Relevance of using length of stay as a key indicator to monitor emergency department performance: Case study from a rural hospital in Thailand

Objective: The present study explores factors related to length of stay (LOS) in a rural public hospital in Thailand and assesses the feasibility of using LOS as an ED key performance indicator. Methods: Using a mixed-methods approach, qualitative methods (in-depth interviews, patients’ chart review and participatory observations) were used to guide and elaborate findings from quantitative analysis of 555 electronic ED records. Results: Multivariate analysis revealed that age, Emergency Severity Index score and number of laboratory tests were significantly associated with LOS. The qualitative approach provided contradicting evidence on the linkage between LOS and patient outcomes. On the one hand, considering the 4 h rule, a child with asthma was referred to a tertiary care hospital because of deterioration after 4 h of ED care. On the other hand, a woman with sepsis was hospitalised with improved condition despite 7 h of ED care. Interviews revealed the waiting time to see doctors was probably the top priority issue for patients. Conclusions: Factors related to LOS in a rural hospital in Thailand are similar and in contrast to those of a previous study in a medical school setting. Reasons for the discrepancy of findings and implications for improving ED services were discussed. Our data support the notion of controversy in using LOS as a key indicator of ED performance in this rural hospital setting. Thus, it is imperative to not rely on any single throughput or process indicators to monitor ED performance, but to take into account a set of indicators including patient outcomes.