Improving emergency department wait times
Improving emergency department wait times
Expert tips to help things move faster
If you have patients waiting for long periods of time in your emergency department, you better start thinking about ways to cut those times. The Centers for Medicare & Medicaid Services is requiring hospitals to report two measures related to ED wait times — median time (in minutes) from ED arrival to ED departure for patients admitted to the facility from the ED, and median time (in minutes) from admit decision time to time of departure from the ED for patients admitted to inpatient status.
Perhaps the most effective measure you can do is to put a provider in triage and make sure the patient sees him or her as soon as he or she walks in the door — before the patient fills out financial forms or gets settled in the waiting room, says John Shufeldt, MD, JD, MBA, FACEP, a principal at his eponymous consulting firm in Scottsdale, AZ, and an emergency physician at St. Joseph's Hospital in Phoenix. Half the people who show up in the ED probably do not need to be there, he says. "The ones who come in with the flu, we can see them in triage. If they need a prescription, you can take care of it right then," he says. The trick is keeping them vertical. "Once they are horizontal, friction and gravity take over."
For patients who do need further care, Shufeldt says that you can move them on in the process. Patients may wait hours after that initial contact with a provider, he says, but they do not feel as though they are waiting because someone has seen them. Door-to-doc times at the hospital are down from hours to minutes. "If someone waits 30 minutes, that's an outlier," he says.
Providers were surprisingly willing to do this — they were there anyway, they now have fewer patients to deal with, and many fewer patients are leaving without being seen, Shufeldt says. Where the percentage of patients who left without been seen was 5-6%, it sits well below 2% now. "Now, if there is a 10-minute wait out there, providers want to jump on it. Their mentality is changed."
Part of the open-mindedness among the providers was that they are paid based on productivity, not hourly. The pay change led to a little pushback, he says, "but they ended up liking it." Initially, the new situation was difficult. "The first week was hell. We wanted to change back to the old system. But within a month we hit our stride."
One unexpected consequence of a short waiting time is an increase in volume in the ED. "The word gets out that they have docs waiting to see you," Shufeldt says.
While the CMS reporting requirements may inspire many hospitals to work on ED wait times, there are plenty of other reasons to consider it. First and foremost, the ED is the front door to the hospital, he says. "It is the way the community sees you." So being efficient and not having hours-long waits for sick patients? It creates goodwill in the community.
This will not solve the entire wait time problem, says Shufeldt. If you have a lot of patients coming through your ED, you may end up with a bed problem for that 20% you want to admit. "You can know in a couple minutes that someone needs to go upstairs," Shufeldt says. "But you may have a four-hour wait for a bed."
The problem is what you do with those patients. If you do not keep something of a lid on those throughput issues, you could see the waits creeping back up in the lobby, no matter how efficient your triaging system is, he says. "We have parked patients in the halls to encourage nurses to find them beds, and we've even reserved beds with phantom patients. If we know there will be 40 or 50 patients admitted that day, who cares what the names are? We'll just reserve them in advance."
At University of California, San Francisco's (UCSF) Fresno facility, they have the same issues with waiting and boarding and throughput that every busy ED has, says Greg Hendey, MD, professor of clinical emergency medicine at UCSF Fresno. He thinks physicians are more amenable to implementing triaging systems in part because they help keep patients from getting angry at long waits. "Docs do not like angry patients," he says.
They have gone through several iterations of triaging in Fresno and struggle most with where to put them once you know you want to admit them. "The issue is less with the ones you can deal with right now or put in a chair. It is those 10 or 20 or 50 patients who need a bed right now," says Hendey. "If you do not find someplace to put them, the whole thing grinds to a halt."
Putting patients in hallways on the units is a current favorite tactic, Hendey says. "They have nicer hallways than we do."
One innovation they have tried is to do a minimal screening exam and then immediately refer appropriate patients out to an urgent care clinic or physician office. "We tell them we are over capacity and are only taking dire emergencies," Hendey says. It is not the most patient-friendly response, but sometimes it has to be done. They have one urgent care center across the street, and they are considering how to ensure that these patients they refer out actually have access to care in a timely manner. There is some talk of putting an urgent care center on site so that patients could simply be shifted to another room, perhaps seeing some of the same providers who staff the ED.
"We live in a drive-through culture where people do not want to wait to see their physician or do not want to give up a work day to make an appointment," says Hendey. "Even if they have insurance, sometimes they come here because it is more convenient for them." Meanwhile, the ED is required to see anyone, any time, and provide that basic health screening exam.
Physicians are under pressure to not miss something, and with all the bells and whistles available in the ED, there is the temptation to over-test. "You can't miss something, you can't make a delayed diagnosis — and it is more complicated than just defensive medicine," Hendey says. All of this adds to pressure on the ED, with more people coming in, more people waiting, and more being done to those who make it through even the most robust triaging.
So they keep trying new things, hoping something will work better — although Hendey says no one believes that there will ever be no wait in a typical urban emergency room. Next up in Fresno is a docket triaging system in which a physician will start preliminary orders and does a basic screening. Some patients will be referred out to the hospital's own or an affiliated urgent care clinic, others processed through. There is some loss in revenue associated with getting those patients to urgent care, where there is less payment, but also fewer requirements for documentation and staffing.
They also keep looking at places that have done really well, Hendey says — Arrowhead Regional Medical Center in the Los Angeles area is one that has made an art of evaluating patients at the door, and Santa Clara Valley Medical Center. "They are aggressive in getting people right at the door and putting them through a series of stations," he says. "And it has paid off."
Hendey is kind of happy that there is going to be this increased push to be more efficient. "They will want us to move patients faster, but I want that to happen anyway. And when we have regulations forcing us to make changes, the hospital becomes very interested in helping us make changes."
For more information on this topic contact:
- John Shufeldt, MD, JD, MBA, FACEP, Principal, Shufeldt Consulting, LLC, Scottsdale, AZ. Telephone: (480) 221-8059.
- Gregory W. Hendey, MD, Professor of Clinical Emergency Medicine, UCSF Fresno Medical Education Program, Fresno, CA. Email: [email protected].
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