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. 2025 Dec;15(4):100896.
doi: 10.1016/j.afjem.2025.100896. Epub 2025 Aug 27.

Factors contributing to extended length of stay in the emergency department and potential strategies for improving patient flow in a central hospital in the Gauteng Province, South Africa

L Motimele  1   2 , V Lalloo  3   4 , T Sefala  1 , A Engelbrecht  1   3 , L Majake-Mogoba  1 , D Basu  1   2
Affiliations

Factors contributing to extended length of stay in the emergency department and potential strategies for improving patient flow in a central hospital in the Gauteng Province, South Africa

L Motimele et al. Afr J Emerg Med. 2025 Dec.

Abstract

Background: Length of stay (LOS) is an integral part of inpatient care in hospitals, particularly in Emergency Departments (EDs). It is an essential performance indicator for the National Indicator Data Set in South Africa. Multiple studies have indicated a correlation between an increased LOS and worse patient outcomes in a variety of acute medical conditions. The study aims to establish the key factors of LOS in the ED at a central hospital in the Gauteng Province of South Africa.

Methodology: A cross-sectional study was conducted over seventeen months (Aug 2023 to Dec 2024) based on 2927 entries of patients admitted at the ED for more than 48 hours. No intervention was done as part of this study.

Results: The median LOS was 2.81 days (IQR: 2-3) with a minimum of 2 days and a maximum of 12 days. A regression analysis demonstrated that the most significant determinants for prolonged LOS were gender and disease group of boarded patients awaiting ward transfer.Significant differences (p < 0.001) in the LOS between clinical disciplines were noted, with medical (45%) and surgical departments (46%) accounting for most boarding patients compared to all other clinical disciplines.

Conclusions: Data demonstrated that 80% of patients in the ED wait an average of 3 days before transfer into the wards. This extended ALOS in the ED has consequences for patient outcomes and the quality of healthcare provided. Based on the findings of this study, strategies to improve patient flow are essential in facilitating timeous discharge from wards and to prioritise the forward flow of patients waiting in ED.

Keywords: Access block; Boarding; Crowding; Emergency medicine; Length of stay.

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Conflict of interest statement

The authors declare no conflicts of interest.

Figures

Fig. 1
Fig. 1
Conceptual framework for emergency department transition phases.
Fig. 2
Fig. 2
Number of monthly long-stay patients vs granted ambulance diversions at the SBAH ED Aug 2023-Dec 2024.
Fig. 3
Fig. 3
Scatter plot of relationship between granted ambulance diversions and number of long-stay patients.
Fig. 4
Fig. 4
Run chart depicting granted ambulance diversion trends and shifts.
See this image and copyright information in PMC

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