Ambulatory Care Quarterly

ED appointment-setting helps manage surges

One of the ways busy EDs are attempting to manage long wait times is by enabling patients who don't need immediate care to make an appointment to be seen in the ED one or two hours in advance.

Critics worry that this type of approach will only encourage patients to use the ED inappropriately for problems that should be seen in a primary care setting. However, hospitals using the approach counter that it is helping them to better manage volume. They also say patients usually are much more satisfied with their care when they don't have to sit in the waiting room for hours and don't know when they will be seen.

"What this allows us to do is if we see there are 10 or 20 patients who show up in the triage area, there is a way of essentially taking out all the available appointments for the next five or six hours or until we catch up," explains Robert Steele, MD, division chief for adult services in the ED at Loma Linda (CA) University Medical Center. "The beautiful thing about this is that for the first time in my life, we have some control over the patient surge."

Include safeguards

Loma Linda University Medical Center is one of more than 20 hospitals in eight states taking advantage of the online, appointment-setting service offered by InQuickER, a cloud-based, software-as-a-service vendor based in Nashville, TN. Most of these hospitals are charging a fee to patients to use the service, although Steele anticipates that his hospital eventually will drop the $25 fee that it currently charges.

Steele emphasizes that it was the ED physicians who wanted to make the service available, based on feedback they received from neighbors in the community and hospital employees. "We are the big tertiary care trauma center. People want to come see us. They feel we provide a very high quality level of service," he says. "But the problem is that they don't want to wait, and they also don't want to feel that they have been put into a waiting room that is filled with people they don't know and don't recognize. They feel uncomfortable in there, so we took those two variables out."

There are safeguards built into the process so medical problems that need immediate attention get picked up, explains Steele, noting that patients input information about their medical problem when they make their appointments online. "The triage nurse looks at that information, and there are actually times when [he or she] will call up the patient and say that based on the information provided, we think you should come in right away," says Steele. "Our ability to evaluate those patients is only as good as what the patients include, although I experience the same thing when I am face-to-face with a patient. If the patient doesn't give me the information that I need, it is difficult for me to make a good decision."

Sandra Schneider, MD, FACEP, president of the American College of Emergency Physicians and a professor in the Department of Emergency Medicine at the University of Rochester (NY) School of Medicine and Dentistry, has looked into the practice of appointment-setting in the ED, and believes that it can fulfill a need. "It has to be done right. We don't want patients being told to wait when they shouldn't wait," she says. "If a person has cut himself and needs a few stitches, that is one thing, but the person who is having chest pain shouldn't be waiting, so there is concern that this needs to be done well."


  • Sandra Schneider, MD, FACEP, President, American College of Emergency Physicians, and Professor, Department of Emergency Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY. Phone: (585) 275-8762.
  • Robert Steele, MD, Division Chief for Adult Services in the ED, Loma Linda University Medical Center, Loma Linda, CA. Phone: (909) 558-4344.
  • InQuickER — a cloud-based, software-as-a-service vendor based in Nashville, TN. Phone: (877) 221-7981. Web:

PACE aids work flow, frees ED for acute care

With surging demand for emergency care, many hospitals across the country are building larger EDs or expanding existing facilities to make room for more beds. Bucking this trend, however, is Virginia Mason Medical Center (VMMC) in Seattle. The health system has a brand new ED that opened its doors to patients in November 2011; however, at 17 beds, the new ED is actually smaller than the old department. But alongside the new facility is an 18-bed Patient Accelerated Care Environment (PACE), a brand new unit that is designed to help the ED and other areas of the hospital operate more efficiently while also connecting patients with the care they need quickly.

"We downsized our waiting room, as well as our bed capacity in the ED to be able to facilitate the care of just those acute patients who are coming into the ED," explains Sharon Mow, MSN, the ED director. Patients who need a few hours of care but do not require admission are quickly moved over to the PACE unit. Also destined for the PACE unit are patients who are in the process of being discharged, as well as the patients who are being prepared for admission. These patients are moved to the PACE unit so that evaluation and treatment can begin immediately before they are transferred to an inpatient bed, adds Mow.

Administrators came up with the concept for PACE when they observed that the needs of patients coming to the ED for care were changing. "Over the last 18 to 24 months, the acuity of patients has continued to rise, really eliminating the need for us to have a fast-track area," says Mow. Instead, what the health system needed was a place to deliver a higher level of care, which is what PACE is equipped to deliver, she says. "We are sending 35% to 40% of our patients over to the PACE unit over the course of the day," adds Mow.