The practice of emergency medicine/original researchUS Emergency Department Performance on Wait Time and Length of Visit
Introduction
Emergency department (ED) crowding in the United States has become so severe that the Institute of Medicine calls it a “national epidemic.”1 Across the nation, an ambulance is diverted away from a crowded ED approximately once every minute.1 Patients who do arrive in the ED have faced increasingly long average wait times and ED visit lengths over the past decade.2, 3 Most important, these increases have been most pronounced for patients with the most acute illnesses.2, 3, 4 In 2006, the average wait time for emergent patients to be treated by an ED provider was 37 minutes, well above the recommended maximum of 15 minutes.4
Prolonged ED wait time and length of visit reduce quality of care and increase adverse events for patients with serious illnesses.5, 6, 7, 8, 9 For example, patients presenting with non-ST-elevation myocardial infarction who have an ED stay of more than 8 hours are more likely to have recurrent inhospital myocardial infarction than patients with an average ED stay.8 Prolonged wait time and length of visit also decrease patient satisfaction10, 11, 12 and increase the number of patients who leave before being seen.13, 14 Therefore, ED wait time and length of visit are important measures of the timeliness, efficiency, safety, and patient-centeredness of emergency care.
Several studies have examined wait time and visit length across the nation in aggregate,2, 3, 15, 16 including a recent comprehensive report from the Government Accountability Office.4 However, none of these studies examined hospital-level variability. The Government Accountability Office report argues that hospital-level conditions such as the availability of inpatient beds are the most important determinants of crowding and delayed care.4 Consequently, from a policy and quality improvement perspective, it is most appropriate to consider these metrics from a hospital rather than patient viewpoint.
The National Quality Forum recently endorsed 10 voluntary consensus standards for emergency care quality, including measures of ED wait time, visit length for admitted patients, and visit length for discharged patients.17 If widely adopted, these measures would be reported at the hospital level. While one study has examined hospital-level performance on visit length for black patients,16 there have been no studies of variation in hospital-level performance on these metrics for all patients. National data on hospital-level performance, which would allow EDs to benchmark themselves against peers and distinguish targets for improvement, are needed.18 Accordingly, we sought to characterize the variation in ED performance in wait times and visit lengths nationally, using data from 2006 National Hospital Ambulatory Medical Care Survey (NHAMCS).
Section snippets
Theoretical Model of the Problem
The central tenet of quality improvement is that “quality is a system property.”19 ED wait time and length of visit have been observed to differ systematically according to race, ethnicity, site of care, and a variety of other immutable patient-level factors.2, 15, 16 Using instead the quality improvement model, we examine ED wait time and length of visit at the system (hospital) level. Describing hospital-level rather than patient-level performance allows for benchmarking, characterization of
Characteristics of Study Subjects
The 2006 NHAMCS data set comprised data about 35,849 patient visits at 364 EDs, weighted to represent 119,191,528 visits to 4,654 EDs. The wait time analysis included 24,889 patient visits to 354 EDs; the length of visit analyses included 33,339 patient visits to 363 EDs. Descriptive statistics for the sample of patients and hospitals are shown in Table 1.
Main Results
Median ED wait times are shown in Table 2. Among acutely ill (emergent and urgent) patients, the median ED wait time was 27.5 minutes, with
Limitations
Our study has some limitations. Data are abstracted from charts by each hospital and may not reflect actual practice, particularly for patients needing the most urgent treatment, who might be examined first and documented later. Between 7% and 31% of the sample was excluded from various analyses because triage assessment or outcome data were missing. However, these visits did not differ systematically from included visits. Triage assessment reliability has been reported to be fair to excellent,
Discussion
In this study, we found that hospital EDs perform fairly poorly in seeing acutely ill patients within the time recommended by the triage nurse and in keeping ED visits for admitted patients within 4 or 6 hours. Less than one fifth of EDs were able to treat at least 90% of their emergent or urgent patients (those triaged to be treated in an hour or less) within an hour; only half kept the ED visit shorter than 6 hours for at least 90% of their admitted patients.
Performance was not only deficient
References (59)
- et al.
Prolonged emergency department stays of non-ST-segment-elevation myocardial infarction patients are associated with worse adherence to the American College of Cardiology/American Heart Association guidelines for management and increased adverse events
Ann Emerg Med
(2007) - et al.
Rapid process redesign in a university-based emergency department: decreasing waiting time intervals and improving patient satisfaction
Ann Emerg Med
(2002) - et al.
Does reduced length of stay decrease the number of emergency department patients who leave without seeing a physician?
J Emerg Med
(1997) - et al.
Factors associated with longer ED lengths of stay
Am J Emerg Med
(2007) - et al.
Does sharing process differences reduce patient length of stay in the emergency department?
Ann Emerg Med
(2001) - et al.
Triage: limitations in predicting need for emergent care and hospital admission
Ann Emerg Med
(1996) - et al.
Five-level triage: a report from the ACEP/ENA Five-level Triage Task Force
J Emerg Nurs
(2005) - et al.
A conceptual model of emergency department crowding
Ann Emerg Med
(2003) - et al.
The effect of in-room registration on emergency department length of stay
Ann Emerg Med
(2005) - et al.
Effect of rotational patient assignment on emergency department length of stay
J Emerg Med
(1996)
Point-of-care testing reduces length of stay in emergency department chest pain patients
Ann Emerg Med
Medical student effect on emergency department length of stay
Ann Emerg Med
Intervention to decrease emergency department crowding: does it have an effect on return visits and hospital readmissions?
Ann Emerg Med
Data-driven quality improvement in the emergency department at a level one trauma and tertiary care hospital
J Emerg Med
Time series analysis of variables associated with daily mean emergency department length of stay
Ann Emerg Med
Hospital-Based Emergency Care: At the Breaking Point
Waits to see an emergency department physician: US trends and predictors, 1997-2004
Health Aff (Millwood)
Increasing length of stay among adult visits to US emergency departments, 2001-2005
Acad Emerg Med
Emergency department length of stay independently predicts excess inpatient length of stay
Med J Aust
The association between emergency department crowding and hospital performance on antibiotic timing for pneumonia and percutaneous intervention for myocardial infarction
Acad Emerg Med
The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments
Med J Aust
Is a prolonged stay in the emergency department associated with adverse events in older patients?
Acad Emerg Med
Evaluation of a fast track unit: alignment of resources and demand results in improved satisfaction and decreased length of stay for emergency department patients
Qual Manag Health Care
Patient satisfaction in emergency medicine
Emerg Med J
Patients who leave the pediatric emergency department without being seen: a case-control study
CMAJ
Racial disparities in emergency department length of stay for admitted patients in the United States
Acad Emerg Med
National voluntary consensus standards for emergency care
Crossing the Quality Chasm: A New Health System for the 21st Century
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Supervising editor: Robert L. Wears, MD, MS
Author contributions: LIH, JG, and EHB conceived and designed the study. LIH and JG obtained the data. LIH, JG, and EHB analyzed and interpreted the data. LIH drafted the article, and all authors contributed substantially to its revision. LIH and JG conducted the statistical analysis. LIH takes responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. This publication was made possible by the Clinical and Translational Science Award grant UL1 RR024139 and KL2 RR024138 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH), and NIH roadmap for Medical Research. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the NCRR or NIH. Dr. Horwitz is supported by Yale-New Haven Hospital and by the NCRR. No funding source had any role in the design and conduct of the study; collection, management, analysis and interpretation of the data; or preparation, review, and approval of the article.
Publication date: Available online September 30, 2009.
Reprints not available from the authors.