Saturday, April 5, 2008

ER Wait Times lowered by Appointments

Can ER wait times be lowered by having appointments? Before someone like Gruntdoc rips me a new one, hear me out. In 1999 I moved out of the big city and started working in some smaller hospitals including an 18 bed, single level hospital in south-western Ontario. One weekend a patient paged to tell me that he had a problem and had called the emergency department and was going to meet the doctor there at 2pm. We do the same thing in our clinic. When a patient is referred for an emergency (pain, infection, facial fracture) we don’t usually tell them to come over and wait, we find the best available time. In fact, Ontario statistics show that the smaller the hospital, the lower the ER wait time.

So why don’t emergency rooms use the same approach to lowering ER wait times? There’s the obvious argument that people seeking care in the ER have, by definition, emergencies which can’t be scheduled. Yeah right. And a Nigerian businessman tells me the cheque’s in the mail. Some ER’s see up to 70% non-emergency cases. And in my experience, another 20% don’t need the rest of the hospital, just the emerg. That leaves 10% that really can’t be scheduled in.

For the usual load of minor cases that need to be seen within 24 hours but not urgently why not schedule them?

Here are the advantages as I see it:
Control – there are ebbs and flows to the day that you can predict (after-school crowd, after-bar crowd, knife & gun club, etc….). More elective patients can be scheduled lighter or heavier during certain times of days.
Patient Satisfaction – even though the total wait may be longer, most of it will be spent at home so their satisfaction will go up. The total wait to the patient may be the same (so there is no additional burden on the system) but the perceived wait will be less and the patient flow in hospital will improve.
Phone Triage – to either divert someone to a walk-in clinic or arrange for a standing order (e.g. for x-rays).

The down side is that the person staffing the phones would have to be expert in scheduling and comfortable following direction regarding which patients need to come right in. There would have to be a process-flow diagram before the patient can be given an appointment to prevent delaying care to a true emergency. I have a nightmare scenario where someone calls for an appointment for chest pain and is stupidly given one 12 hours later. One could make a good argument to have a triage RN on the phone as well.

Technology would have to be heavily relied upon to track patients. There would have to be a means to track “potential” delays in care and keep them low. But with the advent of advanced technology which can schedule, track patient flow, create digital dashboards and balanced scorecards and VoIP phone systems this system is possible to create and make effective..

The experience for our clinic shows that a) mistakes in booking will happen (we’ve booked facial fractures for 2 weeks down the road by accident). Create a system to identify and prevent such errors. b) Even with scheduling our emerg patients still come in during the usual rushes. The emerg managers would have to have significant control of the scheduling process to make it effective c) Patients don’t wait any longer than the rest of our patients once in the door (e.g. in and out in approximately an hour) and they almost all are seen the same day as they are referred.

Just an idea I’m throwing out. I suspect it’s been tried somewhere (and someone will tell me why it didn’t work) and that someone will tell me I’m an idiot. But, unless we try something new the ER wait times will continue to spiral out of control.


Jen McCabe Gorman said...

Ian -

Excellent entry with a novel solution...It'll be interesting to see if anyone knows of an instance where an ED has 'formally' implemented scheduling in the US. When I worked at a small community acute care ED, we had a triage nurse who would sometimes inform people over the phone (after hearing details from the patient about the non-emergent reason for the visit) that they could expect optimum service at, say, 1:30pm barring any unforseen major traumas, etc. which would require the redistribution of resources. I've posted a link over at Health Management Rx. Well done!

Best -
Jen McCabe Gorman
Health Management Rx

Chris said...


I am in the UK and one of our local specialist hospital accident dept's do have appoitments and have done for some time!
Let me know if you want more information!

Ian Furst said...

please email me Chris at the address under my "Host" thingy. I'd love to see some data from a program like this. Ian.