Running head: IMPROVING QUALITY IN EMERGENCY DEPARTMENT WAIT

Improving Quality in Emergency Department Wait Times

Kelly A. DeBolt, Jessica L. House, Marquette A. Marsman, Matthew C. Seiter, and Danielle M.
Warner
Ferris State University

Improving Quality in Emergency Department Wait Times

The purpose of this paper is to describe the importance of improving wait times in the
emergency department. Emergency waiting rooms are high risk for potential catastrophic events
due to prolonged wait times and delayed treatments. Research has shown the negative impacts
on patients when crowding compromises access to emergency care, delaying physician
assessments, diagnosis, and critical treatment plans. Patient satisfaction surveys affect hospital
reimbursement causing organizations to implement new programs to better meet patient
expectations.
Identification of Clinical Needs

Wait time is defined as the time between arrival in the emergency department and the
time seen by a provider (Stauber, 2013). The national recommended time to be seen is 15
minutes or less. There are many challenges when considering the diversity and complexity of
each patient who enters the emergency department. Overcrowding has led to negative outcomes,
ranging from prolonged pain and suboptimal management of infectious diseases to delayed
thrombolytic administration (Christenson, Innes, Boychuk, Yu, & Grafstein, 2010).
People are using the emergency department for their primary care needs with increasing
frequency. Patients who do not have primary care physicians and patients with no health
insurance may feel they have no alternative but to seek treatment in emergency departments.
Those issues place increasing demands and expectations of emergency departments. In 2010,
38% of emergency departments reported they were operating at maximum or over their capacity,
and ED visits had grown to more than 125 million in the United States (Marion, Mays,
Thompson, & Lancaster, 2015).
Emergency departments are reporting increasing numbers of patients who leave prior to
being treated. Critical patients are being left in the waiting room for extended periods of time
resulting in extremely poor outcomes. The 2007 American College of Cardiology and American
Heart Association guidelines recommend that emergency department patients with possible
cardiac ischemia undergo immediate assessment by an emergency triage nurse and physician and
receive an electrocardiogram within 10 minutes (Christenson, Innes, Boychuk, Yu, & Grafstein,
2010). These patients are at increased risk for adverse outcomes when early intervention and
treatment are delayed. Cases of missed acute coronary syndrome are estimated to account for
25% of all emergency department litigation costs (Christenson et al., 2010).
Patient satisfaction in the emergency department has proven a challenge for many
healthcare facilities. The environment is stressful and fast paced with brief encounters from

IMPROVING QUALITY IN EMERGENCY DEPARTMENT WAIT

medical staff and providers. Emergency departments are frequently overcrowded with extensive
wait times. Even with the best communication patients often feel frustrated. Delayed physician
assessments, diagnosis, and treatment can further impact negative outcomes and decreased
patient satisfaction.
Due to financial constraints and lower reimbursement rates for services, organizational
leaders are assessing and implementing enhanced programs that reduce emergency department
wait times. It is essential to strategize with team members to create an environment that is
healthy and serves to minimize excessive and unnecessary wait times. Emergency staff and team
members must work together with implementing quality improvement plans that are feasible and
meet current JCAHO standards. Process improvements must involve leadership that takes into
consideration budgets, strategic goals, and processes necessary to accomplish quality
improvements. Emergency department waiting rooms are high risk, high liability areas for
hospitals. Patients who are greeted by non-clinical personnel or who are not being placed in
available beds increases wait times and prevent patients from receiving timely treatment and
access to care (Marion et al., 2015).
Interdisciplinary Team Design
Well-functioning interdisciplinary teams are vital to the provision of quality patient care
(Yoder-Wise, 2015). The interdisciplinary team will consist of members who work directly with
the emergency department. Team members must be willing to learn, maintain open
communication, assume individual responsibility, and be committed to the success of the project.
The team should consist of members with complementary skills including system leadership,
technical expertise, and day-to-day leadership. The system leader must have organizational
authority to institute change as well as allocate time and resources to the project. The system

IMPROVING QUALITY IN EMERGENCY DEPARTMENT WAIT

leader role could be filled by the Chief of Emergency Medicine. An emergency nurse champion
could fill the clinical technical expert role, as this person should thoroughly understand the
processes of care within the emergency department. In addition to the clinical role, assisting the
team with data collection, interpretation, and analysis could provide additional technical support.
The day-to-day leader of this quality improvement project could be the emergency department
nurse manager. The day-to-day leader should understand the processes and policies of the
emergency department and be able to work effectively with the system leader and the technical
expert (U.S. Department of Health and Human Services, 2011).
Data Collection Method
Prior to designing and implementing a data collection tool for our quality improvement
initiative we must first have a thorough understanding of the current process which we are
attempting to improve upon. We will develop a flowchart detailing the process that is currently
utilized to transition a newly arrived patient from the waiting room to the provider for an initial
evaluation. This creation of the flowchart will help us to visualize the algorithm, which
demonstrates the criteria a patient must meet to either be placed directly into the waiting room or
to be immediately examined by a physician. Yoder-Wise (2015) states that sometimes, just
diagramming a patient care process in detail reveals gaps and opportunities for improvements.
This is the goal of the initial flowchart development with our primary goal of identifying where
the processes can be improved upon to enhance patient throughput in the emergency department.
Care efficiency and throughput are constantly evaluated in the emergency department with
identification of the inefficient processes being a major focus.
Forbes, Osborne, Hartsell, and Wall (2014) determined the quantification of these

IMPROVING QUALITY IN EMERGENCY DEPARTMENT WAIT

inefficiencies, so that specific processes can be improved, is an even greater challenge for
healthcare organizations. The ability of an organization to discover these inefficiencies
and make improvements is essential to increasing satisfaction and providing value-added
care. This requires organizations to examine routine processes and dissect them to
identify where improvements can be made in specific measures.
Tracking the time a patient spends at triage, registration, and during initial provider
assessment will help identify where unnecessary steps can be eliminated or improvements should
be made. For example, we will evaluate if an additional provider is required to help with the
initial assessments of patients.
After evaluating the flowchart for deficiencies, recommendations will then be made to
improve upon the current process. Different algorithms will be created based on ideas generated
and can be tested to evaluate what is most efficient. A line graph can help evaluate and illustrate,
over a given period, what the overall decrease in patient wait time is. Based on the results, and
what the predetermined goals were, adjustments can be made for continuous process
improvement.
Establishing Outcomes
Decreasing patient overall wait times in the emergency department waiting room is the
primary goal of this analysis. The American College of Emergency Physicians (2010)
recommends that the emergency department patient "wait time" should be defined as "door to
provider contact time.
A study done by Horwitz, Green, and Bradley (2010) determined that prolonged
emergency department wait time and length of visit reduce quality of care and increase adverse
events for patients with serious illnesses. The study found that hospital EDs perform fairly

IMPROVING QUALITY IN EMERGENCY DEPARTMENT WAIT

poorly in seeing acutely ill patients within the time recommended by the triage nurse. Less than
one fifth of EDs were able to treat at least 90% of their emergent or urgent patients (those triaged
to be treated in an hour or less) within an hour (Horwitz, Green, & Bradley, 2010).
Some factors contributing to wait times are out of the control of the hospital and reflect
the larger social and economic features of the hospital's environment. Horwitz, Green, and
Bradley (2010) state that the largest contributors to emergency department crowding and delays
in care are not these immutable input factors, but rather throughput and output factors that
are at least partially modifiable. Studies have shown improved wait time or length of visit after
improvements in emergency department throughput such as triage, staffing, laboratory, and
registration.
The goal and outcome of this analysis is to identify strategies that reduce the time that
patients in the emergency department must wait prior to seeing a provider. There is no currently
identifiable standard that emergency departments are responsible for meeting. Our goal is to
reduce the current door to provider wait time by 20% following full implementation of the new
strategy after one month.
Implementation Strategies
Improving long wait times and improving customer satisfaction have become priorities
for emergency departments across the country (Roche, 2007, p. 619). Delayed access to care in
hospital emergency departments (EDs) as a result of impaired patient flow and overcrowding,
poses risks for patients presenting with acute illness (Sullivan et al., 2014, p. 565). Solving
the overcrowding problem starts with eliminating process inefficiencies in patient inflow,
throughput, and outflow (Karpiel, 2004, p. 40).
Inflow

IMPROVING QUALITY IN EMERGENCY DEPARTMENT WAIT

According to Karpiel (2007) inflow refers to the time it takes patients to see a physician
after entering the emergency department. One strategy for reducing these wait times it to create
a triage-driven bed placement where a patient can be taken immediately back to a treatment area
after a quick registration if a bed is available. Instead of doing a full registration, doing a
shortened registration helps to improve emergency department inflow and is also a patient
satisfier. This shortened registration demonstrates to customer the hospitals main priority is
providing care rather than gathering insurance information (Karpiel, 2004, p. 40).
Throughput Strategies
According to Karpiel (2004), throughput refers to the time period when the physician sees
the patient until a decision is made to admit the patient or send the person home (p. 40). One
way hospitals can improve throughput times is to create a fast track or separate area for
patients with lower acuity that can be seen by a mid-level provider (Karpiel, 2004, pg 40). Some
advantages to this method include emergency physicians being allowed the opportunity to focus
more on the critically ill patients and it also allows lower acuity patients to be seen sooner
(Karpiel, 2004, pg 40). Another contributor to the backflow of patients is the inconsistent
availability of lab and diagnostic imaging services. According to Karpiel (2004), an effective
way to alleviate this problem is to have dedicated radiology and lab technicians assigned
specifically to the emergency department, especially during the busiest hours of operation (p.
40).
Outflow
Outflow refers to the discharge of patients from the hospital and to help improve this,
hospitals can implement a number of strategies including preemptive bed requests, faxed
admission reports, and capacity management systems (Karpiel, 2004, p. 41). In some hospitals,

IMPROVING QUALITY IN EMERGENCY DEPARTMENT WAIT

the physician will order a bed early on in care for those patients the doctor feels will need to be
admitted. Another strategy involves the ER nurse faxing report to the floor instead of giving a
verbal report to help reduce the length of time in getting the patient to the floor (Karpiel, 2004, p.
41). Implementation of these strategies helps to reduce the amount of time the patient is in the
emergency department and helps to improve the flow of patients being treated and avoid
congestion and bottlenecking in the ED.
Evaluation
A thorough evaluation will be completed regarding methods for improving emergency
room inflow, throughput, and outflow strategies that are stated above. After implantation of our
mini registration we will evaluate the timeframe from when the patient arrives to the emergency
room to when that patient is actually seen by the patient. The expectation will be that the patient
will have a 45 minute or less door to doctor timeframe with 50% of our emergency room patients
over the first month. We will be evaluating this through data collection in regards to the patient
arrival times and when they are seen by a physician. To improve throughput, we will have a lab
technician and a physician dedicated to the emergency department for one month. After the
month is completed we will evaluate if the additional cost of the staff members if beneficial from
a patient satisfaction standpoint and a financial standpoint. This will be measured through our
patient satisfaction survey and with a cost vs. benefit analysis. Finally, we will measure outflow
by collecting data on the timeframe between when the bed was assigned, to when a hand-off
report was faxed to the admitting floor, and to when the patient actually arrived to the admitting
floor. Our expectation is that all of our patients who are admitted to the floors from the
emergency room will have a fax report to the admitting floor within 15 minutes of a bed

IMPROVING QUALITY IN EMERGENCY DEPARTMENT WAIT

assignment. Evaluation of these strategies allows the interdisciplinary team to continue to gather
and evaluate data to document if the new outcomes are being met (Yoder-Wise, 2015, p. 374).
Conclusion
This paper provides exploration of the importance of improving wait times in the
emergency department. Improving emergency department wait times is vital to patient
satisfaction and to provide quality care to patients. Without change we will continue to see poor
patient outcomes and decreased patient satisfaction. In order to improve quality of care in
emergency departments, wait times must be reduced to decrease door to provider contact times.
We will accomplish this goal by improving the patient registration in the emergency department,
improving the timeframe for receiving diagnostic test and lab results, and by improving the bed
placement process for patients who are admitted to the hospital. With these strategic plans in
place we will evaluate their effectiveness and make improvements to the process as necessary.

References
American College of Emergency Physicians. (2012, October). Standards for measuring and
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Forbes, T., Osborne, K., Hartsell, K., & Wall, B. (2014). Diving into data: Quantifying efficiency
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Horwitz, Green, & Bradley. (2010). U.S. emergency department performance on wait time and
length of visit. Annals of Emergency Medicine, 55(2), 133-141.

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