Reducing Wait Time in the Emergency Department

Excessive wait times at VA hospitals have become front-page news. It is a complaint that I am very familiar with as a physician who has worked in the emergency department (ED) for a long time. And although the problems uncovered at the Phoenix VA Health Care System (where I currently work) and other health care centers involve bringing new patients into the system, not the hours spent waiting in the ED, our experience trying to reduce wait times may provide useful lessons as the VA seeks to reduce the backlog and see all its patients in a reasonable amount of time.

Overcrowding and long wait times are hardly unique to VA EDs, these are problems faced at most large hospitals. Today, the increasing use of the ED is driven by patient demand, changing benefits (insurance/entitlements), and shifting expectations. Many patients in the ED for nonemergent care do not have regular primary care providers. Others may be turning to the ED because of difficulty getting appointments to see a primary care provider. Some patients simply use the ED for convenience (it is open 24 hours a day after all) and because there are no copayments.

Emergency department providers have made many attempts to address wait times and overcrowding; however, these problems are complex, caused by rapidly shifting bottlenecks, making simple solutions challenging and difficult to resolve. Seemingly rational interventions aimed at reducing the wait times are frequently unsuccessful, a result of a rapidly changing and dynamic environment—you are only as fast as delays allow.

IDENTIFYING BOTTLENECKS

Capacity issues can cause bottlenecks in the ED and lead to overcrowding. The capacity of ED resources can vary widely over time. For example, radiology capacity at night depends on the radiology technician on call and how far the technician lives from the hospital (if there is no 24/7 in hospital coverage). Often, external issues can cause problems, such as if the clinics at the institution are closed (for federal holidays at the VA, for example); there is a primary care staff shortage (a nationwide problem); scheduling issues; or the clinic staff are in mandatory meetings. In these instances patients may directly or indirectly get diverted to the ED, slowing its flow.

Similarly, responsiveness or availability of specialists to offer consults can contribute to the time spent in the ED. In addition, the delay in getting patients into a hospital bed after being admitted can sometimes take many hours, tying up the already limited bed availability.

Physician and nursing capacity is even more complicated, because the volume of patients at any one time is unpredictable. Emergency department physicians have a variety of backgrounds and different skill sets; some can process patients more efficiently than can others. And the chemistry among the various staff working on a given shift can also shape capacity. Good team chemistry helps an ED work efficiently.

The demand placed on ED resources also varies, based on the patient mix over time. There are days where seemingly everyone needs a CT scan, which creates a bottleneck. There are other days when it is a trauma day when the X-rays and radiology techs rapidly get backed up. Then there are times when the CT scanner or MRI is down, or other technology issues create delays. All ED processes are interconnected. Unless you increase capacity for those days, the flow will be decreased and waste increased. Contributing further to the ED congestion is the recent trend in the health policy community and at the VA to shrink the ED resources while at the same time trying to improve patient satisfaction scores.

Many communities, like Phoenix, have seen significant shifts in veteran populations as aging veterans choose to move to retirement communities in the south and west. Even the seasonal fluctuations as aging veterans spend the winter months in warmer communities can impact the ED. Combining these trends with recently expanded eligibility standards in the VA system creates an imbalance in the flow of patients and strains the capacity at many facilities like ours. Without adjusting the capacity of the ED (and other departments) to handle more patients, setting new benchmarks to reduce veterans’ wait times is not workable.

Some EDs have experimented with streamlining processes using “lean” business management. Sources of waste and inefficiency are identified and alternate processes developed. The Phoenix VA ED has tried some of these techniques with some success. For example, we have decreased the wait times and fewer patients leave without being seen, while at the same time the patient volume has increased. We now have front-end initiation of a workup based on the presenting complaints. Thorough workups in the ED can be useful, especially if they prevent a costly hospitalization. However, these workups add to the demands placed on the ED’s precious commodity—the bed. 

Flexible Service Environment

The ED is a complex service environment with shifting bottlenecks. To reduce wait times, EDs need flexibility in hiring and shifting responsibilities, but unfortunately federal policies are not easily adaptable for addressing such shifting demands. It routinely takes 4 or more months to hire a new physician or a nurse once a job is offered, to say nothing of the time to recruit them in the first place. If a staff member leaves, typically the position is not filled for months. The VA credentialing and hiring process needs to be thorough but significantly streamlined with the salaries reflective of equal pay for equal work. Currently, this is not the case.

To be able to confront the crowding and long wait times in the ED, the VA needs to address the root causes of crowding. First and foremost, it means expanding access to nonemergent clinics, specialists, and primary care providers. Opening clinics after hours, weekends, and on holidays would be an easy first step with significant cost saving, compared with expansion. Second, the ED needs more resources, such as more beds and additional staff, including specialists (for example, a psychiatric team in the ED). Finally, the VA needs to facilitate the movement from the ED into a hospital for patients who are admitted.

Most important, ED teams must become more nimble and flexible. Lean business practices can help keep the overall process efficient by focusing on eliminating waste or non–value-added elements. A leaner, more flexible ED can not only reduce wait times but also give veterans more value, which is exactly what they deserve.

I have worked side-by-side with the men and women who bring the VA to life, putting in long hours, with diligent attention to the highest standards and a commitment to the mission. We have saved and changed the lives of many of the patients we serve; although it is not always easy for veterans to separate issues of access to care from those of the quality of that care. Though it can be a challenge to work in a VA ED, especially now, it can also be very fulfilling. 

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Excessive wait times at VA hospitals have become front-page news. It is a complaint that I am very familiar with as a physician who has worked in the emergency department (ED) for a long time. And although the problems uncovered at the Phoenix VA Health Care System (where I currently work) and other health care centers involve bringing new patients into the system, not the hours spent waiting in the ED, our experience trying to reduce wait times may provide useful lessons as the VA seeks to reduce the backlog and see all its patients in a reasonable amount of time.

Overcrowding and long wait times are hardly unique to VA EDs, these are problems faced at most large hospitals. Today, the increasing use of the ED is driven by patient demand, changing benefits (insurance/entitlements), and shifting expectations. Many patients in the ED for nonemergent care do not have regular primary care providers. Others may be turning to the ED because of difficulty getting appointments to see a primary care provider. Some patients simply use the ED for convenience (it is open 24 hours a day after all) and because there are no copayments.

Emergency department providers have made many attempts to address wait times and overcrowding; however, these problems are complex, caused by rapidly shifting bottlenecks, making simple solutions challenging and difficult to resolve. Seemingly rational interventions aimed at reducing the wait times are frequently unsuccessful, a result of a rapidly changing and dynamic environment—you are only as fast as delays allow.

IDENTIFYING BOTTLENECKS

Capacity issues can cause bottlenecks in the ED and lead to overcrowding. The capacity of ED resources can vary widely over time. For example, radiology capacity at night depends on the radiology technician on call and how far the technician lives from the hospital (if there is no 24/7 in hospital coverage). Often, external issues can cause problems, such as if the clinics at the institution are closed (for federal holidays at the VA, for example); there is a primary care staff shortage (a nationwide problem); scheduling issues; or the clinic staff are in mandatory meetings. In these instances patients may directly or indirectly get diverted to the ED, slowing its flow.

Similarly, responsiveness or availability of specialists to offer consults can contribute to the time spent in the ED. In addition, the delay in getting patients into a hospital bed after being admitted can sometimes take many hours, tying up the already limited bed availability.

Physician and nursing capacity is even more complicated, because the volume of patients at any one time is unpredictable. Emergency department physicians have a variety of backgrounds and different skill sets; some can process patients more efficiently than can others. And the chemistry among the various staff working on a given shift can also shape capacity. Good team chemistry helps an ED work efficiently.

The demand placed on ED resources also varies, based on the patient mix over time. There are days where seemingly everyone needs a CT scan, which creates a bottleneck. There are other days when it is a trauma day when the X-rays and radiology techs rapidly get backed up. Then there are times when the CT scanner or MRI is down, or other technology issues create delays. All ED processes are interconnected. Unless you increase capacity for those days, the flow will be decreased and waste increased. Contributing further to the ED congestion is the recent trend in the health policy community and at the VA to shrink the ED resources while at the same time trying to improve patient satisfaction scores.

Many communities, like Phoenix, have seen significant shifts in veteran populations as aging veterans choose to move to retirement communities in the south and west. Even the seasonal fluctuations as aging veterans spend the winter months in warmer communities can impact the ED. Combining these trends with recently expanded eligibility standards in the VA system creates an imbalance in the flow of patients and strains the capacity at many facilities like ours. Without adjusting the capacity of the ED (and other departments) to handle more patients, setting new benchmarks to reduce veterans’ wait times is not workable.

Some EDs have experimented with streamlining processes using “lean” business management. Sources of waste and inefficiency are identified and alternate processes developed. The Phoenix VA ED has tried some of these techniques with some success. For example, we have decreased the wait times and fewer patients leave without being seen, while at the same time the patient volume has increased. We now have front-end initiation of a workup based on the presenting complaints. Thorough workups in the ED can be useful, especially if they prevent a costly hospitalization. However, these workups add to the demands placed on the ED’s precious commodity—the bed. 

Flexible Service Environment

The ED is a complex service environment with shifting bottlenecks. To reduce wait times, EDs need flexibility in hiring and shifting responsibilities, but unfortunately federal policies are not easily adaptable for addressing such shifting demands. It routinely takes 4 or more months to hire a new physician or a nurse once a job is offered, to say nothing of the time to recruit them in the first place. If a staff member leaves, typically the position is not filled for months. The VA credentialing and hiring process needs to be thorough but significantly streamlined with the salaries reflective of equal pay for equal work. Currently, this is not the case.

To be able to confront the crowding and long wait times in the ED, the VA needs to address the root causes of crowding. First and foremost, it means expanding access to nonemergent clinics, specialists, and primary care providers. Opening clinics after hours, weekends, and on holidays would be an easy first step with significant cost saving, compared with expansion. Second, the ED needs more resources, such as more beds and additional staff, including specialists (for example, a psychiatric team in the ED). Finally, the VA needs to facilitate the movement from the ED into a hospital for patients who are admitted.

Most important, ED teams must become more nimble and flexible. Lean business practices can help keep the overall process efficient by focusing on eliminating waste or non–value-added elements. A leaner, more flexible ED can not only reduce wait times but also give veterans more value, which is exactly what they deserve.

I have worked side-by-side with the men and women who bring the VA to life, putting in long hours, with diligent attention to the highest standards and a commitment to the mission. We have saved and changed the lives of many of the patients we serve; although it is not always easy for veterans to separate issues of access to care from those of the quality of that care. Though it can be a challenge to work in a VA ED, especially now, it can also be very fulfilling. 

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

Excessive wait times at VA hospitals have become front-page news. It is a complaint that I am very familiar with as a physician who has worked in the emergency department (ED) for a long time. And although the problems uncovered at the Phoenix VA Health Care System (where I currently work) and other health care centers involve bringing new patients into the system, not the hours spent waiting in the ED, our experience trying to reduce wait times may provide useful lessons as the VA seeks to reduce the backlog and see all its patients in a reasonable amount of time.

Overcrowding and long wait times are hardly unique to VA EDs, these are problems faced at most large hospitals. Today, the increasing use of the ED is driven by patient demand, changing benefits (insurance/entitlements), and shifting expectations. Many patients in the ED for nonemergent care do not have regular primary care providers. Others may be turning to the ED because of difficulty getting appointments to see a primary care provider. Some patients simply use the ED for convenience (it is open 24 hours a day after all) and because there are no copayments.

Emergency department providers have made many attempts to address wait times and overcrowding; however, these problems are complex, caused by rapidly shifting bottlenecks, making simple solutions challenging and difficult to resolve. Seemingly rational interventions aimed at reducing the wait times are frequently unsuccessful, a result of a rapidly changing and dynamic environment—you are only as fast as delays allow.

IDENTIFYING BOTTLENECKS

Capacity issues can cause bottlenecks in the ED and lead to overcrowding. The capacity of ED resources can vary widely over time. For example, radiology capacity at night depends on the radiology technician on call and how far the technician lives from the hospital (if there is no 24/7 in hospital coverage). Often, external issues can cause problems, such as if the clinics at the institution are closed (for federal holidays at the VA, for example); there is a primary care staff shortage (a nationwide problem); scheduling issues; or the clinic staff are in mandatory meetings. In these instances patients may directly or indirectly get diverted to the ED, slowing its flow.

Similarly, responsiveness or availability of specialists to offer consults can contribute to the time spent in the ED. In addition, the delay in getting patients into a hospital bed after being admitted can sometimes take many hours, tying up the already limited bed availability.

Physician and nursing capacity is even more complicated, because the volume of patients at any one time is unpredictable. Emergency department physicians have a variety of backgrounds and different skill sets; some can process patients more efficiently than can others. And the chemistry among the various staff working on a given shift can also shape capacity. Good team chemistry helps an ED work efficiently.

The demand placed on ED resources also varies, based on the patient mix over time. There are days where seemingly everyone needs a CT scan, which creates a bottleneck. There are other days when it is a trauma day when the X-rays and radiology techs rapidly get backed up. Then there are times when the CT scanner or MRI is down, or other technology issues create delays. All ED processes are interconnected. Unless you increase capacity for those days, the flow will be decreased and waste increased. Contributing further to the ED congestion is the recent trend in the health policy community and at the VA to shrink the ED resources while at the same time trying to improve patient satisfaction scores.

Many communities, like Phoenix, have seen significant shifts in veteran populations as aging veterans choose to move to retirement communities in the south and west. Even the seasonal fluctuations as aging veterans spend the winter months in warmer communities can impact the ED. Combining these trends with recently expanded eligibility standards in the VA system creates an imbalance in the flow of patients and strains the capacity at many facilities like ours. Without adjusting the capacity of the ED (and other departments) to handle more patients, setting new benchmarks to reduce veterans’ wait times is not workable.

Some EDs have experimented with streamlining processes using “lean” business management. Sources of waste and inefficiency are identified and alternate processes developed. The Phoenix VA ED has tried some of these techniques with some success. For example, we have decreased the wait times and fewer patients leave without being seen, while at the same time the patient volume has increased. We now have front-end initiation of a workup based on the presenting complaints. Thorough workups in the ED can be useful, especially if they prevent a costly hospitalization. However, these workups add to the demands placed on the ED’s precious commodity—the bed. 

Flexible Service Environment

The ED is a complex service environment with shifting bottlenecks. To reduce wait times, EDs need flexibility in hiring and shifting responsibilities, but unfortunately federal policies are not easily adaptable for addressing such shifting demands. It routinely takes 4 or more months to hire a new physician or a nurse once a job is offered, to say nothing of the time to recruit them in the first place. If a staff member leaves, typically the position is not filled for months. The VA credentialing and hiring process needs to be thorough but significantly streamlined with the salaries reflective of equal pay for equal work. Currently, this is not the case.

To be able to confront the crowding and long wait times in the ED, the VA needs to address the root causes of crowding. First and foremost, it means expanding access to nonemergent clinics, specialists, and primary care providers. Opening clinics after hours, weekends, and on holidays would be an easy first step with significant cost saving, compared with expansion. Second, the ED needs more resources, such as more beds and additional staff, including specialists (for example, a psychiatric team in the ED). Finally, the VA needs to facilitate the movement from the ED into a hospital for patients who are admitted.

Most important, ED teams must become more nimble and flexible. Lean business practices can help keep the overall process efficient by focusing on eliminating waste or non–value-added elements. A leaner, more flexible ED can not only reduce wait times but also give veterans more value, which is exactly what they deserve.

I have worked side-by-side with the men and women who bring the VA to life, putting in long hours, with diligent attention to the highest standards and a commitment to the mission. We have saved and changed the lives of many of the patients we serve; although it is not always easy for veterans to separate issues of access to care from those of the quality of that care. Though it can be a challenge to work in a VA ED, especially now, it can also be very fulfilling. 

Author disclosures
The author reports no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the author and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.