There was no delay in waiting time to enter triage and there were no significant differences in median and mean waiting times to enter triage in the different priority patients. This was also true of total time spent in triage. This means that the first contact with the patient is well-managed.
As expected, high priority patients did not wait long to be called into area 1, with a median of 3 minutes waiting time (mean = 20 minutes). In comparison, priority 2 patients spent a median of 1 hour 59 minutes (mean = 2 hours 9 minutes) waiting to be called. Priority 3 patients however, spent a median of 1 hour 36 minutes waiting to enter the area (mean = 2 hours). As expected, priority 2 patients waited longer than priority 1 patients. However, they did not wait less than priority 3 patients in spite of the supposedly greater severity of condition. Similarly, priority 1 patients waited for much less (35 minutes median) than priority 2 or 3 patients (1 hour 42 minutes median, 1 hour 46 minutes median respectively) to be assessed by a casualty officer or nurse for the first time.
Patients were reviewed and re-reviewed by casualty officers and nurses on a regular basis, albeit with occasionally long intervals between such visits. Doctors and nurses dealt with many patients simultaneously, resulting in increased waiting times (tables 1, 2 and 3). As expected, the interaction times (where a casualty officer or nurse is assessing a patient) can be seen to decrease across the three priorities, with mean doctor interaction times varying from 20 minutes (mean 23 minutes) in area 1 to 8 minutes (mean 11 minutes) in area 3. Area 3 was manned by one doctor and one nurse, who saw successive patients as they were called into the area. Thus, no waiting time was required.
Patients requiring admittance when a senior doctor was not present in the emergency department (usually after 2 pm) had to wait for a specialist to come to the department when called. This procedure resulted in delays (table 4), with patients assessed by a senior staying for longer at the emergency department. The wait for specialist review was approximately one hour. Across all areas, imaging (X rays, CTs, and US) took approximately the same time, though it was noted that priority 2 patients wait on average 28 minutes more than priority 1 patients for a CT scan.
As was expected, patients are indeed spending a long time in the ED (tables 1, 2 and 3), and priority 2 and 3 patients spend half that time waiting to be called into their area. Priority 2 patients also spent more time in the ED department in the afternoon than in the morning.
Figures 1 and 2 provide evidence for the need of improvement: graphs showing the percentage of patients who failed to be seen within 1 hour or leave A&E within 4 hours (Figures 1 and 2). However, it would be difficult to attain these targets with the present levels of staff at the MDH ED. 30% of priority 1 and 86% of priority 2 patients waited for more than 1 hour for their first assessment (Figure 1). This might also indicate a failure in the triage system. The latter is not standardized/guided by protocols and very subjective, depending on the experience of nurses conducting triage. The criteria available are not used regularly, and this was noted to result in patients being subjectively moved up or down priorities, as different nurses may have different opinions about how urgent the patient's situation is.
Emergency cases requiring ambulances and resuscitation take up a significant number of staff and this may result in the slowing down of activity in the ED.
It was noted that a very large number of cases attending the ED could have been treated in the primary sector. This applies particularly to limb injuries that need to be X-rayed to exclude or confirm fractures, as evidenced by the large number of patients who presented with traumatic injuries and were referred from Health centres to get an X-ray. X-ray services are not always available in every Health Centre around Malta, since a 24 hour radiographer is not available, and such patients are referred from Health Centres to MDH ED, greatly increasing overall waiting times. A public campaign as to what constitutes an emergency was in place during the study period , but this did not seem sufficiently informative, with patients not needing emergency attention continuing to attend MDH ED in large numbers. In fact, although all health centres were closed on the 27th of August, this made no difference to the amount of people who presented at the Emergency Department when compared to the number of attendees on other days.