# Key indicators contributing to prolonged emergency department stays in Saudi Arabia: a modified Delphi study

## TL;DR

This study identifies key factors causing long stays in Saudi emergency departments, focusing on inpatient boarding and overcrowding.

## Contribution

The study uses a modified Delphi approach to rank indicators of prolonged ED stays in Saudi Arabia, highlighting inpatient occupancy as a top contributor.

## Key findings

- Inpatient occupancy in the ED was the most important indicator of prolonged stays.
- ED nurses identified consult-to-disposition time and physician availability as significant factors.
- Female ED workers rated boarding patients and decision-to-disposition time as higher contributors.

## Abstract

A prolonged length of stay (LoS) in emergency departments (EDs) is a growing issue that affects patient prognosis, resource allocation, and operational efficiency. In Saudi Arabia, an ED stay exceeding 8 h is considered prolonged; however, few studies have identified the key elements contributing to this issue. This study aimed to determine and rank indicators associated with prolonged LoS in EDs based on the consensus of emergency medical practitioners in Riyadh, Saudi Arabia.

A two-round modified Delphi study was conducted from September 2024 to January 2025. Purposeful sampling included emergency physicians and nurses (129 in Round 1 and 137 in Round 2). Participants evaluated 34 potential indicators of prolonged ED stays using a Likert-scale questionnaire. Consensus was defined a priori, and the top 10 indicators were reassessed in Round 2. Statistical analysis using SPSS included medians and interquartile ranges (IQR), with significance set at p < 0.05.

A total of 129 and 137 participants completed Rounds 1 and 2, respectively. The most important indicator identified was the percentage of the ED occupied by inpatients. Other highly ranked indicators included the total ED patient count, average time in the ED for admitted patients, and the number of boarding patients. These indicators consistently showed high consensus, with a median (IQR) of 5 (1). Female ED workers rated inpatient occupancy, time between decision to disposition, and boarding patients as higher contributors to prolonged LoS (p < 0.03). ED nurses rated the average time in the ED for admitted patients, consult-to-disposition time, and physician availability as stronger indicators of prolonged LoS in the ED (p < 0.014).

Inpatient boarding, reflected by the percentage of the ED occupied by inpatients and the number of boarding patients, was the primary factor contributing to prolonged LoS in Saudi EDs. These findings emphasize that prolonged LoS in the ED is a hospital-wide challenge requiring coordinated action from healthcare administrators and policymakers to expedite inpatient discharges and optimize ED processes. Enhancing national programs such as Ada’a by incorporating these indicators into performance metrics may improve ED efficiency and patient care in Saudi Arabia.

The online version contains supplementary material available at 10.1186/s12873-025-01438-y.