Each year, there are well over 100 million hospital emergency department visits in the U.S. In 2017, there were about 139 million, or 43 visits for every 100 Americans.
While wait times have declined in the last decade – now averaging about 40 minutes – they remain stubbornly long. Millions of patients still wait at least two hours to see a provider – 7 million did in 2017 – and that is no guarantee they won’t have to wait even longer for treatment. In California, hundreds of thousands of patients that same year left after getting an emergency department bed but before their care was complete.
How long people have to wait can have a lot to do with the outcome of those visits, sometimes with serious consequences that include longer hospital stays, increased medical errors and higher death rates.
One of us studies how people enroll in and use health insurance, including how often they go to the emergency room and why, while the other is a policy analyst who is focused on access to care for vulnerable populations, in particular those with opioid use disorder. We decided to take a deeper look at what we know about the drivers of emergency department wait times and crowding, especially as the COVID-19 pandemic shows just how important a well-functioning emergency medicine system is.
We studied the literature on emergency wait times and identified several reasons why they remain high. One surprise finding is that many patients likely without true emergencies are told to go to the emergency room by physicians out in the community, which contributes to high emergency department volume.
An obligation to treat everyone
Every day, hospital emergency departments serve as the entry point into health care for Americans who don’t feel right and have nowhere else to go, or have an emergency, like a car accident. This also includes millions of patients seeking routine medical care that is available elsewhere: While the estimates vary widely from study to study, upwards of a third of all emergency department visits could be considered “nonurgent.”
Emergency rooms face a Herculean task. They are asked to be prepared for anything and everything, keep wait times down and costs low. They are mandated by law to treat and stabilize anyone who walks in the door regardless of their ability to pay, a burden that no other part of the health care system faces.
Why the wait?
An obvious driver of crowding and high wait times is how many patients show up for treatment.
A large number of patients who don’t have what rises to the level of a true emergency are referred to the emergency department by outside physicians. These referrals could be because the physician is not sure if they can provide complete care, or because their schedule is too tight to see patients quickly. One study found that about half of “nonemergent” patients contacted another physician first, and 70% of them were told to go to the emergency room.
One of us experienced this firsthand recently. Paul’s rambunctious three-year-old launched herself off the couch head first into the coffee table. There was lots of blood, crying and an immediate trip to urgent care. It was a small wound that the doctor probably could have stitched up himself, but he recommended that Paul go to the emergency room because his daughter might need a plastic surgeon. She ended up not needing stitches and was instead patched up with surgical glue. From her leap off the couch until arriving back home, we probably spent a few minutes with doctors and a couple of hours waiting.
Also adding to the emergency department load is that outside physicians often lack admitting privileges to hospitals. When a patient needs to be admitted as an inpatient but the provider can’t admit them directly, they send the patient to the emergency room for admission instead. A report from the American College of Emergency Physicians suggests that 70% of hospital admissions come through the emergency room, and it is increasing.
For patients who choose to go on their own to the emergency room, it might be exactly the right thing to do. Chest pain can be indigestion or a sign of a heart attack. Playing Monday morning quarterback after the fact, which insurers sometimes do, makes it easy to point fingers at patients for “avoidable” visits, but it is unfair.
There are several options for hospitals and communities to reduce the demand for emergency department services.
Urgent care centers and retail clinics can care for simpler cases that otherwise might have showed up to the emergency room, but the evidence isn’t clear on how much volume they absorb. There is some evidence that retail clinics, like CVS Minute Clinics, may actually increase health care use and spending.
Over half of emergency department visits (57.2%) come outside of business hours, when many retail clinics, along with more traditional options like community health centers and primary care offices, are often closed.
Many urgent care centers are open later and on weekends, but not everyone has easy access to one. Many lower-income neighborhoods do not have access to urgent care. Not surprisingly, when urgent care centers close at night, nonemergent emergency room visits increase.
No beds to be had
No one really knows what the “right” average wait time is. It will always be too long for someone. One of the biggest challenges to reducing wait times is crowding that occurs because the emergency room has no beds available because patients are waiting to be released or moved.
If a patient needs to be admitted but there are no unit beds available, the emergency department often “boards” the patient for hours. The emergency physicians association calls this “a primary contributor to crowding” and notes that over 90% of hospitals routinely report crowded conditions in their emergency rooms.
The situation is even worse when it comes to psychiatric and substance use patients, where limited availability of specialized treatment beds means even longer waits. Space in homeless shelters can matter too. There are many nights when it isn’t safe to send someone back out into the cold with nowhere to go.
Boarding and crowding are not new problems, yet policymakers and health care leaders have struggled to find and implement solutions. Improving this system will require pushing on several levers to connect patients with the right level of care. This effort can help ensure that when true emergencies happen, people can get the care they need quickly.