Dr. Thomas A. Sharon, R.N., M.P.H., D.N.P. is a published author, lecturer and internationally known expert in the prevention of medical errors, patient safety and nursing. He is an Evidence-Based Patient Safety and Outcomes Improvement Consultant.
Shortening Emergency Department Waiting Times through Evidenced-Based Practice
Emergency department (ED) waiting times have a serious impact on patient mortality, morbidity with readmission in less than 30 days, length of stay, and customer satisfaction. A review of the literature bears out the logical premise that since the outcome of treatment for all diseases and injuries is time-sensitive, the sooner treatment is rendered, the better the outcome. Guttmann, Schull, Vermeulen and Stukel (2011) reported a study of 13,934,542 patients seen in an emergency room in Ontario, Canada from 2003 to 2007 and treated and released. Length of stay in the E.R. was measured from time of entry to time of discharge. The mean length of stay ≥6 was compared to <1. Those with the long waiting times had a significantly higher risk of adverse events resulting in hospital admission or death than those with the shorter waiting times.
Carter, Pouch and Larson (2013) conducted a systematic reviewing screening 196 abstracts and finding 11 articles that met the inclusion criteria. Those studies reported significant associations between waiting times and higher mortality and morbidity among those who survived. These authors concluded that extended waiting times in the E.R. has a significant adverse impact on patient safety and outcomes.
Sun, Hsia, Weiss, Zingmond, Liang Han, et al. (2012) performed a retrospective cohort analysis of patients admitted in 2007 through the emergency departments of private acute care hospitals in California. The study included 995,379 ED visits resulting in admission to 187 hospitals. Patients with longer ED waiting times who were admitted had 5% increase risk of death, 0.8% increase of extended length of stay and 1% increased costs per admission. There were 300 in-patient deaths attributable to ED crowding and 6,200 additional hospital days at a cost of $17 million.
It is clear from the literature that untimely hospital deaths and morbidity can be reduced by reductions in ED waiting times. However, there are no standardized methods for accomplishing the task. The Ontario Emergency Room Wait Time Strategy, introduced by the Ministry of Health and Long-Term Care (2008) offered a guideline for reducing ED waiting times focused on efforts in the community to reduce demand for ED visits such as more in-home support for patients with chronic conditions, creating satellite urgent care centers, informing the public about the alternative urgent care centers. There was also a focus on efforts to institute changes within the ED such as making improvements in service efficiency.
When housekeepers play cards…
The standard hospital in the U.S. is like a small city with continuous movement of people in corridors like vehicles moving on streets. The ED is a gateway through which most of the indwellers enter the city. Therefore everything that happens on the upper floors that effects turnaround time can cause extended waiting in the ED. For example, I once had the task of finding ways to shorting waiting time in a New York City ED that was operating in disaster mode 24 hours per day, seven days per week. The paramedics were complaining to the Mayor’s office that they had to wait an average of 45 minutes for a nurse to receive the patient from the ambulance. In conducting my investigation, I found that the ED physicians were taking an average of four hours to render a diagnosis and decide whether to admit or discharge the patient and admitted patients were waiting four hours or more on the average for a bed to open up.
The four hour time lag between physician encounter and disposition was not hard to figure out. It was taking four hours for the lab to return test results in every case. The actual time it took to do each test series was less than ten minutes. There were four lab technicians doing the testing for the entire hospital and the ED. The first change was simply to dedicate one technician to do only ED requests and hire another person to work with the other three to handle the inpatient workload.
The waiting time for beds was another root cause of the ED chaos. I had to walk the floors to see what was holding up the bed turn-over process. The floor nurses were telling me that they had to wait 2-3 hours for housekeeping to arrive. It didn’t make sense. I went to the director of housekeeping and asked him if he was short staffed and he said no. So the two of us went snooping and found a group of housekeepers playing cards in the locker room and none of them were supposed to be on break. The director was flabbergasted. Needless to say, the card-playing crew members scattered and by the next day the bed turnover times averaged about 30 minutes so the average length of time for admitting patients waiting for a bed became less than 1 hour. This ED remained extremely busy being a level I trauma center, but we resolved the main problem of having ambulance gurneys line up like airplanes on the tarmac at a congested airport and the waiting room had fewer occupants on average. We decompressed a balloon that was about to explode.
In conclusion, ED waiting time is a vital component of quality of care and outcomes, since the urgent need for treatment is most often time-sensitive. There is a need to track waiting times and review the trends. The root causes for extended wait times with patients crowding into the waiting room are multiple and require investigation. So what may seem insurmountable, becomes resolvable when you bring in an evidence-based consultant to get it done.
You can contact Dr. Sharon here: nursetom at msn.com
Carter E. J., Pouch, S. M. & Larson, E. L. (2013). The relationship between emergency department crowding and patient outcomes: A systematic review.Journal of Nursing Scholarship 46(2), 106–115.
Guttmann, A., Schull, M. J., Vermeulen, M. J. & Stukel, T. A. (2011). Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. British Medical Journal, doi:http://dx.doi.org/10.1136/bmj.d2983
Ontario Ministry of Health and Long Term Care (2008). Ontario’s emergency room waiting time strategy. Obtained fromhttp://www.health.gov.on.ca/en/pro/programs/waittimes/edrs/strategy.aspx
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