puncture (LP), abdominal paracentesis, gastroscopy, MRI scan and consultations of other specialties.

Post ED phase The post ED phase started after ED discharge until 30-day follow-up. The following variables were collected: post-ED disposition, 7- and 30-day all-cause mortality and 30-day revisit. A combination of 7- and 30-day all-cause mortality and 30-day revisit were called adverse outcome.