“That’s been the trend over the last 10 years, though it has really accelerated over the last couple of years for a number of reasons,” says Sujal Mandavia, MD, senior vice president of the west division at TeamHealth, a Knoxville, Tenn.-based outsourced physician services organization. In part, ED volume has grown because the physical number of EDs decreased significantly between the mid-1990s to mid-2000s, according to Dr. Mandavia. Meanwhile, the number of patients has only increased with the passage of the ACA, which provided greater access to health insurance but not necessarily primary care. About half of providers surveyed by the American College of Healthcare Executives said they saw a notable uptick in volume in the first months after the ACA took effect.
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“[EDs] are the safety net,” says Loretta Samaniego, MD, vice president of physician practice development at TeamHealth. “[EDs] are always there for patients that need us when they can’t get care with someone else.”
While healthcare’s safety net is expected to bear the growing patient demand, it has generally had to do so without adequate resources. More than 75 percent of physicians surveyed by the American College of Emergency Physicians felt their EDs were not prepared for increases in demand. Growing ED wait times indicate these physicians may have been right.
CDC data from 2011 indicated less than one third of patients — 27 percent — were seen in fewer than 15 minutes at EDs around the country, while the mean waiting time to see a provider was 48.9 minutes.
Not only do long wait times put patients at risk and foster dissatisfaction, but they are generally indicative of operational inefficiencies and are associated with significant costs. Fortunately, there are ways to improve processes and engage staff to improve capacity in EDs, even without expanded resources.
Repercussions of Long Wait Times on Staff and Patients
Long wait times negatively affect both the patient and staff experience. Most importantly, long wait times can be a serious threat to patients. “Research has shown in certain conditions, particularly emergent conditions, increased wait time can lead to poor outcomes,” Dr. Samaniego says.
Perhaps more commonly though, longer delays in care mean the patient experience will suffer greatly. Disgruntled patients who have waited a long time for care and don’t understand why start off on the wrong foot. “Patients are starting with a negative experience, and it’s really tough to pull them out of that by the end of the ED visit,” Dr. Mandavia says. It can also lead to lost revenue — patients who are tired of waiting will often leave and seek care somewhere else.
Unhappy patients lead to unhappy physicians and nurses and can even contribute to burnout. Long wait times create a challenging work environment as disgruntled and scared patients relay those anxieties onto caretakers. “We really all went into medicine to take care of patients. That’s our goal every day when we go into work. The frustration of wait times and not getting things done in a timely fashion defeats your purpose of providing the best possible care to the patient,” Dr. Samaniego says. This frustration can lead to burnout among physicians, nurses and other providers. And as Dr. Mandavia notes, “Unless you have great processes and strong team mentality to start with, it can erode teamwork.”
Factors That Drive Wait Times
While volume is the largest driver of wait times, ED capacity is on the other side of the equation. “The question is whether your ED has the capacity to meet the demands of volume on an hour-by-hour basis. That’s where things tend to break down — if there are not enough nurses, providers or beds at a given time, you will have waits,” Dr. Mandavia says. Leadership can create capacity by improving processes in the following areas.
- Door-to-bed time. The time it takes for a patient to come through the door of the ED until they are in a bed can still be decreased in most EDs, according to Dr. Samaniego. “We are looking at an average 20-minute door-to-bed time, and I think that’s just waste.”
- Throughput is the time from when a patient arrives in the ED to time the patient leaves the ED (either by discharge or admission to the hospital). “There are a lot of steps that slow that process down, and a lot of them are traditionally put on the shoulders of the hospital,” Dr. Samaniego says. A frequent issue that slows throughput is known as boarding — when a physician has decided to admit the patient to the hospital, but the hospital is running out of capacity and the patient must remain in the ED, often for several hours, taking up valuable space there.
If these two processes are backed up, the ED waiting room can fill and can even result in ambulance diversion. Patients who call 911 are usually in more urgent need of care than patients who can travel to the ED independently. When ambulances are diverted, they are taken to a hospital that is not only farther away, but also unlikely to be the hospital where they choose to get care on an ongoing basis.
“Doctors have to reinvent a lot of wheels. It makes more waste and it’s more disruptive to families, whose loved ones are a lot further away,” Dr. Mandavia says.
Economic and Noneconomic Costs
Traditionally, when hospitals look at EDs and try to calculate the cost of inefficiencies, they look at patients who left without treatment. These LWOTs are patients who come to the ED, but leave because the wait is too long. The costs associated with LWOTs can be characterized by what Dr. Mandavia calls the three R’s: risk walking out the door, reputation and revenue. Because these patients were sick enough to come to the ED in the first place, there is some risk associated with leaving before receiving treatment. However, LWOTs typically are still healthy enough to choose to leave, which presents a cost to reputation. “Those are the ones who go to the grocery store and tell their friends, ‘I went to general hospital for this and I got sick and left. Don’t go there,'” Dr. Mandavia says. Lastly, they often choose to seek care elsewhere, which represents revenue lost to the hospital initially visited.
However, Dr. Samaniego says EDs need to look beyond LWOTs. “It is a source of revenue loss, but really with the comparison to throughput value, LWOTs are minuscule,” Dr. Samaniego says. She gives the example of an average ED serving 30,000 patients annually. “If you can decrease length of stay by one hour, that could result in an additional 10,000 patients per year.. Even if you are only able to keep 50 percent of those patients — an additional 5,000 patients — in the average ED with a 15 percent admission rate, that translates into $2.7 million in additional revenue for the hospital,” she says.
While a one-hour decrease in length of stay may seem impossible, Dr. Samaniego suggests considering even a 15 minute decrease. By her calculation, that would result in $1.4 million of additional revenue. “EDs are operating on such a narrow margin. Every minute saved can have an incredible impact on hospitals,” she says.
The Solution
How can EDs and hospitals solve these issues? Dr. Mandavia advises going lean to reduce waste throughout the patient visit and tackle the low-hanging fruit first. He also says EDs should take a step back to make sure they have the right capacity.
“The capacity you have more control over is human capital. Do you have the right number of nurses, and are they there at the right time?” he says. “We often don’t have the ability to expand beds to overcome capacity issues in less than a couple of years, so this is not a practical solution.” Instead, leaders have to make functional capacity by reducing the amount of time patients spend in the bed. This can be done by examining opportunities to reduce wasteful processes, workarounds or redundancies during any part of the patient stay from the triage process to lab turnaround time.
Dr. Mandavia recommends seeking input from staff. “They see these problems every day. They live them, and sometimes they have the answer,” he says. Listening is critical to engage staff in solving long wait times. “I believe physician leaders play a really strong role in influencing and implementing solutions.”
Dr. Samaniego adds, “The best way for hospital leaders to engage staff is to involve them in the process, help them understand the problems, make them part of the team and have them be part of the solution — have them benefit from the solution.” In doing so, hospital leadership can help staff members feel as though they are part of the solution. Seeing patients more satisfied can be incredibly motivating.
“It’s not just getting buy in — it’s also having a benefit for each person that they can see and feel,” says Dr. Samaniego.
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