Australasian Emergency Care 22 (2019) 174–179

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Australasian Emergency Care

journal homepage: www.elsevier.com/locate/auec

Research paper

Analysis of factors influencing length of stay in the Emergency

Department in public hospital, Yogyakarta, Indonesia
Happy I. Kusumawati a,∗ , Judy Magarey b , Philippa Rasmussen b
a
The School of Nursing, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Indonesia
b
The School of Nursing, Faculty of Health Science, The University of Adelaide, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Backgrounds: The increasing demand for emergency care may cause prolonged Emergency Department
Received 29 January 2019 length of stay that has an impact on quality of care. In Indonesia, factors influencing Emergency Depart-
Received in revised form 11 June 2019 ment length of stay are difficult to determine. The purpose of the study was to identify factors that
Accepted 12 June 2019
contributed to length of stay at tertiary hospital Yogyakarta, Indonesia.
Methods: A descriptive study was conducted with a cross-sectional, retrospective design. Participants
Keywords:
(n = 139) were patients aged 18 years or over who presented to Emergency Department at tertiary hos-
Length of stay
pital, over seven consecutive days. Data were gathered by reviewing patients’ notes using modified
Emergency Department
Patient flow
data collection tool and by measuring the average time in each stage of Emergency Department patient
Emergency admission journey. Mann–Whitney and Kruskal–Wallis tests were utilised to analyse data.
Results: The median Emergency Department length of stay was 330 min. The acuity level, specialist con-
sultation and need for admission were associated with increased Emergency Department length of stay
(p < 0.05). Laboratory turn around time (median 58 min) and waiting for bed availability (median 167 min)
contributed to prolonged length of stay, for discharged and admitted patients, respectively.
Conclusions: This study assists in understanding factors that most significantly influence Emergency
Department length of stay in an Indonesian hospital and will inform policy makers in development
of strategic plans to improve Emergency Department patient flow.
© 2019 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.

1. Introduction and requesting bed availability; and up to 1 h is allocated for

Emergency care plays a crucial part in public health care
[1,2]. However, due to the increasing demand for care and more
complex management procedures in Emergency Departments
(EDs), patients may experience prolonged waiting times and
length of stay (LOS) [1,3]. Prolonged LOS is not only associated
with reduced quality of care but also increased risk of patient harm
[4–6]. Therefore, timeliness is considered as essential component
in quality of care [7]. There are several ways to improve timeliness
in EDs including applying maximum LOS rules, e.g. the four-hour
rule in United Kingdom or the National Emergency Access Target
(NEAT) in Australia [8–10]. The 2:1:1 is a model of care especially
for admitted patients which divides the four-hour rule into three
timeframes: up to 2 h are allocated for: (1) clinical assessment
and stabilisation, (2) decisions to admit, and (3) decisions to refer
the patient on; up to 1 h is allocated for specialist consultation
∗ Corresponding author.
E-mail address: happy.i.kusumawati@ugm.ac.id (H.I. Kusumawati).
transferring the patient into a ward or transferring to another
hospital, community service or discharged home [11].
The literature also indicates that three main factors are associ-
ated with ED LOS: input, throughput and output. Input factors such
as older patients who frequently arrive with unclear symptoms
and complex comorbidities which are responsible for prolonged
ED LOS [1,12]. The type and complexity of procedures, as well as
the number of imaging tests also contribute to throughput factors
which may influence ED LOS [13–15]. The clinical care pathways
for admitted patients and lack of inpatient beds may contribute to
ED LOS [16–20]. Based on a study about patient flow in Indonesia
in 2015, throughput factor (laboratory turn-around time) was the
most common factor contributing to prolonged LOS [21]. Problems
with processing of laboratory samples, which contribute to pro-
longed LOS, include lack of a computerised system, shortage of
laboratory staff and no specific indicators that laboratory samples
were from ED [21].
In Indonesia, there are no national guidelines to improve the
quality of emergency care and ED patient flow. Even though there
are standards of procedures related to the ED design and operation

https://doi.org/10.1016/j.auec.2019.06.001
2588-994X/© 2019 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
 H.I. Kusumawati et al. / Australasian Emergency Care 22 (2019) 174–179
ruled by Ministry of Health, some EDs are not well designed and
operated. Some challenges, including high demands, overcrowding
and prolonged LOS in ED are also evident. Regarding the ED patient
flow, it is difficult to identify the stage of the patient journey that
contributes the most to the ED LOS. This study aimed to analyse the
factors influencing LOS by measuring the time for every stage of the
patient flow and identify factors that contributed to extended ED
LOS at a tertiary hospital in Yogyakarta Indonesia.
2. Methods
2.1. Settings
The research was conducted in a tertiary public hospital in
Yogyakarta, Indonesia. This hospital is the major referral cen-
tre from Yogyakarta province and the south part of Central Java
province. It serves all age groups of patients, with High Care Unit
(HCU) and an Emergency Operating Theatre and resuscitation room
within the ED. There were a total of 25,357 patients who presented
Fig. 1. Data collection form developed by Martin et al. (2011) and modified by researcher.
175
to the ED in 2016, with an average of 70 per day. The ED has the
capacity to accommodate 26 patients at one time. Cardiology, neu-
rology, paediatric, obstetric gynaecology, and medical emergency
patients are often received.
This ED has applied a system for one senior nurse to be respon-
sible to monitor patients’ journey, provide assistance to patients
following discharge and to support staff delivering care in ED. As
the leader of team, this nurse has a duty to collect the data, iden-
tify, analyse the problems and find solutions to improve patient
flow. This nurse also has responsibility to report the problems
to the nurse manager or head of ED if they need further assis-
tance.
In this ED, the Emergency Severity Index (ESI) is used as triage
tool to prioritise the patients this has five acuity levels (e.g., 1 –
resuscitation, 2 – emergent, 3 – urgent, 4 – less urgent, 5 – nonur-
gent). Triage doctors are responsible for prioritising the patients.
There is no waiting room for walking patients. Therefore, ED has
policy that response time (the time from when the patient arrives
in the ED to when the staff assess or triage doctor prioritise the
patients) is approximately 5 min, except for patients level 1 (0 min).
176 H.I. Kusumawati et al. / Australasian Emergency Care 22 (2019) 174–179

2.2. Participants Table 1

Demographic data.

The participants involved in this study were patients presenting Demographic data Number Percentage (%)
in the ED at a tertiary hospital in Yogyakarta, Indonesia over seven Age
consecutive days. All met the following inclusion criteria: patients 18–30 years 23 16.5
aged 18 years or over who presented to the ED. The exclusion cri- 31–50 years 45 32.4
teria for this study were: paediatric patients, and those who have 51–65 years 41 29.5
>65 years 30 21.6
disability or were prisoners. The exclusion criteria were selected
since these patients not only have different workflows and triage, Gender
Male 68 48.9
but are also from vulnerable populations.
Female 71 51.1

Arrival Mode
Private Transport 77 55.4
2.3. Data collections Ambulance 51 36.7
Others 11 7.9

The data were collected over a period of 168 h from 12 to 18 July Referral Type
2017. Data were collected by reviewing patients’ notes following Doctor Referral 77 55.4
Hospital/Puskesmas Referral 51 36.7
discharge, using a tool developed by Martin et al. [22]. Some minor Transfer from outpatient clinic 11 7.9
modifications were made by a panel of experts, which consisted
Case
of the ED Nurse Manager, Senior Nurse and Doctor and the Head
Medical 48 34.5
of Triage Doctor of ED who reviewed the content validity of the Surgical/Trauma 14 10
instrument (Fig. 1). Two meetings were organised to discuss patient Cardio 16 11.5
flow within the ED. Some items of the instrument were modified Neuro 19 13.7
to fit the context of the ED at tertiary hospital, including laboratory Obstetric Gynaecology 13 9.4
Complication 20 14.4
turnaround time, additional consultation with a specialist for the Others 9 6.5
complex patient, and doctor’s decision for the patient who need
Triage
admission. Data were collected in three stages: patient arrival and
1 10 7.2
initial assessment, the assessment in a cubicle and destination (i.e., 2 52 37.4
whether the patient was discharged or admitted). 3 70 50.4
The data were collected by three research assistants (RAs) who 4 6 4.3
had Bachelor of Nursing qualifications and had completed their 5 1 0.7

clinical placement in the ED at a tertiary hospital in Yogyakarta. To Puskesmas referral: referral from primary health care; medical: chronic illness (dia-
ensure interrater reliability prior to data collection, the researcher betes mellitus, hypertension, pneumonia, etc.), oncology, ophthalmology.
and research assistants (RAs) reviewed patients’ notes following
discharge and measured the extent to which researchers and RAs
recorded the same times for each particular stage. RAs recorded the Table 2
Duration of ED LOS and frequency.
time points for each stage in the patient journey which were already
available in patients’ notes including: arrival time, triage time, time Duration of ED LOS (h) Frequency (patient) Percentage (%)
of assessment by the doctor, laboratory turnaround time, time at ≤4 h 55 39%
which the doctor decided to discharge/admit, bed availability time 5–8 h 40 29%
and exit time. There was no difference in the results among RAs 9–24 h 40 29%
and Researcher for all stages. >24 h 4 3%

2.4. Data analysis 3. Results

Data were analysed using SPSS 24. Univariate analysis or
descriptive statistics were used to summarise demographic data
such as age, gender, referral type, arrival mode, triage, and case.
Bivariate analyses were conducted to compare the variables. Non-
parametric tests (the Mann–Whitney U test and Kruskal–Wallis
test) were used since data were not normally distributed.
2.5. Ethics approval
The study was approved by the Ethics Committee at the Fac-
ulty of Medicine, Universitas Gadjah Mada Indonesia. Exemption
for ethical approval was granted from the Human Research Ethics
Committee (HREC) at the University of Adelaide on the basis that
this study was viewed as the quality assurance and evaluation
activity. To protect participants’ rights, the researcher ensured that
participants’ privacy was respected (anonymity) and all informa-
tion which might identify an individual was treated in a confidential
manner.
3.1. Baseline characteristics
A total of 139 patients’ records were reviewed. The age median
was 51 years (IQR = 39–63). The majority of the patients were aged
35–50 years. The percentage of males and females was almost the
same. Most patients were referred by a doctor and arrived in the ED
by private vehicle. Medical conditions such as chronic illness, oncol-
ogy, ophthalmology, etc. were the most frequent cases (34.5%). The
majority of the patients were classified as triage category 3. Table 1
presents the demographic characteristics of study participants.
3.2. Emergency Department length of stay (ED LOS)
The median ED LOS was 330 min (IQR = 163–580). Table 2 shows
that the percentage of ED visits completed in 4 h was 39.6%. The
number of patients who completed their ED visit in 5–8 h and
9–24 h was identical (29%). Three % of patients stayed more than
24 h in ED.
 H.I. Kusumawati et al. / Australasian Emergency Care 22 (2019) 174–179 177

Table 3
Relationship between independent variables and ED LOS (n = 139).

Independent variables ED LOS Median and IQR (min) Number Asymp. Sig (p)*

Age 0.638
18–30 years 342 (76–539) 23
31–50 years 297 (146–597) 45
51–65 years 351 (211–554) 41
>65 years 356 (231–769) 30

Gender 0.646
Male 347 (164–658) 68
Female 319 (163–546) 71

Arrival Mode 0.057

Private Transport 280 (112–544) 77
Ambulance 360 (173–677) 51
Others 409 (348–649) 11

Referral Type 0.057

Doctor Referral 280 (112–544) 77
Hospital/Puskesmas Referral 360 (173–677) 51
Transfer from Outpatient 409 (348–649) 11

Type of Case 0.058

Medical 338 (112–654) 48
Surgical/Trauma 521 (289–700) 14
Cardiology 303 (263–456) 16
Neurology 265 (212–372) 19
Obstetric Gynaecology 266 (212–450) 13
Complication 384 (290–707) 20
Others 157 (106–411) 9

Triage Level 0.002*

1 364 (158–533) 10
2 341 (204–551) 52
3 348 (207–649) 70
4 45 (40–60) 6
5 15 1

Specialist Consultation 0.000*

Receive Specialist Consultation 435 (334–702) 40
No Specialist Consultation 275 (117–518) 99

Need for admission 0.000*

Discharged 125 (55–216) 35
Admitted 410 (272–664) 104

Puskesmas referral: referral from primary health care; medical: chronic illness (diabetes mellitus, hypertension, pneumonia, etc.), oncology, ophthalmology.
p < 0.05 means significant

3.3. Factors influencing ED LOS
The results showed that acuity level, the need for specialist con-
sultation, and need for admission had a significant correlation with
ED LOS (p < 0.05). As can be seen in Table 3, patients who were
classified as triage 1, experienced the longest time in ED, with a
median of 364 min, while those who was categorised into triage 5,
experienced the shortest median of 15 min. Patients who received a
specialist consultation spent a longer time in ED than those who did
not, with a median of 435 min and 275 min, respectively. Admitted
patients stayed longer in ED than those discharged, with a median
of 410 min and 125 min, respectively.
Fig. 2 shows the average time of each stage of the patient journey
in minutes in ED for both patients who were discharged (n = 35) and
those admitted (n = 104). The median ED LOS was 125 and 408 min,
for discharged and admitted patients, respectively.
For discharged patients, laboratory turn around time con-
tributed to prolonged ED LOS, with a median of 58 min
(IQR = 25–66). For admitted patients, waiting time for bed avail-
ability contributed to prolonged ED LOS, with a median of 167 min
(IQR = 68–371) (see Fig. 2).
4. Discussion
The findings of this study highlight average times for each stage
of the patient flow through the ED and factors contributing to the
ED LOS in a tertiary hospital in Yogyakarta. This research identified
input, throughput and output factors contributed to ED LOS.
4.1. Input factor
This research found that acuity was a significant factor that con-
tributed to increased ED LOS with the patients classified as triage
1 (resuscitation) experienced the longest time in ED, followed by
patients categorised as level 3 and 2. This result was in line with
previous studies [14,18,23–25]. The patients who were categorised
into triage 1–3 need more time to be treated and stabilised in the ED
before they are transferred to appropriate units. The researcher’s
experience is that in the Indonesian setting, treatment is conducted
in ED for high acuity patients which leads to increased ED LOS. Ven-
tilated patients stayed longer in ED due to the intensive treatment
that was given [25]. For a patient with higher acuity, doctors require
more time to decide the appropriate place for the patient, whether
ICU or another ward [25].
This research showed that category 5 patients was discharged
from ED very quickly. This does not fit with the ‘traditional’ pattern,
given they are the least urgent. This tertiary hospital has a policy
that level 5 patients are not eligible to be treated in ED. The triage
doctor have to discharge this patients quickly to outpatient clinic
after being assessed. Although ESI system states that level 2, 3 and
4 patients can wait for 10–60 min to be assessed, this ED has pol-
icy that response time should at least 5 min. It occurs because this
178 H.I. Kusumawati et al. / Australasian Emergency Care 22 (2019) 174–179
Fig. 2. Median time of each stage of patient journey in minutes for admitted (n = 104) and discharged patients (n = 35) in ED tertiary hospital.
ED has no waiting room for patients. The patients should move to
cubicle quickly after triage doctor prioritise them.
Admitted patients spend a longer time in ED than those dis-
charged [16,17,19,23,26,27]. The patient journey for admitted
patients is more complex. After the doctor’s decision to admit is
made and treatment is completed, patients wait for a bed to become
available. Complex patients need more preparation before they are
transferred to the appropriate unit. Lastly, the patient will wait
for the availability of ED staff to transfer them to the inpatient
ward. Studies have shown that clinical care pathways for admitted
patients significantly impact ED LOS [12].
4.2. Throughput factor
The majority of doctors who treat patients in the ED at tertiary
hospital are registrars. If the patient needs specialist consultation,
the registrars have to request this and wait for the consultation
as the specialists treat patients from other departments or may be
in surgery or dialysis unit. Registrars are required to wait for the
specialist doctor’s examination, to determine final diagnosis and
destination for the patient. Specialist consultation is part of the ED’s
culture [13]. Consultations are perceived as ‘difficult’ by emergency
doctors (EDs) because they may feel stress when they work with
specialist doctors and EDs have no ability to make some decisions
i.e. whether the patients should be admitted or discharged [28].
Therefore, good communication between the emergency physician
and the consultant has a significant role in improving patient flow
in ED [29].
4.3. Output factor
Lack of bed availability may cause a delay of transfer of admit-
ted patients to an appropriate ward, particularly in medical/surgical
wards and ICU. Firstly, in tertiary hospital there are a limited num-
ber of ICU and Intermediate Care (IMC) beds. A previous study
reported that over half of admitted patients experienced prolonged
ED LOS due to a lack of inpatient beds [30–33]. Secondly, there is
competition for inpatient beds in tertiary hospital between patients
admitted from the ED and those from the outpatient unit who need
elective surgery. This is congruent with a study in hospitals in the
UK and Ireland, which indicated they were faced with a situation
in which emergency and elective admissions competed for bed
occupancy [34].
Studies have found that increased ED bed occupancy and inpa-
tient bed occupancy are related to prolonged ED LOS [34,35]. A Bed
Occupancy Rate (BOR) of more than 80% in ED may cause over-
crowding and be associated with longer ED LOS [36]. Data from
a tertiary hospital (2015) reported that the highest ED BOR was
91.94%, while the lowest being 83.89%, and the average was 88.56%.
Regarding inpatient BOR, the difficulty of getting a bed in a ward
may be due to the lack of an equilibrium between numbers of dis-
charged and admitted patients. As it is a major referral hospital, in
one day wards may admit patients from the outpatient unit, the
operating theatre and other hospital departments.
In this study, inpatient bed availability was the main factor that
contributed to prolonged ED LOS, since demand for inpatient beds
was high. This new finding contributes to the understanding of
this problem in the Indonesian context. External factors including
unavailability of long-term care options in Indonesia may con-
tribute to ED LOS. A previous study in Indonesia in 2017 stated that
development of palliative care (PC) services has been slow which
is shown by limited number of formal institution which care for
patients with long-term conditions [37]. Many patients who could
be discharged have to stay in the ED or be admitted to a ward
because community services are not available. Lack of adequate
services for transfer of care back to the community may contribute
to the increased hospital bed occupancy and prolonged LOS [34].
Further research is needed to identify where lack of bed availabil-
ity is occurring whether in geriatric, oncology, ICU or another types
of wards. This finding may assist to inform ED to develop screen-
ing tools to enable the prioritisation of patients who are likely to
be admitted or to be discharged from ED. This finding also may
inform policy makers in development of strategic plans to develop
long-term care options in Indonesia.
New insights can be generated from this study to reduce LOS.
The hospital management should consider the important role of
nurses to monitor patient journey and to ensure that patient
movement is as efficient and timely as possible [38]. Since 2000,
this hospital has applied a programme that one senior nurse is
responsible to address ED problems or the crisis (access block,
overcrowding) and support staff delivering care in ED. This nurse
monitors patient timelines, identifies problems and finds solutions.
However, there has been no research to investigate the effective-
ness of this programme although it was adopted some time ago in
this hospital. Further research is important to measure the effec-
tiveness of this programme. The results of this study appear to
indicate further measure are required.
4.4. Limitations
The findings of this study have limited transferability since the
research was conducted in one location. It is also difficult to gener-
alise the results to other health care systems in Indonesia. However,
these findings may assist to inform ED to develop screening tools to
enable the prioritisation of patients who are likely to be admitted or
to be discharged from ED. These results need to be considered since
well-structured national ED LOS and ED patient flow guidelines
have not been and developed in Indonesia.
 H.I. Kusumawati et al. / Australasian Emergency Care 22 (2019) 174–179
5. Conclusion
Bed availability, the acuity level, requirement for specialist
consultation and need for admission were crucial factors that con-
tributed to increased ED LOS. This study assists in understanding
factors that most significantly influence ED LOS in an Indonesian
hospital and may inform policy makers in development of strategic
plans to improve ED patient flow.
Funding
The research was funded by Indonesia Endowment Fund for
Education, Ministry of Finance, Republic of Indonesia.
As an awardee of Indonesia Endowment Fund for Education’s
scholarship, researcher has been eligible for the research grant
funding of IDR 19763089 or equivalent of AUD 1766.
Conflict of interest
No competing interests declared.
Acknowledgement
The authors would like to acknowledge the scholarship support
from Indonesian Endowment Fund for Education (LPDP), Indonesia
Ministry of Finance.
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