Schizophrenia, Chest Pain Top Longest Emergency Department Stays

Ernest Moy, MD, MPH Medical Officer Center for Quality Improvement and Patient Safety Agency for Healthcare Research and Interview with:
Ernest Moy, MD, MPH
Medical Officer
Center for Quality Improvement and Patient Safety
Agency for Healthcare Research and Quality

Medical Research: What is the background for this study?

Dr. Moy: The amount of time that a patient spends in the emergency department (ED) has become increasingly viewed as a quality measure, because length of stay and ED crowding have been linked to quality of care, patient safety, and treatment outcomes. However, current ED length-of-stay measures publicly reported by the Centers for Medicare & Medicaid Services (CMS) combine lengths of stay across all conditions. We suspected that ED length of stay is influenced by the clinical condition of the patient, but didn’t know how disparate times might be. Of course, such stays will certainly be influenced by other factors, which we describe in the paper. Previous studies have helped guide decisions about where to focus resources to improve emergency department services. However, many studies about ED length of stay focus on a single condition, a single or few hospitals, or both, which limits what we can conclude across different conditions.  We were fortunate to find one state, Florida, in the Healthcare Cost and Utilization Project database that provides entry and exit times for a census of emergency department visits for both released and admitted patients to measure length of ED stays by patients’ conditions and dispositions.

Medical Research: What are the main findings?

Dr. Moy: For the 10 most common diagnoses, patients with relatively minor injuries (e.g., sprains and strains, superficial injuries and contusions, skin and subcutaneous tissue infections, open wounds of the extremities) typically required the shortest mean stays (3 hours or less). Conditions involving pain with nonspecific or unclear etiologies (e.g., chest, abdomen, or back pain; headache, including migraine), generally resulted in mean stays of 4 hours or more. However, there were substantial clinical differences among patients released, admitted, and transferred. Conditions resulting in admission or transfer tended to be more serious, resulting in longer stays. Patients requiring the longest stays, by disposition, had discharge diagnoses of nonspecific chest pain (mean 7.4 hours among discharged patients), urinary tract infections (4.8 hours among admissions), and schizophrenia (9.6 hours among transfers) among the top 10 diagnoses.

Medical Research: What should clinicians and patients take away from your report?

Dr. Moy: Our findings should be useful to hospital administrators who want to assess their own emergency department operations in terms of throughput. If they reliably collect entry and exit times, they can tally their cases in the same way we did and compare their patients’ average or median length of time in the ED to the state-wide average for Florida by clinical condition and by what happened to the patient—admission, transfer, or release. Looking at this by condition and disposition gets around the concern that one hospital’s patients are more complicated. If they find a clinical condition where they are way above (or way below) the Florida average, they should investigate why. For example, it may be because they have inefficiencies in their operations, or it may be because some staff are not following guidelines about observing patients for a sufficient period of time.

For patients, I think it helps to know, for example, that you will most likely be in the emergency department a long time if you go with chest pain. You can go prepared with reading materials and any companions can know what to expect. It reduces the frustration level. One of our co-authors had to take her husband to the ED for chest pain right after we had the results from this work and she told him to take a book and expect to be there overnight. All that turned out to be true and it made an already stressful situation much less stressful because of waiting time.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Moy: We have only scratched the surface of what needs to be done in this area.

  • Collecting ED length of stay. ED length of stay is not collected nationwide, but should be. Florida data, which is influenced by an older population on average, should not be used as the ultimate guide for hospital managers or the ultimate benchmark in this area.
  • Furthermore, standards are needed for how ED entry and exit times are collected. Some ideas for standardizing measures of ED duration include:
  • Consistently collecting both the hours and minutes for ED arrival and departure.
  • Collecting length of stay both for treat and release patients and for admitted patients. Without ED length of stay in both databases, a total view of ED performance cannot be assessed.
  • While entry and exit times are essential, adding time to clinical evaluation would enable analysts to determine whether general emergency department efficiency or condition-related treatment times are affecting ED performance.
  • Distinguishing whether an ED visit involves treatment, observation, and/or boarding. These decisions, as well as clinical guidelines and resources beyond the hospital’s control, can influence the length of stay in the ED. Capturing this information allows managers and policymakers to understand the circumstance of patient visits and the different environments in which hospitals function.

Now that hospitals in some states are advertising their current ED waiting times on highway billboards, it raises the question of how these times are measured.

  • Variation in ED length of stay. How much variation exists in ED length of stay across hospitals? Which types of hospitals exhibit shorter or longer ED stays? How different are the outlier hospitals? This knowledge could help to illuminate the challenges that different types of hospitals face in being efficient.
  • Outcomes influenced by ED length of stay? Finally, there is very little information about how the operation of the ED influences the outcomes of patients. Is delay and overcrowding related to poor outcomes or medical errors? We measure the performance of hospitals on many dimensions, but ED performance is typically not one of them.

Promoting such research can improve patient centeredness, transparency, and care improvement. Public information on ED efficiency, by clinical mix and patient disposition, would empower patients to select hospital EDs in their communities based on how well patient care is managed, especially for visits where patients have the time to make deliberate decisions. This would create powerful incentives for hospitals to improve the ED services they provide. 


Length of Stay in Emergency Departments: Variation Across Classifications of Clinical Condition and Patient Discharge Disposition

Moy, Ernest et al.

The American Journal of Emergency Medicine
Published Online: September 22, 2015

Publication stage: In Press Accepted Manuscript

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Ernest Moy, MD, MPH (2015). Schizophrenia, Chest Pain Top Longest Emergency Department Stays 

Last Updated on October 15, 2015 by Marie Benz MD FAAD