ED Wait Times Rising, Even in the Most Urgent Cases

December 2009

By Mary Ann Moon
Elsevier Global Medical News

Patients presenting to the emergency department have only a 75% chance of being seen by a physician within the time recommended at triage, according to a report in the Archives of Internal Medicine.

This represents a 30% increase in ED waiting time during the past decade.

"Most distressingly," waiting time has increased the most for the very patients who can least afford it: More than half of patients judged at triage to require immediate physician assessment have to wait, said Dr. Leora I. Horwitz of Yale-New Haven (Conn.) Hospital and Elizabeth H. Bradley, Ph.D., of the Yale School of Public Health, also in New Haven.

The investigators used data from the National Hospital Ambulatory and Medical Care Survey to assess trends in ED waiting time since a previous report on the issue, reviewing cases seen from 1997 to 2006. The NHAMCS is a probability sample of general hospitals in the United States in which each hospital collects data on a random sample of ED visits during 4-week period every year.

For this study, the researchers assessed a sample of 151,999 ED visits, which represents 539 million visits across the nation.

In 1997, the odds of being seen by a physician within the time recommended at triage were 80%. This has declined during the intervening years for all patient groups.

"Although African American, Hispanic, and uninsured patients were less likely than white or privately insured patients to be seen on time in any given year, all patients suffered similarly from a decreased likelihood of being seen on time during the study period," Dr. Horwitz and Dr. Bradley said (Arch. Intern. Med. 2009;169:1857-65).

Greater acuity of illness was strongly associated with a longer wait time. Of patients judged to need physician assessment within 0-14 minutes, only 57% were seen in that time frame. Similarly, only 73% of patients who required hospital admission were seen within the recommended time.

There likely are many causes for this trend. Per capita use of the ED has risen substantially during this period, from 34 visits per 100 people in 1996 to 41 per 100 in 2006. However, "excess use of the ED for nonurgent care by uninsured patients is not a major factor, accounting for only 0.5% of visits in 2006," they noted.

"Similarly, excess use by black and Hispanic patients for nonurgent care relative to white patients accounted for only 1.1% of all ED visits in 2006."

Instead, "it appears that decreased access to primary health care for all patients and an aging population are more important contributors to the per capita increase in ED utilization." Patient volume has risen by 32% while many EDs have closed, Dr. Horwitz and Dr. Bradley said.

In addition, many EDs still use older, less accurate three-tier systems for triage instead of newer five-level systems, leading to less efficient prioritizing of the most acutely ill patients. Higher overall hospital occupancy rates mean that patients cannot be transferred from the ED to the appropriate inpatient wards in a timely manner.

No financial conflicts of interest were reported.


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