This is the fourth in a series of posts made in preparation for a presentation I will be making for physicians in fellowship training. In the last post, I demonstrated...
Currently in our medical center, there is a running debate about whether the emergency department wait times should be posted on the internet. This is a polarizing question and there are very strong opinions on both sides of the issue. What most people don’t realize is that your local hospital’s ER wait times are already posted on the internet at Medicare’s hospital compare website where you can find the average number of minutes you will wait:
- Total wait to be admitted to the hospital (national average is 5.6 hours)
- Wait to be admitted to the hospital after a doctor decides you need to be admitted (national average is 2.2 hours)
- Total time spent in the ER for non-admitted patients (national average is 2.9 hours)
- Time in the ER before you are evaluated by a healthcare professional (national average is 30 minutes)
If you don’t want to go to the Medicare website, you can go to the Yelp website and search your local hospital and find the same information.
Many hospitals have responded by putting their current wait times on-line or even on billboards outside of the hospital, updated every 5-15 minutes.
But if you read the fine print, it turns out that the ER wait time can mean different things. For example, at HCA Virginia hospitals, the on-line ER wait time is defined as “…the time of patient arrival until the time the patient is greeted by a qualified medical professional” (physician, nurse practitioner, or physician assistant). On the other hand, at the INOVA hospitals in Virginia, the on-line ER wait time is defined as the “…period from registration to assignment of provider (doctor, nurse practitioner or physician assistant)”. At WakeMed in North Carolina, the on-line ER wait time is defined as “…check-in to care being initiated by a doctor, nurse practitioner or physician assistant”. At Middlesex Hospital in Connecticut, the on-line ER wait time is defined as the time “…from registration to having a physician assigned to the case”. When I checked their website this morning, The Mountain States Health Alliance in eastern Tennessee/western Virginia boasted that 8 of their 11 hospitals had an ER wait time of zero minutes but they define their ER wait time as “…amount of time people have been in the waiting room”.
If you read these words carefully, you can see how it would be easy for hospitals to game the system. If I was the medical director at any of these hospital systems, here’s how I would make my ER wait times look better:
- HCA Virginia. I would put a physician assistant behind the registration desk so that each patient would be “greeted by a qualified medical professional” as soon as they walked in the door.
- INOVA Hospitals and Middlesex Hospital. I would have the registration staff “assign a provider” when the patient first registers at the front desk of the ER and then the patient can go wait in the waiting room until an ER bed is available.
- WakeMed Hospital. I would have each patient go straight from the registration desk to a triage area where a nurse practitioner would check that patient’s vital signs, thus minimizing the time from “check-in to care being initiated by a nurse practitioner”.
- Mountain States Health Alliance Hospitals. I would build out a 25-bay triage ward where patients would be taken as soon as they register so that they don’t have to wait in the “waiting area”.
So what are the advantages of publicly reporting your emergency department wait times?
- It is great advertising. A low posted ER wait time is a great marketing tool to attract insured patients to your hospital.
- Motivate your staff. If the doctors and nurses all see a big clock on the ER wall with the current wait time, it gets them motivated to move a little faster.
- Better allocation of resources. If the ER wait time is getting excessively high, then the hospital’s nursing director may be able to re-assign nurses from slow units to the ER and the medical director may be able to bring in additional ER doctors to help out or hospitalists to reduce inpatients “boarding” in the ER.
- Improve patient satisfaction. If you know that the ER wait time is 90 minutes, you’re less likely to be angry if you sit in the waiting room for 90 minutes than if you were expecting to be seen right away.
- Discourage low-acuity patients when the ER is busy. When your ER is full of patients with heart attacks and broken legs, you don’t want to take up precious rooms with a patient who comes in just because he has a cold. Presumably, that patient with a cold will either stay home, go elsewhere, or come back to your ER another time if he sees that he is going to have to wait a long time.
- You control the message. As can be seen from the examples above, there are many ways to define “ER wait time” and you can pick the number that makes your ER look best or that best suits your purposes for posting the ER wait time.
- Even out the work load among different hospitals. If your hospital is part of a larger health system with multiple hospitals in a single geographic area, then this is a way of insuring that the patient distribution among the different hospitals stays even. This makes staffing easier and improves staff satisfaction. This is particularly the case when office-based physicians have to send a patient to the emergency room – knowing which ER has the shortest wait time can best match the health system’s resources with the health system’s physicians’ needs at any given moment.
- Improve timeliness of care in the community. If the EMS squads know that one hospital has an unusually long wait time, then they can re-direct squads to another hospital in the community that is less busy thus ensuring that the entire geographic area’s health needs are being optimized. This has the potential to decrease ER overcrowding and is more proactive than waiting until an ER goes on “divert” status because they can’t take any more patients.
OK, what about the disadvantages of publicly reporting your emergency department wait times?
- “Self-triaging” can be dangerous to patients. A patient with a potentially serious condition may choose to stay home rather than go to the ER if the posted wait time is too long.
- They are not accurate. The ER wait time is inevitably going to be an average for all patients. However, an ER does not work on a “first come, first served” basis. A patient with chest pain suspicious for a heart attack is always going to be taken back first, no matter how long the less acute patients have been waiting. So, an average wait time of 30 minutes may mean 0 minutes if you are having a stroke but 60 minutes if you have poison ivy.
- Increase stress level of the ER staff. If the doctors and nurses feel like they can’t keep up with the hospital’s wait time goal, (often because of patient surges that they can’t control), then they are at risk for getting burned out.
- You may look bad compared to the hospital a few miles away. Particularly if the other hospital chooses a different definition of ER wait time that is more easily achieved than your hospital does.
- You may discourage business. ER charges can be very lucrative, particularly for patients paying out of pocket or patients with commercial insurance. You hate to turn away paying customers.
- Risk patient satisfaction. If you define your ER wait time as “time to assignment of provider” but it still takes 2 hours before the patient actually sees that provider after the provider is assigned, the patient is going to be pretty unhappy if she expected the wait time to mean the time from walking in the door until a physician lays eyes on her.
So, what is the right answer? Well… there isn’t one. You first have to decide what your hospital’s motivation is for posting ER wait times – is it a marketing tool or a resource allocation tool? Next, you have to decide where you want to post waiting times – you will have vastly different effects (and different audiences) if you publicly post times on-line versus on a sign in the ER lobby versus on the hospital’s non-public website. Lastly, you have to decide how you are going to define your ER wait time.
My recommendation is to start by just reporting your ER wait time internally to hospital staff where you can trend the data and determine how you are going to use it to improve patient flow. Then pick a definition of wait time that is meaningful from an administrative standpoint, such as time from registration to actually being seen a physician/NP/PA in an ER room. Once you are internally comfortable with the information and what it actually means, then make it publicly available.
Publicly posted ER wait times should be a part of overall hospital strategy, not a means of hospital self-flagellation.
March 19, 2017