How can you keep average wait less than 1 hour? VHA shares its strategies

Triage nurses greet ED patients at door and send patients directly to beds

If the average waiting time in your ED is more than an hour, maybe you could learn a thing or two from ED managers who report that their patients wait less than 60 minutes for treatment. Key strategies, they say, are to optimize the usefulness of your triage nurse and to pounce on the patients as soon as they step in the ED by assigning an account number — which facilitates ordering labs, X-rays, and patient records — almost before you know anything about their complaint.

VHA, a nationwide network of community-owned health care systems and their physicians based in Irving, TX, reports that its EDs across the country have an average waiting time for a patient to see a physician of between 30 minutes and one hour, measured from the time the patient first walks in until a physician conducts an assessment.

That time is good compared to what most EDs experience, but the network still is trying to shorten the wait, says Jeanne McGrayne, RN, MSN, director of emergency department consulting for VHA. McGrayne is the primary VHA leader responsible for improving ED efficiency and reducing wait times. VHA is a for-profit cooperative with more than 2,200 member facilities nationwide, making it one of the largest health care organizations in the country.

High demand is part of the problem, but the ED managers report the biggest cause of wait time is that the hospital doesn’t have enough beds available when they need to move patients out. The limited ability to quickly move patients from the ED to acute and critical care beds creates a bottleneck in the ED, according to VHA’s annual surveys of its ED managers.

The ED managers also cited uninsured patients using the ED for primary care and the closing of other area emergency departments as significant reasons for overcrowding.

The VHA findings mirror national trends, such as those in the results of a national survey released in October 2003 by the American College of Emergency Physicians in Washington, DC. (For those survey results, go to

"The [VHA] survey results show that issues such as inpatient bed capacity and patient volume are affecting emergency departments’ ability to deliver care, in spite of the staff members’ dedicated efforts," McGrayne says. "Hospitals need to address issues that affect the organization as a whole to truly improve the delivery of care in the ED."

Triage nurses can be crucial link

More than half of the survey respondents said the average waiting time for patients to see a physician was between 30 minutes and one hour, but 65% said their hospitals never turn ambulances away due to not having room in their EDs. (For other survey findings, see box, below.)

VHA Nationwide ED Survey Results
  • Patient violence is the greatest threat to ED personnel for the third straight year. Hepatitis ranked second, followed by HIV.
  • 46% said that their hospitals were planning to expand their EDs within the next 12 months.
  • 41% said that uncompensated care provided by their hospital increased during the past year.
  • 67% of EDs have made special accommodations to handle and treat obese patients.
Source: VHA, Irving, TX.

McGrayne says VHA EDs are reporting better waiting times as a result of several strategies employed throughout the system in recent years. One of the most important involves using triage nurses more effectively. Based on her own work with VHA hospitals and other facilities, McGrayne estimates that at least half of all EDs could greatly improve how the triage nurse is used to improve patient flow.

The key, she says, is for the triage nurse to be more proactive, to actively seek out the patient at the door rather than waiting for him or her to come to the triage desk, and then to do everything possible to get the patient in a bed instead of the waiting area.

Also, most EDs do not assign an account number fast enough, McGrayne points out, so she advocates having the triage nurse handle that task when possible.

"We’re trying to make the triage nurse become more of a greeter, the first person to see the patient," she says. "That’s opposed to the registration staff taking 20 minutes with them and then sending them to the waiting room."

Exactly how the triage nurse works may vary from one ED to the next, dependent largely on the annual volume of patients, McGrayne adds.

With 30,000 annual visits and less, triage nurses should take a more active role in greeting patients and probably can do the job on their own, she continues. Beyond that, the triage nurse can greet some patients at the door but will need another greeter to help with collecting basic information.

"That way, if you have a line of people out the door, the triage nurse can go right to the person with chest pain while the greeter continues with the next person in line," McGrayne says.

"If you consistently have a backup of patients, you may need two triage nurses out there greeting people at the door," she says.

The first person patients see

One hospital that has had success in using a greeter and assigning case numbers right away is FirstHealth Moore Regional Hospital in Pinehurst, NC, which has about 50,000 annual visits. The hospital is not a VHA affiliate, but McGrayne still cites it as a good example of the strategies employed at her own hospitals.

"When the patients come through door, the meeter/ greeter is the first person they see, and they use an electronic documentation system," says Dotty Kuell, RN, BSN, CEN, assistant director of emergency services at FirstHealth Moore.

Kuell enters patients into the system, and then the triage nurse triages them, she explains. They use extra triage nurses if they see more than three triage patients waiting, Kuell says. "If we have open beds, they go directly into an open bed instead of staying at triage," she says.

Unfortunately, there usually are no open beds after 10 a.m., so Kuell says that strategy works well only at the beginning of the day.

The hospital’s wait times have improved in recent years. In addition to use of greeters and assigning case numbers quickly, Kuell’s ED employs an extended care area and other strategies to keep patients moving, she adds.

"We have a 10-bed extended care area we included when we built our new ED three years ago," Kuell notes.

"We have a hospitalist program, and as soon as the patient is admitted, they can go to the extended care area and wait for the hospitalist there. They can get orders done and the initial work-up started," she says.

5 minutes to call ED when bed is open

FirstHealth Moore Regional also has a bed availability committee made up of representatives from the ED and inpatient units. The committee meets to try to iron out any problems in the ED-to-inpatient transfer. Originally it met monthly, but now, after seeing some improvement, it meets quarterly.

The hospital also has established a policy that ensures beds are not left open only because staff are slow in letting the ED know a patient can be sent, Kuell says. From the time a bed number is assigned to take ED patients, the staff on the inpatient unit has five minutes to call the ED for a status report.

Then the ED has 25 minutes to get a patient upstairs to that bed.

"That has helped a lot because now everyone watches their times and works hard to make that happen," she points out. "We track the times, and if there is a trend with missing those cutoffs, we go to those people and find out why. There is accountability built into the whole thing."

The hospital also hosts a meeting each morning for the ED charge nurse and representatives from admissions, recovery, the cath lab, and many other areas involved with patient flow and beds. The attendees discuss what they expect for the day in terms of discharges, admissions, and other concerns.

"A lot of people do that or something similar, but we think it’s important to do this face to face and regularly. A phone call or e-mail just isn’t the same," Kuell explains.

"Meeting every morning builds trust and relationships among individuals so that it’s a little easier when I have to call you and ask for help,"she adds.


For more information on reducing ED wait times, contact:

  • Dotty Kuell, RN, BSN, CEN, Assistant Director of Emergency Services, FirstHealth Moore Regional Hospital, 155 Memorial Drive, Pinehurst, NC 28374. Phone: (910) 215-1118.
  • Jeanne McGrayne, RN, MSN, Director of Emergency Department Consulting, VHA, 220 E. Las Colinas Blvd., Irving, TX 75039-5500. Phone: (972) 830-0000.