As anyone who works in an ED knows, long wait times are not an ED-specific issue. Most of the time, long wait times in the ED aren't due to the numbers of patients being seen in the ED, but rather to the patients who have been admitted to the hospital through the ED and are waiting for a bed to become available, otherwise known as "patient boarding."
With more hospitals posting their low wait times on billboards and websites in an effort to draw in business, how can EDs without a lot of resources even compete?
Cambridge (MA) Health Alliance (CHA) was able to reduce its wait times while simultaneously treating more patients without adding any resources, says Assaad Sayah, MD, president of the medical staff and chief of emergency medicine. CHA is a single institution with three EDs. In 2005, its EDs treated 78,000 patients and went on diversion 8% of the time. Its wait time was almost two hours, and 5% of patients left without being seen.
"Last year we saw almost 100,000 patients; that is 25% growth. We have not gone on diversion for five years. Ninety-seven percent of our patients were in a room in less than five minutes from arrival, and 93% were seen by a provider within 12 minutes. Our left-without-being-seen rate is 0.4%," says Sayah.
The key, says Sayah, is to focus on the 95% of the time that the ED is adequately staffed and patient numbers are consistent. Then, the other 5% of the time, such as during disasters, flu season, or major accidents, the ED can better absorb the impact. "When the busload of injured patients empties, it is easier to manage than when the ED is already two hours behind."
EDs can help reduce their wait times by implementing the following steps.
1. Get support from higher-ups
When it comes to improving ED throughput, the first and most important step is to get buy-in from the institution. "Until hospital administration says everyone has a stake in this and wants to resolve it, it will never be fixed," says Sayah. "EDs are occupied by patients whose emergency care was finished 10 hours ago. Until that is solved, everything else is going to fail."
If hospital administration is reluctant to commit to improving ED throughput, the chief of the ED or the medical staff president can put the issue in perspective. If the hospital posted its ED times on a billboard or the Internet in comparison with other local hospitals, would it be proud? Would patients be more likely to go to a competitor because they would be treated sooner? The answer to this hypothetical scenario may be just what hospital administration needs to get on board.
2. Conduct a walkthrough
Once hospital administration has committed to improving ED throughput, administrative leaders should walk through the ED in the patients' shoes, says Harvey Castro, MD, emergency physician at Quest Care Partners in Dallas/Fort Worth. "You pretend you are a patient and walk through each step. Does it take a long time for a patient to sign in? Do patients have to jump through many hoops? Do x-rays come back right away or does it take 20 minutes?"
Castro notes that many hospitals have set up committees to look at every step and identify bottlenecks, and they are holding each department accountable.
3. Get leaders on the same page
For any throughput initiative to work, the leadership team within the ED, including physician leaders, nurse leaders, and administrative leaders, must be unified. "This is not something that one discipline can resolve," says Sayah.
At CHA, the leadership team is available 24 hours a day to provide the necessary resources when the ED has a need (e.g., a bus accident has caused a surge of patients in the ED). "Most of the time, the ED staff can manage, but when the bus shows up, the staff needs to know who to call and when," says Sayah.
4. Get ED staff on board
The best way to get buy-in from ED staff is to ask for their ideas. "The vast majority of the staff wants to improve the work environment. They don't want to keep apologizing to patients," says Sayah.
"There is a 360-degree theory that you should have everyone's input, even the clerk taking the insurance information. If you have people who are outsiders looking in, you might get better insight," says Castro. "Let's say the clerk notices that the doctors are not calling back within a reasonable time. That is input right there."
Tip: Create teams or committees and have them compete to come up with the idea that saves the most money, reduces wait time by at least 10 minutes, or improves patient satisfaction by two percentage points. Another option is to have employees submit ideas anonymously. "Sometimes it might be better to write down what you think and make it anonymous so you are not influenced by what others say," says Castro.
5. Trim the fat
When Sayal and the chief nursing officer at CHA began evaluating the patient experience from the moment the patient drove into the parking lot through discharge, they realized that each step involved several bottlenecks. They formed multidisciplinary teams and challenged them to eliminate 20% of the steps. In the end, they eliminated 40%.
"The teams met every week, the leadership of the teams met every other week, and every time there was an idea that made sense, we implemented it. We didn't wait for analysis paralysis to happen," says Sayal.
Some of the ideas include:
Putting the sickest patients closest to the staff area to eliminate the need for staff to walk down long hallways repeatedly.
Registering patients after they are given a bed. When a patient walks in, he or she meets with a "patient partner" who needs only three pieces of information to start the process: name, Social Security number or date of birth, and the reason for the ED visit. Within two minutes, the patient is in a room, and the rest of the information, such as insurance coverage, is collected after the patient has been seen and is waiting for test results or to be admitted.
Speaking to patients in their own language. Each patient partner speaks at least three languages, ensuring there are no communication hiccups that may cause a delay in care. At CHA, 42% of patients who visit the ED do not speak English. Of that 42%, the majority speak either Portuguese, Spanish, or Haitian Creole.
Castro notes that some EDs have created "point markers," tests that can be done in the ED instead of being sent off to the laboratory or radiology department. Some hospitals have even gone so far as to install CT scanners in the ED to save time.
6. Keep patients moving
Savvy hospitals are incorporating some of the Disney philosophies that involve keeping guests moving so that waiting hours in line doesn't feel so tedious. "If you were just standing in line, it would seem interminable, but if you were watching a movie or shaking hands with a puppet [like you would at a theme park], you feel like they know you are there and there is a process. It's the psychology of waiting: If you are with someone and doing something, the wait seems much less than if you are by yourself or not moving in any way," says Tracy Sanson, MD, FACEP, associate professor of emergency medicine at the University of South Florida (USF) in Miami.
To keep patients moving and feeling confident in the process of being treated at USF's ED, patients meet with a triage provider who determines what type of care can be started right away, such as x-rays or fluids. "It used to be that you were in a room and you stayed in that room, but we now have a results waiting room," says Sanson. Rather than taking up valuable real estate waiting for blood tests to come back, patients are shuttled to a room with a TV, coffee, and other amenities to keep them occupied while they wait.
In addition, patients who don't need to be in a bed, such as those with a foot injury, might be seen and treated in a chair rather than waiting for an ED bed to become available. "We started to creatively look at our horizontal and vertical patients. Some patients can stay vertical and move through in a more efficient manner," Sanson says.
7. Align incentives
Medical staff and administrative leaders must keep in mind that when asking anyone to change his or her work habits, the first question that person is going to ask is "What's in it for me?" Each institution must figure out a way to align incentives to help people change their work habits to improve throughput.
"Maybe it is financial rewards, work condition rewards, or celebrating successes," says Sayal. Ask employees which type of reward they would be happiest with; not everyone will agree to the same type of reward, so it's best to go with the majority.
Cutting ED wait times is certainly a formidable task, but it doesn't have to involve buying expensive equipment, hiring consultants, or expanding the ED's physical space. It requires ingenuity, hard work, and most of all commitment.
Sayal explains that CHA was previously ranked one of the lowest hospitals in the state with regard to patient satisfaction, but for the past two and a half years, it has ranked in the top quartile. "We have 14 unions and a very difficult patient population, so if we can do it, anyone can do it."
Should your hospital publicly post ED wait times?
More and more hospitals are advertising their ED wait times as a way to draw in business and compete with other hospitals, but is it a good idea? Like so many other questions in healthcare, the answer is "it depends."
According to a Miami Herald article, "Short ER wait times? Billboards tout hospitals' claims," advertising ED wait times is fairly new, and there is no way to guarantee patients will only wait 10 minutes, as the billboard or website promised.
Assaad Sayah, MD, president of the medical staff and chief of emergency medicine at Cambridge (MA) Health Alliance, says that patients have a right to know how long they will be waiting before they pull into the parking lot. "I don't call it advertising; I call it communication," he says.
However, the fear in advertising wait times is that patients will go to the hospital with the shortest wait time without considering whether the hospital can treat them appropriately. "I'd hate to see it come down to time only and not based on the ability of the hospital to take care of what you really need," says Tracy Sanson, MD, FACEP, associate professor of emergency medicine at the University of South Florida (USF) in Miami.
When posting ED wait times, hospitals need to keep in mind that patients may not be savvy enough to understand that if they are having a heart attack, they will be seen immediately; they won't have to wait. Patients may also not understand that if they walk into a stroke center's ED needing stitches on their fingers, they're not going to get the experience they bargained for.
According to Harvey Castro, MD, emergency physician at Quest Care Partners in Dallas/Fort Worth, hospitals measure wait times differently. One hospital may post the average wait time over the past two hours, while another posts the average wait time over the past two months.
To give patients the most accurate information, hospitals should clearly explain how wait times are measured, whether it is on a billboard or the Internet. Hospitals should also include a disclaimer that true emergencies are given precedence. "If someone is having a heart attack, I'd hate to think he drove across town to go to a hospital with the lowest wait time," says Castro.
Patients who contest that the hospital did not live up to the promise of a 10-minute wait are likely to sympathize when they are made to wait longer for a patient experiencing a life-threatening condition. "I'll go in the room and apologize for the wait, and most patients are understanding. Everyone's problem is an emergency to them, but it becomes relative when they see others around them," says Castro.
One of the reasons wait times have become so important is because so many individuals do not have access to primary care or must pay for their healthcare out of pocket. Thus, patients visit the ED instead of a primary care physician for ailments big and small. Whereas 50 years ago, patients were patients, now they are customers, and hospitals have to adjust.
Another reason ED wait times have become so important is that our society highly values convenience. Sanson explains that some patients who lack primary care may visit the ED for a long-standing problem, such as back pain, simply because they decide that today is the day they are going to take care of it, and they can't do it during normal business hours.
According to Sanson, the definition of "emergency" is becoming broad and often involves conditions that may not necessarily threaten an individual's health, but an individual's ability to work. "If I have a sick child today, and my doctor says he can't see my child for three days, which means I can't go to work and the kids can't go to school, I may go to the ED for something that is not life-threatening. Rather, it is threatening to my ability to remain employed," says Sanson.
Given the increasing importance patients place on ED wait times as a factor in their healthcare choices, hospitals should make an effort to post wait times, but with some disclaimers and an understanding that patients may complain if they are forced to wait longer than expected. USF does not post its wait times because it is a trauma center and critical patients often throw off the wait times. A community ED may have more consistent wait times and is therefore better able to advertise accurately.
One option for hospitals is www.healthcarewaittime.com, which allows any ED, physician, or hospital in the country to post wait times. "Right now you have to go to each hospital's website to see the wait times. If you are able to put them on one website, the consumer would have more choices," says Castro, the site's creator.