Background: Emergency department (ED) overcrowding is a persistent global health issue associated with adverse patient outcomes, diminished staff performance, and compromised health-system efficiency. Despite widespread recognition of the problem, there is no universally accepted approach to monitoring ED overcrowding. The use of disparate, nonstandardized indicators hampers cross-country comparison and the development of effective policies. A comprehensive synthesis of indicators currently used is essential to guide the adoption of robust, evidence-based metrics across diverse health care settings. Objective: This study aims to identify, consolidate, and categorize indicators that have been used internationally to assess ED overcrowding and to highlight gaps in their use. Methods: A comprehensive scoping review was conducted from October to November 2023 using four databases: PubMed, Scopus, Emerald Insight, and Google Scholar. Studies were systematically searched using predefined eligibility criteria. Level 1 and 2 screening were independently conducted by 9 researchers (NNMN, KASIP, NFS, NJN, MK, ZL, NNRA, LKY, and ISS) to minimize bias and enhance reliability, and discrepancies were resolved by consensus. A third reviewer (ISS) performed a full-text review, synthesis, and descriptive analysis. Indicators were categorized into input, throughput, and output. Input refers to factors driving ED demand, throughput encompasses internal ED processes such as triage, diagnostics, and treatment, and output addresses challenges in transferring patients to inpatient beds, such as bed shortages or delays. Descriptive analyses were then used to consolidate these indicators and to establish their relative importance. They were ranked based on frequency of reporting across diverse countries and health care settings. Results: Out of 1347 articles screened, 117 articles were included in the study. A total of 307 indicators were retrieved and then consolidated into 26 distinct indicators. The majority of indicators were classified within the throughput domain (209/307, 68%), followed by the output domain (62/307, 20%) and the input domain (36/307, 12%). The most common throughput indicator, which was frequently reported, was ED length of stay, cited 87 times, followed by left without being seen and waiting time, each reported 30 times. Length of stay consistently emerged as a primary marker of systemic bottlenecks and operational inefficiencies across health care systems. Conclusions: This review indicates that throughput measures, particularly length of stay, dominate current approaches to assessing ED overcrowding, whereas input and output indicators remain comparatively underrepresented. By consolidating 26 distinct indicators from 117 studies, this study provides a comprehensive evidence base to support the standardization of metrics for monitoring ED overcrowding internationally. These findings offer practical guidance for policymakers and health care leaders seeking to refine performance indicators, enhance benchmarking, and evaluate interventions aimed at improving patient flow. Further research should prioritize validation of underused indicators and the development of composite measures that better capture the complexity of ED crowding across diverse health care settings.

Introduction: Diabetes educators (DEs) play a critical role in supporting self-management and improving clinical outcomes among people with diabetes. However, their roles within primary healthcare settings in Malaysia remain underexplored, particularly with respect to time allocation for diabetes care and the challenges they face. Methods: A mixed-methods cross-sectional study was conducted in two phases from January 2022 until August 2023. Phase 1 involved a time‒motion study of 51 DEs across 43 public primary care clinics in Negeri Sembilan, which were observed over five working days to quantify the time spent across different activity domains. Phase 2 consisted of three in-depth interviews and five focus group discussions with 27 purposively sampled DEs. The quantitative data were analysed via descriptive statistics, whereas thematic analysis was applied to the qualitative transcripts. Results: Five domains of DE activities were identified: diabetes care, non-diabetes care, administrative, supportive, and personal. DEs spent most of their time on diabetes care (63.3%), but two-thirds of this was indirect care, especially documentation. Non-diabetes responsibilities consumed approximately 26.5% of their time. The qualitative findings revealed three overarching themes influencing DE roles: organisational, patient-related, and personal factors. A central theme of resilience emerged, reflecting DEs’ coping strategies amid multiple roles demands, documentation burdens, and systemic constraints. Conclusions: This study provides new insights on how DEs allocate their time and challenges to Malaysia’s primary health clinics. Although they were able to dedicate substantial time to diabetes care, their effectiveness appeared to be hindered by administrative burden and role conflict. Targeted interventions are needed to streamline workflows, reduce documentation burdens by integrating information system, enhance leaders’ engagement in diabetes care, and clarify DE roles to strengthen diabetes care services in PHCs.

Background This study develops a comprehensive taxonomy of Diabetes Educators' (DEs) activities in Malaysian primary health clinics (PHCs) to analyze the "blurring" of professional boundaries between specialized education and general clinical duties. Methods A sequential mixed-methods design was used. Phase 1 defined role expectations through document analysis and expert interviews. Phase 2 validated activities through five-day direct observations of 51 DEs across 43 clinics. Each trained observer monitored a same DE for five consecutive working days. All DE activities, including clinical duties, administrative tasks, and other related activities (discussions, meetings, community outreach), were recorded. Findings are based on frequency rather than time-weighted workload. Results The taxonomy identifies 146 activities across five domains. While 56.85% are patient-centric, results reveal significant role dilution, with 32.19% of activities dedicated to non-diabetes care. Activities were further classified into Core Specialized, Routine Clinical, and Clerical/Delegable categories, revealing significant systemic task-shifting, ‘Clerical/Delegable’ (39.04%) highlights a heavy clerical burden. This research captures the empirical operational reality of DEs, providing evidence of systemic task-shifting in high-volume settings. Conclusions The taxonomy clarifies the role of DEs by delineating "Core Specialized" from "Clerical/Delegable" tasks. This framework provides an essential evidence-based tool for Family Medicine Specialists to optimize human resource distribution, mitigate role dilution, and improve care quality in high-volume PHC settings.

BACKGROUND Emergency department (ED) overcrowding is a significant global challenge with profound implications for patient outcomes, healthcare delivery, and public health. Addressing this issue requires comprehensive monitoring of patient flow, supported by a well-structured system of performance indicators. Identifying the root causes of overcrowding is crucial for developing targeted, evidence-based indicators to guide national policies. Hence, this study was conducted to systematically review the indicators used across different countries to measure ED overcrowding, aiming to inform strategies for improving ED capacity management and optimizing patient care. OBJECTIVE The primary objective of this study is to systematically identify and outline the indicators used to evaluate ED overcrowding across a range of hospital settings globally. METHODS A scoping review was conducted from October to November 2023. The selected articles were based on predefined criteria. The inclusion criteria require the articles reported in English and related to the keywords, published between 2013 and 2023, and include any study design (qualitative or quantitative). The databases used were PubMed, Emerald Insight, Google Scholar, and Scopus. The identified indicators were descriptively categorised according to input, throughput and output components based on the ED crowding model framework by Asplin et al. 2003 and summarised based on the indicators ranked from frequently used to the least. RESULTS Out of 1,347 articles screened, 117 articles were included in the study. A total of 314 indicators were retrieved and then consolidated into 26 distinct indicators. The majority (68.8%) fall within the throughput component, followed by 19.7% in the output component, while the input component accounts for the smallest proportion at 11.5%. CONCLUSIONS This study highlights that throughput indicators were more prominently studied as key metrics in measuring ED overcrowding. The most frequently utilised throughput (TP) indicator is the ED length of stay, followed by waiting time and the rate of patients leaving without being seen. The review further demonstrates that length of stay (LOS) serves as a critical marker of systemic bottlenecks and operational inefficiencies within EDs. The findings provide valuable insights for policymakers to refine and strengthen existing indicators, helping to address and mitigate the issue of ED overcrowding.

Public health activities under district health offices (DHOs) play a major role in Malaysia’s fight against COVID-19. This article aims to describe and illustrate the public health activity pathway in combating the COVID-19 pandemic, and a team of public health workers who are familiar with DHO work settings was created in April 2020 for that purpose. Review of documents and the Ministry of Health’s updates was carried out, followed by a series of discussions with stakeholders. Based on the steps in the outbreak investigation tasks, the flow of activities from January to May 2020 was listed in line with the phases of the country’s National Movement Control Order 2020. Results show that the activities can be classified into three different sections—namely, the main action areas, category of cases, and level of care. The main process flow of activities comprised the case management and support activities. Case management flow was split into tasks for patients under investigation and persons under surveillance, while the support services existed throughout the phases. The pathways illustrate that the progression of the pandemic translated directly to changes in the pattern of activities, with additional subgroups of activities in accordance with all imposed guidelines.