RUNNING HEAD: Improving Emergency Department Wait Times for Non-Urgent Patients
Improving Emergency Department Wait Times for Non-Urgent Patients
University of Central Florida
NGR 5720
Andrew Lindeman

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Improving Emergency Department Wait Times for Non-Urgent Patients
Executive Summary
Emergency Department wait times are longer than ever and are only expected to only get worse. In a 2009 report published by The Government Accountability Office, the average wait time to see a physician is more than doubled the recommended time. (2009) Current literature, multiple governmental agencies, and hospital organizations around the world are looking at ways to decrease these times with innovated designs. Instituting mid-level providers like Advanced
Registered Nurse Practitioner(s) (ARNP) and Physician Assistant(s) (PA) into Emergency
Departments is fundamental. Having dedicated rapid treatment areas is one of the vital ways to reduce ED wait times, improve treatment modalities, and maintain patient satisfaction scores.
This paper will examine the benefits of instituting a rapid treatment unit (RTU) with the recommendations set forth by Press Ganey. Press Ganey Associates is an organization who works with health care organizations to improve a number of clinical outcomes in all areas. With their team and a rural hospital’s outdated ED processes with lengthy ED times, we will examine the benefits of utilizing such recommendations. Benefits of utilizing this type of process won the
“Innovation Award”, from the Florida Association of Hospitals, and decreasing the average length of stay from 230 minutes to 90 minutes during the first 9-month transformation. This also helped improve the health care workers attitudes and atmosphere.

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Improving Emergency Department Wait Times for Non-Urgent Patients
Background & Significance
Each year across the United States, emergency departments (ED) continue to see a rise in
ED visits. According to the Centers for Disease Control and Prevention, last year, 129.8 million patients were seen across the U.S. in emergency departments. (CDC, 2014) These estimates are expected to rise anywhere from 5-10% per year with no cap in sight (CDC, 2014). Each year
Americans make close to 4 medical visits per year per person.(CDC, 2009) These numbers are staggering, especially with the rising costs of medical care, a blooming aging population and the shortage of health care providers.
Emergency Departments are being bogged down by an influx of patients. In a 10-year study from 1996 to 2006, medical visits including physician offices, hospital outpatient settings and emergency department increased by a whopping 26%, which is 15% higher than the growth of the U.S population. (CDC, 2009) Wait times are increasing in all areas of hospital organizations. The Government Accountability Office published a report indicating that the average amount of time waiting to see a physician in emergency departments is doubled the recommended time. (2009) According to the Centers for Disease Control and Prevention, only
25% of patients are seen within 15 minutes. (2014)
With the influx of patients seen on a regular basis across the United States within emergency departments, new processes are being innovative to improve efficiency, times, and treatments. One such way is the development of treatment units designed to treat specific groups of people within emergency departments. Other processes include free standing clinics, urgent cares, stand-alone emergency departments, clinics located within pharmacies and the ever expanding roles of primary physician offices and new units within hospitals. Mid-level providers

Improving Emergency Department Wait Times for Non-Urgent Patients have also been utilized to try and take some of the burden off of the physicians. These are the
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Advanced Registered Nurse Practitioner(s) (ARNP) and Physician Assistant(s) (PA) whos roles have changed over the last few decades. These roles have extended them from the typical assistants in assisting physicans in procedures and tasks to a more “provider” role in treating, prescribing, and diagnosising all elements of a patient. These roles are being capatilized in all areas of hospital organizations.
Introduction
South Lake Hospital is located in the southern part of Lake County Florida. This nonprofit hospital serves a rural/ suburban area. This hospital was founded in 1947 as a 9-bed clinic to, “provide quality healthcare services to promote healthy lifestyles to his community”. (South
Lake Hospital, 2010, par.3) Since its first day of service, the community in which it serves has grown and services have been expanded. Now this hospital is a 180 acre health, 122 bed hospital and wellness center, which provides numerous services including an emergency services
(department), orthopedic services, cardiac services, surgery center, laboratory, a women’s center and a wound care center, along with many others.
In 2013, the Emergency Department saw 49,158 patients with its 29 bed ED. It was becoming apparent that censuses were increasing, patient satisfaction scores were at an all-time low, attitudes among ED staff were unfavorable, and ED wait times were at an all-time high.
With the assistance of Press Ganey, representatives were brought in to assist the emergency department managers into trying to deal with these issues.

Improving Emergency Department Wait Times for Non-Urgent Patients
Identification of the Problems
When trying to fix the issues that this emergency department was facing, you must first properly identify the issues. Once the issues were identified, a systematic approach was implemented. The representatives and management was able to idenitfy a few issues right from the beginning. These included that our non-urgent patients (ESI level 4 and ESI level 5) were expereinceing extended wait times. Emergency Severity Index (ESI) is a triage tool used in emergency departments to identify the urgency of patients. A level 1 is the most critical (cardiac arrests, imminent respiratory arrest, etc.) through level 5, with 5 being the least critical
(perscription refill, referral, etc). When times were systematically reviewed for these patients
(ESI 4 and ESI 5), they were dramatically way to long. The current process for these patients, was to mix them in with the urgeny patients scattered throughout the emergency department.
There was a separate “Fast track” area with 5 beds, in which a nurse was assigned to these, however during staff interviews with management and Press Ganey respresentatives, this was a high burden to deal with, even though the acuity of these patients were low. This “Fast Track” area did not have an assigned provider, the patient’s chart was just mixed in with all the other severity patients and simply placed in order of their arrival to the bed. It was also identified that these patients (ESI 4 and ESI 5) were typically ambualtory, did not need to be monitored, and did not need to have there own stretcher and or necessarly always change into a gown. These simple identifications, made it easy to identify that each patient didn’t always need their own room. If they did need to utilize a room it was for a short proceudre or exam.
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Improving Emergency Department Wait Times for Non-Urgent Patients
Evidence
It is estimated that between 60%-80% of all patients that present to emergency departments with the United States are non-urgent type patients. (Carter & Chochinov, 2007)
With the help of Press Ganey, a 9 month review of ESI levels showed that close to 36% of patients triaged at South Lake Hospital were triaged into level 4 or level 5. An analysis of times were also calculated for these patients: Average arrival to bed ESI Level (4) 37 minutes and ESI
Level (5) 35 minutes; bed to provider ESI Level (4) 20 minutes and ESI Level (5) 19 minutes; provider to disposition Level (4) 85 minutes and ESI Level (5) 36.5 minutes. (Press Ganey,
2013) Patient satisifaction scores were also compared. Data showed that during these high census times, patient satisifaction scores were typically ranging in the low 80s. With the above information, management, the staff and providers knew something needed to be done in order to rapidly treat and discharge these patients.
Goals
Not only were ESI level 4s and ESI level 5 patients taking to long to get to and get through the system, but every level was. In order to try and address these issues, goals were developed. These goals included: door to bed on all patients <20 minutes, bed to provider < 20 minutes, provider to disposition on all patients <130 minutes, ESI level 4 and 5 turnaround <75 minutes.

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Improving Emergency Department Wait Times for Non-Urgent Patients
Supporting Literature
In 2007, Dr. Alix Carter and Dr. Alecs Chochinov conducted a systematic review of wait times, patient satisifaction and the quality of care and cost effectiveness of the utilization of
Nurse Practitioners in emergency departments. Data showed that with the utilization of NPs, wait times were reduced, satisifaction scores were increased and the quality of care was just as equal to the quality of care by physicans.
Another study in 2007, a case control study, led by Dr. Considine of Deakin University in Australia studied the effects of utilizing fast track type systems in emergency departments.
This study focused on the average length of stay for non-admitted patient. This 3 month study showed that non-urgent type patients had a significantly higher incidence of discharge within 2 hours (53% vs 44%) and 4 hours (92% vs 84%) compared to the control study. This study also showed that fast track type patients decreased the average length of stay without compromising other emergency departments wait times.
Another study located in Australia in 2011, a team of nurses collabrated on evaluating emergency nurses role in a specific emergency department treatment zone (RITZ). This study was a descriptive exploratory study which audited 193 randomly selected patient charts. This showed that with the utilization of RITZ, this was an effective management stragety for certain types of patients. The results showed that the average waiting time was approximately 23 minutes and 85.5% of patients were discharged within 4 hours. (Consicdine et al., 2012)

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Improving Emergency Department Wait Times for Non-Urgent Patients
These studies show that with the utilization of specific units within emergency departments, waiting times can be decreased, treatment can be initiated faster and patients can be discharged quicker.
Implementation of the Plan
In 2010, South Lake Hospital Emergency Department decided to go with a dedicated rapid treatment unit (RTU). Unlike typical fast track areas, this RTU would have 1 room, a dedicated registered nurse, a mid-provider (ARNP or PA) and the primary doctor working with the mid-level would be identified to ensure rapid discharging. This process needed to be implemented right from the beginning of the patient encounter into the emergency department.
First when patients arrive in the ED, they speak with a registration nurse, who can rapidly identify if this is a potential RTU patient, the triage nurse would then confirm this with a set of vital signs and their chief complaint.
Inclusion and exclusion criteria needed to be identified. The inclusion criteria are: ESI 4 and 5, Age 3 months to 65 years of age, URI/ viral syndrome, sore throat, ear ache, cough (no significant dyspnea or comorbid conditions like CHF, COPD), simple rashes, toothaches, minor eye complaints (no foreign bodies or contact lenses), minor back pains, neck pain without trauma, medication refills, minor wounds including simple suturing, request for pregnancy tests or sexual transmitted diseases in males, othopedic injuries without obvious deformity with normal neurovascular exam and simple abscesses.
Exclusion criteria are: all infants less than 3 months of age, sick children with fever greater then 103 F, abnormal vital signs, lacerations involving complicated suturing, chronic

Improving Emergency Department Wait Times for Non-Urgent Patients back pain, patients who failed outpatient therapy (seen for pneumonia and sicharged with antibiotics who are back), intrevenous or intramuscular pain medicaitions.
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The trapid treatment unit had to have its own flow process as well. It was identifed that we did not want RTU patients to be waiting in the same area as other patients. We developed an internal waiting room for these patients. This following process was developed: patient arrives, quick registeration and primary triage, escort patient to RTU exam or internal waiting room, RN and provider perform focused assessment, place orders, initiate documentation, if testing is ordered the patient then returns to waiting room to wait for pending results, once results are received then patient returns to RTU exam rom where providers and RN discharge patient, patient then excorted to registration to ensure all proper documentation with insurance and demographic information is obtained and then patient leave the emergency department.
Results
It was a challenge at first. Chaning old behavior is a science all in its self. When first implementing this process, it was difficult to change from the old “fast track” thinking to this new “RTU” thinking. RTU patients are essentially easier less urgent then fast track type patients.
The triage nurse and screening nurse had even more responsibilities in trying to properly identify these patients within minutes of their arrival, which isnt always so easy, also radiology and lab orders needed to be ordered and done as soon as possible to facilitate the entire process.
Within a few months, it was evident in the atmosphere that the process was doing well.
Staff attitudes increased, waiting times decreased and patient satisifaction scores increased.
Wihin 9 months the average length of stay went from 230 minutes to 90 minutes for ESI 4 and

Improving Emergency Department Wait Times for Non-Urgent Patients
ESI 5 patients. Sotuh Lake Hospital was awarded the
“Innovation Award”, from the Florida
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Association of Hospitals. Our patient satisifaction scores increased from the low 80s to the low and middle 90s. Emergency Department satisifaction scores arent typically to well to begin with, however these 10 points, really proved a lot.

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Improving Emergency Department Wait Times for Non-Urgent Patients
References
Carter, A. E., & Chochinov, A. H. (2007). A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in
the emergency department. CJEM: Canadian Journal Of Emergency
Medicine , 9 (4), 286-295.
Centers for Disease Control and Prevention (2009) Americans make nearly four medical visits a year on average. Retrieved November 21 st
, 2014 from http://www.cdc.gov/nchs/pressroom/08newsreleases/visitstodoctor.htm
Centers for Disease Control and prevention (2013) Emergency Department Visits- data are for the U.S. Retrieved November 21 st
, 2014 from http://www.cdc.gov/nchs/fastats/emergency-department.htm
Considine, J., Kropman, M., Kelly, E., & Winter, C. 2008 Effect of emergency department fast track on emergency department length of stay: a case- control study. Emergency Medicine Journal , 25 (12), 815-819.
Considine, J., Lucas, E., Martin, R., Stergiou, H. E., Kropman, M., & Chiu, H.
(2012). Rapid intervention and treatment zone: Redesigning nursing services to meet increasing emergency department demand. International

Improving Emergency Department Wait Times for Non-Urgent Patients
Journal Of Nursing Practice , 18 (1), 60-67. doi:10.1111/j.1440 172X.2011.01986.x
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Hospital emergency departments [electronic resource] : crowding continues to occur, and some patients wait longer than recommended time frames : report to the Chairman, Committee on Finance, U.S. Senate / United States Government Accountability Office . (2009).
[Washington, D.C.] : U.S. Govt. Accountability Office, [2009].
Press Ganey (2013) Emergency Department- South Lake Hospital.
South Lake Hospital (2010) South lake hospital: redefining healthcare: about South Lake
Hospital. Orlando Health. Retrieved November 21 st
, 2014 from http://www.southlakehospital.com/AboutUs/tabid/56/Default.aspx