ACKNOWLEDGEMENTS

The authors are most grateful to the following persons for review and provision of
information and comments on the draft copy of this document. The views expressed in
the final copy of this document are those of the team members.
Dr R. Bheekhee, Surgical Department , Jeetoo Hospital, Mauritius
Dr R. Sok Appadu, Department of Internal Medicine, Victoria Hospital,
Mauritius.
Dr O. Gopee, General Practitioner, Mauritius.
The authors also wished to thank the Emergency Medical Team and the Management
Team of J. Nehru Hospital in their collaboration to make this project successful.

COMPETING INTEREST
Competing interest is considered to be financial interest or non-financial interest, either
direct or indirect, that would affect the research contained in this report or creates a
situation where a persons judgment could be unduly influenced by a secondary interest
such as personal advancement.
Based on the statement above, no competing interest exists with the author(s) and/or
external reviewer(s) of this report.

INTRODUCTION
BACKGROUND: JAWAHARLALL NEHRU HOSPITAL
Jawaharlall Nehru Hospital (JNH) is situated in Rose-Belle in the district of Grand
Port and caters for the sanitary region number 4 covering the districts of Grand Port and
Savanne with approximately 200,000 inhabitants under the directorate of a Regional
Health Director (RHD).
The Regional Health Director is responsible for the Souillac Hospital and the
Mahebourg Hospital; both are district hospitals of region 4.
There are 17 Community Health Centers and 5 Area Health Centers within its
catchments area.

HISTORICAL BACKGROUND
The foundation stone of J Nehru Hospital was laid in October 1984 by H.E. Zail
Singh, the then President of India.
The first phase of the project began in 1985 and consisted in the building of six 30-bed
wards. The official opening was on 14th November 1990 on the death anniversary of
Jawaharlal Nehru. The launching was done in March 1991 by H.E Dr S. Sharma the then
Indian Vice President. The first Regional Health Director was Dr B. Ramdowar.
The second phase, concerning the setting up of six new wards, a central sterilization
unit and a sewerage plant, was started in August 1993 and was completed in August
1996.

SERVICES PROVIDED
The services provided at JNH are: General Medicine, General Surgical, Renal Surgery,
Orthopedic, Pediatric, Nursery, Gynecology and Obstetrics, Physical Medicine, Chest
diseases, NCD (Non Communicable Diseases Clinic), Skin diseases OPD, ENT Clinic
OPD, Oncology OPD, Ophthalmology OPD, Accident and Emergency Dept, Intensive
care Medical and Surgical, Dental facilities, Haemodyalisis.
Ancillary Departments are: Medical Laboratory Services, X-Ray, Nuclear Medicine,
C. A. T. scan, Physiotherapy, Occupational Therapy, Speech Therapist, Dietician, Social
Worker, Centralized Medical Records Department.
Administrative Services
Regional Health Director
Medical Superintendent
Regional Hospital Administrator & Hospital Administrator
Regional Nursing Administrator
Nursing Administrator Male & Female
Regional Public Health Superintendent
The SAMU Team, a specialized emergency service is also provided to the region 4.
The languages spoken are mostly Creole. French and English are less commonly used
and a local dialect, the Bhojpuri is also popular among older generation of patients.

The emergency department at JNH is operating in a small area facility as project for
expansion is under review and maybe will be implemented in the future. The emergency
department (ED) includes casualty, medical and surgical emergencies, X-ray department,
Medical records and registration, waiting area, triage area, casualty pharmacy and
casualty police station. Although obstetrics and Gynecology clinics, orthopedics clinics
and pediatric clinics operate separately, patients are initially sorted out at the same point
in the Emergency Department then dispatched thereafter. The Methadone Replacement
Clinic also operates within the Emergency Department and caters for concerned patients
form 07h00 to 08h00 every weekday.
Waiting time is an important measure of quality of care in ED (Asplin, 2006).
Prolonged waiting time in ED leads to overcrowding.
Crowding in Emergency Departments has become an increasing problem for hospitals
around the world. This has multiple effects, including poor patient outcomes, prolonged
pain, patients dissatisfaction, patients leaving without being seen, increased frustration
among medical staffs and violence (Derlet and Richards, 2000).

PROBLEM STATEMENT
There are recurrent complaints from patients about prolonged waiting time in JNH
Emergency Department.
The ED at JNH is the first and most critical point of contact with the health care
system in the hospital. The excessive lengths of time patients may wait before treatment
in the ED may negatively color their perceptions of care provided during the visits.
Solving the problem of prolonged waiting time will help achieving timely delivery of
service in ED and this has significant implications for population health.

LITERATURE REVIEW
Efficiency and effectiveness of hospital services have many degrees, but a very
important aspect is excessive waiting time, which is the main complaint of patients
(Clague et al., 1997). Extra waiting time is also non-value adding time because during
this period, resources are not used to improve patients medical condition (Kujala et al.,
2006). Barlow (2002) says that excessive waiting time is a losing strategy in that patient
loses important time; hospitals lose their patients and reputation and staff experience
tension and stress.
Furthermore Bielen and Demoulin (2007) contend that waiting time does not only
affect the service-satisfaction relationship, but also changes the satisfaction-loyalty
relationship. They also found that determinants of waiting time satisfaction include the
perceived waiting time, satisfaction with information provided in case of delays, and
satisfaction with the waiting environment. Becker and Douglass (2008) further propose
that the attractiveness of the physical environment of healthcare facilities can have an
impact on the patients perception of waiting times.
McKinnon et al. (1998) found that patients are less likely to be dissatisfied if their
waiting time is within thirty minutes. Reaching the 30-minute threshold is a terrible job,
particularly for public hospitals where there is excess demand. As noted by Barlow
(2002), the inevitability of demand exceeding capacity causes the long queue, and this is
difficult to accept, either as a patient, or as an observer.
Overcrowding in the emergency and other departments and specialist clinics of
Malaysian public hospitals is not an unusual phenomenon with Manaf (2006) reporting

being overwhelmed by the number of patients in the outpatient clinics of Malaysian

public hospitals. This service is provided almost free at the point of delivery.
A huge differential exists between public and private hospitals whereas private
hospitals may charge more than ten times the fee of public hospitals. Moreover, the
demography of the public hospitals whereby it caters largely to the lower income earners
and public servants also contributes to the overcrowding in Malaysian public hospitals.
Equity of access to health care is clearly stated in the vision statement of the Ministry
of Health, which implies that everyone should have a fair opportunity to attain their full
health potential, and no one should be deprived from achieving it.
A five-country hospital survey by Blendon et al. (2004) found that Canada, Britain and
the USA reported average waits of two hours or more. In Hong Kong public hospitals,
Aharonson-Daniel et al. (1996) found that the longest time that patients spent at the clinic
was in waiting for consultation where 82 per cent of total visit time is spent in the waiting
room. In Britain, the official and publicized waiting time according to the Patients
Charter is thirty minutes, although the reality may be quite different.
On many occasions, the strain of waiting for long periods has even led to verbal
aggression by patients towards the nurses or clinic receptionists (Bolton, 2002). In
Malaysian public hospitals, work carried out by Manaf (2006) indicated a positive
correlation between satisfaction with waiting time and outpatient satisfaction. While
research has established the relationship between patient satisfaction and length of
waiting time, Ittig (2002) contends that when customers are external, waiting time has an
effect that is similar to that of a price. This means that customers become more aware of
the price demanded in time, and adjust their behavior accordingly.
Thus, even in cases where there is monopoly control over customers as with hospital
emergency room, there may be adjustment of behavior such as long delays causing
patients to consider a hospital facility or private practitioner in the future. A number of

factors have been cited to contribute to lengthy waiting time. Health professionals work
in a hospital system that is paralyzed by volume, undermined by staff shortage and
flawed by aging equipment (OBrien-Bell, 2005).
Further, according to Garber (2004), long and complicated work processes and
unnecessary duplication of tests can prolong waiting time in clinics. In Britain,
inefficiencies in hospital and clinics have also been blamed on consultant practices of
patient recycling which reduce the ability to see new patients (Amstrong and Nicoll,
1995). This has led researchers such as Clague et al. (1997) to suggest operational
research solution by using computer simulation to improve the efficiency of clinic
waiting time.
The quantitative approach to waiting time has also been echoed by Siddhartan et al.
(1996); Kaandorp and Koole (2007); Zhu et al. (2009) who suggested a queuing model to
reduce waiting times in emergency department by classifying patients into four
categories, from major trauma to non-emergency or primary care patients. AharonsonDaniel et al. (1996) suggested the use of computer simulation in the management of
queues in outpatient departments in Hong Kong public hospitals. As in Malaysian public
hospitals, those in Hong Kong are also burdened with excessive waiting time due to the
inexpensive treatment provided by these hospitals in comparison to the private hospitals.
Qualitative research undertaken on hospital waiting time (Uehira and Kay, 2009) on
Japanese hospitals interestingly identify three types of patients: IJHCQA 24, 7508
(1) One who visits hospital infrequently and is uneasy there;
(2) One who visits hospital fairly often and is irritated by long waiting time; and
(3) One who visits hospital extremely often and is often bored.

WAITING TIME AT REGISTRATION

Patient satisfaction is a concept that has been receiving increasing attention in the past
few years. Waiting time is considered to be an important determinant of patient
satisfaction. Over the years, wait management has been studied by researchers as an
important aspect and has been well recognized as a factor influencing satisfaction in
many service industries including health care. This is an important subject because of the
increasing value of time for patients. As they experience a greater squeeze on their time,
short waits seem longer to them than ever before. Therefore, to attain higher levels of
patient satisfaction levels, the hospitals need to focus on making patients feel that they
are wasting as little time as possible.
According to a recent study by the American College of Emergency Physicians A
multitude of factors are responsible for delays including greater medical needs, prolonged
ED evaluations, inadequate bed capacity, and redundant use of the ED by those with no
other alternative to primary medical care (ACEB 2000b pg 241)
Many firms have tried the obvious approach to the problem, which is managing the
actual wait time through operations management. In the perceptional wait management
literature, some studies have investigated waiting times for different services (Hornik,
1984; Katz, 1991; Pruyn and Smidts, 1991; Taylor, 1994, Dansky, 1997; Anita, 2009). In
these studies, researchers generally have been focused more on the relation between
actual and perceived waiting times and their effect on customer satisfaction.
Furthermore, studies have investigated the effects of waiting time fillers on customer
satisfaction and perceived waiting times (e.g. Katz, 1991; Taylor, 1994). These studies are
based on the idea of changing waiting time into experienced time by entertaining,
enlightening and engaging the customer (Katz, 1991). The waiting time fillers that were
provided in the previous studies include: music (Baker, 1996; Chebat, 1993), ambient
scent (McDonnel, 2002), duration information (Katz, 1991), television (Hogan, 1978;
Pruyn and Smidts, 1998), and News (Katz, 1991).

Service times and wait times have to be distinguished from each other. Wait times
represent the idle time experienced while waiting for the next service to be delivered, and
add no value to the patient. Service times represent the hands-on time that providers
spend with patients. We do not aim to reduce service times for any individual service nor
do we challenge the clinical content of particular services, as we believe that the
opportunity for health care providers to work significantly faster in any particular stage is
limited. Our efforts to shrink wait times as opposed to service times are entirely
consistent with the notion of lean process improvement (Womack and Jones, 2003;
Womack et al., 2005), in which waiting is viewed as a non-value-added activity. Service
times, on the other hand, represent a value-added activity for the patient, since they are
receiving direct care from a health care provider.
Patients arrive at the ED through multiple channels including walk-ins and
ambulances. A good physical layout of the ED is necessary in order to expedite patient
flow. There are theoretical and empirical evidences in the literature that there is a direct
link between affect and subjective time perception. Environmental elements in the service
setting may directly influence the affective state of an individual (Meherabian and
Russell 1974).
Literature also suggests that the hospital architecture need to facilitate patients access
by eliminating long corridors and providing easy access and visibility of the service
providers. Depending on how quickly the patient can be quickly registered (assigned a
medical record number) and triaged (sorting of and allocation of treatment to patients)
determines how fast the patient will be ready to be placed in a bed and be seen by a
doctor (Hall 2006). Medical care is delivered through a network of service stations, and
there is a potential for delay in multiple locations. Emergency Departments also interact
with general hospital care, as frequent source of queuing is the inability to place a patient
in a hospital bed once treatment of completed in the ED (Hall 2006).
Overcrowding in the emergency department (ED) is undesirable as it creates access
issues and leads to delays in care. Yet, there is increasing evidence that overcrowding and

its subsequent delays frequently occur (Committee on the Future of Emergency Care in
the United States 2007, Burt and Schappert 2004).
There has been a growth in the development of predictive modeling in healthcare. It
has been well documented that arrival patterns to the ED exhibit seasonal patterns. For
instance, Green et al. (2006) considers how to modify staffing decisions based on known
patterns in arrival rates to the ED. By using a point-wise stationary approximation and
utilizing the fact that the majority of patient arrivals occur in the middle of the day, the
authors were able to adjust staffing hours in order to reduce waiting times and,
subsequently the number of patients who left without being seen.
Beyond time-varying arrival rates, predictive models have become much more
nuanced and accurate. For instance, Tandberg and Qualls (1994), Rotstein et al. (1997),
Jones et al. (2009), Sun et al. (2009) develop predictive models based on time-series
analysis to predict emergency department workload. Schweigler et al. (2009), McCarthy
et al. (2008), Jones et al. (2002) also examine prediction of ED visits, while Wargon et al.
(2009) provide a nice overview. Note that, instead of forecasting just the mean arrival rate
for a future time interval, many of these models are capable of making accurate
predictions of the arrival counts, on a daily (Sun et al. (2009) and Figure 1) or even
hourly basis (Tandberg and Qualls 1994).
A primary motivation in developing these predictive models has been to guide
operational decision-making, such as staff roster and resource planning (Sun et al. 2009)
or decisions related to on-call staffing (Chase et al. 2012). However, while there has
been substantial attention paid to developing such predictive models, there has been
limited work demonstrating how they can best be utilized to improve system
performance.
There have been many solution approaches that have been suggested to address this overcrowding problem.

Some hospitals have resorted to increasing bed capacity to deal with growing demand
(Japsen 2003, Romano et al. 2004) or using queuing theory to improve staffing decisions
(Green et al. 2006). Other approaches have been to encourage and educate patients when
it is inappropriate to visit the ED and perhaps more useful to visit their primary care
physicians (PCPs) (McCusker and Verdon 2006 Riegel et al. 2002).
Studies claim that the impact of considerable numbers of low- acuity patients drives
ED congestion. Siddhartan (1996) suggests that EDs enforce a toll on non-emergency
users of the facility, so as to deter their usage. Such a toll could be created by widening
the clinical definition of emergency patients this would force non-emergency patients to
linger longer before being seen, thus making them potentially less likely to visit an ED.
Others have suggested that a fast-track facility could be used to efficiently cope with an
onslaught of low-acuity patients, hence reducing their impact on overall congestion
(Cooke, 2002; Fernandes, 1995; Rodi, 2006). Attempting to quell this debate, Schull
(2007) showed that greater numbers of low-acuity patients do not affect length of stay
and door to doctor times for medium or high acuity patients.

THE TRIAGE SYSTEM

Triage is defined as the process of sorting and prioritizing patients for care. It comes
from the French word, trier, meaning to sort out. The triage system came into use in the
1960s in the emergency department because of the demand of the emergency services
outpaced the available emergency resources.

ED space, equipment and staff were

insufficient to meet the requirement to cope with the radical increase in ED attendances
and thus a system to assess and prioritize the patients need for care arouse. Triage is
nowadays accepted as an integrated part of the Ed patient assessment for safe and
efficient operation of the ED.
The aim of the triage is to ensure that patients are treated in the order of their clinical
urgency and that care is given in a timely and appropriate way. Thus, the triage system

takes into consideration the acuity of the disease to determine the waiting time of patient
rather than the time of arrival to the ED.
The ED triage begins at the very moment the patient steps in the ED. To triage a
patient, an assessment of the patient is carried out, usually by a skilled senior nurse.
Three major components are taken into considerations, namely; chief medical complaints,
a physical assessment and collection of vital signs. Following the assessment, the patient
is assigned an acuity rating which indicates the length of time that the patient can safely
wait before being seen by a clinician.
Acuity ratings are based on a triage scale. However, the design of the triage scale
differs considerably between EDs. The most widely used triage tool in the UK is the
Manchester Triage Scale (MTS). After choosing a discriminator, the triage nurse assesses
the urgency with which the patient needs to be treated. Treatments assessed as to be
immediate, urgent or routine are allocated the color categories red, amber or yellow, or
green respectively as shown by Table 1.

The Australasian Triage Scale (ATS), as shown in Table 2, is designed to be used in

hospital-based emergency services throughout Australia and New Zealand. The triage
assessment and the ATS code allocated must be recorded.

AUSTRALIAN TRIAGE

AUSTRALIAN TRIAGE

AUSTRALIAN TRIAGE

SCALE CATEGORY
ATS 1
ATS 2
ATS 3
ATS 4
ATS 5

SCALE CATEGORY
immediate
10 minutes
30 minutes
60 minutes
120 minutes

SCALE CATEGORY
100%
80%
75%
70%
70%

Likewise, several triage scale exist between different EDs. However, for a triage to be
effective the triage scale must be reliable, valid and easy to use.

THE TRIAGE SYSTEM AND WAITING TIME

The effect of the triage system for reducing waiting time has been assessed in different
studies. In Australia, a study was conducted by Kwa and his colleagues to determine
whether the introduction of a fast-track area altered the time of care and patient flow in
the Ed. The study concluded that such a fast-track can help meet the demand of the
increasing attendances in the ED, allowing lower-acuity patients to be seen quickly
without a negative impact on high-acuity patients.
Miro et al. also managed to decrease waiting time through the triage system.
Tamburlini et al. with regard to the evaluation of the triage function in the Ed observe that
both wait time and patient crowding could decrease after educating nurses and the
establishment of a triage system in the ED. Another study in Iran conducted by Khankeh
et al., showed that there was a significant difference between the mean wait time in the
experiment (triage group) and control groups

THE TRIAGE GROUP AS A MULTIDISCIPLINARY ASSESSMENT

The triage system in most ED is carried out by experienced and skilled nurses.
However, a multidisciplinary assessment at the triage can be thought as a new way
forward.
Richardson et al. conducted a study in an Australian ED to evaluate a dual doctor and
nurse triage system.

The multidisciplinary triage comprise of a senior registrar or

consultant and a triage nurse. This team would have the ability to deliver definitive
treatment and dispositions to some patients and streamline the management of others.
Investigations and treatment can be initiated before referrals are made to specialized
units. The study indicates a statistically significant in being seen with the ATS guidelines
for patients in triage categories 3 and 4 but not in 2 or 5. However, the authors observe
slight improvements in the proportion of patient seen in categories 2 or 5 and if greater
number of patients were studied in these categories, the findings might have reached
statistical significance.

NAVIGATING TRIAGE TO MEET TARGET WAITING TIMES

Navigation is based and relies on the concept of triage but eliminates extra steps.
Diaz-Alonso et al. explains how the triage process (i.e. MTS) at her emergency
department at Medway NHS Foundation Trust, Kent was replaced by a simpler system in
which nurses undertake initial assessments. The steps involved in the MTS are shown in
Figure 1 and those involved in the navigation are shown in Figure 2. These algorithms
show that the introduction of the navigation has reduced the number of steps prior to

patients being seen by the clinicians, which has ensured that people with life-threatening
conditions are identified earlier.

PATIENTS CONCEPTION OF THE TRIAGE ENCOUNTER AT THE ED

Few studies have been conducted regarding the patients conception of the triage
encounter.

Watt et al. showed that patients across all triage levels value good

communication and good behavior from nursing staff. Patients are worried about their
health status when they attend the ED and they expect to be treated as individuals.
However, while staff believes that they communicate well and are well mannered
towards patients, the latter perceive the opposite. Furthermore, when patients are given
information about the triage system in use, they understand and accept the system.
Wellstood et al. found that patient value effective communication short waiting time
over many aspect of care. At the same time, the interaction between staff and patient is
important for patients perceptions of ED care. Cooke et al. showed that ED patients
expectations appear to be similar across all triage levels.
Moller et al. described patients conceptions of the triage encounter at the emergency
department (ED) at a central hospital in southern Sweden using the phenomenographic
approach. Five types (Figure 3) of encounters emerged: the insecure, the humanistic, the
logistical, the information exchange and the physical environment of the encounter. The
triage encounter usually takes a few minutes to carry out if the nurse is effective, but
should include a humanistic approach that can be easy to forget if the nurse only focuses
on medical aspects. To facilitate more positive experiences of the triage encounter, the
staff has to care for and treat the patients as human beings with a holistic approach. The
triage encounter revealed several different needs for each patient, which the triage nurse
has to identify and cope with in a professional manner. The patients described the value
of a good start when they arrived at the ED and they were impressed by the staffs
general consideration, which is important for a good encounter at the ED.
Lack of information about the triage system and about waiting times as well as
worries about what happens and being too scared to ask questions, were of most
significance for a negative triage encounter. A better logistical and informative triage
encounter is very important in order to minimize the waiting time and make the waiting

time acceptable for patients and decrease worries that arise because of being ill in an
unknown environment. More studies are needed in all five types of triage encounters.

Implications for triage nurses are to include other aspects than medical in the triage
encounter, such as patient information and the triage nurses general appearance, and to
treat the patient with a holistic approach. One implication for ED managers is to make
sure that there are enough triage nurses on duty in order to enable the triage encounter to
be performed based on the needs of the patients.

FIGURE 3

WAITING TIME OF THE MEDICAL STAFFS-PATIENT

INTERACTION
In this chapter we are going to review what literature mentions about the waiting time
during the interaction of the patient and the healthcare professional in the emergency

department of hospitals. The healthcare professionals that we are going to discuss are the
registered nursing officers and the doctors working in the emergency department.

NURSING STAFFS
After the triage procedure, the patients journey continues towards the nursing officers
posted in the emergency unit who will prepare the patient for the doctor to see as well as
inform the doctor about cases that must be seen as a priority.
Much time is wasted during the interaction of the patient with the nursing officers.
The objective of being seen by a nurse prior to attend the doctors consultation is to
prepare the patient for better assessment by the doctor. Vital signs for example blood
pressure, pulse rate, blood oxygen saturation, random blood sugar finger prick test, body
temperature and urine analysis for sugar and albumin are taken by the nursing officers
prior to sending the patient to the doctor. Moreover if a patient comes with soiled wounds
and unclean dressings, an initial cleaning and dressing of the wounds is done to allow the
doctor to make a better assessment of the condition.
Time is wasted in this area because sometimes nurses take vital signs that are not
relevant to a particular case for the concerned attendance of the patient, for example
checking blood glucose for a non diabetic patient. In this context there has been many
studies concerning the relevance of Emergency Nursing Personnel in the emergency
department.
A pilot project in Wollongong Hospital in New South Wales (Australian Nursing
Journal Oct 2001) has reduced waiting time in the emergency department by giving
emergency nurses more clinical autonomy and allowing nurses to carry minor procedures
and treatment. The pilot project demonstrated a reduction in waiting time from 46
minutes to 17 minutes for the patient in the emergency department.

Literature has shown a marked reduction in the length of stay of patients in the
emergency department when being cared by Emergency nurses (Jennings et al., 2008).
However some authors disagree that Emergency Nurses has any correlation with the
waiting time of the patients in the emergency department. Considine et al (2006)
compared emergency department waiting times (medical assessment and treatment),
treatment times and length of stay for patients managed by an Emergency nurse to the
traditional emergency department care and showed that there were no significant
differences in median waiting time, treatment times and emergency department length of
stay between the two categories.
More studies must be carried out to assess the significance of having nursing officers
specially trained in emergency medicine in reducing the waiting time of patients and ED
patient flow.

MEDICAL STAFFS
By medical staffs we mean doctors posted in the emergency department. In Mauritius
they are known as Casualty Officers. Usually they are the senior most doctors in the
hospital and have undergone training as a medical officer in all major departments
including internal medicine, surgery, orthopedics, pediatrics, gynecology, cardiology and
anesthesia.

These doctors are considered to be the most experienced in the hospital and can deal
with any incoming emergency. However in practice we have seen that sometimes junior
doctors are posted in the Emergency department after some initial major postings in other
units and are not well versed with all the emergencies that may occur.

The idea of having only Emergency Physicians posted in the emergency department
has been taken up in many countries. A study conducted at Latrobe Regional Hospital,
Victoria, Australia (OConnor et al., 2004) with the objective of assessing the effect of
presence of an Emergency Physician in the ED has on access indicators has shown an
improved performance within the group and marked reduction of waiting time in the ED.
Emergency Physician were more apt at putting the right diagnoses and requesting fewer
and only relevant laboratory investigations and quickly discharging patients in the
emergency setting.
However not all hospitals can afford to replace all medical officers in the emergency
department by Emergency Physicians. The lack of manpower, training and financial
resources constitute a major step back in implementing this project in all hospitals.

WAITING FOR INVESTIGATIONS

A significant proportion of time spent by patients in the emergency department is
waiting for the results of investigations requested by the doctor which will determine the
management of the case.
Laboratory turnaround time is defined as the period of time from the test ordering to
the time the results are made available to the personnel of the emergency unit.
Some of the common tests asked for are hemoglobin, Prothrombin time and International
Normalized Ratio, White Cell and Platelets counts, Urea and Electrolytes and urine
pregnancy tests.
Jalili et al (2012) conducted a study to measure the laboratory turnaround time delay
for Hemoglobin, Potassium and Prothrombin Time in an Iran Government Hospital. The
time taken from the physician order, nurse registration, blood draw, specimen dispatch
from the emergency department, specimen arrival at the laboratory, result availability in
the test turnaround process were recorded and the intervals between the steps (order

processing, specimen collection, emergency department waiting, transit and within

laboratory time ) and total turnaround time were calculated and it was shown that the
longest intervals were Emergency Department waiting time and order processing.

STAFFS SHORTAGE
Shortage of the healthcare professionals in the emergency department is one of the
major causes of delay and overcrowding. During week ends and public holidays it has
been observed that the number of attendances to hospitals may double. When this arises,
a lack of resource personnel will inevitably lead to overcrowding and increase in waiting
time of patients.
Bing et al (2006) conducted a research at the Alberta Heritage Foundation for Medical
Research with the aim of identifying the strategies that may reduce emergency
department overcrowding. Shortage of staff is one of the top priorities that needs to be
addressed in order to reduce waiting times of patients in the ED. The study demonstrated
the need for more Emergency Physician Coverage during crisis hours and additional
nursing and medical staffs as the need arise.
Literature has shown that staff shortages in many emergency departments leads to
frustration, tiredness, inability to cope and deliver adequate services to the patient
(Jayaprakash et al., 2009).

STAFFS WELFARE

The welfare of staffs is equally important in reducing waiting time in the emergency
department. It must be remembered that the emergency department is a stressful place to
work and the staffs of the unit must be properly supported and catered for.
Barach et al (2009) demonstrated that support for staffs working in the emergency
department is a useful way of reducing waiting time for the attending patients. Design
and implementation of appropriate working environment with adequate support for staffs
increase staffs satisfaction and performance.

STAFF-STAFF RELATIONSHIP
A good communication between all the members of the emergency department is vital
in reducing the waiting time of patients during ED visits.
Good communication skills between nurses and doctors will allow better management
of the casualties. Requests from doctors must be clearly understand by the nursing
members and fulfilled. Feedbacks from the nurses are equally important in the
management of patients in the emergency department. A good interpersonal relationship
between the members of the emergency team will allow the team to work as a family and
responds better to crisis.
Problems in communications pose risks to patients safety and increases the waiting
time of patients in the emergency unit (Reader et al., 2009).

STAFF-PATIENT RELATIONSHIP

Literature has shown that physicians who demonstrate a concern for the patient as an
individual and sympathies with patients significantly improved patient outcomes
(Hausman. 2004)
Moreover patients who were told the expected waiting time and kept busy while
waiting had higher satisfaction perceptions (Naumann, Miles. 2001).

NON URGENT CASES IN ED

One of the reasons why there is overcrowding at hospitals which results in increase
waiting time is the fact that a lot of patients attend ED for non urgent cases. Non-urgent
patients as cause of crowding in ED has been largely reported (Ardagh et al., 2002;
Trzeciak and Rivers, 2003; Afilalo et al., 2004; Vertesi, 2004; Schull, Kiss & Szalai,
2007).
Valuable time is lost in the sorting and treatment of these non urgent cases and these
lead to overcrowding of waiting rooms. However the term non urgent is not well defined
in literature and what is non urgent for the medical staffs may be urgent and distressing to
the patient.

WAITING TIME FOR THE FINAL DISPOSITION OF THE PATIENT

At present, our hospitals are facing an increasing demand for hospitalization, for
medical staff due to the introduction of innovative technology in diagnostic and
therapeutic procedures, for higher standards in clinical safety and, finally, an increasing
patient demand for better quality services[henrich and al 2005..nurses econAllder S,
Silvester K, Walley P 2010,].

Optimal bed management is a strategic aim in any hospital as the provision of an

inpatient bed, together with the staff and supplies involved, accounts for much of its most
complex and expensive activity. The way beds are managed affects the way other hospital
departments perform since many are dependent on bed availability, such as emergency
services, operating theatres, etc. At the same time, these other hospital departments have
an impact on bed usage [National Health Service of England and Wales; 2003].
Therefore, it is important to have an efficient and correct bed management in order to
improve service delivery.
An admission to a bed as an inpatient in an acute hospital is a major event,
independent of this admission being an emergency or from a waiting list. First of all,
patient experience will depend on the availability of beds. When patients need an
emergency admission, it is important to be admitted quickly and to an appropriate bed,
avoiding unnecessary waiting times in the emergency room. On the other hand, if patients
are being admitted from a waiting list for elective surgery, it is important to minimize the
number of occasions that admissions are cancelled as a result of there being no bed
available,( National Health Service of England and Wales; 2003. ) .
The hospitalization process has three main stages: an admission, an inpatient period
and a final stage with the discharge process. An inefficient bed management in any of the
three stages of the hospitalization can cause a mismatch between demand and capacity. It
has been proved that when bed demand exceeds capacity, patient admissions and
scheduled surgical procedures can be delayed or cancelled. Traditionally, it has been
assumed that the variability in the demand comes from the emergency patient.
Interventions focused primarily on emergency departments have had limited
success [Ann Intern Med 2008].
However, repeated case studies have shown that elective admissions are often the
major cause of variation as they are more unpredictable than the emergency
admissions [BMC Health Serv Res 2007, 7:187.]. In addition, the greatest variation is in

the number of discharges and, therefore, efforts to reduce variation should start with the
discharge process and not in the admission process. Thus, planned discharges 24-h in
advance would allow a higher planning and an optimal bed assignment.
Furthermore, the discharge process should start at the point of admission in the case
of planned admissions, as in some cases the estimated length of stay without a medical
complication is known. Discharge planning allows for a better and quicker bed
assignment in hospitals and the development of nurses and other staff working in
discharge coordinator roles (Br Med J 2002, 325:610-1). In this sense, it has been proved
that multidisciplinary teams can improve the delivery of health services and patient care.
Hospitals can combine process management with information technology to redesign
patient flow for maximum efficiency and clinical outcomes. Information is the foundation
of any patient flow initiative. Patient flow is built upon the capture, integration and
sharing of information, both within and across the different departments and staff. This
critical foundation can be immensely challenging to hospitals both with numerous
information systems and departments that operate as silos. Actionable information
triggers patient care events and enables automated reminders. The aim of this study was
to evaluate how hospital capacity was improved through focusing on standardizing the
admission and discharge processes.

REDUCING WAITING TIME IN A HOSPITAL PHARMACY

Waiting time in hospital pharmacy has been documented to be a source of
dissatisfaction among patients (Uehira and Kay, 2009; Bielen and Demoulin, 2007;
Kujala et al., 2006; Barlow, 2002; Hart, 1996; Gupta et al., 1993; McKinnon et al., 1998).
Hart (1996) says that it is the one of the most consistent character of dissatisfaction that
has been associated with hospital service.

RESEARCH METHODOLOGY
PURPOSE OF STUDY
The purpose of the study was to investigate and analyze the waiting time of patients in
the Emergency Department of Jawaharlall Nehru Hospital in Rose Belle, Mauritius.

OBJECTIVES OF THE STUDY

1 .To identify factors influencing waiting time of patients in the Emergency Department
of J. Nehru Hospital.
2. To identify areas of inefficient patient flow in the ED of J. Nehru Hospital.
3. To propose solutions and recommendations to reduce waiting time of patients in the
Emergency Department of J. Nehru Hospital and improve patients satisfaction.

STUDY DESIGN
This was a descriptive qualitative analysis based on observation done over a period of
five consecutive days during week days in the month of November 2014.

STUDY SETTING
Jawaharlall Nehru Hospital is a regional hospital of Region 4. It is situated on the
outskirts of Rose Belle village next to the Motorway.
The hospital is a regional hospital providing tertiary level of healthcare to more than
200000 inhabitants of Savanne and Grand Port districts. Annexed to it are two district

hospitals, the New Souillac Hospital and the Mahebourg Hospital. There are 5 area health
centers and 17 community health centers within its catchments area.

STUDY POPULATION
Five patients per day over a period of five consecutive week days, chosen randomly
from 9h00 till 16h00, who attended the Emergency Department of J. Nehru Hospital on
the days the study was conducted.
An average of 250 patients attends the Emergency Department of J. Nehru Hospital every
day.

INCLUSION CRITERIA
Five patients per day, all adults, of 20 years of age and above, attending the Emergency
Department of J. Nehru Hospital.

EXCLUSION CRITERIA
1. Pediatric patients attending the Emergency Department of J. Nehru Hospital during the
study period.
2. Stable and Unstable patients going directly to Gynecology Emergency Unit and to
Labor Ward.
3. Stable and unstable patients going directly to Orthopedic Emergency Unit.
4. Inpatients of J. Nehru Hospital.
5. Relatives and Accompanying persons.

VARIABLES
1. Acuity: no acuity scale was used. Triage was performed by the on duty Triage nurse
posted in the Emergency Department of J. Nehru Hospital.
2. Time of Arrival: it was defined as the time that the patient approached the help desk to
express his or her desire to be treated.
3. ED Waiting Time: defined as time from arrival of patient at help desk in the
Emergency Department until start of consultation by medical officer.
4. ED Length of Stay: defined as time from arrival to final disposition (admission or
discharge).

DATA COLLECTION AND ANALYSIS

Only adults of 20 years of age and onwards were observed in the study. A total of five
patients per day, picked randomly over a period of five consecutive days were chosen.
The study was conducted from 9h00 till 16h00 by two members of the team posted at J.
Nehru Hospital. The study was done by observation only.
The time was monitored using the team members own watches, which was
synchronized with each other and with the main clock in the Emergency Department of J.
Nehru Hospital.
As soon the patients approached the help desk, the time was recorded and subsequent
intervals divided into waiting time for registration, waiting time of triage, waiting time
during interaction with healthcare personnel ( casualty nurses and medical officers) and
waiting time up to final disposition (admission, discharge, review, queuing at the
pharmacy) were recorded.

The data was analyzed by the two team members. Descriptive data such as the waiting
time at different areas were calculated. No statistical software was used to evaluate the
data.

RELIABILITY AND VALIDITY

Reliability was achieved by the optimal functioning and equally calibration of the teams
watches.
Another team member checked the compilation of the time recorded at each interval.
No pilot study was conducted to check the validity of the study.

STUDY BIAS
If the personnel of J. Nehru Hospital knew about the study, they could boost their
performance during the study period.
To minimize the study and information bias, neither the patients nor the staffs of the
Emergency Department at J. Nehru Hospital were informed of the study.
There was no interference from the team members in the normal routine work of the
Emergency Department.
However the study is subject to confounding bias as the turnout of patients varies
significantly during week days and week ends. The number of patients usually increases
during the eve and during public holidays; end of months and during winter season (flu
season).

LIMITATIONS
1. Satisfaction of patients and staffs were not considered.
2. The results cannot be generalized and does not reflect the waiting time in other
regional hospitals of Mauritius.
3. The study was conducted over a short period of time.
4. Sample selection was random and limited.

RESULTS OF THE STUDY

CHARACTERISTICS OF STUDY PATIENTS
Twenty five patients were randomly surveyed during the study. Descriptive statistics is
presented below.

Table 3: characteristics of study patients (n = 25)

VARIABLES

FREQUENCY

PERCENTAGE

AGE GROUP
20-40 YEARS OF AGE

28

40-60 YEARS OF AGE

11

44

60 AND ONWARDS

28

MALE

10

40%

FEMALE

15

60%

Table 4: Distribution of patients by gender

Figure 4: Gender Distribution of patients

Figure 4 show that 40 percent of the surveyed patients were males and 60 percent of them
were females.
Figure 5 shows final disposition distribution of patients
Figure 5 shows that 90 % of the patients were discharged and 10 % were admitted.

WAITING TIME IN THE EMERGENCY DEPARTMENT

Table 5 shows the waiting time by patients age groups

AGE GROUPS

MEAN WAITING TIME (MIN)

20-40

15

40-60

22

60 and onwards

30

Figure 6 shows a graphical representation of the waiting time by day of presentation

Figure 7 shows a graphical representation of the patients interaction time at

various flow stations in the ED
Figure 8 shows a graphical representation of the mean waiting time of patients at
various flow stations in the ED

ANALYSIS OF THE RESULTS OF STUDY

1. During the study period, it was observed that most of the attending patients at the
Emergency Department of J. Nehru Hospital were in the age group of 40-60 years old.
(44 %)
2. Sixty percent of all the observed attendances were females.
3. Of the observed attendances 90 percent of them were discharged.
4. An analysis of the mean waiting time showed that the patients of age groups 60 and
above waited the most in the Emergency Department (around 30 minutes).
5. Monday and Wednesday were the busiest days in the Emergency Department of J.
Nehru Hospital during the study period.
6. The most time is spent during the patient-doctor interaction.
7. Waiting to be seen by the doctor was the longest recorded waiting time for the
observed patients.

DISCUSSION
Patient satisfaction is a worthwhile goal of health care service (Shea, 2008). It has
been suggested that waiting time is the most important determinant of patient satisfaction.
Waiting time statistics have become an important standard by which health care is
measured.(Su,2009;Kawakami,2008;Kim,2009)and long waiting times induce negative
effects on the quality of the hospital .
Reducing outpatients' waiting time is not only valuable for the patients but also is
helpful to decrease the hospital workload. Analysis of the data has revealed that longest
waiting time occurred when the patients had to wait in the queue:
1. To register at record office
2. To be seen by doctor
3. To have investigation done
4. To get admitted in ward
5. For collection of medicines at pharmacy
6. To have review card at record office

ATTENDANCES IN THE ED
From the study carried out, we notice that peak attendances occur on Mondays
resulting in long waiting hours and crowded waiting areas on that day and that 90% of the
daily attendances are discharged right from the emergency department.
Though the study does not reflect the situation in all emergency units across the
island, the result is certainly justified as far as J. Nehru Hospital is concerned and is in
accordance with the Temporal and demographic variations in attendance at accident and
emergency departments article by A Downing and R Wilson published in the emergency
medicine journal.

Multiple factors account for the fact that Monday is the day with the maximum
attendances.
Following their social and recreational activities during weekends, people tend to
attend the emergency department early on Monday morning since they do not feel well
enough, feel exhausted and feel the need of meeting a medical and health officer to be
prescribed some rest in the form of a medical certificate.
Also, following weekend parties and heavy consumption of fat rich foods, protein rich
foods and alcohol, there are often emergency cases attending the hospital and reveal to be
myocardial infarction or cerebro-vascular accidents.
Again following weekends, there are multiple physical injury related attendances;
injury being common during unequipped and disorganized weekend leisure activities.
Monday attendances also include those individuals who come for renewal of
medications, having lost their medications during their weekend visits to their relatives
and those individual who decide and take resolutions to comply to their treatment on a
fresh week and come to seek treatment for their chronic illnesses.
As for the fact that 90% of attendances are being discharged right from the
emergency department, there are several reasons accounting for it.
It is noticed that there is innumerable non-urgent, cold cases directed to the emergency
department; that not only add on the waiting time for those attending for higher acuity
cases but also add on the workload of the emergency units staff and hinder their overall
performance. This goes in accordance with studies carried out about ED congestion
(Siddhartan (1996)); reviewed earlier.

There is a culture of attending major hospitals and in particular the emergency

department in the hope of seeking the best treatment for minor conditions instead of
visiting the primary health care centers. This is also supported by literature by (McCusker
and Verdon 2006 Riegel et al. 2002).
There is also the culture of attending all health service facilities available for the same
minor issue and visit all the facilities several times until there is satisfaction with the
doctor met.
It is also common notice that the same patients come again after seeking treatment and
so, since they are already treated and is being followed up as out patients, do not need
admission.
At a slim margin, it can happen that the doctors working in the frontline miss out sub
acute conditions that might need admission. But usually all emergency and urgent cases
are rightly picked up and those requiring admission are admitted.
There are also a number of patients who come to the emergency department with
referral notes from primary health centers for matters that could have been dealt with at
the primary level but has not been so because of lack of equipment or break down of the
available equipment. There are also patients coming to the emergency department with
referral from private practitioners and could have been directed to the outpatient
department instead of adding workload on the emergency department.

DOCTER-PATIENT INTERACTION
Results of our short study indicate that most of the time spent in the Emergency
Department of J. Nehru Hospital was during the interaction of the patient with the
medical officer.

We understand that this does not necessarily reflects the trend in other regional
hospitals in Mauritius but similar findings were reported by Banerjea and Carter (2006)
during a survey on waiting time in developing countries.
In the context of J. Nehru hospital, the high amount of time during the doctor-patient
interaction is multifactorial:
1. Different complexity of cases: each case attended by the medical practitioner is
different form one another. The doctor may spend minutes to examine a minor
injury and spends a lot of time in diagnosing and treating a cardiac failure patient.
Literature supports this observation and according to Derlet and Richard (2000),
patients acuity influences waiting time in the emergency department.
2. The number of doctors present in the Emergency Department will also have an
impact of waiting time. During our study, from 9h00-16h00, there are three
consultation rooms available for Emergency care but it was observed that doctors
decide on shifts on their own and at one time, there was only one doctor seeing all
the emergency cases coming at J. Nehru. Literature also reports that the number of
doctors physically present in the ED influences the overall waiting time of
patients (Derlet and Richard 2008).
3. Doctors usually wait for some initial investigations before deciding on the final
disposition of the patients in ED. Depending on the time taken for the results to be
available; some patients may wait longer than others. In literature we have taken note that
the Laboratory Turnaround Time Delay has a major impact on the rapidity of emergency
health services (Jalili et al., 2012).
4. A rather shocking observation made at the Emergency Department of J. Nehru
hospital is that most of the emergency medical team comprises of young doctors. Though
we do not doubt their knowledge, we believe experience plays a major role in delivering

rapid and efficient emergency care to patients. Moreover, we believe that having
Emergency Physicians posted in the ED or at least one Emergency Physician to supervise
the medical team, can drastically reduce the waiting time in ED. Literature supports this
arguments and it has been documented that having Emergency Nurse Practitioners
(Jennings et al., 2008) and Emergency Physicians (OConnor et al., 2004) reduce the
waiting time of patients in the ED.

WAITING FOR THE DOCTOR

Our result showed that waiting to be seen by the doctor was the longest recorded
waiting time for the observed patients. After registration and triage, patient spent most of
the time in the waiting room till they are seen by the physician. The effect of the triage
system has been evaluated in several countries to reduce waiting time. The effect of the
triage system for reducing waiting time has been assessed in different studies.

In

Australia, Kwa and his colleagues concluded that such a fast-track can help meet the
demand of the increasing attendances in the ED, allowing lower-acuity patients to be seen
quickly without a negative impact on high-acuity patients.
Miro et al. also managed to decrease waiting time through the triage system.
Tamburlini et al. with regard to the evaluation of the triage function in the ED observe
that both wait time and patient crowding could decrease after educating nurses and the
establishment of a triage system in the ED.

Khankeh et al. showed that there was a

significant difference between the mean wait times in triage group.

In Mauritius, till now no study has published the effect of triage on waiting time in our
hospitals. Our triage system can be reinforced to improve the waiting time. In all triage
system, there need to be a triage scale for acuity ratings. However, the design of the
triage scale differs considerably between EDs.

In Mauritius, we noticed that no valid and reliable triage scale has been defined and
used. Thus, patients are directed either to the unsorted department or to the casualty
department after taking a brief history by the triage nurse. Unfortunately our triage
system does not categorize patients treatment as to be immediate, urgent or routine.
We strongly belief that such categorization of patients will help to minimize waiting time
by allowing lower-acuity patient to be seen quickly without compromising the treatment
of high-acuity patients.
Waiting time can be further reduced by better use of nurses at the triage level. A pilot
program in Australia has reduced waiting times in the ED by giving emergency nurses
more clinical autonomy.

In this study, nurses were allowed to carry out minor

procedures and treatment such as prescribing pain killers and investigations. The new
system reduced the average waiting time for ED patients from 46 minutes to 17 minutes.
However, a multidisciplinary assessment at the triage can be thought as a new way
forward. The multidisciplinary triage comprise of a senior registrar or consultant and a
triage nurse.

This team would have the ability to deliver definitive treatment and

dispositions to some patients and streamline the management of others. Our triage
system lack skilled and trained nurses for this purpose. Redesigning the triage system in
our hospital; triage scale and categorization of patient with development of performance
indicators, trained emergency nurses and implementation of senior registrar at the triage
will be an ideal setting to reduce waiting time in ED.

The introduction of the navigation can as well be considered to reduce the number of
steps prior to patients being seen by the clinicians, which ensure that people with lifethreatening conditions are identified earlier. Patients can thus be seen directly by the
triage nurse as they step in the ED and relevant information concerning identity of
patient, physical examination, treatment initiated and investigation sent recorded and
passed on to record officer who scan and electronically enter these data. Thus, these data

can be easily accessed by the doctors. Such a document can be designed and
implemented. We propose one such document (Table 6) but need to be piloted before use.

Date

Time

Navigator

Name

Date of Birth

Details of Navigator

Observations
Blood pressure
Heart Rate
Respiratory rate
Pain score
/10
General examination
Neurological observations
Investigations
Full blood count
Urea and electrolytes
Coagulation profile
Amylase
C-Reactive protein
Treatment location
Priority number

temperature
Body Mass Index
Pupils size
Glasgow Coma scale

Liver functions
Glucose level
Troponin level
Beta-HCG level
Other tests
Trolley

Electrocardiograms
Chest XR
Other X-rays

wheelchair

Number
Directed to
Waiting room
Unsorted department
Treatment and management
Drug
Dosage
Route

Casualty Department
Name

and Time given

signature

Though our study has not focused on patients perception of the triage system, we
belief that it is an important area to carry out a study in our hospital. Understanding

patients perception of the triage encounter in our hospital will definitely help improve
the interaction between the staff and the patients. Furthermore, when patients are given
information about the triage system in use, they understand and accept the system,
thereby reducing conflicts between the staff and patients.

WAITING AFTER DISPOSITION BY THE DOCTOR

Patients may be less able to judge the technical quality of the care they receive, but
they do judge their social interaction with the Hospital care workers. Pharmacy
professionals must increase patients awareness of the value of pharmaceutical care
services .Attempts should therefore be made to reduce the time on the components:
registration of patients and dispensing of medicines so that more time could be devoted to
counseling while reducing the total time spent by the patient in hospitals.
Queuing models have been applied to the analysis of waiting lines in healthcare
organizations and the goal of such analysis is to minimize the costs of waiting and to
provide quantitative data to assist in system planning. In a study to identify a priority
queuing model of a hospital pharmacy unit, the authors used queuing theory to evaluate
waiting times in the outpatient department.
In the analysis of prescription dispensing in an Australian hospital pharmacy, the
authors used the work measurement technique to determine standard times for all the
activities involved in dispensing in- and out- patient prescriptions along with the total
amount of labor required to perform the activities.
The paper patient casualty card and prescription, although historically effective, has
always been a somewhat painful prescribing medium for physicians, patients, and
pharmacists. The biggest problem with paper prescribing for physicians is the amount of
time needed to recall from memory or look up which medication and dosage to prescribe
more than 20,000 products. They then must legibly write each prescription. Pharmacists
deal with hundreds of prescriptions each day and must legally account for each one, must

store them, and be able to retrieve them for refills. Thus alternative ways generating and
maintaining prescriptions with computers are often sought. Computer-based writing of
prescriptions by physicians addresses many of the problems posed by the paper
prescription.
Record officers, nursing officers and pharmacists would save much time not having to
interpret physicians writing and save much space for their daily works. The time needed
for retrieval of prescriptions for refills would be greatly diminished. Implementing a new
plan is costly and often requires additional changes in the current working process. The
alternative is to use computer simulations to predict the impact of changes on outcomes.
Computer simulation is a powerful tool that can support evidence-based health care
policies and management in a risk-free environment. The use of a simulation to test
alternative plans can improve efficiency at a minimal cost. The results of this case study
in a community hospital indicated the usefulness of efficiency at a minimal cost.

CONCLUSIONS
As being the case in most countries, overcrowding and increasing waiting time in the
Emergency Departments of overseas hospitals, J. Nehru Hospital also does not escape
this global trend.
Though the Emergency Medical Team was observed to react promptly to any urgent
cases coming to the ED, lack of human resources and experience among the dedicated
medical team was influential in determining the overall length of stay in the ED.

What can be concluded from the attendances pattern is that our population is not
aware of the purpose of an emergency department and uses it as a free facility for seeking
medical help.
Overcrowding and long waiting hours occur not because of inadequate spacing and
improper control of the system but because of misuse and improper communication about
the purposefulness of the emergency department.
Strategies that could significantly speed the process of service delivery like queuing
models can be adopted to minimize the costs of waiting and to provide quantitative data
to assist in system planning. So that more time could be devoted to serve and counseling
of the patients.
This study is a preliminary study and gives an overview of the waiting time in the ED
of our hospital. However, further studies with larger population study need to conducted
to confirm our findings.

RECOMMENDATIONS
There is a need to educate the population about the health system and its functionality.
They need to be taught how to use it appropriately. They need to know that primary
health centers are at their disposal for all their daily health issues and queries and that
they need to rush to the emergency department only for life threatening issues and in
cases where immediate medical intervention is necessary.
There should be the setting up of a system of predicting peak attendances during the
day, the week, the month and the year so as to provide more staff at times of peak to help
in reducing wait times and the impression of crowdedness in the waiting area.

There is a need to form all doctors in the region about proper use of the facilities
offered at the primary healthcare level and set proper guidelines about who and when to
refer to the emergency department for treatment.

RECOMMENDATIONS IN THE TRIAGE SYSTEM:

1. Developing a valid and reliable triage scale to facilitate categorization of patients and
performance indicators to assess the efficacy our triage system
2. Experienced and trained Emergency nurses at the triage encounter with a degree of
autonomy to take decision
3. Develop a multidisciplinary triage system consisting of a nurse and a senior registrar or
consultant
4. The introduction of navigation to decrease the number of steps prior to be seen by the
physician
5. Inform patient of the triage system and take into consideration their perception of the
triage system for further improvement of our care.

RECOMMENDATIONS FOR STAFFS

1. Require adequate number of nurses and doctors. Additional staffs should be mobilized
during peak hours and peak periods to cater for the increasing demand of emergency
healthcare.
2. The Emergency Department must be run by the most experienced team in the hospital,
able to deal with any emergency quickly and adequately. Younger doctors should be
posted in major units and thoroughly trained first before being sent to work in the
emergency department.
3. The ministry should ponder over the project of training emergency nurses and doctors
and review the overall personnel of the emergency department.

ADDITIONAL RECOMMENDATIONS
1. Waiting area could be made more attractive by putting up notice boards and posters
giving information to public about health education, dangers of self medication, latest
innovation and developments in the field of Hospital care and hospital services.
2. Air conditioning of entire pharmacy area required, as people feel suffocated due to
over congestion in peak hours of transaction.
3. Token system can be introduced, instead of queuing up to register and again queuing
up to see doctor and lastly but not least queuing up for medication and treatment.
This helps in preventing people from jumping the queue.
4. To allow any one person in queue to collect the medicines and allowing the hospital
attendants also to join them. A small wait area could be made for other patient attendees.
5. To clearly specify the queues for emergency department and other specific department.
6. To increase the dispensing counters, to reduce the burden of overcrowding.
7. To have a facility before joining the queue to inform the patients whether the
prescribed medicines are available in the pharmacy, this could reduce the burden of
waiting.

LIST OF TABLES AND FIGURES

LIST OF TABLES
1.
2.
3.
4.
5.
6.

Manchester Triage Scale

Australasian Triage Scale
Characteristics of the study population
Distribution of patients by gender
Waiting times according to patients age groups
Navigation table

LIST OF FIGURES
1. Steps in the Manchester Triage Scale
2. Steps involved in the Navigation of the Manchester Triage System

3.
4.
5.
6.
7.
8.

Phenomenographic Triage Scale in Sweden

Gender distribution of patients
Final disposition of patients in the ED
Waiting time by day of presentation
Patients interactions at various flow stations in the ED
Waiting time at various flow stations in the ED