Investigating the relationship between how a chief complaint is expressed and the patient workflow

Introduction Emergency departments and hospital emergency departments are one of the indispensable pillars of public hospitals in a country due to their critical role in providing urgent medical care to patients in dire need of prompt treatment at all times of day and night (1,2). The efficacy of the emergency department is evaluated by waiting times. The speed of service delivery in health centers, especially in emergencies, is particularly important in reducing the mortality and morbidity of any disability (3). Patients’ waiting time may also lead to the formation of negative attitudes towards the hospital and care providers (2,4). The duration of stay is influenced by individual characteristics such as age, sex, disease status, patient management style, and organizational and management characteristics of the hospital (4). Also, in the three Canadian, the US, and the UK countries, the percentage of those who stayed in the emergency room for less than 4 hours was 76%, 72%, and 96%, respectively (5). Approaches to admission and discharge, quality and quantity of communication and interdepartmental collaborations, including the collaborations with other medical departments in admission, and support for important factors affecting the duration of stay have been demonstrated in various studies (1,6,7). The patient process in the emergency department includes all the steps that are taken from the patient’s arrival to the emergency department to the final diagnosis and management. This Original Article Volume 6, Issue 2, 2020, p. 63-67

determines the duration of time the patient is in the emergency department. All departments must work as part of a team, and if one of them is in trouble and unable to function effectively, bottlenecks will develop (8).
In previous studies workflows in the emergency department of Imam Reza hospital, as the general center in northwestern and East Azarbaijan province, with the focus on bottlenecks and hospital admissions as well as management were conducted (9,10), but considering that these studies are not up to date and due to the Health Transformation Plan implemented by the Ministry of Health, the hospital workflow has been changed and the state hospitals have become very crowded. In this regard, the bottlenecks have been changed. Therefore, there is a need to review bottlenecks in new conditions and plan to reduce bed occupancy and hospitalization. The purpose of this study is to investigate the relationship between the patients' chief complaint and their departure to the emergency room.

Methods
This is a retrospective, cross-sectional descriptive study. Non-traumatic patients who referred to the emergency department of Imam Reza hospital during 2018 were selected and included in the study. Patients whose documentation was incomplete were excluded. All patients who had any medical chief complain entered the study, patients who had trauma or his document were not clear were excluded. Age, sex, chief complaint and time of final decision and time of departure from the emergency department as well as hospitalization to the ward were included in the checklist. The obtained data were entered into IBM SPSS software version 15.0 and analyzed with the significance level below 0.05. The intraclass correlation coefficient was used to evaluate the agreement between the evaluators at both time points. Pearson's regression was used to examine the relationship between the collected data. The significance level was considered as P ˂ 0.05.

Results
In this study, all non-traumatic patients referring to Imam Reza hospital in the year 2018 were 57 000 which did not follow a normal distribution based on Kolmogorov-Smirnov analysis (P ˂ 0.001). The mean age of patients was 53.34 ± 20.38 years with a median of 53.00 years and mode was 40 years. The minimum age was 1 year and the maximum was 116 years. In terms of sex, 31588 patients (55.6%) were males and 25 250 were females (44.4%). The most common complaints of patients ware weakness, abdominal pain, headache and dizziness (Table 1). Over 46% of patients were discharged from the emergency department and 17% of patients were admitted to hospital wards. In addition, 32% of patients had either escaped or left the emergency department against medical advice, or referred to a designated hospital by personal vehicle. Considering that all these three types were ultimately recorded as discharge against medical advice, it was not possible to distinguish them ( Figure 1). Among these patients, 5119 (9%) received outpatient prescriptions without staying in the emergency department. This indicates that the patient was only checked by a physician and left. Also, 35 785 patients There was a significant relationship between the chief complaint and the duration of stay in the emergency department (P = 0.046). Patients with dyspnea due to heart disease, bloody vomit, bloody stool, constipation, jaundice, anemia, decreased consciousness levels, diabetes, diabetes complications, shortness of breath and kidney discomfort stayed longer in the emergency room compared to other complaints or average staying time ( Figure 2).

Discussion
In the study by Hosseini et al, the mean age of patients was about 40 years, similar to the study by Cardin et al in traumatic patients admitted in the emergency room (11,12). In the current study, 31588 patients (55.6%) were males and 25250 were females (44.4%). Hosseini et al indicated that the majority of patients were men and only 20% of patients were women (11). The most common complaints in patients were weakness, abdominal pain, headache and dizziness. In our study, 46% of patients were discharged from the emergency department and 17% were admitted to hospital wards. Also, 32% of patients had either escaped or left the emergency department against medical advice, or referred to a designated hospital by personal vehicle. Considering that all these three types were ultimately recorded as discharge against medical advice, it was not possible to differentiate them.  the emergency department for a long time due to the high number of patients referring to specialties not related to the center, the overcrowding of wards, and the significant number of unnecessary and non-emergency paraclinical requests. The presence of the emergency specialists plays an important role in improving services and patient satisfaction through the management of noted problems (14). The study of Hosseini et al found that the most important reasons for the decline in bed occupancy rate, daily bed occupancy and increased bed activity were the timely decision making for patients after the presence of an emergency medicine specialist (11). In our study, on the whole, 44340 patients (78%), excluding single-visit patients, left under 12 hours. Also, 49459 (87%) patients, including single-visit patients, left the emergency room under 12 hours. Therefore, patients' stay and its duration are important indicators in evaluating the quality of emergency services. In a study conducted in hospital emergency departments at the University of California in order to assess patients' waiting time, results showed that patients waited for an average of 56 minutes for a physician and 42% of patients had a wait time more than 60 minutes (15). In a study conducted by Amiri et al in Imam Reza hospital, despite the hurdles such as working with a new emergency medicine team and lacking sufficient workforce to manage the ward, patients were cared within a few minutes. Besides, the first visit time was brief and all patients were visited by residents and medical teachers (9). Previous researches have been conducted on the workflows in the emergency department of Imam Reza hospital with a focus on bottlenecks and hospital admissions rate, patients and management (9,10). Findings revealed that there was a significant relationship between the chief complaint and the duration of stay in the emergency department (P = 0.046). In addition, patients with dyspnea due to heart disease, bloody vomit, bloody stool, constipation, jaundice, anemia, decreased consciousness levels, diabetes, diabetes complications, shortness of breath, and kidney discomfort stayed longer in the emergency room compared to other complaints or average staying time.

Conclusion
How the patient present he/she chief complain has an impact on the length of time they wait to leave the emergency room, and most patients with problems related to internal medicine have the longest stay in the emergency room; in particular gastrointestinal patients have the longest stay in the emergency room.

Ethical issues
This study was approved by the Regional Ethic Committee of Research, Tabriz University of Medical Sciences, code no: IR.TBZMED.REC.1398.1101.