Duration of Patients' Visits to the Hospital Emergency Department

Zeynal Karaca; Herbert S Wong; Ryan L Mutter


BMC Emerg Med. 2012;12(15) 

In This Article


Length of stay (LOS) is perceived as an important indicator of quality of care in Emergency Departments (EDs).[1] Increased LOS at EDs may contribute to systematic problems in the delivery of efficient and high quality medical care in the U.S.[2] Increased LOS may mean that patients wait longer to see ED physicians and to obtain critical treatments and test results.[3] Among the thoughtful measures related to duration in the ED that are of interest to policymakers and providers are door to diagnostic time, door to treatment time (including the provision of pain medicine for certain conditions), ED arrival to ED departure time, and decision to admit to ED departure time for patients that are admitted. The Centers for Medicare & Medicaid Services (CMS) began data collection on three ED throughput timing measures on January 1, 2012.

There is a growing body of literature on the factors associated with longer ED LOS. Researchers deconstructed the association between static crowding measures (waiting room volume, census, number boarding, and inpatient occupancy) and waiting room, treatment, and boarding times experienced by ED patients.[4] The literature finds that when more people are waiting to be treated, intervals between phases of care at EDs lengthen and the waiting line becomes longer. This also illustrates the fundamental relationship between crowding (waiting lines) and delays in patient care.[5] ED LOS is positively associated with the hospital occupancy rate and number of emergency admissions.[6] The crowding factors increase waiting and boarding time but not treatment time.[7] Increasing numbers of low-complexity patients do not significantly lengthen the waiting time or ED LOS for higher complexity patients.[8] Certain census variables (e.g., the number of admissions from the ED per day) and the number of intensive care and cardiac telemetry units affect ED length of stay across many hospital settings.[9]

Increased LOS at EDs may contribute to ED crowding, which has become a major public health problem in the United States. ED crowding can contribute to poorer patient outcomes and to lost-demand for ED services (and the associated revenue) when patients leave without being seen.[10] ED crowding presents obvious operational and logistic problems for hospitals, and raises serious ethical concerns.[11,12] The moral problems posed by ED boarding and resultant crowding have a variety of undesirable consequences such as increased patient waiting times, decreased ability to protect patient privacy and confidentiality, impaired evaluation and treatment, and difficulties in delivering person-centered care.[13]

This study uses a previously unused data source that captures ED visits for entire states to explore ED LOS by admission hour, day of the week, patient volume, patient characteristics, hospital characteristics, and area characteristics. ED visits are limited to those in which the patients are treated and released (T&R), i.e., not admitted to the same hospital. The study contributes to the existing literature in the following important way: Existing studies examining emergency department LOS, crowding, and resource use generally employ data drawn from a sample of ED visits, obtained from a survey, or tracked as part of a before-after intervention study.[13] One of the largest of these data filesa is a nationally representative sample of 138,569 ED visits over a 5-year period.[2] In contrast, our data file includes 4.9 million ED visits in a single year. Healthcare policies designed to provide solutions to increased ED LOS, ED crowding, and related issues may produce better outcomes when they are based on large databases. Such large databases may shed light on the wide variations in utilization patterns of ED services and the significant differences in patient-related and market-specific factors.[14] Our findings may inform public and private policymakers on a broad range of issues including, but not limited to, Monday volume, impact of hospital bed size and hospital status on the average duration of T&R ED visits, and differences in duration by race.

aFurther details about these data files are available at http://www.cdc.gov/nchs/ahcd.htm.