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Have you ever wondered why sometimes there are long waits in the hospital ER?   Or how about why others who check in after you are seen before you? Sometimes as patients when our fear and pain supersede anything else,  we lack patience.  This is perfectly understandable as it goes right along with Maslow’s hierarchy of needs.  However, patience is exactly what we need sometimes in a hospital setting.

Imagine you are in a crowded emergency department waiting room.  You have been registered and seen by the triage nurse.  You might be in pain or nauseated and there you sit, waiting.  Now imagine how you would feel if a woman came through the entrance carrying her child and is quickly whisked away to the treatment area.  And there you sit.  This is beyond irritating.  How would you react to this situation?

This scenario is very real and happened in a hospital where I worked many years ago.  Customers in our ED waiting room became very angry when this mother and child were seen before anyone else. Their patience was nil because they too were there to be seen and had been waiting.   What people didn’t understand was that child died that day.

I tell this story because I know that this happens in emergency rooms all over the country every day.  Our customers do not always understand the flow of the ED and inpatient units.  When people do not understand why things are happening or not happening, they become frustrated and angry.  Delays are not always related to such an emergent case as the one I described, however there are generally good reasons why there might be waiting time in the hospital.

So let’s discuss the process of the emergency department to help you understand how it all functions.

Patient Throughput

What do hospitals strive for?  Patient throughput is a term used to describe how customers are moved through the system.  It is the goal in most emergency departments for patients to see a physician, nurse practitioner or physician’s assistant within 30 minutes of when they arrive at the hospital.  The faster patients can be seen, the safer they are and the better their clinical outcomes will be.

It is important for consumers to understand that it is never the goal to make you wait.  The medical team works diligently to keep patient throughput moving to ensure everyone’s safety.  A hospital does not get paid any more money based on the amount of time you spend in the emergency department

Now that we understand goals and objectives related to throughput, let’s discuss the actual process through the ED and the hospital.

Registration

Registration is the “check in process.”  This will happen sometime during the beginning of your visit, but the process may be a little different in each hospital.  It is very important to understand that those who work in registration are not medical personnel but their job is essential to your safety.

Some have the perception that registration questions can wait because this is an emergency.  However,  it is through the registration process that patients are properly identified and provided with an arm band.  That arm band is essential for every department to make sure all of the tests and medications are being administered to the right person.    It is so vital to have a correct identification band so that the hospital staff can continuously double check this information as you move through the system.  This is to ensure that the correct tests are completed on the correct person which translates to providing the right results and treatment plan to the right person.

Triage

When you enter the emergency department, the first clinician that you will see is the triage nurse.  Hospital triage is  “The process of sorting people based on their need for immediate medical treatment as compared to their chance of benefiting from such care. “  The objective of triage is to determine who are the sickest patients and get them to the treatment area first.  The triage nurse uses a detailed set of criteria to make these decisions.  The basic premise of that criteria is summed up in four important questions:

  • Does the patient need immediate life saving intervention?
  • Is this a patient that shouldn’t wait?
  • What kind and how many resources will the patient require?
  • What are the vital signs?

The results of the triage determine the order in which patients are seen.  For example, a person who presents with a swollen ankle will be seen after a patient who comes in with chest pain even if the person with the ankle injury arrived first.

Being a triage nurse is an enormous responsibility.  These nurses generally have a good bit of emergency room experience and are specially trained to follow the triage algorhythm.

The Treatment Area

The results of the triage will determine the order in which you are taken to the treatment area to see the doctor, nurse practitioner or physician’s assistant.  Once a patient is seen by a provider, any necessary testing will be determined and ordered.

The amount of time the testing takes varies greatly.  It all depends on the amount of tests, what kinds of tests and scheduling.  For example, an MRI will take much longer than blood work.  Also, if there is another patient in the MRI machine, the next patient cannot be started right away.

If the doctor decides that you need to be admitted to the hospital, an attending physician, the one that will manage your care in the hospital, is called. The goal would be to transport you to the inpatient unit within 30 minutes of that decision.

Why the delays?

So why are there delays in the hospital sometimes?  This is the part of the process that many do not understand.  If all of the goals strive for 30 minutes or less, why would anyone have to ever wait?  The answer to this question can vary.  The most important thing that hospital associates can do for their customers is to explain what may be causing a delay, provide expected time frames and simply communicate with those who are waiting.  Possible reasons for delays are:

  • An increased number of patients in the emergency department. This often happens at certain times of the day or during certain seasons.  Emergency rooms tend to be busiest during non business hours like the evening and certainly during the winter with all the colds, flu and other viruses going around.
  • Unexpected severe emergencies: When a patient is brought to the emergency room with a life threatening condition it takes most of the ED resources, meaning doctors, nurses and techs to treat that patient.  This will likely cause delays for others that are waiting to be seen.
  • A high hospital census: If there is a patient in every inpatient bed it is more difficult to maintain efficient throughput from the emergency room.  The time of year usually affects hospital census the most.  Hospitals can put measures in place such as early morning discharges to help with throughput, however we do not want to discharge patients if they are not 100% ready.
  • Infection precautions: There are certain infections people can get which require them to be in a private room.  For hospitals whose rooms hold two patients, this situation will close a bed so that the patient can have a private room.
  • Other medical conditions: There are a host of other medical conditions that may require a patient be placed in a private room:  decreased immune system, confused and combative and suicide precautions are just a few.  However again, if the hospital has shared rooms, these situations cause the closing of one bed in order to accommodate the patient.
  • Maintenance issues: Sometimes there is a problem with a patient room requiring repairs.  The maintenance staff will not work on a room if it is occupied.  Therefore, sometimes rooms have to be closed causing a decrease in available beds.

ER or Urgent Care

Urgent care facilities are a great alternative to using the emergency room in some cases.  Urgent care centers are often run by emergency room practitioners and can treat many of the ailments that you may consider more minor emergencies.  Below are lists from Cleveland Clinic to help you see when you should go the ER or urgent care.

 Go to the ER if:

  • Loss of consciousness
  • Signs of heart attack or stroke, including sudden, severe pain and/or chest discomfort or difficulty breathing
  • Uncontrolled or excessive bleeding
  • Coughing up or vomiting blood
  • Head injury or any major injury
  • Severe burns
  • Sudden or unexpected paralysis
  • Poisoning, suspected poisoning or drug overdose
  • Accidents, including falls and car crashes or injuries caused by violence, such as gunshot wounds
  • Extreme emotional distress, including suicidal or homicidal feelings

Go to Urgent Care if:

  • Sprains and Strains
  • Earaches
  • Sore throats
  • Rising temperature
  • Stomach flu
  • Cold and flu symptoms, including sore throat
  • Pink eye
  • Sinus infections
  • Urinary tract infections
  • Seasonal allergies

Conclusion

In summary, it is never the intention of any hospital to have delays in the emergency room.  Efficient throughput has proven to lead to better clinical outcomes for the patient.    However, there are times when unavoidable delays happen.  There is always someone you can talk to about delays or any other concerns you may have (i.e. charge nurse or nurse manager).   If you feel you need emergency attention, please consider the list above.  If you come to the emergency room, please understand that everything you experience happens for a reason.  We are here to help you heal safely and efficiently.