Harvard – Health Care



U.S. emergency departments (EDs) nationwide are often overburdened by a high volume of patient visits, resulting in lengthy wait times.

This can be especially harmful for those most urgently in need of care. It’s clear that when lifesaving care is delayed, a patient’s medical condition can worsen, leading to poorer clinical outcomes and excess spending on services that could have been prevented.

Harvard Business Review estimates that the number of patients who leave without being seen has almost doubled in recent years, and further research indicates that 24% of those patients return to the ED within seven days. 

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What’s more, a study published in Clinical and Experimental Emergency Medicine directly ties ED crowding to increases in patient morbidity and mortality, and the study also notes adverse impacts on patient satisfaction. Overworked staff may also experience burnout and discontentment, leading to high ED turnover rates, which further compounds the problem.  

So, what can be done to reduce ED crowding?

Skills shortages and financial constraints mean that increased ED staffing levels are rarely a suitable solution. Instead, organizations seeking to smooth the flow of patients through the ED can focus on the effective utilization of technology and human resources, enhancing care delivery models, and ensuring a successful continuum of care upon patient discharge from the ED.

Here are several strategies organizations can apply to manage ED demand through local interventions at the department and organization level, and through improved engagement with partners across the wider healthcare ecosystem.

Understand and act on data-driven insights 

At the core of ED crowding is a hospital’s ability to deliver strategies for ED optimization by applying healthcare technologies and business intelligence and analytics to streamline performance improvement initiatives. Health systems can match ED resources to patient demand by modeling various skill mix and rostering approaches and by proactively forecasting patient traffic and capability requirements. Advanced analytics can also enable for rapid deployment of clinical or administrative resources from other areas of the healthcare system into the ED to respond to an unexpected surge in patient volume.

Analytical insights can also serve as a foundation for quantitative targets and metrics that help to measure and improve upon ED performance over time. The Journal of Hospital Medicine recommends incorporating Key Performance Indicators (KPIs) to improve quality and workforce capabilities, such as reducing discharge wait times to under 20 minutes and increasing the number of discharges from inpatient to 30% or greater by midday.

This second KPI, otherwise known as the “discharge by noon” concept, can improve the capacity of ED staff to address afternoon visits in a timely fashion by efficiently closing out patient encounters from earlier in the day. As EDs tend to be busiest from 11 a.m. to 5:00 p.m., the greatest bottleneck of admissions occurs in the late afternoon between 2 p.m. and 4 p.m.

Staff occupied with the major influx of admissions are not able to attend to awaiting inpatient discharges, which has an impact on both ED crowding and long wait times.

Within clinical settings outside of the ED, health systems can incorporate business intelligence and analytics tools to help promote long-term patient health and lower overall ED utilization. Cutting-edge analytical capabilities can support early detection of diseases by recognizing patterns in health data that can be used to predict the onset of disease, alerting providers to act early, and lowering the risk of a future ED visit.

Enhance clinical processes and workflows 

Technology also offers solutions for ED process redesign and optimization. For example, the use of electronic checklists with built-in clinical decision support capabilities can help to reduce the uncertainty of diagnosis and treatment alternatives.

Point-of-care testing in the ED for nonacute conditions can deliver real-time diagnostic results to enable for swift clinical decision-making, treatment, and discharge. Operational processes can also be streamlined with technology to reduce administrative overhead. These are only a few of the many possible applications of technology that can help to enhance clinical and administrative outcomes. Health systems can begin by documenting the existing processes to identify potential pain points and areas of inefficacy.

This information can then be applied to develop targeted improvements through the application of innovative technology solutions.

Health systems can also implement rapid assessment and triage models, stationing experienced providers within the ED waiting room to quickly identify and deliver care to the most acute patients. This approach eliminates the need for an initial severity assessment by a more junior-level clinician. Mount Sinai Medical Center in New York City is blazing the path for emergency geriatric medicine by redesigning their ED to simultaneously accommodate low- to medium-acuity patients so doctors can attend to the high-acuity patients.

Effective internal escalation, review, and referral processes can also help to shorten consult lengths and time to diagnosis, by removing non-value adding time, such as gaps between request and delivery. Additionally, EDs can offer patients the opportunity to preregister online en route to the hospital so that low- or medium-acuity patients are redirected to visit with an independently licensed provider such as a nurse practitioner or physician assistant upon arrival. 

Collaborate with the wider health ecosystem to preserve ED resources for acutely ill patients 

Within many health systems, ED wait times are inflated by a high volume of patients who present to the ED unnecessarily. Treating low- to medium-acuity patients in an ED setting diverts critical resources away from the treatment of high-acuity patients in greatest need of lifesaving care.

According to the International Journal for Quality in Health Care, the three primary causes of preventable ED visits in the United States are alcohol abuse, mood disorders, and dental complications. The researchers point out, “Our most striking finding is that a significant number of avoidable visits are for conditions the ED is not equipped to treat. Emergency physicians are trained to treat life- and limb-threatening emergencies, making it inefficient for patients with mental health, substance abuse, or dental disorders to be treated in this setting.” Similarly, patients with chronic conditions are likely to present to the ED for visits that could have been avoided through improved care management in non-ED settings.

To better manage ED resourcing and adapt ED pathway delivery to enable assessment, diversion, and triage, hospitals can incorporate frameworks that facilitate a mutually beneficial partnership with emergency services providers and payers. An exemplar program is Medicare’s five-year Emergency Triage, Treat, and Transport (ET3) pilot program, which addresses the problem of too many low- to medium-acuity patients in the ED by changing the reimbursement model for emergency transport for participating provider systems.

The ET3 program offers emergency services providers equivalent reimbursement to that which they would earn for transporting patients to the ED when they instead transport low- to medium-acuity patients to an appropriate alternative destination for the level of care they require or connect patients to a telehealth visit onsite. Medicare predicts that ET3 participating healthcare systems could lower ED utilization among Medicare patients by 16%.

To prevent patients from returning to the ED unnecessarily, healthcare systems can connect patients to ongoing care, resources, and/or observation programs upon discharge from the ED. For example, community paramedics programs can send a clinician to conduct regular check-up visits at a patient’s home, where the clinician records the patient’s vital signs, collects routine laboratory samples, provides ongoing medication support, helps a patient to understand potential “red flags” in his or her condition, and monitors the progress of the condition over time.

If a patient’s medical condition worsens, the clinician can deliver medication to the patient’s home or direct the patient to an outpatient care setting, helping to prevent a medical emergency and a possible trip to the ED. Evidence shows that this framework can be especially effective for patients who have behavioral or mental health conditions, including chemical dependency, and are at a statistically higher risk of presenting to the ED.

Realize the benefits of lowered ED utilization

Long ED wait times reduce the quality of patient care, increase healthcare costs, and lower patient and staff satisfaction—and are often entirely preventable. Healthcare systems can act to combat these issues through an emphasis on preventative care, technology-informed decision-making, interstakeholder collaboration, and a willingness to introduce innovative care delivery models to ensure that patients receive the appropriate level of care based on the acuity of their condition. Moreover, hospitals can drive financial performance to streamline ED optimization initiatives, allowing an increase in revenue per visit by removing low-acuity patients, and in turn improving health system performance.

A holistic approach that simultaneously optimizes the way EDs operate and when patients should be treated within this setting will ensure an improved patient experience for those most in need of emergency services.

Charlie Paterson, Meghan Marx, and Nadeem Fazal are healthcare experts at PA Consulting.