Thursday, February 9, 2017

Why Do People Wait in Emergency Departments?

Last week, there were stories in the media that focused on emergency department (ED) wait times across the country.  One story was about the data collected, from April 1, 2015, through March 31, 2016, by the Centers For Medicare & Medicaid Services (CMS) which showed that Maryland Emergency Department (ED) wait times are the longest in the nation.  According to CMS, patients waited for an average of 53 minutes in Maryland before they were seen by a medical professional compared to the national average of 22 min.  At GBMC, the CMS stats showed that we had an average of 60 minutes during that year before a patient was seen by a doctor or nurse.

To understand the problem of ED overcrowding we should consider the diagram below:

A number of years ago, the Robert Wood Johnson Foundation created this diagram to help people understand the underlying reasons that people wait in emergency departments. Fundamentally, it’s a problem of supply and demand and flow.  Anything that increases the number of patients arriving to be seen will increase the chance of waiting (input), and anything that slows down the assessment and treatment of patients (throughput) or anything that prevents their departure (output) will increase the waiting.

If we want to reduce ED overcrowding. we can start by trying to reduce the number of patients coming to the ED (like we have at GBMC) by making it easy for patients with real needs but who don’t have true emergencies to be seen in primary care. We are now open well into the evening and on Saturday and Sunday. We can also work to make sure everyone has health insurance since people without health insurance come to the ED because many physician offices won’t take them without insurance or they cannot afford to pay out of pocket.

Once we have reduced the number of patients arriving at the ED to only those with true emergencies we should work on the processes within the ED like registration, assessing the patient, and getting needed tests done expeditiously. A recent change that has slowed patient assessment within the ED somewhat is our desire to send more patients out with home care. This requires taking more time with the chronically ill in particular, to assure that they can be safely discharged.

But everyone who has ever studied ED overcrowding knows that the real culprit in ED waiting is the outflow of patients. In most hospitals historically, the single biggest cause of patients waiting in the ED is because patients who need to be admitted are waiting for an inpatient bed to be vacated and cleaned. These patients take up valuable ED space and “block” other patients from being seen. This problem is improved by improving the flow from admission to discharge to bed cleaning on the inpatient units. Sometimes a clean bed is available but a nurse to care for the patient is not, this is being made more common by the nursing shortage.

A relatively new cause of waiting due to outflow from the ED is the lack of mental health beds, especially in the state of Maryland, and notably at GBMC because of our proximity to Sheppard Pratt. On most days in our ED, we have from 5-12 patients waiting for a mental health placement and taking up beds that could be used for the next sick patient coming to the ED. With our present mental health system, there just are not enough beds to cover those in need. Hospitals, like Sheppard Pratt, are always full. When one patient is discharged, there are always others waiting to fill the bed.

In next week’s blog, I will talk about what GBMC is doing to identify and treat behavioral problems earlier to try and reduce the need for mental health beds.


  1. My daughter was brought to the GBMC ED by ambulance this week, and we did wait for about 30 minutes to get put in a room, and while we were waiting the ED went to Code yellow. I was most most impressed with the all the people who took care of my daughter. Registration took a few seconds because my daughter's information was already in Epic because she had recently seen her PCP. The nurses and other clinicians we worked with were very caring and compassionate, and she was discharged after about 3 hours. While I hope to never have to come to the ED again, if I have to, I will ask for GBMC.

  2. Thank you for your trust, Anonymous. I am very grateful for the hard work, expertise, and caring of our ED staff. I hope that your daughter is recovering well.

  3. Why don't you have a 24 hour urgent care center on site for people who aren't in a "911" emergency but need immediate care that cannot wait until their primary care center opens the next day? I ended up in your ER Friday night because it was after-hours and I needed care for an allergic reaction - there wasn't anywhere to go except the ER.

  4. Thanks, Saratai. I am not sure what time you had a need on Friday evening or if you called your primary care physician. Family Care Associates is on our campus and sees patients Friday evening. If they in fact were closed when you called, I am not sure what allergic reaction you had that wasn’t an emergency and couldn’t wait until the next morning? True allergic reactions can be very serious. I am glad you got care and I hope you continue to recuperate well.

  5. I recently went to Sinai's ER 7 and there were prominent signs displaying all the area Urgent Care centers that patients can go to. This minimized the ER wait dramatically, as patients turned around & went to those centers.

    I took my husband to GBMC ER at night years ago & waited first to see an assessor (which was a relatively short wait) who confirmed that he needed to be seen in GBMC ER. We subsequently waited 8 hours just to get stitches in my husband's finger, when we could have just turned around & gone to an Urgent Care center for this & been in and out within 1 hour (guaranteed), paid a whole lot less (or nothing w/insurance) & would have freed up the GBMC OR that much more. We learned our lesson that time & always go to Urgent Care centers whenever possible.

    1. Thanks for your comments, Anonymous. I would always go to my primary care office and send my loved ones to their primary care office for anything that wasn’t a true emergency because we have developed trust in our physicians and their teams. Our primary care offices do not handle lacerations so we recommend the GBMC Emergency Department. We are working on all aspects of patient flow to reduce waits and delays including getting advanced primary care for everyone to reduce waiting in all ED’s.

      I apologize to you for your husband’s wait in our Emergency Department. Our staff was working very hard but the ED was obviously overcrowded. We will continue to work to reduce unnecessary visits to the ED, to improve our ED throughput, and work to improve the outflow of admitted patients to reduce waits and delays.

  6. I completed a practicum project for my clinical informatics certificate on patients with mental illnesses who are frequent users of the emergency room. These patients often have problems connecting with a primary care provider, and the difficulty in navigating a complex health system can be impossible for people whose ability to plan and make decisions is affected by mental illness...thus leading people to just "go to the ER" when there is a problem. If we are able to help patients with mental illness connect with the medical care they need before their problems become unmanageable, we could at least reduce the number of times they present to the ER.

  7. Thank you, Peter. I agree and please watch for the next blog where I will discuss our work with Sheppard Pratt to embed behavioralists and psychiatrists in our patient centered medical home sites.


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