CMS requires that hospitals report time-based metrics to evaluate how EDs are performing, and it is likely that some of these metrics will determine Medicare reimbursement rates in the near future. “As reimbursement to hospitals may be tied to these metrics, it’s essential to accurately record the time of arrival,” says Christopher Houston, MD. “The way times are recorded needs to be standardized to ensure compliance and provide a valid comparison between hospitals.”
Little is known about how long patients wait before they are triaged. Most facilities use the time of initial triage and registration as the time of arrival, but triaging is a detailed process that takes time to perform. “If multiple patients arrive at the same time, there may be delays in registering patients and recording times to triage,” explains Dr. Houston. This unrecorded wait time prior to triage may lead to an underestimation of time-based metrics.
In a study published in the Western Journal of Emergency Medicine, Dr. Houston and colleagues sought to quantify the time spent waiting to be triaged for all patients arriving to the ED. If patients did not go directly to a bed or triage, an observer greeted them as they entered the ED and recorded the time of arrival. The triage time was recorded as usual and the difference between arrival time and triage time was then calculated.
According to the results, patients often waited more than 10 minutes from the time of arrival to the ED until they were triaged. “This represents about 30% of the average national door-to-doctor times,” Dr. Houston says. As the number of patients registered in the previous hour increased, the percentage of patients who waited more than 10 minutes for triage also increased significantly. This waiting time is not accounted for in normal reporting of ED throughput metrics but may have an effect on quality of care. The data imply that door-to-doctor times are longer than what standard methods of reporting would indicate.
More to Come
As volumes in EDs continue to increase, the goal of decreasing wait times has been difficult to accomplish. One solution to the problem may be to have a physician in triage, but this may not be feasible at all institutions. “The phenomenon of unaccounted time waiting for ED triage is likely occurring throughout the country,” Dr. Houston says. “Triage in the ED can become saturated quickly, so it’s important for EDs to develop and implement strategies that address these situations.” He adds that more studies are also needed to explore this issue further and ensure that time-based metrics can be assessed appropriately.
Readings & Resources (click to view)
Houston C, Sanchez LD, Fischer C, Volz K, Wolfe R. Waiting for triage: unmeasured time in patient flow. West J Emerg Med. 2015;16:39-42. Available at: http://westjem.com/articles/waiting-for-triage-unmeasured-time-in-patient-flow.html.
Wiler JL, Gentle C, Halfpenny JM. Optimizing emergency department front-end operations. Ann Emerg Med. 2010;55:142-160.
Welch S, Davidson S. Exploring new intake models for the emergency department. Am J Med Qual. 2010;25:172-180.
Horwitz LI, Bradley EH. Percentage of US emergency department patients seen within the recommended triage time: 1997 to 2006. Arch Intern Med. 2009;169:1857-1865.