Lindsey Davis, Carson Tew, Savannah Jefferson
Group 7
Emergency Room Waiting Times
Background
Emergency room wait time is defined as “door to provider contact time”. This is the time from the point that the patient walks into the ER until they see the physician. The emergency room wait time and the length of visit is different. The length of visit is measured by from the time the patient enters the emergency room until the time they are discharged from the emergency room. Emergency department overcrowding has become a huge problem in the United States. The Institute of Medicine is calling it a “national epidemic.” Across the nation an ambulance is diverted from an overcrowded emergency room approximately once every minute (Horwitz). Prolong wait times decrease satisfaction and often times occurs in patients leaving before they have been seen. Patient wait time can vary according to the patient’s race, ethnicity, gender, and location. Therefore, we have to look at hospital-level wait times instead of patient-level wait times in order to accurately examine the system. This will allow for a better understanding of the positive and negative outliers and assess effective care practices.
There are many people that go to the emergency room when they could go to a place such as an urgent care to get treatment. People that do not have emergency situations just cause the waiting rooms to become more crowded. Triage nurses evaluate the patient’s condition and symptoms when they enter the emergency room and decide who needs to see a physician quickly and who might have to wait. The high-severity patients take priority in an emergency room. So even if you have a patient that has been waiting over an hour to see a physician, if you have a high-severity case come into the emergency room they will see a physician before the patient that has been waiting longer. Patients that have chest pains or stroke like symptoms will be moved to the top of the list. These patients need to be treated as quickly as possible whereas other patients with lesser severe symptoms can wait longer for treatment. Many people don’t understand this whenever they go into an emergency room. They believe that they should be seen right away because they don’t understand what all is going on behind the waiting room doors.
The Washington Adventist ER and Grandview Medical Center in Birmingham have both implemented a “fast track” area in the emergency room that evaluates patients as they walk into the door of the emergency room. Triage nurses evaluate these patients and rate their symptoms on a scale typically 1 to 5, 1 being the most severe cases and 5 being extremely mild. Patients who receive a rating of 1 to 3 are typically referred to the emergency room to see a physician. The remaining patients who are rated in the 4-5 category are seen by medical staff depending on the severity. These ailments can consist of lacerations, colds, coughs, and fevers. The benefit of having a fast track ER is that it keeps patients with minor symptoms from crowding up the emergency room when there are people who need actual care. There are a lot of people who go to the ER for simple things and it ultimately wastes time and space. A fast track ER will keep these patients from overcrowding the already busy emergency room. Another benefit of having the fast track ER is that if one of the less severe ailments turns into something more severe or life threatening they will have access to a full ER.
The Centers for Disease Control and Prevention reported in 2014 that the average wait times are around 30 minutes and the average treatment times are about 90 minutes. The average time a patient spends in an ER is around 2 hours (). A survey was released stating that the passing of the ACA did not decrease emergency room crowding as hoped. Instead the Affordable Care Act actually increased the wait times. Diagnosing wait times can take a long time. Nurses are having to run tests, blood work, and take images via x-rays or CT scans in order to rule out life-threatening conditions. In some severe cases a patient might have to wait to see a specialist. Emergency physicians are available all day long in an emergency room but specialists are not. Normally specialists take call which means that they have to be called into work when they are needed. Many of these specialists are skeptical of taking call in emergency rooms because there are concerns about reimbursement and getting sued. The patients that need to see specialists have to wait in the emergency room and therefore, take up space. This is one of the many causes of the overcrowding of emergency rooms.
Boarding is also a huge problem when considering long emergency room wait times. Emergency room boarding is when patients admitted in the ER are held for hours or even days until an inpatient bed becomes available in the hospital. Hospital restrict the number of beds available to patients who are admitted through the emergency room. This is a major cause of the long wait times. There is nowhere for new patients to go when old patients are taking up all the space waiting to be admitted as an inpatient. According to the Centers for Disease Control and Prevention, 62 percent of hospitals reported that some admitted patients were boarded for longer than 2 hours or more at some point in the year (Fact Sheets). Boarding is also one of the reasons that ambulances are diverted from one emergency room to another. Nurses have to decide if they are going to move patients to the hall in order to open up a room for a more severe patient. Emergencies are not planned for and the emergency room staff has to act accordingly. Their main goal is to give every patient the best care possible and it can be difficult when there are too many patients with not enough space.
Patient flow is defined as the movement of patients through the hospital’s care system. Patient flow is an important indicator of timeliness, safety, and quality of care received. Patient flow is considered efficient when there are minimal delays at each point of the delivery process with no decrement in the quality of care. Bottlenecks prolong delays of patients already in the system as well as those awaiting entry, so it is important that bottlenecking is prevented. Financial incentives discourage hospitals from opening up more inpatient beds to those patients admitted through the emergency department which in turn increases the boarding of patients. Patients that are scheduled for elective admission are given the priority to inpatient beds within the hospital because they are a more reliable source of revenue. People that are scheduled for elective admission can leave and go to another hospital while someone that is already admitted through the emergency department is likely to stay. Hospitals depend on the revenue from those patients who are scheduled to be admitted for a surgical procedure or treatment. These patients are a reliable source of revenue while walk-in patients are typically less likely to be insured or have the means to pay. These walk-in patients can be financially harmful to the hospital by leaving them with the medical expenses. Hospitals benefit financially from the volume of the patients. This discourages hospitals to reserve and keep beds open for patients walking in through the emergency department.
Standalone emergency rooms are currently used as a solution to combat overcrowded ERs in densely populated areas. The initial idea behind the standalone emergency room was that it would allow patients a more convenient, cheaper, faster alternative to an overcrowded hospital ER. Some of these standalone emergency rooms have invested heavily into the ascetics instead of the care aspect of these ERs. These standalone ERs have not been beneficial to serve the cause that they were initially created for. They have increased costs for those who choose to use their services. When these standalone emergency rooms were first introduced people were expecting costs to be lower and more economical. People that have used the services provided by these standalone ERs were taken by surprise when their bill came in the mail. Across 32 states, more than 400 free-standing ERs provide quick and easy access to care. But they also are prompting complaints from a growing number of people who feel burned by hospital-size bills, like $6,856 for a cut that didn’t require a stitch or $4,025 for an antibiotic for a sinus infection (Johnson). When customers see these costs, they result to going back to hospital emergency rooms nullifying the desired effect that these standalone ERs were designed to fix.
Wait times in emergency rooms have a huge impact on patient satisfaction. In American society, today we have adapted to the social idea that we want it and we want it now. This has given many expectations of immediate care without wait times. People today are comparing the service they receive at a medical institution to the service they would receive at a hotel or restaurant. Patients are expecting to walk into an emergency and room and have a nurse and doctor greet them at the door. In this fast pace society patients are not used to waiting so their satisfaction is instantly affected when they are met with waiting times. Press Ganey estimates that the average patient spends about 22 minutes waiting to see a doctor at a clinic, and more than four hours from entrance to discharge in the emergency department. As wait times balloon, the patient's experience worsens, and so does the risk of infection (The Push).
Problem Statement and Policy Proposal
America's emergency rooms (ERs) are in crisis. Crowding, delays, and diversions have increased to epidemic proportions. In the United States healthcare system, ER visits account for 11% of outpatient encounters, 28% of acute care visits, and 50% of hospital admissions. Now, the lack of ER crowding is considered a measure of the success of a hospital or system. Our policy proposal is implementing a new type of doctors – 24-hour doctors – and setting up a reimbursement method for hospitals for a lower ER wait time.
Shareholders
ER crowding appears to affect certain populations disproportionately. A survey by the Center for Healthcare Research and Transformation revealed that “uninsured” patients are three times more likely to use ERs and are sicker than their “insured” counterparts (6). The Agency for Healthcare Research and Quality (AHRQ) found that 60% of rural ER visits are made by “poor” patients, and a 2011 study noted that hospitals serving “low-income” patients have the highest rates of patients leaving the ER without being seen by a physician. A study by Pitts et al revealed that, although ERs employ only 4% of the active physician workforce, they account for 38% of all acute care visits in the country. In contrast, medical specialists account for 60% of the active physician workforce but manage 43% of acute visits. Considering low-income and uninsured populations, the same study found that ERs account for 51% of all acute visits by patients covered by Medicaid or the State Children's Health Insurance Program (SCHIP) and 64% of all acute visits by individuals with no insurance.
In-Depth in the Policy
The first part of out policy is creating a new type of doctor – a doctor available 24 hours. A 24-hour doctor would reduce waiting time by keeping the nonemergency cases out of the ER. Overuse of the ED for minor complaints that could be dealt with at the GP level decreases the quality of care and increases ER costs (Rieffe). A study conducted by Lee et al. found that 57% of ER attendees were primary care cases (Lee). Our society loves convience and what is more convientient of being able to have a doctor come to your home? We would give an incentive for students in medical school to go into this specialty by offering help with paying pact of the cost of medical school. The 24-hour doctors would be paid by Medicaid, Medicare, private insurerors, or out-of-pocket. There would be a co-pay for those with insurance. Basically the 24-hour doctors would be seen as regular physicians. Our second part of our proposal is a reimbursement to hospitals for a lower ER time. This would be a pay-for-performance investment by our government, similar to the Hill-Burton Act. The overuse of U.S. emergency departments (EDs or ERs) is responsible for $38 billion in wasteful spending each year. Hospitals would be rewarded for improvements in achieving specific benchmarks for ER/ED length of stay or wait time, as specified by the federal government: a maximum of X amount of hours would be decided for patients admitted to the hospital or triaged as high acuity (defined through a Triage and Acuity Scale; level I [resuscitation], II [emergent], or III [urgent]) and X hours for nonadmitted low-acuity patients (defined through a Triage and Acuity Scale level VI [less urgent] or V [nonurgent]). There would be targets for compliance with benchmarks that would be determined through evaluation methods. The federal government would work with healthcare economists to determine the eligiability for the pay-for performance through a retrospective observational study. By eligiability we mean eligiable for funding, designated hospitals must meet certain conditions, like hospitals with ERs that accept urgent or emergency ambulance patients 24-hours a day and 7 days a week and a set amount of annual ER visits.
Implementation and Evaluation Timeline
On January 1, 2019 is when the introduction to the idea of the 24-hour doctors would be introduced to medical students and the public. This would be introduced through press confrences, having people go and speak at medical schools, and having an informative and easy to understand website. 8 months of 2019 will be spent on informing and then the other 4 months of the year will be a signing up period. Into the year of 2020 applicants would be able to apply until March, then those (only depending on the amount of applicants) who were accepted in the program would be chosen and notified. Through the use of six sigma, we would determine the effects on cost and quality after 5 years. The reimbursement to the hospitals would be distributed in 3 waves in 2020. In wave 1 of the program, hospitals with the largest number of patients exceeding ER length-of-stay benchmarks were targeted, with subsequent expansion to additional eligible hospitals annually. All participating hospitals were notified which wave they were allocated to before the introduction of the program; thus, lead time varied from a few months for wave 1 sites to at least 1 year for wave 2 sites and more than 2 years for wave 3 sites. Notice of annual performance targets for the program will typically given between January and March for the upcoming fiscal year. The first wave will target extreme ER lengths of stay (>24 hours) and set a performance goal of a 5% improvement in provincial ER length-of-wait/stay targets. In the second wave, the performance goal will be 10%. The third wave will set a performance goal of 15% and also mandate a decrease in time to initial physician assessment. Incentives will be allocated internally within each hospital, but there will be stipulations to not use payments to supplement physician income. Funds will not be restricted to the ER and can be used to improve flow in inpatient areas as well. Failure to attain specified targets could potentially render payments subject to recovery. There will not be a “tournament” or competitive component to the payment design, this will allow certain high-performing hospitals to lead shared-learning events and activities facilitating the distribution of best practices. Because selection criteria for pay-for-performance hospitals will change from wave to wave, we will conduct separate analyses for each wave according to the fiscal year they were introduced to the program. By comparing the baseline characteristics of the pay-for-performance hospitals and controls in the fiscal year before each wave with respect to age, sex, ED length of stay, physician initial assessment, ED volume, teaching hospital status, admission rates, percentage of resuscitation and emergency patients (through Triage and Acuity Scale level I or II), and amount of Medicaid and Medicare patients the hospital sees. Then we will conduct difference-in-differences analyses to compare the change in each outcome in the first fiscal year after the introduction of pay for performance between program and control hospitals. We would compare the differences after each individual year for 10 years, then monitor every other year.