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Posted: January 13th, 2024
Reducing Waiting Times in Emergency Departments
Waiting times in emergency departments (EDs) are a major concern for patients, health professionals, and policymakers. Long waits can lead to dissatisfaction, poor outcomes, and increased costs. Therefore, many strategies have been proposed and implemented to measure and improve ED performance. In this blog post, we will review some of the main approaches and their characteristics, based on the current evidence from the literature.
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How to measure ED performance
ED performance is a complex concept that involves multiple dimensions, such as quality, safety, efficiency, effectiveness, timeliness, accessibility, and patient-centeredness. To capture these aspects, various indicators have been developed and used in different settings and contexts. According to a systematic review by Guttmann et al. [1], some of the most common indicators are:
- Length of stay (LOS): the total time spent by a patient in the ED, from arrival to discharge or admission.
- Left without being seen (LWBS): the proportion of patients who leave the ED before receiving medical attention.
- Time to physician initial assessment (PIA): the time elapsed from arrival to the first contact with a physician or a nurse practitioner.
- Time to treatment: the time elapsed from PIA to the initiation of a specific treatment or intervention.
- Time to disposition: the time elapsed from PIA to the decision to discharge or admit the patient.
- Admission rate: the proportion of patients who are admitted to the hospital from the ED.
- Return rate: the proportion of patients who return to the ED within a specified period (e.g., 72 hours) after discharge.
- Mortality rate: the proportion of patients who die in the ED or within a specified period (e.g., 30 days) after discharge or admission.
These indicators can be measured using automated information systems or manual data collection methods. However, there is no consensus on the optimal way to measure them, as different definitions, data sources, and calculation methods may affect their validity and reliability. Moreover, these indicators may not reflect all the aspects of ED performance that are relevant for patients and providers. Therefore, it is important to use a comprehensive and balanced set of indicators that can capture both clinical and non-clinical outcomes [1].
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How to improve ED performance
Many interventions have been proposed and implemented to improve ED performance, targeting different stages of the ED process and involving different disciplines and roles. A scoping review by Austin et al. [2] identified 38 interventions that can be classified into two main categories: changes to practice and process, and changes to team composition.
Changes to practice and process refer to interventions that aim to modify or optimize the way care is delivered in the ED. Some examples are:
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- Triage: the process of sorting patients according to their urgency and acuity, using standardized tools or protocols (e.g., Canadian Triage and Acuity Scale).
- Fast-track: a dedicated area or pathway for patients with low-acuity conditions, who can be treated quickly and discharged without requiring extensive investigations or consultations.
- Streaming: a similar concept to fast-track, but applied to patients with different levels of acuity, who are directed to different areas or pathways according to their needs and resources available.
- Care transitions: interventions that facilitate the transfer of patients from the ED to other settings or levels of care, such as hospital wards, observation units, or community services.
- Technology: interventions that use information and communication technologies to support ED processes, such as electronic health records, computerized order entry, telemedicine, or decision support systems.
Changes to team composition refer to interventions that aim to modify or enhance the roles and responsibilities of ED staff. Some examples are:
- Advanced nursing roles: nurses who have additional training and skills to perform tasks that are traditionally done by physicians, such as triage, assessment, diagnosis, treatment, prescribing, or referral.
- Scribes: assistants who document patient information and orders in electronic health records on behalf of physicians, freeing them from clerical duties and allowing them to focus on clinical care.
- Pharmacy: pharmacists or pharmacy technicians who provide medication-related services in the ED, such as reconciliation, dispensing, administration, monitoring, education, or consultation.
The role of patients in improving ED performance
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Patients are not passive recipients of care in the ED; they can also play an active role in improving ED performance. Two interventions that address this aspect are:
- Supporting patient decisions: interventions that provide information and guidance to patients about their options for care in the ED or alternative settings (e.g., primary care), helping them make informed choices that match their preferences and needs.
- Providing patient education: interventions that provide information and advice to patients about their condition, treatment plan, self-care strategies, follow-up care, or preventive measures.
The outcomes of interventions to improve ED performance
The outcomes of interventions to improve ED performance can be categorized into five key domains: time, proportion, process, cost, and clinical outcomes. Some examples of outcomes for each domain are:
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- Time: LOS, PIA, treatment time, disposition time.
- Proportion: LWBS, admission rate, return rate, mortality rate.
- Process: compliance with guidelines, protocols, or standards; quality of documentation; patient or staff satisfaction; patient or staff experience.
- Cost: resource utilization; cost-effectiveness; cost-benefit; cost savings.
- Clinical: complication rate; adverse events; infection rate; readmission rate.
However, not all interventions report outcomes across all domains, and the evidence on the effectiveness of interventions is often mixed or inconclusive. Therefore, it is important to evaluate the impact of interventions using rigorous methods and appropriate measures, taking into account the context and the stakeholders involved [2].
Conclusion
ED performance is a multifaceted concept that requires a comprehensive and balanced approach to measure and improve it. Various indicators and interventions have been developed and implemented to address different aspects of ED performance, but their validity, reliability, and effectiveness may vary depending on the setting and the situation. Therefore, it is important to tailor the interventions to the specific needs and resources of each ED, and to monitor and evaluate their outcomes using appropriate methods and measures.
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References
[1] Guttmann A, Schull MJ, Vermeulen MJ, Stukel TA. Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ. 2011 Jun 1;342:d2983.
[2] Austin EE, Blakely B, Tufanaru C, Selwood A, Braithwaite J, Clay-Williams R. Strategies to measure and improve emergency department performance: a scoping review. Scand J Trauma Resusc Emerg Med. 2020 Jun 15;28(1):55.
[3] Vainieri M, Panero C, Coletta L. Waiting times in emergency departments: a resource allocation or an efficiency issue? BMC Health Serv Res. 2020 Jun 17;20(1):549.
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[4] How to Reduce Wait Time in the Emergency Room [Internet]. wikiHow. 2021 [cited 2024 Jan 13]. Available from: https://www.wikihow.com/Reduce-Wait-Time-in-the-Emergency-Room
[5] Moscelli G, Siciliani L, Gutacker N, Cookson R. The Effect of Wait Time Targets in Emergency Departments. NBER Working Paper No. 24579 [Internet]. National Bureau of Economic Research; 2018 [cited 2024 Jan 13]. Available from: https://www.nber.org/bah/2018no2/effect-wait-time-targets-emergency-departments
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