Factors affecting time-to-disposition at a district hospital emergency centre in Cape Town, South Africa

Emergency centre crowding adversely affects the quality of care, and the wellbeing of both patients and healthcare providers. The interplay between emergency centre crowding and clinicians' time-to-disposition remains poorly understood, with evidence of complex associations involving system-level variables. This study describes and quantifies factors influencing time-to-disposition at a district-level hospital emergency centre in Cape Town, South Africa.

We conducted a secondary analysis of an existing dataset comprising all emergency centre consultations in a Cape Town District Hospital Emergency Centre over three randomly selected four-week periods in 2019. A retrospective chart review was performed on a random subsample (n=1,000) to assess the impact of special investigations. Multivariable binary logistic regression was used to identify independent predictors of prolonged time-to-disposition.

A total of 9,356 consultations were analysed. The overall median (IQR) time-to-disposition was 95 (33-241) minutes; 32.8% exceeded three hours. Triage acuity was the strongest independent predictor of time-to-disposition exceeding three hours in multivariable analysis (Emergent vs Routine: aOR 5.30, 95% CI 3.72-7.55; Very Urgent: aOR 3.61, 95% CI 2.67-4.89), paediatric age group (aOR 0.30) and trauma presentation (aOR 0.65) were independently protective. Registrar (resident) managed consultations were independently associated with prolonged time-to-disposition (aOR 1.35, 95% CI 1.18-1.55). Special investigations were the dominant predictor in the investigations subsample (aOR 6.96, 95% CI 4.43-10.94), with laboratory turnaround, median 198 (127-301) minutes from specimen collection to registration, identified as the principal bottleneck. Very urgent presentations (47.2% of patients) and admitted patients (36.5%) represented the highest-impact subgroups by combined burden of prolonged time-to-disposition and patient volume.

Triage acuity, age group, trauma category, clinician category, and special investigations were independently associated with time-to-disposition. Laboratory turnaround is a major modifiable contributor to throughput delays. Interventions targeting high-impact subgroups, particularly very urgent presentations, admitted patients, and those requiring laboratory investigations, offer the greatest potential for improving throughput.