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.