Table 9 Root causes of patient flow challenges and their outcomes across the healthcare system
Category | Subcategory | Outcomes of challenges No |
|---|---|---|
Population Patients & Providers) | Demand fluctuations (changes such as seasonal increases in demand, and unanticipated events [56] | 4,5 |
Patient's characteristics/Patient-related factors (extremes of age, critically ill, social determinants of health and …) [39, 55, 75, 76] | 1,3,5,7,9,10,11,16 | |
Acuity mix of the patients in the ED [15, 36, 55, 61, 68, 72, 73] | 1, 3, 4, 5,7,8,9,10,11,12 | |
Rising demand for ED visits and hospitalisation due to aging population [15, 32, 66, 72, 74] | 2, 5,11 | |
Increase of the poor population with consequent difficulty to face health costs [72] | 5,11 | |
Mismanagement of treatable diseases at home [72] | 5,11 | |
Language differences [57] | 5 | |
9,13 | ||
4,5,6,13,15 | ||
High staff turnover [39] | 13 | |
Lack of awareness of systems and processes particularly among temporary staff [76] | 5,8 | |
Insufficient training of professionals practicing in the ED [56, 66, 76] | 5 | |
Capacity | 4,5,6,7,8,9,11,12,16 | |
11 | ||
4,5,7,8,12 | ||
5,7,8,12,13,15 | ||
High percentage of beds occupied by boarders [39] | 7,13,15 | |
1, 3,7,9,10,13,15 | ||
11,15 | ||
6,9,13,15 | ||
Rising readmissions [75] | 4,5,6,9,15 | |
Shortage of hospital discharge rooms [72] | 5,11 | |
Limited human resources/Health care understaffing [7, 15, 27, 39, 55, 58, 72, 73, 75, 76] | 1, 3, 5,7,8, 9,10,11,12 | |
Unavailability of Healthcare Assistants [76] | 8 | |
EMS traffic/volume [68] | 4,5,6 | |
Lack of social services to facilitate difficult patients’ discharge | 5,8,11 | |
1,3, 4,7,9,10,13,15 | ||
Reduced health funding [72] | 5 | |
Increased inpatient length of stay (IPLOS) [15] | 5,6,11 | |
Limited access to diagnostic services in community [15] | 5,8 | |
The high daily census of inpatient critical care and cardiac telemetry units [15] | 7 | |
Insufficient availability of beds in community-based care settings [76] | 2,4,5 | |
Time and day variations in patient flow[55] | 1, 3, 7, 9, 10 | |
Process | Challenges with diverting low acuity patients from ambulances to alternative care sites [55, 72, 73] | 5,7,8,12 |
Insufficient communication and poor collaboration between teams [29] | 6,15 | |
5,11,14 | ||
Failure to identify available beds and fragmented bed management process [29, 72] | 5,11 | |
Exit block, delayed discharge, and delayed disposition decisions [15, 29, 34, 39, 72, 75] | 5,6,7,8,9,11,15,16 | |
5,7,9,15 | ||
Demand for diagnostic tests and imaging studies/delays in receiving test results [15, 39, 55, 75] | 1, 3,5,7,8, 9,10,11,13,15 | |
Inadequate integration of ED facilities with imaging and diagnostic departments, on-call specialists, and extended medical services [58, 72, 75] | 7,8,5,11 | |
Lack of health care network integration [27] | 6,15 | |
Ineffective transitions of care/Referral patterns [55] | 3, 7, 9, 10 | |
Prolonged trainee assessment and review time/presence of junior medical staff in ED [15, 31, 76] | 4,5 | |
Collaboration lack between health personnel [72] | 5,8,11 | |
The reluctance of hospital staff to admit patients from ED [75] | 5,7,11,15 | |
Inability of staff to adhere to guideline-recommended treatment [15] | 5 | |
Difficulties and issues encountered during the triage process [27, 60, 72] | 5,7,8,12 | |
Difficulties in accessing urgent healthcare service [72] | 5,8,11 | |
Ineffectiveness of Interventions targeting frequent ED users [72] | 5,11 | |
Limitations on nurses' authority to initiate certain treatments [33] | 8 | |
Low effectiveness of basic care services [27] | 5,6 | |
Lack of seasonal disease prophylaxis [72] | 5,11 | |
System complexity" or "complexity of public hospitals [29] | 15 | |
Variations in local emergency medicine/Differences in emergency practice [36] | 7,4 | |
Wrong diagnosis [75] | 5,7,9,11,16 | |
Lack of Integration between EDs and Inpatient Services [13] | 4, 6 | |
5,8,11,13,15 |