40 Chapter 2 One solution to reduce the LOS of these patients at the ED could be a better collaboration between these specialties and the emergency physicians. Our ED is 24/7 staffed with emergency physicians and could assist the departments of surgery, internal medicine ad pulmonology in order to minimize LOS at the ED. These interventions may also facilitate increasing the capacity to treat more patients with the same resource allocations at ED’s and, therefore, improve the availability of quality care for older patients. Prevention of prolonged LOS is not a goal by itself; the group of older patients is vulnerable and susceptible for complications when assessment at the ED is incomplete. Physicians should always be aware of that a prolonged LOS may indicate that a higher level of expert care is needed. Limitations This study should be interpreted in light of its limitations. Since this is a retrospective study, we relied on accurate record keeping by ED workers. The LOS was calculated based on the registered values of time of arrival and time of departure. It could be that due to prioritizing clinical care over registration logistics, the actual time of arrival and departure may slightly differ from the times registered in the clinical records. Second, we included patients based on ascending patient identification number. Prior to inclusion, we consulted our IT-department to evaluate the attribution process of these numbers at our institution. The allotment is not based on chronology and can be considered random, but it is possible that our inclusion process may not have terminated the possibility of selection bias completely based on attribution algorithms of the hospital information system that are unknown to us. Third, a few risk factors for a prolonged LOS at the ED are logical (e.g. multiple consultations, multiple diagnostic interventions). These risk factors could partly be eliminated by performing only the most necessary consultations and diagnostic interventions at the ED. All other consultations and diagnostic interventions could be postponed to the ward. Also, when consultations and diagnostics are indicated to be performed at the ED, this could be done as soon as possible in an attempt to prevent prolonged LOS at the ED. We choose not to exclude these common-sense risk factors for prolonged LOS at the ED, because the intention of our study is to thoroughly examine all potential risk factors for a prolonged LOS at the ED. Fourth, as not all patients are primarily treated by emergency physicians, confounding by indication is an important limitation of this study. Finally, with regards to unplanned revisits to the ED, it could be that patients might have visited another ED and were therefore not registered as a revisit.
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