Our data assessed triage performance, timeliness of care, and length of stay in ED. It evaluated the feasibility and validity of the CTAS outside of Canada. Our results show an indirect relationship between CTAS acuity level and RTP: as CTAS acuity level increased, RTP decreased and LOS increased. ED patients who left the ED without being seen were of low CTAS acuity levels.
The majority of our ED patients were category IV and V (75.7%), which is in line with the percentage of CTAS IV and V in the Principality of Andorra ED of 76.82% . The lower percentage of levels I & II (0.6%) could be due to many reasons such as random errors, or assigning a patient an inappropriate low triage level. This is not a trauma hospital and, hence, this could be another reason leading to low percentages of levels I & II. Tables 1 and 2 demonstrate the RTP time generally increased as triage acuity fell. Although this is expected, fractile response rates were actually higher in levels IV and V (61% and 83% respectively), than in level III (36%). This lower fractile response rate could be due to a variety of reasons including space limitations, eligibility for care at this hospital, ED volume, or language spoken. Bias and prejudice might also play a role in this lower response rate.
Our data also showed that, for the most critically ill patients (level I&II), RTP was rapid and LOS was greatest, which are in line with CTAS objectives. This is expected because these patients required more time and manpower resources for the care and management of their critical condition, thus, contributing to a prolonged LOS in the ED (Figure 2 and Table 1).
Hospitalization rate is a marker of the severity of illness. Hospital admission rate through our ED, in this study, was 6.7%, which is in agreement with other studies [9, 13]. However, other studies showed higher percentage of hospitalization through the ED [7, 14]. These variations in hospital admission rates could be due to several factors including hospital size, number and types of specialties in the hospital, triage system, patients' eligibility, and insurance coverage. Admission rates are generally correlated with CTAS triage level; in this study, the majority of our ED patients were categorized as levels IV and V. Furthermore, our hospital is a specialized tertiary care institute, where patients are transferred from other hospitals in the region. This may explain, in part, the low admission rates through the ED.
Previous studies showed that up to 15% of patients left ED without receiving any medical attention [15–18]. Likewise, our ED's estimated LWBS rate is approximately 9.8%, however, this is higher than our quality indicator of < 2%. Using CTAS, recent study in United Arab Emirates, showed a rate of 4.7% LWBS , Canadian studies reported rates between 3 - 3.57% [20, 21], and 7.4 - 15.0% in the USA [17, 22–24]. These international variations in LWBS may reflect differences in culture, ED structure or service delivery. "Left without being seen" is related to many factors, such as ED efficiency, patient volume and acuity, understaffing and overcrowding [23, 25]. In keeping with CTAS objectives, our data demonstrated that of 118 patients, who left without being seen during the study period, none were in Levels I or II (Resuscitation or Emergent), and only 14 (11.9%) were in Level III. This implies that in our ED patients who LWBS, generally, have conditions of a less acute and less urgent nature.
Waiting time studies offer constructive information to identify system inefficiencies and for benchmarking purposes. With a growing population and an increasing demand for medical care in EDs throughout the Gulf region and elsewhere, there is a need for comparative studies both locally, as well as, internationally to document and account for avoidable areas of delay in the care of emergency patients, and hence, improve quality of care. Our study is one of a few, which examines the CTAS in EDs outside of Canada.