A recent study by Press Ganey reports that the average length of stay (LOS) in U.S. emergency departments is 3.7 hours. The study was completed in 2005 and shows considerable variations between states. The shortest ED LOS was in Iowa (138.3 minutes) and Nebraska (146.1 minutes), while Maryland (246.9 minutes) and Arizona (297.3 minutes) reported the longest stays. An emergency department stay ends when the patient is admitted to the hospital or goes home. (You can see a table of LOS by state here.)

"There is hardly a hospital in the country that
is not in some way focused on wait times in the emergency room," says
Melvin Hall, Press Ganey's president. Hall says patients don't mind
waiting if they know why? for example, if doctors are treating someone
critically injured? or if they are told how long the wait will last.

Some hospitals, such as Robert Wood Johnson
University Hospital in Hamilton, N.J., promise that emergency-room
patients will see a nurse in 15 minutes or a doctor in 30 minutes. If
not, the emergency-room portion of their bill is waived. "It's been a
huge hit," says Christy Stephenson, hospital president.

Stephenson does not say just what kind of "huge hit" the program has on patients or the hospital. Besides satisfaction, long ED stays can indicate down stream patient flow bottlenecks that can impact patient safety. Patients in the ED waiting for patient rooms can be at risk for inadequate surveillance and other patient care risks.

Hall says rural Midwestern states tended to fare well in the report
because their hospital occupancy rates are lower and they see fewer
emergency patients. He also says metropolitan hospitals see more
patients with routine medical problems, who tend to wait longer for
care than the critically injured.

We have been in the midst of the largest hospital building boom on record. I suspect that there is more than ED or hospital room capacity issues at play here. There are a number of proven techniques for improving patient flow in emergency rooms, yet most hospitals have yet to adopt them. Both variable acuity nursing units and unit based boarding are two relatively easy ways to reduce ED length of stay.

Variable acuity nursing units (or variable acuity beds, or universal beds) are standard nursing units with the added ability to care for more acute patients. Because critical care areas are a common patient flow bottleneck, these changes have the ability to use patient monitors and ventilators on sicker patients outside of traditional critical care areas. By off loading patients who are not truly critical, capacity in critical care areas is conserved, reducing ambulance diversions and ED bypasses.

When patient flow backs up in the hospital, patients waiting in the ED to be admitted are "boarded." This means they either take up an ED bed or are placed on gurneys an rolled into holding areas like hallways. The inherent risks to patient safety are why the JCAHO instituted patient flow requirements in 2005. But rather than board patients in the ED, a few hospitals send them up to their service unit. Boarding one or two patients on an appropriate nursing unit is safer than boarding a dozen or more patients in the emergency department. Nurse to patient ratios are better on the nursing units, and patients can be "on service" where they can receive care specific to their condition (pediatrics, oncology, orthopedic, etc.)

Both of these techniques represent bigger culture changes for hospitals than they are capital equipment or workflow changes. Frequently hospitals rely on outside consultants to assess needs and facilitate lasting and effective change. This latest Press Ganey report demonstrates hospitals still have a long way to go.