Friday, April 22, 2005

Emergency Department Waiting Times

Anyone that has waited in an emergency department (ED) knows the frustration of sitting around for hours at a time both to be seen and to be evaluated and treated. Clearly this is not an experience that anyone with a life would care for. However, there are reasons far more important than inconvenience for promoting short ED waiting periods:
  • ED's that get backed up are unable to accept ambulance runs if they have no beds available. This can create a serious strain on public emergency response services.

  • When ED waits are excessive, patients and families get frustrated and often leave. This tends to screen out patients with minor problems but inevitably screens out some with serious illnesses which remain unevaluated.

  • Patients arriving to an ED are occasionally mistriaged as being less seriously ill than they are. Such patients are sometimes sent to the lobby to wait unmonitored where they have been known to die of unsuspected life-threatening illness. The system is much more forgiving of mistriage if the wait to be seen is brief.
In 2000, for reasons like these, the U.K. National Health Service (NHS) created a set of guidelines one of which requires that the time from arrival to transfer or discharge from an emergency department (ED) be within four hours. These guidelines were clarified in 2003 with some clinical exceptions to this rule. (By these criteria by the way, the ED depicted in the show E.R. would be under heavy sanctions since the patients seem to stay for days.)

The purpose of such rules is presumably to induce hospitals not meeting these requirements to improve efficiency, patient flow and manpower. While this is an admirable goal, there may have been some unintended consequences.

The British Medical Journal (online version), published a study showing that a disproportionate number of ED patients are either admitted or discharged in the last twenty minutes of that four hour window. The actual study has a very informative graph of the distribution of emergency department "disposition" times. The spike (and subsequent drop-off) between 220 and 240 minutes is striking, particularly for the admitted patients although a much smaller spike is clearly seen for discharged patients as well.

While this data cannot prove it, it seems likely that patients are being dispo'd (a slang term short for dispose: to send the patient out with a care plan) with significant concern for keeping within the NHS guidelines.

Is it possible that clinical decisions are being made not so much out of regard for patient care and safety as for regulation compliance? It seems like quite a stretch to assume that this distribution of waiting times conforms so perfectly to the guidelines.

I remember reading an apropos anecdote in The Making of a Surgeon, William Nolan's wonderful account of surgical training at Belleview hospital in New York City. He expressed surprise that there were never any intraoperative deaths at his institution. He later understood that if anyone appeared to have died during surgery, they would be quickly sewn up and hustled out of the O.R. before being pronounced. The idea was that dying in the O.R. meant much more scrutiny and paperwork and was to be avoided at all costs.

Nolan's patients were dead and there were few patient safety issues (at least no short-term ones) created by such gaming of the system. In the ED however, this is not necessarily the case. Ideally, all clinical decisions (including when and how to dispo patients) should be made strictly on the basis of what's best for the patient. This study at least supports the possibility that the NHS regulations themselves influence disposition decisions. This is not how it should be.

Admittedly, firm conclusions are difficult to draw from this data. First of all, we have no way of proving that the observed bolus of dispositions didn't also occur prior to the new regulation. Second, there is no way of concluding that this rush to dispo patients is in any way detrimental to patient care.

The study's value lies not so much in its conclusions but in the questions it raises. Perhaps laying down blanket regulations regarding process is not such a productive idea. Maybe the NHS could better achieve its objectives by giving a greater weight to regulations regarding outcomes. Developing rules such as how long patients can be made to wait strikes at the process and seems like micromanaging.

The NHS isn't primarily concerned with ED waiting times. What it really wants to do is reduce the incidence of ambulances being redirected from their hospital. Wouldn't an outcome-oriented rule such as limiting how often this can be permitted to occur be better? Likewise, a concern is that patients are leaving the ED without being seen. Why not focus on this more important parameter and limit the percentage of cases where this is allowed to occur? Rules such as these would then leave it up to the hospitals to decide how these goals can be best achieved.

As I've said elsewhere in this blogsite, I'm no libertarian. I believe that there are very valid reasons for government involvement. I just think that such involvement should be engineered so that interventions are kept at a minimum and that when necessary, they achieve their intended effects.


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