Accident Emergency Department: How to Reduce Patient Waiting Time

Patient waiting time is a pertinent component of the quality of healthcare services in health institutions. This paper presents a review of literature relating to several issues that surround patient waiting time. The main issues covered in the literature review include conceptualization of patient waiting time and the impacts of long patient waiting time. Other issues are the operations of Emergency Departments (EDs), the reasons for the long patient waiting time in various EDs, and proposals for eliminating the bottlenecks. The literature review will provide the foundation for further work in determining how to eliminate long patient waiting times.

Definition of Patient Waiting Time

The term “patient waiting time” carries different meanings in different works depending on usage. Different scholars use it to express different sets of periods that relate to the time it takes patients to access health services. Sinreich and Marmor (2005) distinguished between two types of waiting periods as turnaround time and patient waiting time. In their view, turnaround time was the total time the patient spent in the hospital.

On the other hand, a patient waiting time referred to the time the patient spent in the waiting areas before accessing health services. The difference between the two periods was that the turnaround time included the period that the patient spent while receiving care. In a study of six major hospitals in Israel, the total patient waiting time as defined by Sinreich and Marmor (2005) constituted 51-63% of total turnaround time.

Roper St. Francis Healthcare (RSFH, 2010) looked at patient waiting time as the time it took to admit a patient after physicians decided to admit the patient. Their local terminology for this period was the “door to bed” duration. It referred to the total time it took between the arrival and the admission of a patient (RSFH, 2010). Sullivan (2012) on the other hand used the phrase “wait time” to refer to the duration starting with the arrival of a patient and ending with the time of discharge or admission (p. 2).

The comparison of the use of the term “patient waiting time” makes it clear that the use of the term is contextual. In broad terms, it may refer to any period where a patient is inside the door of the hospital but is still within the reception of the facility. It is possible to look at it as the dormant time spent in the hospital, or the total time spent in the hospital. Any work that seeks to address the delays in inpatient waiting time must define the term to clarify the intended meaning. Otherwise, the term is open to interpretation from various scholars.

Sullivan (2012) provided four metrics for measuring patient waiting time in Newfoundland and Labrador. These metrics form a very good set of indicators relating to the main issues for consideration when conducting an analysis of patient waiting time. The metrics include the time it takes to see a doctor after arrival at the hospital and the total time a patient spends in the ED. They also include the percentage of patients who leave without seeing a doctor and the levels of patient satisfaction in the hospital. Each of them provides information relating to different aspects of the quality of healthcare services in any specified institution.

Importance of Reducing Patient Waiting Time

It is imperative to consider the reasons why it is important to reduce patient waiting time in hospitals and EDs in particular. McHugh, Van Dyke, McClelland, and Moss (2011) gave five reasons why it is important to reduce patient waiting time in hospitals. First, they pointed out that overcrowding in EDs affects the quality of healthcare. Sullivan (2012) took this issue further by stating that long patient waiting times led to overcrowding, which in turn increased the probability of making mistakes by the medical staff. Secondly, they reasoned that a long patient waiting time was costly to healthcare facilities because of lost revenue.

This occurred when patients left before seeing a doctor or when a hospital diverted ambulances to other hospitals. Thirdly, it was becoming mandatory for hospitals to report on their patient waiting time as a precondition for receiving funding (McHugh et al., 2011). American hospitals were going to start reporting their crowding statistics to Medicare and Medicaid centers. This report would in turn have an impact on the prospects of receiving funding from these two sources (McHugh et al., 2011). This approach of reporting on the patient waiting time was also due for implementation in Newfoundland and Labrador (Sullivan, 2012).

The fourth reason was that crowding in the ED compromised community trust (McHugh et al., 2011). This meant that the confidence of the people who accessed health services in a hospital was reduced if there was a long patient waiting time. Finally, McHugh et al (2011) argued that crowding in the ED is something that hospitals could control. Therefore, there was no excuse to allow it to happen. All the literature reviewed proposed various solutions to the problem of long patient waiting time, which was a basis to believe that all the authors agreed that it is possible to control the problem.

Activities in the EDs

Emergency rooms receive patients who are experiencing a condition that requires immediate attention. A medical emergency does not have to be life-threatening. Similarly, not all life-threatening conditions qualify as emergencies. This is why many EDs try to prioritize the severity of emergencies. In this sense, an emergency room serves as a sorting center of sorts for assessing the condition of arriving patients. The staff members in the ED then decide whether the patient needs treatment and discharge, treatment and admission, or treatment and referral.

Hospitals classify the urgency of dealing with each patient. Usually, patients with life-threatening medical conditions such as stroke or cardiac arrest receive immediate attention (Santibanez, Chow, French, Puterman, & Tylesley, 2008). Secondly, those with serious health conditions such as asthma attacks are second. The third level of priority is for patients with minor health issues such as flu or fever.

After arrival in the ED, a patient goes through registration, nursing assessment, consultation, investigation, and treatment (Sullivan, 2012). Any delay in these processes leads to an increase in patient waiting time. These stages are not necessarily sequential. In some cases, a patient goes back for consultation after investigation. These iterations occur whenever an issue requires more attention than is available initially.

Causes of Long Patient Waiting Time in EDs and Other Departments

Long patient waiting times may result from a single cause or a combination of factors. Long patient waiting times can affect any department within a hospital. The common element that underpins all delays in the provision of healthcare services is an increase in the arrival rate of patients without a corresponding increase in the rate of service. This is in line with Little’s Law that predicted that as long as the rate of arrival of patients exceeds the rate of service, overcrowding would occur (Sinreich & Marmor, 2005). Overcrowding is one of the main symptoms of long patient waiting times in hospitals. In turn, overcrowding increases patient dissatisfaction and affects the morale of staff. However, patients can experience long patient waiting times even in cases where there is no visible overcrowding in waiting areas.

The main causes of delay in service provision in EDs include unsuitable levels of staff in the hospital, and unclear roles and responsibilities among staff members (RSFH, 2010). Other factors include long distances between interdependent facilities, and the unsuitable layout of the ED (Sinreich & Marmor, 2005). Sullivan (2012) concurs that staffing levels, as a factor that influences patient waiting time, affect the rate of service provision.

In addition, Sullivan (2012) states that the layout of a health facility can increase the patient waiting time. Inappropriate staffing levels, in this case, may mean that the facility does not have adequate staff or that there is poor optimization of shifts. The layout affects the ease of access to equipment and supplies. This adds to the patient waiting time significantly by increasing the time hospital personnel needs to access the equipment.

The patient waiting time in surgical services departments mainly arises from a variable number of patients per day. The number of patients scheduled for surgery changes daily. In days with high demand, patient waiting time increases (McHugh et al., 2011). A situation very similar to this one occurs at the British Columbia Cancer Agency, where the number of appointments to see physicians vary daily (Santibanez et al., 2008). The facility also has severe space constraints since it also acts as a teaching and research center (Santibanez et al., 2008).

Another reason for crowding is an underestimation of the time it takes to handle an appointment by physicians (Santibanez et al, 2008). In situations where this occurs, the problem is that there is insufficient information available to the physician regarding how many patients can see him in a single day. Allocating too little time results in crowding because of delays in providing health services.

Many countries do not have benchmarks associated with patient waiting time, thereby preventing efforts to find ways of reducing the patient waiting time in EDs (Sullivan, 2012). Lack of standards makes it very difficult for regulators to enforce measures that would ease the congestion problems in hospitals. The setting of benchmarks by international and regional health agencies can help to ease the problems.

Options that Exist for Reducing Patient Waiting Time in EDs

To reduce patient waiting time in EDs, McHugh et al. (2011) proposed the formation of a patient flow team to handle patient flow issues on an ongoing basis. The team should include at least one member from departments that handle patients directly. It should also include at least one member of senior management such as the head of quality assurance. Partly, this stems from the realization that ED crowding is a system issue, not localized to the ED.

All the services in the hospital have a bearing on the speed with which the ED can handle patients. Similarly, Sullivan (2012) advocated for system-wide efforts in the reduction of patient waiting time in the ED. Other departments such as X-rays and laboratories may increase the patient waiting time by a wide margin if they are not actively involved in addressing long patient waiting times. Any efforts to improve the patient waiting time need to involve all departments in the hospital.

A modern approach to the design of EDs is the use of smaller waiting rooms adjacent to the relevant consultants to reduce crowding. This measure does not eliminate long patient waiting time, but it reduces the impacts of crowding (Santibanez et al., 2008). Crowding is one of the negative effects of long patient waiting time. It increases the anxiety that patients experience as well as the tension that health workers handle.

A simple solution for dealing with long patient waiting times is to enforce the start time of appointment-based departments such as oncology centers (Santibanez et al., 2008). A late start affects all the subsequent appointments during that day. This method worked in BCAA because starting on time ensured that each patient who came in good time did not have to wait for Oncologists to clear a backlog of appointments.

An interesting solution to the long patient waiting time proposed by Sullivan (2012) was to increase the number of community-based doctors and satellite clinics. This is a viable way of reducing patient waiting time since these clinics can handle some patients heading for the ED. The downside is some patients will still insist on coming to the main hospitals because of the feeling that they will get better care from a team of specialists at the ED.

Another novel solution proposed by Sullivan (2012) in the context of the literature reviewed was greater public involvement in improving patient waiting time by holding discussions on how to improve patient waiting time.

Methods in Use to Reduce Patient Waiting Time

There is a need to find solutions that solve the problem of a long patient waiting for time based on the understanding that turnaround time influences patient satisfaction with service in the ED. Usually, patients want services on demand. They want services as soon as they arrive in the ED irrespective of the severity of their condition (RSFH, 2010). RSFH (2010) found that they could reduce the total time in the ED by centralizing the reporting of patients discharged. This made it easier for the ED staff to know which beds were available, and which ones would be available shortly. This made it possible for them to reduce the total time it took to admit a patient after arrival in the ED (RSFH, 2010).

Another strategy used by RSFH is staggering the timing of shifts for the staff. This enables the facility to avail the correct number of personnel to handle patients depending on demand fluctuations. The methods applicable to any institution largely depend on the local factors. These solutions work for different institutions depending on the severity of the causes of long patient waiting times. Every institution must examine its own needs and situation before adopting a solution to long patient waiting times.

References

McHugh, M., Van Dyke, K., McClelland, M., & Moss, D. (2011). Improving Patient Flow and Reducing Emergency Department Crowding: A Guide for Hospitals. Rockville, MD: AHRQ.

RSFH. (2010). Quality Improvement Initiatives: Reducing Emergency Room Wait Times. The Consult , pp. 3-7.

Santibanez, P., Chow, V., French, J., Puterman, M., & Tylesley, S. (2008). Reducing Patient Wait Times and Improving Resource Utilization at BCAA’s Abulatory Care Unit through Simulation. Vancouver: Canadian Institute of Health Reseach.

Sinreich, D., & Marmor, Y. (2005). Ways to Reduce Patient Turnaround Time and Improve Service Quality in. Journal of Health Organization and Management , 88-105.

Sullivan, S. (2012). A Strategy to Reduce Wait Times in Newfoundland and Labrador. Newfoundland: Department of Health and Community Services.

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