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Length of stay and associated factors among pediatric patients in the pediatric emergency unit of the Tikur Anbessa specialized hospital, Addis Ababa, Ethiopia

BMC Emergency Medicine volume 24, Article number: 170 (2024) Cite this article

Abstract

Background

Length of stay in the emergency department is used as a quality indicator to gauge the overall efficiency of emergency care. The performance measure was used to evaluate the quality of care provided in the emergency department.

Objective

To assess the length of stay and associated factors among pediatric patients admitted to the pediatric emergency unit of Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia.

Methods

An institution-based prospective cross-sectional study design was employed. A systematic random sampling technique was used to select the study participants. Data were collected via semi-structured, interviewer-administered questionnaires and chart reviews. Analysis was performed via the Statistical Package for Social Science software version 27. Binary logistic regression analysis was conducted to identify variables associated with the length of stay. The study was conducted in the Pediatric Emergency Unit of Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia, from March 15 to April 15, 2023.

Results

A total of 268 patients participated in the study, with a response rate of 97.81%. The majority of the participants were male (157, 58.6%), with a median age of 3 years. The study revealed that 180 participants (67.2%) experienced a prolonged length of stay. The variables significantly associated with prolonged length of stay included residency (AOR = 2.04, CI: 1.03, 4.025), triage category (AOR = 3.25, CI: 1.08, 5.974), number of investigations (AOR = 2.381, CI: 1.038, 5.462), and waiting for imaging (AOR = 4.230, CI: 1.638, 10.93).

Conclusion

Many pediatric patients stayed in the emergency room for more than 24 h because of factors such as residency, triage category, number of investigations, and the need for imaging. To address this, we recommend streamlining triage processes, increasing imaging resources, providing additional staff training, developing integrated care pathways, and advocating for policy changes to increase emergency room efficiency and improve patient outcomes.

Peer Review reports

Introduction

The length of stay (LOS) in the emergency department (ED) is defined as the duration from patient arrival to discharge, referral to another facility, or hospital admission [1, 2]. This approach is crucial for increasing patient satisfaction and optimizing ED operations. The ED serves as a critical facility for promptly evaluating and stabilizing patients requiring immediate medical attention, operating around the clock [1].

Globally, there has been a persistent imbalance between the supply and demand for emergency services over the past two decades [3, 4]. This imbalance has resulted in a surge in emergency department (ED) admissions that exceeds the rate of population growth, thereby contributing to extended ED length of stay. In the United States alone, approximately 30 million children require emergency care annually, with pediatric ED visits on the rise [2, 5]. Studies have indicated that extended emergency department (ED) stays can increase mortality rates by 15–30% [3, 6,7,8].

Identifying the factors influencing LOS is critical for monitoring overcrowding and ensuring efficient throughput in the ED [9, 10]. It serves as a key performance indicator affecting hospital costs and healthcare system efficiency [11]. Developed countries often target an ED length of stay threshold of less than 4 h [11,12,13,14]. Ethiopia's 2016 Hospital Transformation Guidelines set a one-day limit for ED length of stay [15].

Numerous factors contribute to extending the LOS in pediatric EDs and are influenced by healthcare system capacity, triage accuracy, decision-making delays, and diagnostic service utilization [16, 17]. In addition, professionals' ability to correctly triage a number of patients and the use of medical services such as imaging or laboratory tests might increase the length of stay in the emergency department (ED) [18,19,20,21,22,23,24].

Previous research has identified various patient-specific factors (e.g., age, triage level, and diagnosis) and facility-specific variables (e.g., hospital size and specialist consultation) as key determinants of ED length of stay [20, 22,23,24,25,26]. Pediatric ED wait times not only compromise patient care but also exacerbate socioeconomic challenges for families, communities, and countries. Prolonged wait times decrease hospital admission rates, escalate healthcare resource utilization, and heighten the risks of hospital-acquired infections, morbidity, and mortality while also diminishing patient satisfaction [3, 6, 8, 27,28,29,30].

Despite the critical importance of understanding LOS in pediatric emergency units, this area remains under-researched, especially in low-resource settings such as Ethiopia. Tikur Anbessa Specialized Hospital, where emergency medicine is an emerging specialty, lacks studies on this topic. Therefore, this study aims to comprehensively assess pediatric patient LOS and its determinants in the ED of Tikur Anbessa Specialized Hospital. The magnitude and importance of this study lies in its potential to fill significant research gaps and provide empirical data specific to Tikur Anbessa Specialized Hospital and similar contexts. By understanding factors contributing to extending LOS, such as patient demographics, triage protocols, and diagnostic delays, healthcare providers can implement targeted interventions to streamline ED workflows and enhance patient outcomes [18,19,20,21,22,23,24]. Furthermore, this study is crucial for informing hospital administrators and stakeholders, enabling informed decision-making regarding resource allocation, staffing, and facility management in the pediatric ED.

Practically, the findings of this study will aid policymakers in evaluating and refining ED programs, potentially reducing healthcare costs associated with prolonged LOS and improving overall healthcare delivery. Additionally, this study could serve as a foundational resource for future research endeavors, providing a baseline for comparative studies and guiding evidence-based practices in pediatric emergency care settings.

Research question

Is there a length of stay in the pediatric emergency unit?

What are the factors determining the length of stay in the pediatric emergency department?

Methods

Study area, period, and design

The study was conducted at the pediatric emergency unit of Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia, from March 15 to April 15, 2023. A prospective cross-sectional study design was applied. Tikur Anbessa Specialized Hospital, located in Addis Ababa, the capital city of Ethiopia, offers tertiary care and is open to emergency services 24 h a day, seven days a week. The hospital, governed by Addis Ababa University (AAU), is the largest and oldest hospital in Ethiopia, with over 700 beds (http://www.aau.edu.et/chs/tikur-anbessa-specialized-hospital/background-of-tikur-anbessa-hospital/). The pediatric emergency unit, located on the first floor, has 45 beds and admits, on average, 15–20 patients per day and 450–600 patients per month.

The composition of Ethiopian emergency departments at tertiary hospitals varies across different institutions. On average, similar to Tikur Anbessa Hospital, the emergency department is staffed by a healthcare team that includes 7 emergency and critical care physicians, 5 specialized nurses with MSc degrees in emergency and critical care, and 15 BSc nurses. However, there are no paramedic or general practitioners. Specifically, in the pediatric emergency department, the team consists of 2 physicians, 2 MSc nurses, and 7 BSc nurses.

Study population

All randomly selected pediatric patients were admitted to Tikur Anbessa Specialized Hospital's pediatric emergency unit.

Inclusion criteria

Pediatric patients (aged 1–14 years) who visited the emergency department during the study period were included.

Patients whose guardians provided informed consent for participation in the study.

Exclusion criteria:

Pediatric patients were immediately transferred to another facility without receiving initial treatment at the emergency department.

Patients whose guardians declined to participate or withdrew consent at any point during the study.

Sample size determination

A single population proportion formula was used to determine the sample size. The proportion of patients with a prolonged length of stay (p = 0.79) was taken from a previous study conducted at Wolaita Sodo University Teaching and Referral Hospital [31], considering a 95% confidence interval and a margin of error of 5%. The formula used was n= \(\frac{(\frac{Z{\alpha}}{2})^{2}P(1-P)}{d^{2}}\) n = where.

n is the sample size, z@/2 = is the critical value for the normal distribution at the 95% confidence level, d is the margin of error, and P is the proportion. After adding a 10% nonresponse rate, the final total sample size was 274. For the second objective (factors), the authors used the Epi-info version 7 computer program, assuming a 95% confidence interval, 80% power, and the ratio of exposed to non-exposed (R) for various factors and parameters. However, the calculated sample size for the second objective was smaller than the sample size derived from the first objective.

Sampling and triage

The study used a systematic random sampling technique, selecting every second admitted child as a participant. Ethiopian hospitals employ the South African triaging method (ESI), categorizing patients as red (immediately life-threatening), orange (managed within 10 min), yellow (managed within 60 min), green (wait 240 min), or blue or black for suspected death or deceased patients.

Triage process

In Ethiopia, the triage process begins at the entrance of the emergency department (ED) in the designated triage area. Patients are sorted on the basis of the severity of their condition and resource availability, as previously described.

Red tag: Patients who require immediate treatment.

Orange tag: Patients should be treated within 10 minutes.

Yellow tag: Patients should be treated within 60 minutes.

Green tag: Patients can wait until unstable patients are stabilized.

Additionally, all patients, regardless of their initial triage category (red, orange, yellow, or green), can be re-triaged and categorized on the basis of their response to emergency care or resuscitation.

Operational Definitions

Length of stay

The length of stay in the emergency department (ED) begins when the patient enters the unit and ends when the patient is discharged home, admitted to a hospital bed, or transferred to another institution [2].

Prolonged length of stay

Patients who stayed in the ED for more than 24 h for various reasons [15].

Not prolonged length of stay

Patients who stayed in the ED for 24 h or less [15].

Pediatric Emergency patients

Pediatric emergency patients: Pediatric patients aged between 7 days and 12 years who presented to the emergency room.

Description of checklists, tools, and semi-structured interview questions

The required data were collected from parents or guardians through face to face interviews via semistructured questionnaires and chart reviews, which were adapted from previous studies [1, 17, 18, 31, 32]. This study employed structured questionnaires, observational checklists, and semi-structured interview questions to assess factors influencing the length of stay (LOS) among pediatric patients in emergency departments at Tikur Anbessa Specialized Hospital.

Structured questionnaire

Sections:

Demographic Information: Age, gender, job title, experience, and education.

Clinical Processes: Timeliness of care, adherence to guidelines, and communication.

Administrative Processes: Resource availability, patient registration efficiency, and patient flow management.

Perceived challenges: Clinical and administrative obstacles impacting LOS.

Sample Question:

The emergency department has sufficient staff to handle the patient load efficiently.

Observational Checklist

Trained observers used this checklist to record key clinical and administrative processes with binary scoring (yes/no).

Components: Clinical processes: Patient triage, initial assessment, medication administration, and vital sign monitoring.

Administrative processes: Patient registration, medical supply availability, and record management.

Sample Items:

Patient triage was completed within 15 min of arrival.

Medications were administered as per the prescribed protocol.

Reliability and validity.

Reliability was assessed via Cronbach's alpha, which indicated a high level of internal consistency (Cronbach's alpha = 0.85). The validity of the tool was confirmed through expert reviews and comparisons with literature, ensuring that the tools accurately measure the intended outcomes in the participant context.

Data collection procedure

Data were collected by three BSc-qualified nurses and one supervisor through interviews and medical record reviews, beginning from the patient’s arrival and triage in the emergency room to their discharge from the ED. Eligible patients were identified at triage, where initial data on arrival times and presentation characteristics were recorded. Further sociodemographic and organizational details were gathered at various treatment points and from chart reviews post stabilization, with final details on diagnostics, total length of stay, and disposition recorded at discharge.

Data quality control

The supervisor and data collectors were trained for one day to ensure the quality of the data. They discussed how to approach participants and perform measurements. Furthermore, throughout the data entry and cleaning processes, the consistency and completeness of all the data were checked.

Data analysis and interpretations

After verifying completeness, the data were coded and entered into Epi Data version 4.6 and then exported to SPSS version 27 for analysis. Outliers and multicollinearity were checked via standard residuals and the variance inflation factor, respectively, and variables with a factor over ten were removed. Binary logistic regression identified associations between the dependent and independent variables; those with a p value under 0.25 were included in the multivariable analysis. Variables significant at a p value less than 0.05 and with an adjusted odds ratio (AOR) within the 95% confidence interval were considered factors associated with length of stay (LOS). The results are presented in figures, tables, graphs, and charts.

Results

Sociodemographic characteristics of the study participants

A total of 268 patients participated in the study, resulting in a response rate of 97.81%. The median age of the participants was 3 years, ranging from a minimum of 10 days to a maximum of 12 years. The majority of the respondents were aged 1–3 years (30.6%). Most participants were male, totaling 157 (58.6%). Over half, specifically 147 (54.9%), resided in rural areas. One hundred thirty-two participants (49.3%) were paying patients (Table 1).

Table 1 Sociodemographic Characteristics of the Study Participants, Ethiopia, 2023 (N = 268)
Full size table

Presentation and clinical characteristics of the participants

Among the participants, 143 (53.4%) arrived by taxis, and 164 (61.2%) were classified as urgent in triage. Half, or 135 (50.4%), were referred from governmental health institutions. The most common reasons for emergency visits were acute illness and medical cases, affecting 52.6% and 78.4% of the participants, respectively. Nearly two-thirds (60.4% or 162 participants) received first aid before arrival (Table 2).

Table 2 Presentation and Clinical Characteristics of Participants in Tikur Anbessa Specialized Hospital, Ethiopia 2024
Full size table

Time- and organizational-related factors of the participants

Among the participants, 143 (53.4%) arrived at the emergency unit in the morning, and 208 (77.6%) came on weekend days, with 114 (42.5%) reporting illness durations of 13–24 h. All participants underwent laboratory tests, 223 (83.2%) had imaging studies, and 264 (98.5%) received medication in the emergency room. Consultations were conducted for 185 (69%) of the participants (Table 3).

Table 3 Time- and organizational-related factors of pediatric patients admitted to the pediatric emergency unit of Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia, 2023 (N = 268)
Full size table

Length of stay

One hundred eighty participants (67.2%) stayed in the pediatric emergency unit for more than 24 h, whereas 88 (32.8%) had a length of stay of 24 h or less. The minimum stay duration was 3 h, accounting for 1.1% of the participants; the median stay duration was 72 h; the mean stay duration was 96 h; and the maximum stay duration was 672 h, affecting 0.7% of the respondents (Fig. 1).

Fig. 1
figure 1

Length of stay for pediatric patients admitted to the pediatric emergency unit of Tikur Anbessa Specialized Hospital Addis Ababa, Ethiopia, 2023 (N = 268)

Full size image

The most common reason for staying in the emergency unit for more than 24 h was the absence of inpatient beds, affecting 159 participants (88.3%) (Fig. 2).

Fig. 2
figure 2

Reasons for more than 24 h for pediatric patients admitted to the pediatric emergency unit of Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia, 2023 (N = 180)

Full size image

Factors influencing length of stay in pediatric emergency care

In the binary logistic regression model, the multivariable analysis revealed the following specific findings: Compared with urban residents, rural residents were twice as likely to have a prolonged length of stay (AOR = 2.040; 95% CI: 1.034–4.025). Patients categorized under urgent triage were three times more likely to have a prolonged length of stay than nonurgent patients were (AOR = 3.247; 95% CI: 1.083–9.742). Patients who underwent more than three lab tests were more than twice as likely to have a prolonged length of stay as those with fewer tests (AOR = 2.381; 95% CI: 1.038–5.462). Compared with pediatric patients who did not have imaging studies, those who had imaging studies were hospitalized approximately four times longer (AOR = 4.230; 95% CI: 1.638–10.929) (Table 4).

Table 4 Summarizes these associations for pediatric patients admitted to the Tikur Anbessa Specialized Hospital's pediatric emergency unit, Addis Ababa, Ethiopia, in 2023 (N = 268)
Full size table

Discussion

This study revealed that approximately 180 patients (67.2%, 95% CI of 61.8–72.9) stayed in the emergency unit for more than 24 h. This finding is greater than those of previous studies, such as those in Guangzhou, China [2]; North Taiwan, 0.9% [33]; the United States, 22% [34]; California, 30% [35]; and southern Nigeria, 16.4% [5]. The possible differences might be due to the well-equipped health systems in high-income countries versus the inadequate resources and poorly equipped healthcare professionals in low-income countries such as Ethiopia. Additionally, variations in the definition of prolonged length of stay in pediatric emergency units across different countries could explain the discrepancies. For example, in Nigeria, a prolonged stay is defined as 72 h or more [5], whereas in Taiwan and California, it is 8 h or more [33, 35], and in Australia, the USA, and Saudi Arabia, it is greater than 4 h [11, 12, 34]. This study used a threshold of more than 24 h, which was based on the Ethiopian Hospital Service Guidelines of 2016 [15]. This study is comparable to the studies conducted in Kenya, Tanzania, and Uganda [36,37,38]. However, the length of stay observed in this study was higher than that reported in studies conducted in Australia and South Africa. This discrepancy may be attributed to the suboptimal implementation of international triage protocols, such as the Manchester Triage System, the Australian and South African five-tier triage system, or the Emergency Severity Index (ESI) scoring system, in the Australian and South African context [39,40,41]. Moreover, in Ethiopia the Reverse Triage Tool Leuven (RTTL) not applied, this tool has developed by researchers at University Hospitals in Belgium, used to estimate and identify patients who could be safely early discharged [42, 43]. However, recent research suggests that introducing artificial intelligence could optimize the triage system and reduce the length of stay [44].

The findings suggested that patients from rural areas, patients categorized as urgent in triage, those undergoing more lab investigations, and those requiring imaging were more likely to stay longer in the emergency unit. Moreover, the absence of inpatient beds was a crucial factor in prolonging the length of stay in the emergency room.

The study indicated that residency in rural areas was significantly associated with prolonged stays in the pediatric emergency unit, which is consistent with previous research conducted in Iran [32]. This might be due to the inability of rural patients to afford admission expenses and delays in implementing investigations and imaging. The study also demonstrated that patients categorized as urgent in triage typically experienced longer stays in the emergency department. This prolongation often results from the need for retriaging urgent cases, in contrast to emergent cases, which are promptly treated and transferred. Conversely, nonurgent cases are usually sent to outpatient services, necessitating comprehensive interventions that contribute to extended stays [45].

Furthermore, patients who underwent more than three laboratory tests had significantly longer stays in the emergency department than those with three or fewer tests. This pattern aligns with findings from similar studies conducted at East Carolina University, Taiwan, and New Jersey [33, 46, 47]. Physicians often request multiple laboratory tests to confirm diagnoses and assess patient prognoses, which in turn can significantly increase the length of time patients spend in the emergency department [33, 46, 47].

Moreover, this study revealed that undergoing an imaging study was significantly associated with longer pediatric emergency stays, similar to findings from studies in southern Ethiopia, Iran, Cohen Children's Medical Centre, California, and East Carolina University [24, 31, 32, 35, 46]. This is likely because imaging studies are essential for accurately diagnosing patients, which is crucial for physicians when deciding whether to refer patients to another hospital, discharge them, or admit them. Since imaging studies typically require more time compared to other types of investigations, largely due to overcrowding in the radiology department. The study highlights that an extended stay for pediatric patients in the emergency unit leads to overcrowding, making it difficult to provide adequate emergency care. This circumstances also escalates the workload for emergency professionals, which may result in burnout and a reluctance to accept new cases, thereby contributing to prolonged lengths of stay [48]. A study conducted in Kenya and Tanzania reported that the availability of health professionals at their work site and the number of patients can affect the length of stay or waiting time in the emergency department [36,37,38].

Strengths of the study

The strength of this study lies in its comprehensive approach, which uses both observational checklists and structured questionnaires, increasing its reliability and credibility.

Limitations of the study

The cross-sectional study design inherently limits the ability to establish causality, as it captures data at a single point in time and is subject to recall bias in the participants. One significant limitation of this study is the impact of the sampling season and the prevalence of seasonal diseases on the findings. The data collection period coincided with the rainy season, a time when certain infectious diseases, such as malaria and respiratory infections, are more prevalent. This seasonal variation may have influenced the type and severity of cases that presented to the emergency department, potentially skewing the results. For example, the increased incidence of malaria during the rainy season could lead to a greater proportion of patients requiring immediate or urgent care, thereby affecting the overall triage categorization and length of stay (LOS) metrics.

Conclusion

The study revealed that a significant number of pediatric patients remained in the emergency room for more than 24 h. The key factors associated with the length of stay included residency, triage category, type of diagnosis, number of investigations, and undergoing imaging studies. To mitigate these issues, emergency professionals should prioritize patients with medical diagnoses and those requiring multiple laboratory tests and imaging studies to reduce the length of stay. Additionally, the Ministry of Health and policymakers should enhance supervision of emergency service management. Further research using a prospective study design is recommended to gain more detailed insights.

Availability of data and materials

The data supporting the findings of this study are available within the manuscript.

Abbreviations

ED:

Emergency Department

EDLOS:

Emergency Department length of stay

EEG:

Electroencephalogram

ETAT:

Emergency triage Assessment and treatment

FMOH:

Federal Minister of Health

LOS:

Length of stay

PED:

Pediatric Emergency Department

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Acknowledgements

The authors are grateful to the data collectors, the Addis Ababa University College of Health Sciences Department of Emergency and Critical Care, the health professionals in the pediatric emergency unit, and all study participants for their contributions to the study's success.

Funding

No funding was received for this study.

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Authors and Affiliations

  1. Department of Emergency Medicine and Critical Care, College of Health Sciences, Addis Ababa University, P.O.BOX 1176, Addis Ababa City, Ethiopia

    Telayneh Addis Zeleke, Wagari Tuli Nora & Lemlem Beza Demisse

  2. Department of Pediatrics, College of Health Sciences, Addis Ababa University, Addis Ababa City, Ethiopia

    Muluwork Tefera Denberu

  3. Department of Emergency and Critical Care Nursing, College of Medicine and Health Sciences, Bahir Dar University, P. O. Box 79, Bahir Dar City, Ethiopia

    Ousman Adal

Authors
  1. Telayneh Addis Zeleke
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  2. Wagari Tuli Nora
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  3. Muluwork Tefera Denberu
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  4. Ousman Adal
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  5. Lemlem Beza Demisse
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Contributions

TAZ: Selected the title, drafted the proposal (conceptualized and designed the study), analyzed and interpreted the data, and drafted the manuscript. WTN: Approved the title, proposal, and thesis with some revisions. MTD: Approved the proposal and thesis with some revisions. LBD: Finalized the thesis, revised the manuscript, and provided constructive comments. OA: Commented on the thesis and finalized the manuscript. All the authors have read and approved the final manuscript.

Corresponding authors

Correspondence to Ousman Adal or Lemlem Beza Demisse.

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Ethical approval and consent to participate

Informed consent to participate was obtained from all participants in the study. The study was reviewed and approved by the Institutional Review Board (IRB) of Addis Ababa University, approval number aau.2345. The IRB ensured that all ethical guidelines were followed and that participants were fully informed about the nature and purpose of the research before consenting to participate.

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Not applicable.

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The authors declare no competing interests.

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Zeleke, T.A., Nora, W.T., Denberu, M.T. et al. Length of stay and associated factors among pediatric patients in the pediatric emergency unit of the Tikur Anbessa specialized hospital, Addis Ababa, Ethiopia. BMC Emerg Med 24, 170 (2024). https://doi.org/10.1186/s12873-024-01089-5

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Keywords

BMC Emergency Medicine

ISSN: 1471-227X

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