INTRODUCTION

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

INCLUDEPICTURE "http://health.gov.mu/English/Documents/dot.gif" \* MERGEFORMATINET

Regional Health DirectorMedical SuperintendentRegional Hospital Administrator & Hospital AdministratorRegional Nursing AdministratorNursing Administrator Male & FemaleRegional 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. Aharonson-Daniel 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 over- crowding 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

SCALE CATEGORYAUSTRALIAN TRIAGE

SCALE CATEGORYAUSTRALIAN TRIAGE

SCALE CATEGORY

ATS 1immediate100%

ATS 210 minutes80%

ATS 330 minutes75%

ATS 460 minutes70%

ATS 5120 minutes70%

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 3WAITING 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 Med2008].

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 Res2007,7:187.]. 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 J2002,325:610-1). 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)

VARIABLESFREQUENCYPERCENTAGE

AGE GROUP 7 28

20-40 YEARS OF AGE

40-60 YEARS OF AGE 11 44

60 AND ONWARDS 7 28

Table 4: Distribution of patients by gender MALE

10

40%

FEMALE

15 60%

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

ANALYSIS OF THE RESULTS OF STUDY1. 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 done4. 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 life-threatening 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 pressuretemperature

Heart RateBody Mass Index

Respiratory ratePupils size

Pain score /10Glasgow Coma scale

General examination

Neurological observations

Investigations

Full blood countLiver functionsElectrocardiograms

Urea and electrolytes Glucose level Chest XR

Coagulation profileTroponin levelOther X-rays

AmylaseBeta-HCG level

C-Reactive protein Other tests

Treatment location

Priority numberTrolley / wheelchair Number

Directed to

Waiting roomUnsorted departmentCasualty Department

Treatment and management

Drug

DosageRouteName and signatureTime given

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 STAFFS1. 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 RECOMMENDATIONS1. 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 FIGURESLIST OF TABLES

1. Manchester Triage Scale

2. Australasian Triage Scale

3. Characteristics of the study population

4. Distribution of patients by gender

5. Waiting times according to patients age groups6. Navigation table

LIST OF FIGURES

1. Steps in the Manchester Triage Scale

2. Steps involved in the Navigation of the Manchester Triage System

3. Phenomenographic Triage Scale in Sweden

4. Gender distribution of patients

5. Final disposition of patients in the ED

6. Waiting time by day of presentation

7. Patients interactions at various flow stations in the ED

8. Waiting time at various flow stations in the ED