Study: Wait times continue to lengthen — Visits increase as EDs disappear

Some EDs cut wait times despite odds stacked against them

A new study published online by the journal Health Affairs had some sobering, though perhaps not surprising, news for ED managers. Between 1997 and 2004, waits increased 36% (from 22 to 30 minutes, on average) for the more than 90,000 ED patients whose records the researchers reviewed.1

The study, which analyzed the time between a patient's arrival in the ED and when they were first seen by a physician, used data from the National Center for Health Statistics. Even more alarming were the results for more seriously ill patients:

  • For those patients who a triage nurse classified as requiring immediate attention, waits increased by 40% (from 10 to 14 minutes).
  • For ED patients suffering heart attacks, there was a 150% increase: from eight minutes in 1997 to 20 minutes in 2004.
  • One-quarter of heart attack victims in 2004 waited 50 minutes or more before seeing a doctor.

During the time period of the study, the number of ED visits increased from 93.3 to 110.2 million. At the same time, the number of hospitals operating 24-hour EDs decreased by 12%, according to the American Hospital Association.

For ED staff and managers, these numbers should come as no surprise, says lead author Andrew P. Wilper, MD, who is a fellow in internal medicine at Harvard Medical School and affiliated with the Cambridge Health Alliance, both in Cambridge, MA. "It also confirms what many people who came to the ED as patients have seen," he says.

But why are waits increasing even more dramatically for the patients who most desperately need immediate attention? "The thinking is that it is probably related to the general overcrowding, although I want to add we don't prove causation," says Wilper. "Another important cause is the bottlenecks created by the lack of available inpatient beds."

As for what can be done about, says Wilper, "We need to get more resources in the ED," in terms of staffing and space. "But in addition, we have to see some change in the financial incentives hospitals receive for patients who come to the ED," he says.

In an observation all too familiar to ED managers, Wilper notes that patients who come to EDs are seen by administrations as relative money losers. "Without having to invoke base intentions, we see that the financial incentives are not there to expand EDs, and that's a big part of the problem," says Wilber.

Bucking the trend

Despite these undeniable trends, and despite the fact that many of the solutions offered by Wilper seem to be out of the hands of ED managers, there are EDs across the country that are bucking these trends and reducing their wait times.

"Our wait times have definitely come down in that [the study's] time frame," asserts Jeff Nickel, MD, FACEP, medical director of the ED and chairman of medicine for Parkview Hospital in Fort Wayne, IN, which sees more than 60,000 ED patients a year.

"We have created a chest pain policy that focuses not only on getting these patients back as quickly as possible — if not immediately — but on frontloading the entire work force."

It is his ED's policy that when a patient presents with chest pain, they go immediately to a bed, he says. When they get to the bed, an EKG is ordered by protocol, which, says Nickel, brings down their door-to-data time. The results are brought immediately to a physician. [A copy of the protocol is available.]

If the EKG shows an acute myocardial infarction (MI), "the doc goes in right away, and a page goes out simultaneously to everyone on the 'MI activate' team," says Nickel. That team includes anyone who might possibly be involved in the patient's care: representatives from the main lab, the cath lab, and radiology, as well as the chaplain and the critical care unit (CCU) charge nurse. "We get the cardiologist at the bedside within 10 minutes of arrival," says Nickel. "The nurses will even prep the patient, shaving the groin, and so forth. These little things eliminate the time it takes to get them ready for catheterization."

To reduce door-to-doc times for any condition, says Nickel, "You have to have everyone involved — from pre-hospital providers to anyone who would be in contact with the patient during their stay — to come up with the protocol. It's amazing what you can do when you all get together to make some improvement." If, as an ED manager, you try to do something like this as an isolated department, he adds, you never will be successful.

At Southeastern Ohio Regional Medical Center in Cambridge, as soon as an EKG from an ED chest pain patient is printed, "Typically, they bring it to us right away and stick it in our face," says Eric Fete, DO, the ED medical director.

It was not always like this, he emphasizes. "We fine-tuned our process last year," he says. "Before, the EKGs stacked up on the desk, but we decided to have the lab give it personally to the doc — or at least tell us the results were in — and we've been pretty consistent."

Door-to-doc times at the ED, which sees about 34,000 patients a year, average just more than half an hour for all patients. In terms of chest pain patients, however, "we pretty much have a policy that the EKG is done [immediately] and they get to the doc in five minutes — and we meet that," says Fete.

The chest pain protocol dictates that if a patient coming into the ED has a chief complaint of chest pain, he or she is brought right back for treatment — not triaged "That's how it should be," he says. "We mainly look for heart attacks, angina, and so forth. It's tailored to acute coronary syndrome."

One of the most important components of improving patient flow is the culture change of moving patients speedily, Fete says. "You really want to get patients back as quickly as you can and get everyone involved," he says. "It's a team culture kind of thing, and that's harder to do than other changes."

Since many of the flow problems faced by EDs are really centered in other parts of the hospital, it's often necessary to win the support of other department heads and even the hospital board to get the necessary changes in place. For John Reid, MD, chairman of emergency services at Cape Fear Valley Medical Center in Fayetteville, NC, that involved convincing his board to invest $2.6 million in an outside consulting firm.

"One of the 'Aha' moments came when I was trying to convince the CEO our problem had to do with bed availability upstairs, like finding beds that were really available but were not reported as such," Reid recalls. "The CEO decided to visit the ED for four days in a row. He actually marched the floors and found available beds that had not been reported, so he realized it was not just an ED problem."

To sell the idea to the rest of the hospital administration and board, Reid showed them that improving the process was in their own best interests. "The reputation of the ED had been pretty bad, and everyone in town had a story about the ED," says Reid, who realized that the hospital board members were also local politicians.

"The board was made up of county commissioners," he explains. "I told them that to change the image of the ED in the eyes of the community would be a win for them as politicians as well as a win for the public."

Reference

  1. Wilper AP, Woolhandler S, Lasser KE, et al. Waits to see an emergency department physician: U.S. trends and predictors, 1997-2004. Health Affairs. Doi: 10.1377/hlthaff.27.2.w84. Published online Jan. 15, 2008. Accessed at content.healthaffairs.org.

Sources

For more information on reducing wait times, contact:

  • Eric Fete, RN, BSN, DO, Medical Director, Emergency Department, Southeastern Ohio Regional Medical Center, Cambridge, OH. E-mail: EFete@emp.com.
  • Jeff Nickel, MD, FACEP, Medical Director, Emergency Department, Parkview Hospital, Fort Wayne, IN. E-mail: JRNickMD@aol.com.
  • John Reid, Chairman of Emergency Services, Cape Fear Valley Medical Center, Fayetteville, NC. Phone: (910) 609-4000.
  • Andrew P. Wilper, MD, Fellow, Internal Medicine, Harvard Medical School, Cambridge, MA. Phone: (503) 260-4948.