Triage Outcomes and Patient Flow in a Tertiary Emergency Department: A Prospective Audit

Abstract

Background: Emergency department overcrowding is a global healthcare crisis that compromises patient safety, delays time-sensitive treatments, and increases morbidity and mortality. Triage systems such as the Emergency Severity Index guide resource allocation, yet comprehensive prospective data on patient flow metrics and triage outcomes from Indian tertiary emergency departments remain sparse. Methods: A prospective clinical audit was conducted over 12 months from Feb 2023 to Jan 2024 at a tertiary emergency department in India. All 2,400 consecutive adult presentations were included. Patients were triaged using the five-level Emergency Severity Index. Time-stamped data were collected for door-totriage, door-to-doctor, and emergency department length of stay. Disposition patterns, leftwithout-being-seen rates, and temporal variation in patient volume were analysed. Multivariate logistic regression identified predictors of prolonged emergency department length of stay exceeding six hours. Results: The triage distribution was ESI Level 1 in 4.2%, Level 2 in 12.8%, Level 3 in 38.5%, Level 4 in 28.0%, and Level 5 in 16.5%. The median door-to-triage time was 6 minutes (IQR 3–12), median door-to-doctor time was 24 minutes (IQR 12–48), and median emergency department length of stay was 4.2 hours (IQR 2.1–8.6). The overall admission rate was 38.2%, left-without-being-seen rate was 6.8%, and emergency department mortality was 1.7%. Peak volume occurred between 6 PM and midnight, accounting for 35.6% of daily presentations. Independent predictors of prolonged length of stay were ESI Level 2–3 acuity (adjusted OR 3.24, p < 0.001), awaiting specialist consultation (aOR 2.42, p < 0.001), advanced imaging requirement (aOR 2.68, p < 0.001), and evening presentation (aOR 1.86, p = 0.004). Conclusion: Emergency department overcrowding during evening hours significantly prolongs patient flow times. Specialist consultation delays and imaging waits are the primary modifiable drivers of prolonged length of stay. Increased staffing during peak hours, fast-track pathways for low-acuity patients, and point-of-care testing are recommended.