Advertising emergency department wait times has become popular for U.S. hospitals. This is often promoted on billboards but can also be available on apps and hospital websites. Although some say this helps to drive traffic to the ED, others argue it has safety risks as patients may decide to chose a hospital further away to avoid waiting when they need immediate care, what many call “self-triaging.”
Long wait times can affect patient outcomes. Patients may get tired of waiting and leave without treatment, or “wait dangerously long for care,” when EDs are overcrowded. In 2009, the national average time of an ED visit was 4 hours and 7 minutes.
“There’s not an ED in the country that doesn’t monitor its wait times and tries everything under the sun to get them down,” Dr. Alfred Sacchetti, American College of Emergency Physicians (ACEP) spokesman and chief of emergency services at Our Lady of Lourdes Medical Center in Camden, NJ, told Healthcare Dive. “The disconnect comes from what the ED can do to decrease the wait times versus what they need from the hospital to decrease the wait times.”
Additional concerns regarding advertising wait times include inaccurately reported wait times – ie., the billboard or website said 20 minutes, but the patient ends up waiting more than three hours; the lack of a standard definition of “wait time;” and directing patients who don’t have an emergency to opt for the ED instead of going to a primary care doctor for treatment.
ED visits continue to rise
The number of emergency visits in the U.S. hit 133.6 million in 2013, up from 92.6 million visits in 1993, according to the American Hospital Association – nearly a 44% increase. It’s interesting to note that during the same time, 558 emergency departments closed.
This spike may be attributed, in part, to the overall physician shortage -- especially primary care physicians -- as well as the fact there are only 42,000 emergency medicine physicians nationwide. A lack of access to care, especially in rural areas, forces many to use the ED as their primary care facility. The ACA has also contributed to an increase by bringing many more patients into the ER who could previously not afford it. Dr. Mark Reiter, former president of the American Academy of Emergency Medicine (AAEM) told Emergency Medicine News, “Anecdotally, it does seem as though many EDs have seen greater than 5% volume increases year-over-year, perhaps due to the ACA, and I expect this will further strain patient waiting times.”
In fact, a 2015 ACEP survey of 2,099 emergency physicians found 75% said visits have significantly increased since 2014, with 90% adding the severity of illness has also increased. States that haven’t expanded Medicaid are seeing more hospital and ED closures. Dr. Michael Gerardi, immediate past president of ACEP, said in a press release last year, “Hospitals received less Medicaid funding for charity care when the ACA took effect because more people were supposed to have health insurance coverage…The average reimbursement for a Medicaid patient in the ER is about $43, but it’s much lower in many states.” Many primary care physicians won’t accept Medicaid due to low reimbursements, forcing more patients to the ED for treatment. “Just because people have health insurance does not mean they have access to timely medical care,” added Dr. Gerardi.
Another major cause of increased wait times and ED crowding is “boarding.” Dr. Barnewolt told Healthcare Dive this has been a “uniform problem across the nation for the past 20 years.” Patients can be held in the emergency room for days until an inpatient bed becomes available. “The ER waiting time is always attributable to how many patients are being boarded in the ER,” Dr. Sacchetti added. “We can see that in our own numbers. When the ER is empty and we’re not boarding anyone, we can keep the waiting room almost empty. Our time from when a patient is placed on a stretcher until they’re seen by a clinician is three minutes.”
Another factor that’s contributing to wait times, said Dr. Sacchetti, is the specific insurance criteria for hospital admission reimbursement. “In the past, I could just examine a patient and decide they need to be admitted. Now I have to wait until I get all my test results to justify admitting a patient, so patients are in the ER much longer before a decision can be made whether to admit them.”
Accuracy of wait times can be questionable
“Wait times are important to people. As a consumer, if I’m going anywhere, whether it’s medical or I’m getting my tires changed, I want to know how long it’s going to take,” Dr. Brien Barnewolt, chairman and chief of the Department of Emergency Medicine at Tufts Medical Center in Boston told Healthcare Dive. “This holds true for emergency care as well – once you publicize it, you need to deliver it,” he added. However, the definition of “wait time” still remains unclear. “I don’t know how well it’s understood by patients or institutions. What we do know is that one of the biggest patient satisfiers is the wait time to be seen by a clinician – whether it’s a physician assistant, nurse practitioner or a physician,” Dr. Barenwolt explained.
Here’s where it gets murky: Hospitals can interpret “wait time” as being the time from when a patient arrives until he is seen by a receptionist, a triage nurse or a physician – all with substantially different time frames. However, CMS has established a standard definition for “wait time” as the time measured when a patient arrives until he is evaluated by a licensed provider (physician assistant, nurse practitioner or physician), according to ProPublica. Hospitals are responsible to confirm that data is correct before submitting it to the government.
An investigation of several Florida hospitals’ posted ED wait times last year by News 6 an Orlando-based TV news station, found them to be grossly inaccurate. Although many hospitals advertised wait times of around 30 minutes on their websites, when reporters called to confirm, they were told wait times were closer to 3 to 4 hours. Florida Hospital responded to the news agency’s inquiry, “The emergency room wait times posted online are intended to be a tool for consumers, but it is not a guarantee. As our website states, the wait time represents a rolling-average of the previous 60 minutes for all patients. While everyone’s health is paramount, certain patients will be seen fast than others due to the severity of their emergency.”
Solutions to reduce wait times
Although there haven’t been any clinical studies regarding the effects of posting ED wait times on patient care outcomes, several solutions have been developed to mitigate long waits. Tufts Medical Center is using a program called InQuicker that provides an online scheduling option for its ED. This is geared toward patients who need to be seen urgently but don’t have a major emergency. The patient can book an estimated treatment time and the information is sent to the ED. “We review the reason for the appointment electronically and make sure it’s something that can wait and then put that patient in a queue,” explained Dr. Barnewolt. The patient can wait wherever they want (instead of the ED) and when they arrive, the ED already knows why they are there and they can get immediate care.
Dr. Barnewolt said they have been able to gather data on the patient population using the tool since June 2015: 60% are new to their medical center, 60% are female, 40% are male, the average age is 32, and most access the program from a mobile device. “It doesn’t drive a huge number of patients to our ED – we might see 2 or 3 patients a day from InQuicker out of 130. It’s not a majority of our patients, but it does serve a purpose.”
Both Drs. Barnewolt and Sacchetti agree that advertised ED wait times are not the sole metric that drives traffic to a hospital. “You have to have great care, friendly folks, and good outcomes,” said Dr. Barnewolt. Dr. Sacchetti added although the advertised wait times are “useful for some people,” the more important factor is what is the hospital’s reputation for their wait time? Also, it’s important to know the hospital’s caliber of care. “Are you going to be treated by board-certified emergency physicians or someone who’s moonlighting in the ED?” he asked.
However, Dr. Edwin Leap, an emergency physician based in South Carolina, wrote in a recent blog, the “go directly to the ER” mentality of modern American medicine” is what's driving more ED visits. Many patients are also told to go to the ED for follow-up care. Along with fewer emergency departments, physician shortages, more patients with insurance, and an aging population, Dr. Leap said the ED “has become the default.” “I want to take care of everyone,” he wrote. “But the Titanic that is emergency medicine in America is sinking. We really, honestly can’t bear the burden for all the chaos of our national healthcare.”