Anyone who has ever visited a hospital emergency room has experienced over crowding and long waits to see a doctor. I have been on both sides of the fence as a patient and as an emergency nurse. It is a nasty situation that brings out the worst in all of us. Some years ago, the emergency department administrator in a hospital that I was working in had the bright idea to hire a magician to entertain the folks in the waiting room. This man was a clever entertainer, but he was playing to the wrong audience. While he was doing his rope trick one patient told him to hang himself. Another man told him where to shove his rabbit and a woman shouted, "Why don't you conjure me up a doctor so I can get treated for this lousy migraine?"
That administrator's goal was to find a way to get people to accept an unpleasant and dangerous situation rather than finding the route causes and implementing changes. Therein lays the answer to the mind boggling question, "Why does such a state of affairs that causes harm to the respective community and damages the providers' reputations persist in virtually every urban hospital in the country?"
Root Causes and Potential Liability
The harmful effects of prolonged E.R. waiting time as well as root causes and solutions are well documented in the medical literature (see references). Therefore, when medical and nursing errors occur in the emergency department the existence of certain conditions that administrators could have identified and resolved can be an issue of hospital liability. For example, recent headlines in South Florida revealed that a young man in his forties was found dead in a major hospital emergency waiting room. The initial investigation revealed that his body was stone cold when one of the nurses found him still seated in a chair with his head leaning against a wall. Apparently, he had been dead for several hours while his family was frantically looking for him.
Investigating a Death Related to Overcrowding
The underlying reason why this man was literally forgotten to death is obviously over crowding. There were so many people in the waiting room moaning, groaning, complaining, and making loud insulting comments that no one notice a quiet man in the back corner of the room who appeared to be sleeping. The next logical step is to examine the factors that contributed to the overloading of people in the treatment and waiting areas. Therefore, in conducting a proper investigation for corrective action the following questions need answers:
Does the hospital administration track waiting time?
What is the average waiting time as per the tracking reports?
Is the triage nurse located in a place where he or she can see what is going on in the waiting room?
Did the triage nurse periodically monitor the patients in the waiting room?
What is the average turn-over time for a bed on the floors (the time it takes for housekeepers to clean a bed between patients)?
How many emergency room gurneys are there and are they routinely returned to the E.R.?
What is the average turn around time for blood and urine tests (most take three minutes or less to perform while the doctors wait 3-4 hours for the reports)?
Does the administrator notify the 911 EMS dispatcher to divert ambulances to other hospitals when the hospital in question has no empty beds?
The Standards of Care and Corrective Action
In reviewing the literature for established standards, Spaite, et al reported that administrative focus on correcting such problems that cause slow downs and bottlenecks in patient flow have reduced average waiting time by one half (7). Additionally, Lambe, et al reported that a survey of emergency department administrators established that over crowding is defined as an average waiting time of more than one hour and the waiting time is the time of initial entry to the first physician contact (4).
1) This provides sufficient evidence that a general consensus exists as to what is good and proper:
2) That a hospital providing emergency care services must keep track of ED waiting time;
3) That administration must make every effort to keep average waiting time within one hour by eliminating correctable situations that cause delays in moving current patients, which in turn cause delays in treating new patients;
3) That there be enough nurses conducting triage and monitoring all patients who remain the waiting room for sudden changes in their condition.
Summary and Conclusion:
We know from the many studies that have been published that in most cases, prolonged waiting times in emergency departments can be reduced. We also know that over crowding can be ameliorated a significant degree by conducting a proper inquiry and making a few simple changes in administrative policy. Therefore, it is incumbent upon every hospital executive with command responsibility over the emergency department to take waiting time seriously and regard an average of more than one hour as unacceptable. Moreover, the hospital's cadre of board room denizens must take every reasonable action to find and correct such contributory factors as described above when emergency room over crowding (with the staff operating in disaster mode) has become the normal condition.
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