The other day, I was asked, “What is your definition of a no wait ER?” I did not mean to be sarcastic, but I think my answer sounded that way: “It is when you go to the ER in a hospital and you don’t have to wait.”  Let me explain. A no wait ER means that when you go to the ER, there is no waiting in the waiting room. You get taken straight back to a treatment area. After that, you do not wait for care (i.e. urgent care). The care team enters the room with you. Instead of telling your medical history multiple times: first to the nurse, then to the resident, and then to the senior physician, the whole care team enters at once and you tell your story just one time. Now, you may have to wait for test results (EKG, blood work, X-rays), but waiting is minimized because those tests are performed in a coordinated fashion and the results are delivered as soon as they are ready. You are informed in advance of the duration of tests and when you will receive results. If you need to be admitted to the hospital, you are transferred to your hospital room in less than half an hour. If you are discharged home, it takes a few minutes, rather than 45 minutes. Is this a fantasy?  Is this even possible?

A no wait ER is possible. You just need 2 ingredients: belief and commitment. You need a belief that it can be done. You need commitment to make it happen. The belief stems from the examples from around the country and around the world where eliminating unnecessary delays is a focus. The commitment comes from knowing that making patients wait in an ER is not good medicine and can be dangerous.

Eugene Litvak, an industrial engineer from the Institute of Healthcare Optimization and Harvard University, has written and spoken extensively about flow in hospitals. Dr.Litvak points to the differences in natural variability (i.e. most ED patients across the country arrive between 4 PM and 12 midnight) and artificial variability (i.e. surgeons do more surgeries on Mondays than on Fridays). Litvak argues that diminishing the impact of the artificial variability will allow a smoother patient flow in the ER and throughout the hospital.

The ER is a great place to examine bottlenecks as ER flow is typically an outcome of patient flow in the rest of the hospital. If your discharge process from the inpatient ward is inefficient, it can be felt in the ER. If the hospital is full, the ER gets backed up with patients waiting for admission. If elective surgeries are scheduled unevenly, then the intensive care units and wards get filled unevenly. Some organizations decide building more rooms is the answer. However, Litvak and others have proven redesigning processes is the key to minimizing peaks and valleys in patient volume and flow in hospitals.

The Emergency Nurses Association recommends the following solutions:

  1. Immediate bedding
  2. Bedside registration
  3. Advanced triage protocols
  4. Physician/practitioner at triage
  5. Kiosk check-in
  6. Patient tracking systems
  7. Robust hospital surge capacity plans

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Paul Rosen

Paul Rosen, MD was named ‘One of the First 100 Innovators’ by the U.S Federal Government Agency for Healthcare Research and Quality. He is a blogger, podcast host, TEDx speaker, author, and teacher. Dr. Rosen is a pediatric rheumatologist at Nemours/Alfred I. duPont Hospital for Children. He serves as the Clinical Director of Service and Operational Excellence for Nemours. He is an associate professor of pediatrics at the Sidney Kimmel Medical College at the Thomas Jefferson University. He is the director of the physician executive leadership program at SKMC. He serves as volunteer faculty at the University of Central Florida College of Medicine. Dr. Rosen was named the head of the Philadelphia/Delaware chapter of the Society of Physician Entrepreneurs (SoPE). He teaches medical students about improving the patient experience. He received a masters of public health degree from Harvard University and a masters of medical management degree from Carnegie Mellon University. Dr.Rosen’s interests include patient-physician communication, family-centered care, team building across health disciplines, the patient experience, and improvement of health care delivery.

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