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ORIGINAL RESEARCH

Length of Stay in the Emergency Department and

Its Associated Factors at Jimma Medical Center,
Southwest Ethiopia
This article was published in the following Dove Press journal:
Open Access Emergency Medicine

1
Abdulwahid Awol Ahmed Background: Prolonged emergency department stays can adversely affect patient outcomes
Shemsedin Amme Ibro 1 leading to an increased length of hospital admission and higher mortality. Despite this fact,
Gemechis Melkamu2 there are few data describing emergency department length of stay and associated factors in
Sheka Shemsi Seid 1 Ethiopia.
Objective: To assess length of stay in the emergency department and its associated factors
Temamen Tesfaye 1
among patients visited adult emergency department of Jimma Medical Center, Jimma town,
1
School of Nursing and Midwifery, Jimma southwest of Ethiopia.
University, Jimma, Oromia Region,
Ethiopia; 2School of Medicine, Jimma Methods: Institution-based cross-sectional study was conducted from April 9, 2018 to
University, Jimma, Oromia Region, May 11, 2018. Overall, 422 patients presented during study period were sequentially
Ethiopia
included in the study. A semi-structured questionnaire was used to collect data through
interview, observation and medical record review. The collected data were cleaned, entered
to Epi-data 3.1 and exported to SPSS version 21 for binary and multivariable logistic
regression analysis. To identify factors associated with outcome variable, candidate variables
were fitted to multivariable analysis, and those with P-values <0.05 were considered as
significantly associated.
Results: More than one-third, 162 (38.4%), experienced prolonged length of stay in the
emergency department. The odds of prolonged stay were higher among rural area residency
(AOR, 3.0; CI, 1.279–7.042), evening presentation (AOR, 4.25; CI, 1.742–10.417), and
night-time presentation (AOR, 14.93; CI, 4.22–52.63), and having at least one diagnostic
investigation (AOR, 4.48; CI, 1.69–11.88). However, participants who did not experience
shift changes of nurses during their stay (AOR, 0.003; CI, 0.001–0.010) had a less prolonged
stay.
Conclusion: A significant proportion of patients experienced a prolonged stay at the
emergency department. Age, rural residency, evening and night-time presentation, shift
change and having a diagnostic investigation were predictors of prolonged stay. Thus,
establishing time-targeted service for patients can reduce the length of stay.
Keywords: emergency department, length of stay, prolonged stay

Introduction
The emergency department (ED) is a 24-hours location serving an unscheduled
Correspondence: Abdulwahid Awol patient population with anticipated needs for emergency care. It represents the
Ahmed
Jimma University, P.O. Box-378, Jimma, “front door” to the province of the health care system for many patients, which
Oromia Region, Ethiopia represents about three-fifths of inpatient hospital admissions.1,2 Emergency
Tel +251933824284
Email abdiiawol@gmail.com department length of stay (ED LOS) starts from entrance to the unit and does

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Ahmed et al Dovepress

not end until the patient is either discharged home, Methods and Materials
admitted to hospital or transferred to another institution. Study Design and Settings
This time period indicates how well an ED is working An institutional-based cross-sectional study was con­
and performing.1 ducted at the adult ED of Jimma Medical Center (JMC)
Varies studies3,4 defined prolonged ED LOS as a length from April 9, 2018 to May 11, 2018. JMC is located in
of stay of more than 6 hours at the ED; it is used as Jimma town, 352 km southwest of the Ethiopian capital,
a performance indicator to assess the quality of care in Addis Ababa. Currently, JMC is the only teaching refer­
the ED,5 and evidence suggests that ED LOS of more than ral hospital in the southwest part of Ethiopia. In addition,
6 hours is associated with increased mortality.3 JMC is the only hospital with a formally organized
Worldwide, there is an increasing demand for hospital emergency department in the area, and the department
ED visits.6,7 Visits to the ED rose by 65% from 2001 and is one of the youngest units, which was recently pro­
2011,8 resulting in increased waiting times, prolonged moted from an emergency room rendered under outpa­
stays, overcrowding, and delayed admission.9 Increased tient department services. The department serves as an
LOS in the ED may leads to crucial costs and may have intake unit and inpatient admission unit for critically ill
implications on patient safety and is also associated with patients. Currently, the ED is staffed with nurses, emer­
hospital occupancy rate.10 Prolonged ED stays can gency physicians and emergency and trauma practitioner
adversely affect patient outcomes,11,12 leading to increased nurses. On average, about 11,964 and 997 patients visit
length of hospital admission, higher inpatient cost, and adult ED annually and monthly, respectively.
mortality.13–15
Evidence has revealed that prolonged ED stays leads to Population
an estimated 15%–30% higher rate of mortality7,16–18 and is Study population: All patients presented to the ED during
also viewed as an evidence of poor hospital performance.19 the study period were consecutively included in the study.
Prolonged stay in the ED is an independent risk factor for
pneumonia and each hour increases the risk by approxi­ Eligibility Criteria
mately 20%.20 Mortality rate increased from 2.5% to 4.5% Patients less than 18 years of age and those who are unable
with increasing LOS less than 2 hours to 12 hours or more.15 to give their consent due to inability to speak or altered
With this many consequences of a prolonged stay, it is also mentation where no available accommodating attendants
a global challenge. For instance, more than half (58.9%) of were excluded.
respondents in Canada and about 10.2% in Iran experienced
prolonged stays in the ED.3,21 Sample Size and Sampling Procedure
Possible causes for prolonged stays have been men­ A single population proportion formula was used to deter­
tioned in different studies. They may arise both from mine sample size, considering 50% proportion of prolonged
professionals’ inability to perfectly triage patients and stay, a confidence interval of 95%, and a margin of error of
limited capacity of the system.22 Health care utilization 5%. Thus, considering a 10% of non-response rate, the final
such as laboratory or imaging tests, specialty consulta­ calculated sample size was 422. All patients presented to the
tions and admissions, increased from the non-urgent to ED were sequentially enrolled in the study until the desired
emergent case in the ED, but there is variability in ED sample size was reached; thus, the arrival of the patients at
LOS.23 ED was assumed to be randomly occurring.
The increased demand for emergency department and
prolonged ED stay had a negative impact on quality care Variables
and patient outcome. Despite this, there is a paucity of The dependent variable was the status of ED LOS.
data describing ED LOS and associated factors in Africa, Independent variables were factors categorized under
particularly in Ethiopia. Therefore, this study aimed to three categories. Specifically, socio-demographic factors
assess ED LOS and associated factors among patients were Age, Sex, Address, Marital status, Educational status,
visiting the adult ED of Jimma Medical Center. Such Occupation. In addition, factors related to presentation and
data would help to design evidence-based problem- clinical characteristics include: Mode of arrival, Onset
solving mechanisms. characteristic, Mental status, Triage level, Diagnosis, and

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Dovepress Ahmed et al

Comorbid illness. Organizational factors were: multivariable logistic regression at P-values ≤0.25. Then,
Presentation time, Day of the week, Care received in the in multivariable logistic regression analysis, factors signif­
ED, Diagnostic investigation, Shift changes, Time of icantly associated with outcome variable were identified at
initial intervention and Disposition. P-values less than 0.05 and adjusted odds ratios at 95% CI.
Model fitness was checked by Hosmer–Lemeshow good­
Data Collection Tools and Procedure ness of fit (P = 0.21). A multicollinearity test was done
A semi-structured interviewer-administered questionnaire (SE < 2.0).
that was developed through a review of published
literatures3,5,6,10,11,13–15,19,21,22,24,25 based on the objectives Data Quality Assurance
of the study was used to collect data and medical records To insure quality of data, supervisor and data collectors
were also reviewed. The questionnaire contains 32 items were trained for one day. The questionnaire was translated
organized under the aforementioned four major parts. to local languages (Afaan Oromo and Amharic) by lan­
Eight data collectors and one supervisor were employed guage experts, and then backtranslated into English by
among BSc-qualified nurses and supervised by the princi­ anindependent translator to ensure consistency.
pal investigator. Its face validity was confirmed by a team Translated questionnaire versions were discussed by the
of experts in emergency medicine, emergency physician team of the Mega-project to identify and resolve inade­
and emergency nurses. quate expressions/concepts of translation and alternatives
Data were collected from the patients following pre­ were suggested. The final versions of the questionnaire
sentation, admission and prior to discharge from the ED were pretested on 10% of the sample at JMC two weeks
through respondent interview, observation and medical prior to actual data collection to ensure reliability and
recordreview. The data collection procedure is illustrated necessary modifications were made. On-site close super­
as follows: first, eligible patients were identified by data vision was carried out by a supervisor and the principal
collectors at the triage room while resident staff were investigator to supervise the data collection process and to
triaging patients on arrival. Hence at arrival, time and ensure the completeness and consistency of the filled ques­
other presentation characteristics were recorded at the tionnaire on a daily basis. Further, consistency and com­
triage room. Following this, other information such as pleteness of data were throughout data entry and cleaning
socio-demographic characteristics and other organiza­ process.
tional-related factors were obtained at interviews, chart
review and observation of patients at different treatment
points, and after patient gate stabilized otherwise. Finally, Ethical Consideration
information such as diagnostic investigations and overall Ethical clearance was obtained from Jimma University
treatments done were recorded from medical records, Institute of Health IRB on January 25, 2018, with refer­
whereas overall length of stay at the department and final ence number IHRPGD/353/2018. An official letter was
disposition were recorded right before the patient was given to JMC administration and permission to continue
discharged from the ED. Hence, essential time-related with data collection was obtained. The informed verbal
factors were ED arrival time and the overall length of consent process was approved by the Jimma University
stay between presentation and discharge from ED. Institute of Health Institutional Review Board, and this
study was conducted in accordance with the Declaration
of Helsinki. The study participants explained the study
Data Processing and Analysis Plan
objectives and the right to withdraw at any point. The
The collected data were checked for completeness, con­
participation of the respondents was on the basis of
sistency and accuracy. Data were coded, entered and
voluntary participation. To maintain confidentiality and
cleaned using Epi-data 3.1 and exported to SPSS version
anonymity of data, they were re-coded upon entry.
21 for analysis. Descriptive statistics were done to sum­
marize the background characteristics of study partici­
pants. The overall length of stay was dichotomized ED Results
LOS ≤6 hours and >6 hours, then binary logistic regres­ A total of 422 patients with a response rate of 100%
sion was done to determine candidate variables for participated in the study.

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Socio-Demographic Characteristics Table 1 Socio-Demographic Characteristics of Patients Who

Visited The Adult ED of JMC, Jimma Town, Oromia Region,
The mean age of the participants was 33.1 ± 16.4 years. More
SouthWest of Ethiopia, 2018 (n = 422)
than half (233, 55.2%) of participants were male; approxi­
Characteristics Number (No.) Percentage (%)
mately half (218, 51.7%) of respondents were married, 304
(72.0%) were from Oromo by ethnicity, and 257 (60.9%) Total visits 422 100
were Muslim. About two-thirds (280, 66.4%) of the respon­ Age
dents were residents of Jimma town. The majority (297, 18–29 years 240 56.9
70.4%) of the respondents attended formal education. 30–39 years 62 14.7
40–59 years 71 16.8
Nearly one-third (135, 32.0%) of respondents were students,
60–69 years 26 6.2
whereas 120 (28.4%) were farmers (Table 1).
70+ years 23 5.5

Sex
Presenting Characteristics Female 189 44.8
A commercial taxi was the mode of arrival to ED for about Male 233 55.2
153 (36.3%) of the patients; those arriving by ambulance Address
accounted for 94 (22.3%). Medical conditions were the Rural 142 33.6
leading causes of presentation and accounted for 183 Urban 280 66.4
(43.4%), followed by injuries 136 (32.2%). Infectious dis­ Marital status
eases accounted for the fewest causes of ED visits (103, Married 218 51.7
24.4). The majority (351, 83.2%) of the patients presented Single 194 46.0
Othera 10 2.4
with a single diagnosis.
The acuity level of presentation on triage was Religion
observed; the proportion of patients triaged as higher Muslim 257 60.9
Orthodox 106 25.1
acuity of red and orange category were 17 (4.0%) and 43
Protestant 58 13.7
(10.2%), respectively. The majority (374, 88.6%) of the Catholic 1 0.2
respondents were fully alert on arrival to the ED (Table 2).
Ethnicity
Oromo 304 72.0
Presentation Time and ED-Related Amhara 63 14.9
Dawaro 26 6.2
Characteristics Otherb 29 6.9
The majority of the respondents presented to the ED dur­
Literacy status
ing daytime, specifically 181 (42.9%) arrived during the
Illiterate 95 22.5
morning, while 171 (40.5%) presented during the evening.
Read and write 30 7.1
Furthermore, 340 (80.6%) respondents presented during Secondary school 94 22.3
working weekdays. The majority of respondents (357, University/college 84 19.9
84.6%) received care while at the ED. Similarly, the Primary school 119 28.2

majority (329, 78.0%) had at least one diagnostic investi­ Occupation

gation; 129 (30.6%) had laboratory tests and 293 (69.4%) Farmer 120 28.4
underwent at least one imaging study. Respondents who Daily labor 32 7.6
Employees 44 10.4
experienced shift changes of nurses during their stay at ED
Merchant 66 15.6
accounted for 183 (43.4%). A quarter (105, 24.9%) of Student 135 32.0
patients were admitted to an inpatient unit; where Otherc 25 5.9
the majority (315, 74.6%) were discharged and 2 (0.5%) Notes: aDivorced, widowed, separated; bGurage, Gambela, Kefa, Kambata, Silte,
were transferred to other facilities (Table 3). Tigre; cHousewife, unemployed.

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Table 2 Presenting Characteristics of Patients Who Visited The Table 3 Presentation Time and ED-Related Factors Among
Adult ED of JMC, Jimma Town, Oromia Region, Southwest of Patients Who Visited The Adult ED of JMC, Jimma Town,
Ethiopia, 2018 (n = 422) Oromia Region, Southwest of Ethiopia, 2018 (n = 422)
Factors Number Percent Factors Number Percent

Mode of arrival Time of the day

By taxi 153 36.3 Morning 181 42.9
By ambulance 94 22.3 Evening 171 40.5
By public car/track 94 22.3 Night 70 16.6
By foot 75 17.8
Day of the week
Othera 6 1.4
Weekday 340 80.6
Main primary diagnosis category Weekend 82 19.4
Medical conditions 183 43.4
Received any intervention in the ED
Infectious illness 103 24.4
Yes 357 84.6
Injuries 136 32.2
No 65 15.4
Presence of Comorbid Illness
Having at least one diagnostic investigation
Yes 72 17.1
Yes 329 78.0
No 350 82.9
No 93 22.0
Triage Category
Laboratory tests
Redb 17 4.0
Yes 293 69.4
Orangec 43 10.2
No 129 30.6
Yellowd 190 45.0
Greene 172 40.8 Imaging studies
Yes 147 34.8
Mental status
No 275 65.2
Fully alert 374 88.6
Comatose 9 2.1 Shift change experience
Confused 39 9.2 Yes 183 43.4
a b c d
Notes: Motor cycle, carried. Red: Emergent; Orange: urgent; Yellow: less No 239 56.6
urgent; eGreen: non-urgent.
Discharge from ED
Admitted 105 24.9
Discharged 315 74.6
ED Length of Stay
Transferred 2 0.5
The median (IQR) ED length of stay among the respondents
was 4 (1.6–13.5) hours. More than one-
third (162, 38.4%) of patients experienced a prolonged
stay at the ED. The rest (260, 61.6%) were discharged responsible diagnosis, mental status, presentation time,
from the ED within 6 hours. time of initial intervention, having at least one investi­
gation and shift change of nurse were found to be
Reason for Prolonged ED LOS from significantly associated with a prolonged stay in the ED.
In multivariable logistic regression analysis the follow­
Respondent’s Perspective
The reasons for prolonged ED LOS among respondents ing independent predictors of ED LOS >6 h were identi­
who experienced a prolonged stay were waiting for fied: age, residency address, mental status, day of week,
results of investigation, waiting for specialist consultation, time of day, diagnostic investigation, and experiencing
and absence of an inpatient bed, which accounts for 80 nurses' shift change.
(49.4%), 62 (38.3%) and 31 (19.1%), respectively. The odds of prolonged stay at ED among respondents
of age 40–59 years were 5.4 times (AOR, 5.38; CI, 1.81–­
Factors Associated with Prolonged 15.87) higher than those of 18–29 years. Patients from
Emergency Department Length of Stay rural areas were three times (AOR, 3.00; CI, 1.279–7.042)
In the bivariate analysis, age, address, marital status, more likely to have an ED LOS more than 6 hours than
educational status, occupation, triage category, most were urban residents.

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Table 4 Multivariable Analysis of Factors Associated with ED Length of Stay Among Patients Who Visited The Adult ED of JMC,
Jimma Town, Oromia Region, Southwest of Ethiopia, 2018
Factors ED Length of Stay No. (%) COR (95% CI) AOR (95% CI)

Prolonged Not Prolonged

Age
18–29 years 73 (17.3) 167 (39.6) 1 1
30–39 years 22 (5.2) 40 (9.5) 1.26 (0.70–2.27) 0.55 (0.20–1.53)
40–59 years 39 (9.2) 32 (7.6) 2.79 (1.62–4.78) 5.38 (1.81–15.87)b
60–69 years 18 (4.3) 8 (1.9) 5.15 (2.14–12.35) 4.52 (0.82–25.00)
70+ years 10 (2.4) 13 (3.1) 1.76 (0.74–4.20) 0.97 (0.24–3.97)

Address
Rural 71 (16.8) 71 (16.8) 2.08 (1.37–3.14) 3.0 (1.28–7.04)b
Urban 91 (21.6) 189 (44.8) 1 1

Mental status
Fully alert 134 (31.8) 240 (56.9) 1 1
Confused 5 (1.2) 4 (0.9) 2.24 (0.59–8.47) 8.20 (2.05–32.26)b
Comatose 23 (5.5) 16 (3.8) 2.58 (1.31–5.05) 3.38 (0.32–35.71)

Time of the day

Morning 57 (13.5) 124 (29.4) 1 1
Evening 74 (17.5) 97 (23.0) 1.66 (1.07–2.56) 4.26 (1.74–10.42)c
Night 31 (7.3) 39 (9.2) 1.73 (0.98–3.05) 14.93 (4.22–52.63)c

Day of the week

Weekday 136 (32.2) 204 (48.3) 1.44 (0.86–2.40) 2.59 (1.01–6.64)a
Weekend 26 (6.2) 56 (13.3) 1 1

Diagnostic investigation
Yes 144 (34.1) 185 (43.8) 3.24 (1.86–5.67) 4.48 (1.69–11.88)b
No 18 (4.3) 75 (17.8) 1 1

Shift change
Yes 150 (35.5) 33 (7.8) 1 1
No 12 (2.8) 227 (53.8) 0.01 (0.01–0.02) 0.003 (0.001–0.010)c
Notes: aP-value < 0.05; bP-value < 0.03; cP-value < 0.001.
Abbreviations: COR, crude odds ratio; AOR, adjusted odds ratio; CI, confidence interval.

The odds of a prolonged stay at the ED among respondents investigation. Furthermore, those who did not experience
who presented with confused mentation were 8.2 times (AOR, a shift change of nurses during their stay were about 99.7%
8.20; CI, 2.05–32.26) higher than those fully conscious on (AOR, 0.003; CI, 0.001–0.01) less likely to have a prolonged
presentation. An evening presentation was 4.3 times (AOR, ED LOS than those experiencing shift changes of nurses
4.25; CI, 1.74–10.42) more likely to have a prolonged stay during their stay in the ED (Table 4).
than a morning presentation, while night-time presentation
was 14.9 times (AOR, 14.93; CI, 4.22–52.63) more likely to Discussion
have prolonged stay than a morning presentation. The emergency department (ED) represents the “front
Furthermore, the odds of experiencing a prolonged stay at door” to the province of the health care system for many
the ED among those presenting during weekdays were 2.6 patients, which starts from entrance to the unit and does
times (AOR, 2.59; CI, 1.01–6.64) higher than those who not end until the patient is either discharged home,
presented at the weekend. The odds of experiencing admitted to hospital or transferred to another institution.
a prolonged stay at the ED among those having at least one The patient’s length of stay is a major indicator reflecting
diagnostic investigation were 4.5 times (AOR, 4.48; CI, 1.­ how well an ED is working, and the overall efficiency and
69–11.88) higher than those having no any diagnostic quality service of an ED.1,26 The level of emergency

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Dovepress Ahmed et al

department length of stay (ED LOS) is context-based and may not admit to inpatient or discharge patients during the
varies from country to country. The present study assessed night shift; night shift arrivals to ED need to wait until daytime
the level of patients’ length of stay at ED and associated to be admitted or discharged. Thus, this will increase the length
factors with prolonged stay at ED of JMC, southwest of of stay at the ED. In addition, expert consultation and diag­
Ethiopia. nostic or therapeutic modalities are less available at night
The median (IQR) ED length of stay was 4 (1.6–13.5) compared to during theday. This explanation may work for
hours, which is lower than the median LOS reported by an possible prolonged stay at ED among patients who presented at
international study done in Switzerland, France and the the weekend. However, in this study, those who presented
United States, which was 5.5 (5.1–5.6) hours,24 and about during the week were more likely to experience a prolonged
twofold lower than the finding of a study conducted in stay at the ED than those who presented at the weekend. This
Ontario, Canada, which was 7 (4–13) hours.3 The differences may be due to a relatively high proportion of patients visiting
may be attributed to differences in size of the study popula­ on weekdays at the weekend, which were in a five to one ratio.
tion, the high proportion of non-urgent cases observed in the Furthermore, the paradox may be due to the present study
present study, and the difference in health care system level design that involved small number of study subjects presented
of advancements. Usually non-urgent cases would stay at the over a short study period. Nevertheless, this discrepancy
ED for a shorter period of time, and unlike our emergency should be repeated by further studies, and probably further
medical care, a well-developed emergency medical system in prospective studies explaining the reason behind it will be
the western world, non-urgent patients would be exempted needed in the future.
from visiting the ED or traced out on arrival. Similar to our study finding, a study conducted at an
According to the findings of the present study, 38.4% academic hospital in the Netherlands28 revealed that
of patients experienced a prolonged stay in the ED, which patients with altered consciousness had a higher likelihood
was relatively lower than prior study conducted in of a prolonged stay at the ED. This might be due to the
Canada,3 Saudi Arabia,13 while higher than a study done complexity of the patient’s response with altered menta­
in Iran.21 This discrepancy may be due to the difference in tion to be managed within a short period of time.
study design; sample size, variation in presenting charac­ Unlike previous studies,23,29 a prolonged stay at tge ED
teristics of patient those visiting emergency department. was not associated with arrival by ambulance in this facil­
More than half of patients (61.6%) had an ED LOS of 6 ity-based study. This has implications for the interpretation
hours or less. This is consistent with the Canadian of previous studies, and also for the design of studies to
Association of Emergency Physician’s recommendation,4 further understand the relationship between level of ED
an internationally recognized performance indicator used LOS and mode of arrival to the ED. In accordance with the
to assess the quality of emergency care.5 finding of this study, the study conducted in the USA30,31
Patients from rural areas were about 3.0 times more and Canada23 revealed that the use of diagnostic tests and
likely to have a prolonged stay. In fact, those rural area advanced diagnostic imaging (computed tomography,
residents were traveling from increased distances with less magnetic resonance imaging) were found to be associated
access to fast transportation, pre-ED care during transpor­ with a prolonged ED length of stay.
tation and primary care facilities. Therefore, this delay in Similar to this study, a study conducted in Israel10 revealed
presentation may contribute to worsening of disease con­ that experience of nurses' shift change appears to be a major
ditions which in turn resulted in increased treatment dura­ factor that has significant influence on ED LOS. This could be
tion at hospital. Literatures indicating that pre-ED care due to miscommunication and lack of continuum-of-care
such as pre-hospital care given to the patients in emergent which may occur during hand over management. Similarly,
conditions at the scene and during transportation to hospi­ the result of a retrospective study conducted in the USA25
tal can affect treatment outcomes at the ED.27 showed increased LOS among patients experiencing a shift
The present study identified that patients who presented change of nurses during stay in the emergency department.
during the evening and night-time were more likely to have The strength of this study is that it was the first of its
a prolonged stay than those with a morning presentation. kind in the study area and provided information on ED
According to the findings of the study conducted in Canada,3 LOS and associated factors. Further, this study has used
ED arrival at night was more likely to have a prolonged stay at different data collection methods including respondent
ED. The possible explanation could be the fact that the hospital interviews, observation and document review to collect

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Open Access Emergency Medicine 2020:12 233
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Ahmed et al Dovepress

subjective and objective data related to patients across the approval of the version to be published, and agree to be
timeline from arrival to discharge. accountable for all aspects of the work.
However, some limitations need to be taken into account.
First, this one-month cross-sectional study which was per­
formed at a single academic institution may limit the ability
Funding
The source of fund for this research work is Research and
to apply the study conclusions to another hospital with
Postgraduate Director Office, Institute of Health, Jimma
a different patient population. Second, the study design cannot
University.
account for possible seasonal variations in disease incidence
and, hence, ED patient populations. Lastly, there were also
inconsistencies among different literature in the description of Disclosure
ED LOS which limits the ability to compare and appropriately The authors report no conflicts of interest in this work.
plan.1
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