Rawalpindi Medical

University, Rawalpindi.

Identifying the predictors of ER utilization

and/or over-utilization and assessment of
patients’ awareness about triage system in a
tertiary care hospital of Punjab, Pakistan.

Ward Group: H

4th year MBBS, 2022-23

Batch In charge: Dr Asif Maqsood Butt

Supervisor: Dr Afifa Kulsoom

Department of Community Medicine and Public Health, Rawalpindi

Medical University, Rawalpindi.
 Student’s Research Project (SRP)
Completion Certificate
The batch H 4thyear MBBS Session 2022-23 has completed this SRP titled
“ Identifying the predictors of ER utilization and assessment of patients’
awareness about triage system in a tertiary care hospital of Punjab,
Pakistan.”

as a university requirement of experiential research training in health research

methods in the subject of community medicine under immediate supervision of the
batch in charge, supervising faculty and head of the department. Each student has
participated as co-researcher equally. All research work is done under need of the
study objectives, study design and study settings accordingly. The original data has
been deposited to and is an asset of the department of Community Medicine
Rawalpindi Medical University, Rawalpindi.
Name & Signature of Batch Representative
______________________________________
Remarks:
_________________________________________________________________
Name & Signature of the batch in charge:
Remarks:
_________________________________________________________________
Name & Signature of Supervising Senior Faculty:

Head of the Department:

 Names and Signature of the Batch H Students
(Co-Researchers)
Session : 2022-23
Name Class Roll Role Signature
number
Sawaira Arshad Malik 194 Ideation, planning,
questionnaire making and
approval, data
collection& entry,
analysis, manuscript,
reporting
Sawera Shafique 195 Data collection and entry
Shahreen Asif 196 Data collection,
manuscript writing,
management
Shiza Asad 201 Data collection& entry,
questionnaire making
Sofia Shahzad 202 Data collection& entry,
questionnaire making
Sumayya Malik 204 Data collection& entry
Tayyaba Tabassum 214 Data collection& entry
Zartashia Zeghum 228 Data collection& entry
Saqlain Shahzad 278 Data collection& entry
Muhammad Hassan 306 Data collection & entry
Haider Mansha 321 Data collection
Abedal Rehman MA Abushamala 342 Data collection
Reem Hani Abdul Wahid Qatanany 353 Data collection
Nour M N Radi 354 Data collection
Sana Ullah 356 Data collection& entry,
questionnaire making
Layla Riyad Mousa Sadeh 365 Data collection
Sabir Nawaz 367 Data collection
Mubarak Farah Hassan 370 Data collection
Abdul Wahab Muhammad Adan 373 Data collection
 Table of Contents
1. Dedication
2. Introduction
3. Objectives and Rationale
4. Operational Definitions
5. Methodology
6. Results
7. Discussion
8. Conclusion and Recommendations
9. Acknowledgement
10. References.
 Dedication

Dedicated to the torch-bearer of humanity; Prophet Hazrat Muhammad

(PBUH) and humanity itself.
 Introduction

In a study aimed at assessment and evaluation of patterns of health conditions presenting in

emergency medicine department in hospitals of Pakistan, it is necessary to highlight the
importance of emergency medical services and the strain they are under due to the patients’
perception of certain medical conditions; whether they are to be managed acutely in emergency
department or should be seen and treated in out-patient department. In societies like Europe,
Presenting Complaints (PCs) are used as a tool to determine the urgency and severity of care
demand. PCs vary with age but most frequent were extremity problems, abdominal or chest pain,
uncontrolled BSR or BP(1). In studies to find out the predictors of emergency room utilization,
different factors such as literacy rate of patients and general health awareness are taken into
account(2). It is still a matter of debate to specify the patients and conditions that should be dealt
by emergency department(3).The author aims at emphasizing patients’ awareness regarding their
disease and where do they expect it to be managed in a hospital. Studies conducted beforehand,
emphasized the correlation between literacy rate of the patient with ED visits, healthcare utilization
patterns and rate of hospital admission(4). Literature available on emergency care utilization
emphasizes the concept of overcrowding* where OPD cases cluster in ED and affect the quality
of care or required attention is diverted.(5) Researchers and health policy makers plan to relieve
the strain on ED by awareness regarding a warning statement to ED patients and implementation
of triage system.(6)Furthermore, we plan to seek opinions from consultants regarding patients’
disease and its severity and whether it should be treated in emergency department or OPD follow
ups were to be done. Researches and medical literature defines different causes of
crowding/overcrowding in Emergency departments including lack of patient education about the
working of EDs and inefficient triaging or counseling system(7).

The study further aims at establishing an opinion about the

health seeking behavior and level of patients’ awareness of triage system in emergency medicine
departments in hospitals of Punjab and whether or not they are willing to comply withthe triage
system. Overcrowding in hospitals is also inversely associated with the efficacy of triage system
in EDs and it significantly increases the waiting time for urgent cases(8). Finally we are supposed
to comment on the efficacy of emergency healthcare services, the burden on emergency
department due to misconceptions and lack of awareness of patients about their disease and its
management , we also attempt to find out habitual ED visitors in a tertiary care hospital. These are
the factors that put strain on hospitals EDs with regards to healthcare providers required, drugs
availability, time of physicians and funds spent on some of the non-urgent patients keeping the
more needy ones in line (9). Suggestions have been given to minimize the cost spent and
workforces required in EDs by sorting out the patients through triage and provide care and services
to non urgent patients separately to improve healthcare utilization.We further conclude by
quantitatively stating the number, frequency and pattern of disease presented in ED and how we
need to educate and train our staff members and install any further equipment to manage our patient
load. We can also conduct public awareness campaigns regarding the judicious and justified use
of Emergency Health care services.
 Objectives:
 To ask the CMO about patients’ knowledge of different medical conditions belonging to
OPD or ER* and their lack of knowledge being a major factor in increasing the burden on
emergency department.
 To analyze the pattern and frequency of different medical conditions presenting in
Emergency and severity of the conditions to be determined by CMO.
 To evaluate effectiveness of triage system* in reducing the crowding in hospitals.
 To comment on predictors of utilization of emergency healthcare services* in tertiary care
hospitals of Rawalpindi.

Rationale:
 To give an analysis of the number and percentage of different medical conditions
presented in Emergency and to comment on ER load due to over-utilization of emergency
services.
 To get an idea of predictors or factors that bring people to ER instead of OPDs in
concerned departments.
 Better management and control of emergency services.
 To spread awareness among the patients about different conditions of varying severity
that are to be dealt with by different departments and different zones of triage in
emergency medicine.
 Operational Definitions:
1. Emergency Medicine: it is a medical specialty that focuses on the diagnosis, treatment and
management of acute illnesses and injuries that require immediate medical attention. Emergency
medicine also encompasses the coordination and organization of emergency medical services
which include ambulance services, pre-hospital care, and communication systems to ensure a
timely response to emergencies.
2. Triage system: the process of rapidly screening and categorizing patients to prioritize care
based on the severity of their condition and resources available.
3. Emergency healthcare services: it can be understood as a system of medical care and support
that is designed to provide immediate and acute medical attention to individuals facing sudden
illness, injury or other health emergencies.
4.Overcrowding: There is no proper consensus on what overcrowding actually can be defined as
but it can be understood as a situation when there is a delay in provision of healthcare services due
to overwhelming number of patients for workforce available at a particular department.
Materials and methods:

Study Design:
 Descriptive
 Cross sectional study

Study setting:
 Holy Family Hospital, Rawalpindi, Punjab , Pakistan
 Rawalpindi Medical University, Rawalpindi.

Study Population:
 Patients presenting to Dept of Emergency Medicine, holy family hospital, Rawalpindi.

Study Duration:
 May-October 2023(6 months)

Sample Size:

 300-350 patients

Sampling Technique:
 Convenience sampling

Inclusion Criteria:
 All patients presenting to Emergency department.

Exclusion Criteria:
 Incomplete data
 Unverified patient data
 Data of patients admitted from OPD directly to in-patient.

Data Collection Tool:

A validated self-administered questionnaire, comprising of questions to patients regarding their
demographic details, the nature of their disease, their perception and expectations about their treatment, the
department they prefer to present in, consultants’ opinion about the patient and his disease and finally
whether or not the patient knows about the triage system in hospitals and if yes, how well does he know
about it?

Data Collection Procedure:

 Informed consent will be taken from all the patients after explaining the title, purpose and objectives
of the said research and with the assurance that their confidentiality will be maintained at all costs.
 Demographic details of the patient and other data points shall be collected through a validated self-
administered questionnaire.
 Any incomplete or invalid responses shall be discarded and given no importance in the calculation
of results.

Data Collection Technique:

 Research questionnaire shall be filled by the researcher though interview-based approach after
taking informed consent and provision of detailed explanation to patients wherever they want it.

Data Analysis Procedure:

 Microsoft Excel
 SPSS v.23
 QUESTIONNAIRE
Demographic Profile:

Age: Gender: M F F

Occupation:

Govt. Semi Govt. Private Self-Employed

Businessman Student Unemployed

Other _________________________________________________________________________

Educational level:

Primary school (up to 5th grade)

Secondary school (up to matriculation)

Higher school(up to FA/FSc)

Graduate

Masters or above

Other _________________________________________________________________________

1. Presenting complaint or provisional diagnosis

Have you ever visited the Department of Accident and Emergency in the tertiary care hospital of
Rawalpindi, Punjab? Yes No

2. If yes, how frequently have you visited in the past year?

Once weekly Once monthly Twice monthly Once 6 monthly Once in a Year

3. What were the main health problems or symptoms that led you to seek emergency medical care?

4. From a range of 1-10 please rank your severity of symptoms? Please mark the picture
5. When a health professional approached you to consult regarding your symptoms.

a. <1/2 hour

b. < 1 hour

c. 1-1.5 hrs

d. upto 2 hrs

e. more than 2 hrs

6.Do you think that this is as a delay in receiving medical care in the Emergency Department?

Yes No

6. If yes, what were the reasons for the delays; that was informed to you by doctor or you experienced?

a) Patient Load
b) Unavailability Of Staff
c) Shortage of Staff

7. Were you counselled about your or your patient’s Condition?

Yes No

8. Were you informed to proceed and receive your treatment in a colour coded area?

Yes No

9. Do you know what that colour coded area is known as

Yes No

If yes, Please write the name of that area ______________________________________

10. Were you or your Patient were moved to other colour coded areas according to symptoms.

Yes No

11. Please select your level of satisfaction about emergency healthcare services
Not at all Satisfied Partly Satisfied Satisfied More than Satisfied Very Satisfied

For the Consultant/CMO:

1. Do you think this condition( P/C or provisional diagnosis) should have been presented in ER?
Yes No
2. what is the time limit to approach such Patient.
3. a. <1/2 hour
4. b. < 1 hour
5. c. 1-1.5 hrs
6. d. upto 2 hrs
7. e. more than 2 hrs

3. Have you counselled the patient and attendants about patient condition?

Yes No

8. Were Patient or attendants well informed about Triage System

Yes No
9. Did you counselled patient about triage System
Yes No
10. How many of your staff members have dealt with this patient?
a. 0-1
b. 1-2
c. 2-4
d. More than 5
11. What do you prefer to do if a willing OPD patient present to ER?
a. Counsel
b. Treat in ER
c. Deny any help
12. What do you prefer to do with a resilient OPD patient presenting in ER?
a. Counsel
b. Seek police assistance
c. Treat in ER
d. Deny any help
13. Please write Up to three or less (Any Number) of issues that you encounter in Emergency in
provision of Health care?
1_______________________________________________________________________
2______________________________________________________________________
3_______________________________________________________________________
14. What do you suggest a Solution to the Above Issues Encounter in Emergency Department?
1_______________________________________________________________________
2______________________________________________________________________
3_______________________________________________________________________
 Consent form for the research project frequency and pattern of
health problems presenting in department of emergency medicine
and patients’ awareness of triage system in a tertiary care hospital
of rawalpindi, punjab.

I_______________ am willing to participate voluntarily in this research titled; frequency and pattern of
health problems presenting in Emergency Department and patients’ awareness of triage system in a
tertiary care hospital of Rawalpindi, Punjab being conducted by Ward group H 4th year MBBS. I am fully
aware of objectives of this survey and I also know that there is no harm or benefit to me if I participate.
However, I have been ensured by the researcher that my data will remain confidential. I allow the
researcher to use this data for scientific purposes and that I can opt out of the research at any time.

Signature Mobile no.

‫اجازت نامہ برائے شمولیت تحقیق‬

‫ میں اس‬-‫ رضا کارانہ طور پر اس تحقیق میں حصہ لینے کو تیار ہوں‬---------------------_--‫میں‬
‫تحقیق کے مقاصد سے آگاہ ہوں اور جانتا ہوں کہ اس تحقیق میں حصہ لینے سے میرا کوئی نفع نقصان‬
‫ محقق نے مجھے یقین دہانی کروائی ہے کہ میری معلومات کو خفیہ رکھا جائے گا میں‬-‫نہیں ہوگا‬
-‫تحقیقی مقاصد کے لئے اپنی معلومات کو استعمال کرنے کی اجازت دیتا ہوں‬

-------------‫دستخط‬
 Results
A total of 372 patients presenting to ER of Holy family hospital participated in the study with 189(50.8%)
males and 183(49.2%) females. Among all the patients presenting to ER during a period of 1 month, 260;
69.9% were actually ER patients( 137males, 123 females) according to the CMO or attending doctor
while 112; 30.1 (52 males, 60 females) were not ER patients, they should have been treated in OPD. This
extra 30% patients put a burden over ER staff and supplies; overshadowing the patients who actually need
ER care and putting a strain over hospital supplies.

The figure below shows the frequency of different health conditions presented in ER during a period of 1
month

Frequency Percentage
Burns 1 3
Pain 32 8.6
Acute Gastro-enteritis 120 32.3
Trauma 59 15.9
Uncontrolled hypertension 18 4.8
Chronic kidney disease 8 2.2
Stroke 7 1.9
Anemia 5 1.3
Appendicitis 11 3.0
Jaundice 10 2.7
Chest pain 4 1.1
Congenital anomalies 1 .3
Complicated pregnancy 1 .3
Uncontrolled blood sugar 8 2.2
Hematemesis 5 1.3
Cancer 6 1.6
High grade fever 30 8.1
Shortness of breath 11 3.0
Gynecological problems 1 .3
Hypotension 6 1.6
Unconscious 4 1.1
Poisoning 4 1.1
Hepatitis 5 1.3
Skin diseases 3 .8
Gallstones 4 1.1
Hemorrhoids 1 .3
Urinary Tract Infections 7 1.9
Total 372 100.0
Out of the total population of 372 participants, we classified them into three levels of severity of their
disease with mild(pain scale 1-3), moderate (pain scale 4-6) and severe(pain scale7-10), the following
figure presents a relationship between severity of symptoms according to patient and doctor’s opinion; if
his condition is justified to be treated in ER or needs OPD referral:
 200

180

160

140

120

100 justified ER patient

OPD patient
80

60

40

20

0
mild moderete severe

Relationship between severity of symptoms (patients’ opinion) and doctor’s opinion of the patient being justified ER
patient or OPD patient presenting to ER.

Among the total participants of 372, only 112(30.1%) knew about the system of triage existing in ER
where patients are screened according to the severity of their symptoms and they are treated in different
zones according to the time they can wait; while 260(69.9%) totally had no idea about it.

The following figure shows the relationship between level of satisfaction and gender of the participants

160

140

120

100

80
dissatisfied
60 satisfied

40

20

0
male female
The following figure shows the odd’s ratio of relationship between doctor’s opinion about the patients
presenting complaint and delay in provision of ER services

Time to Approach Doctor’s opinion about presenting complaint

time yes No total
1/2hrs 188 48 236
Upto 1 hr 57 31 88
1-1.5 hrs 10 11 21
Upto2 hrs 3 12 15
More than 2 hrs 1 11 12
260 112 372
Amongst the 372 total study participants 100 said that there is a delay in provision of ER services; the
following figure presents reasons of delay in provision of ER care according to the patients:

FREQUENCY PERCENT
Patient load 75 75.0
Unavailability of staff 16 16.0
Shortage of staff 9 9.0
Total 100 100.0
 Demographic Details

Gender

male
female

Age of Participant

90
80
70
60
50
40
30
frequency
20
10
0
 Educational status of Participant
120

100

80

60

40
frequency
20

Occupation

140

120

100

80

60
frequency
40

20

0
 Discussion
Our study was aimed at finding out the major predictors of ER utilization and undue stress on ER
services and personnel due to over-utilization of emergency instead of OPD or concerned in-
patient department. We found out through our sample size of 372, that 30% (n=112) with males
n=52 and females n=60 were not actually ER patients according to the attending doctor. The
doctor analyzed this by looking at the presenting complaint as told by the patient, major
symptoms reported by the patient and general condition of the patient. This over-
burdenization/over-crowding of the ER is a matter of concern for the doctors as well as the
management as the patients who actually require ER care or are in the red zone of the triage may
be over-looked or ignored leading to major casualties in emergency.

The data reveals that most number of patients presented

with complaints of acute gastro-enteritis (i.e vomiting, diarrhea, abdominal pain, or nausea)
n=120(32.3%) with varying level of severity of their symptoms. If we can manage to provide
separate counter or counseling for these patients a large share of the burden on ER can be
relieved and staff is directed towards only extremely severe cases. Next most common complaint
was trauma, that is a must to be treated in ER and should be provided adequate care after triaging
to manage the patients according to the time they can still wait for medical services while the
doctors relieve or comfort more serious cases. In this case again triaging and categorization is
very important as many conditions only require nursing care and advice for home. Another
common complaint of many patients was high grade fever (n=30, 8.1%) due to variable causes
but mostly due to upper respiratory tract infections. This problem can easily be managed on OPD
basis and should be filtered in ER-green zone or referred to OPD.

Now if we look deeply into the demographic details of ER

care seekers, most of them belong to 20-29.9 yrs age bracket(n=80,21.5%) which means that
young adults are utilizing the ER most due to varied reasons. Most of them are housewives
(n=127, 34.1%) and their most common complaints are Acute gastroenteritis and UTIs. This is
followed by students of varying ages (n=82, 22.0%). Most of the ER visitors are either
uneducated(n=93,25%) or have attained only primary level(n=99, 27%) of education who could
not even tell their mobile numbers, so they have a little knowledge of where to present
themselves in the hospitals. A greater number of participants had their first visit to ER (n=210,
56%) followed by those who had their second visit in a year and came to ER due to previous
satisfying experience. There were a small number of habitual visitors as well where most of them
were either addicts or psychiatric patients and were surely a nuisance in the ER as they diverted
all the attention towards themselves. The data suggests that the least number of visitors were
undergraduate or graduate individuals which means ER visits are definitely related to the level of
education of the patients; the more educated an individual is, the better he knows what
department and doctor suits him. Again they can choose to consult private sector due to better
economic conditions. Patients with low socio-economic status usually present in ER due to free
medication and least waiting time where most of them are laborers or daily wagers who cannot
afford to miss a day at work.

Coming to talk about the waiting time, most of the

participants said they got the treatment in less than 30minutes (n=296, 79.6%) which is the least
waiting time if we compare it to other developed or even developing countries where most of the
patients have to book themselves beforehand or waiting time exceeds 5-6hrs and only trauma and
critical care patients are managed on immediate/ priority basis. This practice is not only
burdenizing ER staff but also putting a strain over hospital equipment and medication supplies
and at the same time OPD patients in ER are pushing actual critical patients back who are
usually not even in a state to speak for themselves. Efforts need to be directed towards the
efficacy of triage system and patients education about the working of ER so that better outcomes
can be achieved from ER care.

The research also aimed to find out how many individuals knew about
or understood the concept of triaging where patients are classified into different categories
according to the severity of their condition and time they can wait before getting required
treatment. 258 participants (59%) had no idea about the existence of triage system or color coded
zones while only 113 (30.8%) said they knew about it or have remotely heard about it. Efficacy
of triage is inversely related to ER crowding; the more efficient triage, the lesser the crowding
and hence better care for critical cases. The study found out about the gap in patients’ knowledge
of triage and also inefficient triaging that is leading to more 30% extra patients in ER that can be
easily treated in OPD or in-patient settings.

100 participants (27%) said that there was delay in provision of

ER services amongst which 75% said that the delay is due to patient load on ER. Only 16% said
it was due to staff unavailability. Now if we compare our statistics to studies in America, China,
UK or Russia the main factors behind ER utilization there are old age, health insurance, chronic
diseases and trauma while these statistics totally change in countries like Pakistan and India
where the major driving factors are free medical services, 24/7 availability, instant provision of
services and lack of knowledge and education with unemployment adding to it. In developing
countries where most of the people are busy at their work during the OPD timings, the only
option left for them is ER as it provides treatment with least waiting time and is available
throughout the day and night. Now that most of the housewives, students and unemployed are
not bound to any duties they are the most frequent visitors while laborers or working people
usually present after working hours. Amongst the study participants 288(77.2%) were satisfied
with ER services while 84(22.5%) were not satisfied, with the main reason being delays due to
excessive patient load.

To our knowledge this study is first of its kind or very few ones to find out
the causes of ER crowding and the efficacy of our triage system. It will contribute significant
data and recommendations to administration of tertiary care hospitals in Pakistan with developed
departments of accident and emergency. The study aimed to highlight the factors behind
excessive ER utilization and crowding and also highlighted the doctors’ opinions about their
preference when non-ER patients come to already busy ER and put a strain over staff as well as
supplies of all sorts. This study can be used as a pilot study to assess the causes of ER crowding
and efficacy of triage in different cities of Pakistan. These results can be used by the hospital and
university administration to develop policies and strategies to reduce stress on ER care providers.

Finally, despite all the effort to inculcate the most information about
ER over-crowding; our study has a few limitations. It was conducted on the patients presenting
to ER of Holy Family Hospital, Rawalpindi only and cannot be generalized in a different setting
or in secondary or primary care sectors in Pakistan or other countries where demographics,
availability of resources, educational status of participants and health seeking behavior might be
totally different. Another possible limitation of this study is that most of the results rely on
patients’ opinions and that can be subject to a lot of humanly variations in response to exactly
similar conditions. It can also vary according to pandemic or endemic states or level of
development of health sector.
 Conclusions and Recommendations

Our results indicate that the ER is being significantly over-utilized and burdenized because of
lack of knowledge of the patients, their low socio-economic status and in-efficacy/lack of
knowledge of the triage system leading to burn-out among the ER doctors and lesser attention to
actual ER patients who need immediate management.

Education and awareness about the working and effective utilization of ER shall be provided to
the general public either through media or spreads of pamphlets or verbal guidance to ER visitors
so that department of accident and emergency is only focusing on actual emergency or critical
care patients.
 Acknowledgements
Sawaira Arshad Malik1

Shiza Asad2 ,

Shahreen Asif3 , Asif Maqsood Butt 3 ,Sawera Shafique3, Sofia Shahzad3,Sumayya Malik3,
Tayyaba Tabassum3,Muhammad Hasan3, Sana Ullah Khan3

Zartashia Zeghum4, Saqlain Shahzad4

Haider Mansha5
Abedal Rehman MA Abushamala5
Reem Hani Abdul Wahid Qatanany5
Nour M N Radi5
Layla Riyad Mousa Sadeh5
Sabir Nawaz5
Mubarak Farah Hassan5
Abdul Wahab Muhammad Adan5

1,2,3,4
Fourth year MBBS Rawalpindi Medical University session 2022-23.
3
Senior Demonstrator Community Medicine Department Rawalpindi medical University.
 References
1. Yarmohammadian MH, Rezaei F, Haghshenas A, Tavakoli N. Overcrowding in emergency
departments: A review of strategies to decrease future challenges. J Res Med Sci. 2017;22:23.
2. Abegunde D, Kabo IA, Sambisa W, Akomolafe T, Orobaton N, Abdulkarim M, et al. Availability,
utilization, and quality of emergency obstetric care services in Bauchi State, Nigeria. Int J Gynaecol Obstet.
2015;128(3):251-5.
3. Andrews AL, Bettenhausen J, Hoefgen E, Richardson T, Macy ML, Zima BT, et al. Measures of ED
utilization in a national cohort of children. Am J Manag Care. 2020;26(6):267-72.
4. Azeredo TR, Guedes HM, Rebelo de Almeida RA, Chianca TC, Martins JC. Efficacy of the
Manchester Triage System: a systematic review. Int Emerg Nurs. 2015;23(2):47-52.
5. Darraj A, Hudays A, Hazazi A, Hobani A, Alghamdi A. The Association between Emergency
Department Overcrowding and Delay in Treatment: A Systematic Review. Healthcare (Basel). 2023;11(3).
6. Di Somma S, Paladino L, Vaughan L, Lalle I, Magrini L, Magnanti M. Overcrowding in emergency
department: an international issue. Intern Emerg Med. 2015;10(2):171-5.
7. Ferriols Pérez E, Kanjou Augé N, Genovés González J, Burón Pust A, Payà Panadés A, Carreras
Collado R. Inadequate visits to the emergency department by pregnant women. J Obstet Gynaecol.
2018;38(2):161-6.
8. Jeyaraman MM, Copstein L, Al-Yousif N, Alder RN, Kirkland SW, Al-Yousif Y, et al. Interventions
and strategies involving primary healthcare professionals to manage emergency department
overcrowding: a scoping review. BMJ Open. 2021;11(5):e048613.
9. Kenny JF, Chang BC, Hemmert KC. Factors Affecting Emergency Department Crowding. Emerg
Med Clin North Am. 2020;38(3):573-87.
10. Kilfoyle KA, Vrees R, Raker CA, Matteson KA. Nonurgent and urgent emergency department use
during pregnancy: an observational study. Am J Obstet Gynecol. 2017;216(2):181.e1-.e7.
11. Levy AR, Khalil E, Chandramohan M, Whitfill TM, Cicero MX. Efficacy of Computer-Based
Simulation as a Modality for Learning Pediatric Disaster Triage for Pediatric Emergency Nurses. Simul
Healthc. 2022;17(5):329-35.
12. Lindner G, Woitok BK. Emergency department overcrowding : Analysis and strategies to manage
an international phenomenon. Wien Klin Wochenschr. 2021;133(5-6):229-33.
13. McKenna P, Heslin SM, Viccellio P, Mallon WK, Hernandez C, Morley EJ. Emergency department
and hospital crowding: causes, consequences, and cures. Clin Exp Emerg Med. 2019;6(3):189-95.
14. Oberlin M, Andrès E, Behr M, Kepka S, Le Borgne P, Bilbault P. [Emergency overcrowding and
hospital organization: Causes and solutions]. Rev Med Interne. 2020;41(10):693-9.
15. Sartini M, Carbone A, Demartini A, Giribone L, Oliva M, Spagnolo AM, et al. Overcrowding in
Emergency Department: Causes, Consequences, and Solutions-A Narrative Review. Healthcare (Basel).
2022;10(9).
16. Savioli G, Ceresa IF, Gri N, Bavestrello Piccini G, Longhitano Y, Zanza C, et al. Emergency
Department Overcrowding: Understanding the Factors to Find Corresponding Solutions. J Pers Med.
2022;12(2).
17. Williams P, Csipke E, Rose D, Koeser L, McCrone P, Tulloch AD, et al. Efficacy of a triage system to
reduce length of hospital stay. Br J Psychiatry. 2014;204(6):480-5.
18. Zimbro KS, Maduro RS, Ver Schneider P, Hahn DS, Paulson JF, Morgan MK. Efficacy of the Crisis
Risk Triage Scale in Inpatient Units Within the United States. J Healthc Qual. 2023;45(1):51-8.