Can posting ER wait times be dangerous to patients?

You’ve probably experienced that age-old ritual of cooling your heels in an ER waiting room hoping that it won’t be too many hours before a nurse lets you inside the sliding doors.

Simon Bradley tweeted this to my Twitter Account @WCBADoctorBrian: “My buddy had a deep laceration between the thumb and the index finger – a full layer of skin.  Took 10 hours at (name of hospital withheld), fastest in town.”

A growing number of Emergency Rooms in the United States have taken the consumer-savvy step of posting their wait times in an effort to speed things up.  Scottsdale Healthcare in Arizona operates four emergency departments.  Every three minutes, Scottsdale gives patients a fairly close estimate of how long they can expect to see a doctor, a physician assistant or a nurse practitioner at one its four ER sites. The times are posted automatically on electronic billboard as well as the hospital’s web site.  Henrico Doctors’ Hospital in Virginia posts wait times on a huge billboard located outside the hospital.  A growing number are doing it right across the US.

Hospitals in the US see posting wait times as a way to beat out the competition by boasting they see patients in the ER faster.  In addition, companies that operate chains of Emergency Rooms find that posting wait times smoothes out patient demands for ER services by encouraging patients to visit an ER that has a shorter wait time.  Some Emergency Rooms are posting wait times to embarrass the hospitals in which they’re situated into doing more to shorten the wait.

In Canada, there’s no competition for patients.  Emergency Rooms are a bit behind the curve.  Some loosely keep track of wait times so they can keep patients in the waiting room better informed.  In Ontario, where I practice, the province has set a target of being seen and treated within 4 hours of arriving with a minor problem and 8 hours of arriving with a major medical problem.  In that province, you can log onto a web site and find out how often the hospital ER you go to sees patients within a prescribed or recommended maximum amount of time.

In British Columbia, the provincial government recently announced $22 million in financial incentives for Emergency Rooms that shorten the wait.  So far, I’m not aware of any Emergency Rooms that put wait times on web sites and social media in a way that could influence the behavior of people who are thinking of going to the ER.  However, I am aware of urgent care centers in Canada that do post wait times.

The idea of arming potential patients with information on wait times seems like a smart nod to consumers.  Clearly though, there are risks involved.  No doubt Emergency Rooms that shorten the wait get bragging rights.  But I want to know what they do to shorten the wait.  My fear is that they’ll cut corners.  Just shortening the encounter between patient and health care professional to 5 or 10 minutes can shorten the overall wait, but at what cost to the quality of the visit?

My biggest fear is that posting wait times could lead patients to make inappropriate and perhaps even fatal decisions.  I can well imagine a patient with chest pain checking on the Internet and finding that the hospital closest to him has a 40-minute wait, while the second closest hospital 15 minutes farther away has a three-minute wait.  He decides to drive across town to the farther hospital and suffers a fatal heart attack during the trip.

Patients need to be aware that the ER queue is not ‘first come, first served’.  Life threatening problems get seen right away regardless of the length of the queue.  I’m also concerned that posting long wait times will discourage patients with potentially life-threatening problems from coming to the ER at all.

To me, the posting of ER wait times is emblematic of a larger issue.  Those who work in Emergency Rooms must re-double their efforts to connect with patients.  They need to demonstrate that they care about patients as people, not just as diseases.  They need to understand that wasting patients’ time in the ER is a serious inconvenience to them.

The one thing they should never do is discourage patients from coming to the ER.

Adapted from a blog post that appeared on White Coat, Black Art.

Brian Goldman is an emergency physician and author of The Night Shift: Real Life In The Heart of The E.R., published by HarperCollins.

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  • http://natickpediatrics.net Rob Lindeman

    “Those who work in Emergency Rooms must re-double their efforts to connect with patients. They need to demonstrate that they care about patients as people, not just as diseases. They need to understand that wasting patients’ time in the ER is a serious inconvenience to them.”

    Proposed Edit: “Those who work in primary care must re-double their efforts to connect with people. They need to demonstrate that they care about “patients” as people, not just as diseases. They need to understand that wasting people’s time in the ER is a serious inconvenience to them.”

    REPEAL EMTALA

    • Brian

      Throwing the baby out with the bathwater, are we?

  • http://natickpediatrics.net Rob Lindeman

    MIssing the point, we are! Okay, let’s cut the Yoda-speak: The part of EMTALA that needs to be repealed is the mandate to see all comers. That doesn’t make good rhetoric, so I keep it short. Let’s throw out the bath water and keep the baby, k?

    The point of my response is that people with non-emergent complaints should be managed by their physicians. Too many of us abdicate our duty to treat by sending people to see you. It sounds non-controversial proposition, but many of my colleagues (pediatricians) do not appear to agree.

    • Anon EM doc

      EMTALA says all comers must be provided with “an appropriate medical screening examination” to determine if he is suffering from an “emergency medical condition.”

      It doesn’t say that we have to fix all your problems with a smile in 30 minutes or less. If you can be triaged appropriately to a local urgent care center, in my opinion you should be.

      That’s where we’re messing up; not telling people “no” when it’s appropriate to do so.

  • Rob Lindeman

    I’ll second that. Problem is, I don’t believe EMTALA allows such triage (someone correct me if I’m wrong). Also, triage would cause hospitals to lose the visit and procedure charges, not to mention the possibility of scoring admissions

    • Jman

      I believe it calls for a screening exam and stabilizing treatment before discharge or transfer. Unfortunately, admissions don’t mean much if you don’t have insurance.

  • http://survivingtheemergencyroom.blogspot.com/ Ron Clark, M.D.

    EMTLA requires a medical screening exam and the provision of stabilizing medical care for unstable medical conditions. If the patient is not unstable, then EMTLA does not apply. The problem is that once the patient is being seen in an ER, regardless of whether they are stable or not, ER staff should not send them “somewhere else” (ie urgent care center) without properly informing that medical provider (anti-dumping law). Some would say if the patient is not unstable, EMTLA does not apply and they would be correct, but the medical staff refusing care would be playing with fire. -Ron Clark, M.D. — author of “Surviving the Emergency Room (Amazon.com)

  • Smart Doc

    EMTALA, Medicaid, and other Freeloaders waiting time:

    “If it is not a real emergency, you will be the last served.”

  • http://ethicalnag.org/2010/09/29/cardiologists-implant-unnecessary-stents/ Carolyn Thomas

    “…a target of being seen and treated within 4 hours of arriving with a minor problem and 8 hours of arriving with a major medical problem…”

    Did I read that right? Are you actually saying that in Ontario, the target is to have a minor problem tended to twice as fast as a MAJOR medical problem?

    Makes me kinda glad I decided to have my heart attack here in B.C. Please tell me that’s just a typo.

  • http://www.impatient4change.blogpsot.com Every Patient Matters

    Interesting choice of topics for Dr. Goldman to cover, given the poor wait times track record in his own city.

    In fact, in a hospital he is familiar with, one can wait 5 hours with appendicitis to be seen, 17 hours to get a catscan (showing it burst), 24 hours to get antibiotics, 42 hours to get transferred to the in-patient surgical ward, 48 hours to see one’s staff surgeon, and over five months to get an appendectomy.

    In that same hospital, another patient was hunched over in pain and sobbing as she bled shortly before she was to deliver her baby. Her husband paced up and down and demanded of the triage nurse, when would she be seen? In Iran, his home country, his wife would have been seen immediately, but here she was waiting hours. The triage nurse, of I think the well-meaning but burned-out variety, shouted, “If you don’t like it, call your MPP! (Member of Provincial Parliament, our political representative in Ontario) It’s only going to get worse!” You could see that it tore at her, knowing that it was not ok, but she couldn’t change things, and with an aging population, our system is in decline.

    In fact, at some Toronto hospitals, full ambulances can be seen waiting with their desperate patients.

    Is Dr. Goldman blaming the triage nurse, telling her to “re-double [her] efforts to connect with patients,” to “demonstrate that [she] cares about patients as people, not just as diseases”, to “understand that wasting patients’ time in the ER is a serious inconvenience [sic] to them”?

    Well, Dr. Goldman, I disagree. I don’t think it was that triage nurse’s fault. I think the couple needed a doctor, not a soother.

    Sometimes it is the triage nurse’s fault, though. In the first case (of the appendix), that triage nurse graded the situation as 4/5, obviously incorrectly. And that may have contributed to the inordinate wait time.

    And sometimes the triage nurse could be nicer. I’ve seen one yell at a woman who was probably in her ’90′s, because the tiny woman did not want to leave when discharged (she said she was still sick and didn’t get the help she needed).

    Dr. Goldman ends with, “The one thing they should never do is discourage patients from coming to the ER.”

    Again, Dr. Goldman, I disagree. I think there are many things hospitals should never do, and one of them is misrepresent to the public how severe our wait times problem is. It’s bad, much more than an “inconvenience”. Let’s deal with it.

  • http://www.impatient4change.blogpsot.com Every Patient Matters

    In the interests of disclosure, I should say that I attended a town hall led by Dr. Goldman for his radio show “White Coat Black Art” in the fall.

    During the event which lasted longer than two hours, Dr. Goldman’s team never found time for my question, “Do you think we should have Ombudsman oversight over hospitals in Ontario?”

    The questions were pre-screened and I was left to wonder if I was the only one with a question about accountability, or if other folks with similar questions were also excluded from the discussion.

    The issue of oversight does relate to wait times because we might ask the Ombudsman to have a look at Ontario’s wait times strategy, if only the government would let him have jurisdiction. But the hospitals continue to lobby against oversight, and so we continue to be the only province without it. Wait times will have to wait, I guess.

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