Wait times in an Emergency Department have become longer and cause increased risks for hospitals. Patients who are not immediately screened and treated pose a threat of worsening of their symptoms. Hospitals have seen deaths in their waiting areas due to back log and the inability to screen and have the patient seen by a medical provider in a timely manner. These issues not only cause harm to patients but can impact the financial status of a hospital. Hospitals that depend on the Emergency Department for admissions are at the greatest risk of negative financial impacts. High occupancy rates engender chronic bed shortages, which are further exacerbated by unpredictable patient arrivals. While departments can identify their high utilization times, it is hard to predict the type of patient that will arrive at their doorsteps. In addition to potential risks, large wait times lead to patient dissatisfaction and a loss of business. Boarding is a well$-$described phenomenon within the emergency department $($when patients often stay for several additional hours while awaiting hospital admission due to a lack of available inpatient beds.

The hospital to be examined is an inner$-$city hospital with a residency program. It is licensed for $150$ inpatient beds. The payer mix is $65\%$ Medicaid patients, $37\%$ Medicare patients, and $3\%$ private pay or uninsured. The hospital is part of a larger health system.

The hospital is experiencing $5$ years of negative profit margins. The emergency department is the primary source of patient admissions. It is a $14-$bed unit that sees $47,000$ visits a year. Patients are often seen in the hallways due to overcrowding.

The admissions from the emergency department account for $97\%$ of the total admissions. The unit is overwhelmed with patients leading to significant issues. Patient experience scores are in the lower quartile. The left without treatment rate in the Emergency Department is $12\%.$ This means that patients register and are triaged but leave before they can be seen by a physician or physician extender. These patients or their insurance cannot be billed for any care or time that was provided since there was no medical screening. This is a loss of revenue and patients if the patient goes to another hospital.

The average time for a patient in the emergency department is $5(1)/(2)$ hours. The time to admission for ICU patients is on average $12$ hours. The time for a medical$-$surgical admission is $8$ hours. Additional time information includes:

Time from registration to triage is $8$ minutes

Triage to a bed in the Emergency Department is $12$ minutes

Time from going into the emergency department to seeing a medical provider is $20$ minutes

Time from being seen by a medical provider to decision to admit or discharge is $4$ hours

Time from decision to discharge to leaving the emergency department is $1$ hour

Time from decision to admit to a regular be is $3(1)/(2)$ hours

Time from decision to admit to an ICU bed is $7(1)/(2)$ hours.

The hospital is experiencing an over budget situation for salaries in the emergency department. This is largely made up of overtime costs for registered nurses. There is a high turnover rate for physicians. This is due to burnout and the intensity of the work. Recruitment costs for an emergency physician is $$85,000$ to $$100,000$ per physician. The salaries for the physicians are within the $65$ percentiles for the area.

The hospital occupancy is $85\%.$ The length of stay is above the geometric mean for the acuity and diagnoses that they see. This means that patients are staying longer on average than the same type of patients in other hospitals.

The average stay in the ICU is above the national average. The boarding of ICU patients is a frequent situation due to high occupancy on the general floors. The ICU is starting to discharge patients from their unit.

The discharge process on the general floors is complex. There are rounds in the morning with residents to identify potential discharges. The attending physicians then round and confirm that the patient can be discharged. Case management then arrives to handle the discharge. The average time to discharge a patient is $8$ hours with most discharges occurring after $1$ PM$.$

The CEO has asked the senior leadership to address the issue of Emergency Department wait times. They are looking for potential solutions. There needs to be short$-$term fixes and long$-$term solutions.

What questions should the team be asking and what approach should they take? The biggest question is whether they should enlarge the Emergency Department? Will this address the issue?

As you consider this case, think about the information you have been given?

Which areas might be addressed in the short$-$term to improve the patient flow?

What are the barriers to decreasing the wait times?

What processes can be improved?

What recommendations would you make to the CEO?

Short term recommendations

Long term recommendations