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

Introduction: 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. Methods: 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. Results: 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. Discussion: 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.