Pennsylvania Patient Safety Advisory Managing Patient Access and Flow in the Emergency Department to Improve Patient Safety ABSTRACT patients who leave without being seen (LWBS), as From 1996 to 2006, the annual number of emergency well as by measuring other discrete blocks of time department (ED) visits increased approximately between patient initial presentation and final dis- 32% from 90.3 million to 119.2 million, according position.3 Delays in care and treatment can result to the Centers for Disease Control and Prevention. in further patient illness or even death.4 According Simultaneously, as the number of patient visits to Joint Commission sentinel event statistics, there increased, the number of hospital EDs decreased was a 31% increase in the number of reports linked from 4,019 to 3,833, increasing the number of to delay in treatment, from 7.7% of total reports in annual visits per ED and contributing to crowding. 2007 to 10.1% of total reports in 2008.5 Recogniz- In 2009, Pennsylvania healthcare facilities reported ing that when patient flow becomes impeded EDs to the Pennsylvania Patient Safety Authority 1,930 become crowded, a 2005 Joint Commission patient events of complications of procedures or treatments flow standard requires hospitals to plan, implement, or tests from the ED. Existing and proposed ED monitor, and measure patient flow activities related to measures (e.g., from initial patient presentation to admitted patients who are in temporary bed locations final departure)—specifically those from the Hospital in areas like the ED (“boarders”); patients who are Quality Alliance, the Centers for Medicare and placed in overflow locations; ambulance diversions; Medicaid Services, the Oklahoma Foundation for the supply of available beds; efficiency of areas where Medical Quality, and the National Quality Forum— patients receive care; safety of areas where patients show that national payment and quality organizations receive care; and access to patient support services.6 have recognized the importance of standardizing ED performance measures. Facilities can use this data to Several studies have presented further evidence that manage patient access and flow in the ED, to increase ED crowding contributes to poor quality care. A retro- patient satisfaction, to improve quality of care, and spective analysis of patients older than 30 years with to optimize patient safety. This article focuses on chest pain syndrome who were admitted to tertiary strategies to increase patient safety and improve care hospitals from 1999 through 2006 (n = 4,574) quality during the ED visit from the point of patient showed an association between ED crowding and a arrival to the diagnostic evaluation. (Pa Patient Saf higher risk of adverse cardiovascular outcomes.7 Addi- Advis 2010 Dec;7[4]:123-34.) tional studies show correlations between high ED wait times and the following: patient mortality,8,9 time to antibiotic for patients with pneumonia,10 time to thrombolysis,11 and time to analgesia for patients with Emergency Department Statistics severe pain.12 Addressing ED crowding and wait times may be the first step in addressing patient safety and Emergency departments (EDs) are under pressure to quality of care in the ED. provide care that is safe, effective, patient-centered, timely, efficient, and equitable—a difficult task under National Payment and Quality Organizations any circumstances, but one that is even more difficult Endorsing ED Metrics in the presence of ED crowding. According to the Centers for Disease Control and Prevention (CDC), Recognizing the potential problems associated with ED from 1996 to 2006 the annual number of ED visits crowding, several national payment and quality organi- increased approximately 32% from 90.3 million to zations have developed ED metrics that measure periods 119.2 million. Simultaneously, as the number of between patient initial presentation to the ED and final patient visits increased, the number of hospital EDs departure from the ED. Currently, the Hospital Quality decreased from 4,019 to 3,833, increasing the number Alliance is collecting two voluntary emergency depart- of annual visits per ED. CDC also found that the ED ment parameters: (1) median time from ED arrival to was the portal of entry for more than 50% of the non- ED departure for admitted ED patients and (2) admis- obstetric acute care admissions in the United States, sion decision time to ED departure time for admitted an increase from 36% in 1996.1 Furthermore, the patients.3 These parameters are likely to be included in role of the ED has evolved from providing primarily the Reporting Hospital Quality Data for Annual Pay- life-saving treatment to providing urgent unscheduled ment Update in 2012, highlighting the importance of care to patients unable to gain access to their primary ED data collection and tracking for payment as well as care providers, as well as to providing care to Medic- for quality and patient safety purposes. Additionally, aid beneficiaries and to patients without insurance.2 the Centers for Medicare and Medicaid Services (CMS) and the Oklahoma Foundation for Medical Quality All these factors contribute to crowding in the ED, propose a third metric,” median time from ED arrival which can be measured by average patient wait times, to ED departure for discharged ED patients” to be average door-to-doctor times, and the percentage of included in the clinical quality measures for electronic Vol. 7, No. 4—December 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 123 Pennsylvania Patient Safety Advisory submission.13 In 2008, the National Quality Forum metrics occur in the patient arrival to diagnostic eval- (NQF) endorsed 10 ED quality measures for hospital- uation phase (LWBS; door-to-diagnostic evaluation). based ED care to help decrease patient wait time, Finally, the last data metric occurs in the final phase increase physician productivity, and increase patient of ED treatment (admission decision to departure safety.14 Three of these NQF-endorsed benchmarks time) (see Figure). are being considered by CMS for inclusion in the The Pennsylvania Patient Safety Authority received public reporting system in 2012. 1,930 reports of complications of procedures or treat- NQF’s measures 1 and 3 represent length of stay in ments or tests from the ED care setting in 2009.* One the ED. Measure 2 represents throughput in the ED— hundred were Serious Events (events that harmed how efficiently patients are moved from the ED to the patients; 5%), and 1,830 were Incidents (so-called next care setting. Measures 4 and 5 represent patient near-miss or no harm events; 95%). Analysis of these arrival and triage efficiency. events shows that potential threats to patient safety can occur during the patient arrival to diagnostic eval- Care Along the ED Continuum of uation phase, the diagnostic evaluation to disposition Quality Metrics decision phase, or the disposition decision to final Table 1 shows that EDs must begin tracking—and discharge phase of ED treatment. The Figure shows a will soon start reporting—this data to national payer breakdown of these processes in the ED with correlat- groups. Once this data is consistently collected, it will ing data collection points. be important to improve metrics without jeopardiz- ing quality or negatively affecting patient safety. Two * As of January 16, 2005, the Authority ceased report classifica- tions for “Complication of Procedure/Treatment/Test, Emergency of the data metrics span the entire length of the ED Department, Left without Being Seen/Left before Visit Com- encounter (ED arrival to final disposition for admit- pleted.” Reports submitted under these categories were not ted and discharged patients). Two additional data counted in the analysis. Table 1. Summary of Emergency Department (ED) Data Parameters under Consideration for Public Reporting in 2012 by the Centers for Medicare and Medicaid Services MEASURE NO. IDENTIFIER METRIC DEVELOPER DESCRIPTION Centers for Medicare & 1. Median time from ED CMS; Oklahoma Foundation Median time (in minutes) from Medicaid Services (CMS) arrival to ED departure for Medical Quality (OFMQ); ED arrival to ED departure for Emergency Department-11 for admitted patients admitted patients (NQF 0495) Reporting Hospital Quality National Quality Forum (NQF) Data for Annual Payment NQF 0495 Update (RHQDAPU) CMS ED-21 2. Admission decision time CMS; OFMQ; RHQDAPU Median time (in minutes) from to ED departure time for admission decision time to NQF 0497 2 admitted patients departure from the ED for ED patients admitted to inpatient status (NQF 0497) CMS ED-31 3. Median time from ED CMS; OFMQ Median time (in minutes) from arrival to ED departure ED arrival to departure from NQF 0496 2 for patients discharged the ED for patients discharged from the ED from the ED (NQF 0496) NQF 04983 4. Door-to-diagnostic Louisiana State Median time (in minutes) from evaluation by qualified University (LSU) first contact in the ED to the medical personnel time when the patient sees qualified medical personnel* for the first time for evaluation and management (NQF 0498) NQF 04993 5. Left without being seen LSU Percentage of patients leaving by qualified medical without being seen by qualified personnel medical personnel (NQF 0499) * The designation of qualified medical personnel must be set forth in a document approved by the board of trustees or governing body of the hospital and meet the requirements of CMS manual §482.55. Notes 1. QualityNet. Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU). Measure comparison (inpatient hospital quality measures) [online]. [cited 2010 Apr 29]. Available from Internet: http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename= QnetPublic%2FPage%2FQnetTier3&cid=1138900298473. 2. Table 20: Proposed clinical quality measures for electronic submission by eligible hospitals for payment year 2011-2012. In: Centers for Medicare and Medicaid Services. Medicare and Medicaid programs; electronic health record incentive program; proposed rule. Fed Regist 2010 Jan 13;75(8)1896. 3. National Quality Forum (NQF). NQF endorses measures to address care coordination and efficiency in hospital emergency departments [online]. 2008 Oct 29 [cited 2010 May 12]. Available from Internet: http://urgentmatters.org/media/file/NQF%20Press%20Release.pdf. Page 124 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 4—December 2010 Pennsylvania Patient Safety Advisory The Authority further analyzed 412 of the reports camera tapes showed that the man stopped submitted from August 1, 2009, through December moving 11 minutes after his arrival in the wait- 30, 2009. Forty of these events occurred during the ing room, and that he was found to be dead of patient arrival to diagnostic evaluation phase, 258 dur- a massive heart attack almost an hour after he ing the diagnostic evaluation to disposition decision had come to the ED—and only after another phase, and 114 during the disposition decision to dis- patient had alerted ED staffers to the motion- charge from the ED phase of treatment. less man. Eighty-eight contributing factors were identified as being The Pennsylvania Department of Health’s investigation associated with these 412 event reports (see Table 2). found that ED employees were not aware of a facility Table 3 lists the variety of factors that can contribute policy for checking on patients in the waiting room to events that occur in the ED setting. For the 40 and that no nursing staff monitored or maintained an reports in the patient arrival to diagnostic decision awareness of activity in the ED waiting room.16 phase, there were 17 contributing factors in 12 cat- The first step in improving the ED intake process is egories. The remainder of this article focuses on the to collect the necessary data to analyze patient flow strategies for optimizing patient safety and improving and front-end processes. The American College of data metrics during the first phase of ED treatment: Emergency Physicians’ (ACEP) Emergency Medicine patient arrival in the ED to diagnostic evaluation (also Practice Committee defines the ED front-end process referred to as the “door-to-doctor” phase). as the span of time from the patient’s initial arrival in the ED to the time the ED healthcare provider Patient Arrival in the ED to Diagnostic Evaluation formally assumes responsibility for the evaluation and Patient arrival in the ED to diagnostic evaluation management of the patient (diagnostic evaluation by encompasses the patient registration and triage pro- a qualified provider).17 Timeliness of care during this cesses, as well as placement in a treatment room or initial period can influence the outcome of the entire area to await diagnostic evaluation. These time inter- ED visit and is an important consideration for patient vals can pose threats to patient safety in a variety of safety, as well as one of the strongest predictors of ways. For example, as reported in a Philadelphia-area patient satisfaction.18 In order to improve timeliness news source, the following event occurred in a of care, EDs must first understand facility-specific uti- Pennsylvania hospital in 2009:15 lization and census patterns. A 63-year-old male had gone to an area ED and reported feeling pain in his left side. Security (continued on page 127) Figure. Emergency Department Care Metrics Patient Arrival in Emergency Department Diagnostic Evaluation to Disposition Decision (ED) to Diagnostic Evaluation Disposition Decision to Discharge from the ED Includes: Includes: Includes: Patient arrival in ED Continued physician assessment Monitoring patients until bed/unit availability Patient triage Tests ordered or until ready for discharge Placement in ED Consults ordered Communication and handoff to next Waiting for test results unit/facility/care setting Physician arrival/diagnostic evaluation Disposition Patient teaching and discharge Potential Threats to Patient Safety: Transportation Unmonitored patients in waiting areas Potential Threats to Patient Safety: Rushed/inaccurate triage processes Untimely consultations Potential Threats to Patient Safety: Patients who leave without being seen Untimely tests Unmonitored boarders in the ED Unmonitored patients in rooms waiting for Poor assimilation of data Poor communication and handoffs diagnostic evaluation Poor coordination of care Incomplete patient education and teaching Incomplete/inaccurate patient assessment Unmonitored patients in treatment rooms Patient transportation difficulties ED arrival to discharge for admitted (1) and discharged (3) patients Left without being seen (5) Admission decision to departure time (2) MS10543 Door to diagnostic evaluation (4) Vol. 7, No. 4—December 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 125 Pennsylvania Patient Safety Advisory Table 2. Pennsylvania Patient Safety Authority Serious Events and Incidents by Patient Treatment Phase, August through December 2009 TOTAL SERIOUS PATIENT TREATMENT PHASE REPORTS EVENTS INCIDENTS Patient arrival in emergency department (ED) to patient assessment 40 2 38 Physician assessment to disposition decision 258 9 249 Disposition decision to discharge from ED 114 3 111 Total 412 14 398 Table 3. Contributing Factors Reported to the Pennsylvania Patient Safety Authority by Patient Treatment Phase, August through December 2009 CONTRIBUTING FACTORS IDENTIFIED FACTORS BY PATIENT TREATMENT PHASE Diagnostic Patient Arrival Evaluation To Disposition To Diagnostic Disposition Decision To Final Evaluation Decision Discharge Factor Total Team Factors Communication problems between 2 4 2 8 providers Change of service 1 1 Cross-coverage situation 1 1 Shift change 1 1 Total 3 6 2 11 Work Environment Distractions/interruptions 1 4 2 7 Limited access to patient information 1 1 Equipment malfunction 1 1 Total 3 4 2 9 Task Factors Training issues 1 3 1 5 Emergency situation 2 2 Total 1 5 1 7 Staff Factors Inadequate system for covering patient 1 1 care Insufficient staffing 1 1 Issue related to proficiency 1 7 2 10 Total 2 7 3 12 Patient Characteristics Lack of patient compliance/adherence 3 6 3 12 Lack of patient understanding 4 1 5 Lack of family member cooperation 1 1 Total 3 10 5 18 Organization/Management Factors Presence of boarder patient 1 1 Unclear or ambiguous policies or 1 1 procedures Procedures not followed 2 13 3 18 Total 3 13 4 20 Other Contributing Factors 2 6 3 11 (not specified) Total Contributing Factors 17 51 20 88 Page 126 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 4—December 2010 Pennsylvania Patient Safety Advisory (continued from page 125) For instance, a high waiting room census may indicate either a long triage queue or a high ED occupancy rate Forecasting ED Utilization (during patient arrival to diagnostic evaluation phase). Studying data over time permits accurate predic- Occupancy (percentage of filled beds) may indicate tions regarding utilization. According to a May 2010 that the department itself is at full capacity (during National Center for Health Statistics data brief, diagnostic evaluation to disposition decision phase). approximately one-fifth of the civilian, noninstitution- The number of boarders in the ED may indicate alized U.S. population had one or more ED visits in decreased capacity within the hospital units (during a 12-month period in 2007.19 The Emergency Depart- disposition decision to discharge from the ED phase).7 ment Benchmarking Alliance Annual Data Survey Once demand has been predicted through analysis of 2007 highlighted some recognizable trends in ED historical utilization and census data, staffing levels data, including the following:18 can be matched to the demand. Departments can ■ Total arrivals increase from midmorning until develop a series of early warning signals (triggers) that noon and then hold steady until midnight, when signify a capacity-to-demand mismatch, and interven- they decrease. tions aimed at mitigating the mismatch. For instance, if capacity (department census/total available beds) ■ Pediatric arrivals surge before adult arrivals and exceeds 80%, an ED may elect to implement a dis- decrease sooner. charge team to quickly discharge stable patients, have ■ Senior citizen arrivals surge in the late afternoon, physicians meet to determine whether any patients can and these patients will wait longer before leaving return at a later time for diagnostic testing during low without being seen. census times (offloading), or create an express admis- ■ The census (see discussion below) increases until sions team to move admitted patients through the noon, stays high through the evening shift, and ED.18,20 These strategies must comply with the Emer- then quickly decreases to its lowest point at 5 a.m.; gency Medical Treatment and Labor Act (EMTALA) the cycle then repeats. (i.e., the patient must receive a medical screening examination, and it must be determined that the ■ The busiest days of the week are Saturdays and patient does not have an emergency medical condition Mondays. and is stable for discharge). Per EMTALA, “stable” ■ The busiest months are July, August, and December. means that the patient is unlikely to deteriorate during discharge within a reasonable medical certainty.21 ■ The most common chief complaints are abdominal pain, chest pain, and orthopedic injuries. Accurate utilization and census tracking has led to a Individual ED statistics may not match the above list number of EDs publicly posting forecasted ED wait exactly, but the list provides a benchmark for facilities times on their websites (e.g., Gulf Coast Medical Cen- to analyze in the context of specific ED trends. Once ter: http://www.egulfcoastmedical.com; Baton Rouge facilities can accurately predict demand (utilization), General: https://www.brgeneral.org/site.php). they can begin to plan ED capacity to match the Tracking Clinical Performance Metrics demand. Utilization patterns must be analyzed in con- In addition to the operational metrics listed in junction with departmental census data. Table 1, EDs monitor a number of clinical perfor- Tracking Census Data mance measures, some of which are reported on Census data describes what is happening in an ED the CMS website at http://www.hospitalcompare. during specific time intervals. For example, data can hhs.gov/Hospital/Search/SearchMethod.asp. Most illustrate the following: ED personnel are aware of the clinical performance measures for surgical care, myocardial infarction, ■ Census by hour, day, month, or year heart failure, pneumonia, and childhood asthma ■ Waiting room census care. NQF also endorses 10 quality measures for the ED, 4 of which are related to clinical performance ■ ED occupancy (occupied beds/total beds) measures (i.e., sepsis, pregnancy tests for females with ■ Percentage of patient admissions abdominal pain, anticoagulation for acute pulmonary ■ Percentage of trauma cases embolus patients, pediatric weights in kilograms). These are available at http://www.qualitymeasures. ■ Percentage of patient admissions to the intensive ahrq.gov/browse/nqf-endorsed.aspx?term=emergency care unit +department+and+national+quality+forum. Overlay- ■ Percentage of pediatric patients ing clinical performance metrics with utilization and census data can assist EDs with predictive utilization ■ Percentage of patients with certain clinical patterns. For instance, if the busiest time in the ED complaints is from 10 p.m. to 1 a.m., analyzing the clinical pre- Census data allows EDs to predict utilization for given sentation of patients during this high-census time can periods and avoid bottlenecks in ED intake processes help managers ensure that the appropriate type and before they occur. It is important to understand how level of staff are available to handle the patient popu- different census measures correlate to facility capacity. lation. A large body of clinical literature suggests that Vol. 7, No. 4—December 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 127 Pennsylvania Patient Safety Advisory ED crowding and long wait times are associated with Initially, the triage nurse assesses only acuity level, both unfavorable clinical endpoints (mortality rates) which is determined by the stability of vital func- and delays in various clinical process measures, such tions and potential for life, limb, or organ threat. If as time to treatment for conditions like acute myocar- a patient does not meet high acuity level criteria (ESI dial infarction, thrombosis, antibiotic administration level 1 or 2), the triage nurse then evaluates expected for pneumonia, and pain management.7, 9-12 resource needs to help determine a triage level (ESI level 3, 4, or 5). Resource needs are defined as the Front-End Patient Flow Processes and Patient number of resources a patient is expected to consume Safety Concerns in order for a disposition decision to be reached. Patient Triage Detailed information about the ESI triage system can be found at http://www.ahrq.gov/research/esi/ The purpose of ED triage is to quickly assess and esihandbk.pdf. categorize incoming patients and to identify emer- gent patients. Triage nurses or other professionals Door-to-Doctor Time are trained to quickly recognize patients who require Door-to-doctor time is the median time (in minutes) immediate, life-sustaining care and to categorize and from first contact in the ED to the time that the prioritize the remaining patient population. Rapid, patient sees qualified medical personnel for the first accurate triage of patients in the ED is key to success- time for evaluation and management of the medical ful ED operations. Patients who are undertriaged are condition (NQF 0498), also referred to as the patient at risk for deterioration while waiting; patients who arrival in the ED to diagnostic evaluation phase. The are overtriaged may use scarce resources (e.g., tak- universal service quality goal is to have patients seen ing an open bed, which may be needed for another by a physician in less than 30 minutes.18 Data from patient requiring immediate care). Accurate triage the 2006 National Hospital Ambulatory Medical categorization can only be accomplished when a reli- Care Survey (NHAMCS) (n = 119,191,000) shows that able and validated triage tool, in which all applicable 61.8% of patients waited more than 30 minutes but healthcare providers have been trained, is used. less than one hour to see a physician (mean 55.8 min- There are several triage systems in the United States, utes; median 31 minutes).2 When the door-to-doctor consisting of three-, four-, or five-level triage param- time increases, the percentage of patients who leave eters. The National Center for Health Statistics without being seen increases, too (see “Walkaway converted to a five-level triage data collection system Population”). The national LWBS rate, according to in the 2005 National Hospital Ambulatory Medical the 2006 NHAMCS report, was approximately 2%.2 Care Survey (NHAMCS) for the ED.22 The prevailing While ESI does not specify door-to-doctor bench- triage method is the Emergency Severity Index (ESI), marks in minutes per acuity level, both ATS and which is endorsed by the Emergency Nurses Associa- CTAS do, as shown in Table 5. tion and ACEP.23 Other frequently used tools are the In the ED, situational awareness is critical, and it Australian Triage Scale (ATS) and the Canadian encompasses patients in waiting rooms, as well as Triage and Acuity Scale (CTAS). patients in various stages of treatment throughout the ESI is a five-level triage tool that categorizes ED department. The Authority has received reports involv- patients by evaluating both patient acuity level and ing patients at various points during the patient arrival resource needs (see Table 4 for ESI level definitions). to diagnostic evaluation phase of ED treatment. Table 4. The Emergency Severity Index (ESI) CATEGORY DEFINITION STATISTICS ESI 1 Severely unstable patient, must be seen immediately by a physician, Represents 2% of all patients; often requires an intervention (e.g., intubation) to be stabilized 73% of ESI 1 cases are admitted ESI 2 Potentially unstable patient, must be seen promptly by a physician Represents 22% of all patients; (within 10 minutes), often requires laboratory and radiology testing, 54% of ESI 2 cases are admitted medication, and admission ESI 3 Stable patient, should be seen urgently by a physician (within Represents 39% of all patients; 30 minutes), often requires laboratory and radiology testing and 24% of ESI 3 cases are admitted medication, and usually is discharged ESI 4 Stable patient, may be seen nonurgently by a physician or midlevel Represents 27% of all patients; provider, requires minimal testing or a procedure, and is expected to 2% of ESI 4 cases are admitted be discharged ESI 5 Stable patient, may be seen nonurgently by a physician (or midlevel Represents 10% of all patients; provider), requires no testing or procedures, and is expected to be 0 of ESI 5 cases are admitted discharged Source: Reiter M, Scaletta T. On your mark, get set, triage! Emerg Physicians Mon [online]. 2008 Aug 31 [cited 2010 May 25]. Available from Internet: http://www.epmonthly.com/subspecialties/management/on-your-mark-get-set-triage. Page 128 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 4—December 2010 Pennsylvania Patient Safety Advisory ■ Before patient registration: Alternative Triage Strategies The patient was found on the street and brought in Patient Registration by fire rescue and stated he wanted to stay warm and Door-to-triage time is the first detectable period refused to be seen by a physician. The patient was in within the patient arrival to diagnostic evaluation a wheelchair and was placed in the waiting room. phase of the ED visit. Minimizing this time is an Later, he was noted to be snoring in the wheelchair; important patient safety goal. One efficient means to subsequently, he was found unresponsive. [He was] do this is through an evaluative registration process. taken to the treatment area and advanced cardiac This may consist of a “quick look” triage process life support protocol was initiated. whereby a nurse stationed at the ED entrance per- ■ During and after the triage process: forms an abbreviated triage assessment in conjunction with a preregistration process designed to capture The patient was triaged with a history of chest pain just enough demographic detail to assign a patient on and off, but not present at triage. [The patient account number and produce a patient identification was] sent back to waiting area and then developed band, ideally within 30 seconds.20 Once this basic pain. [The patient was] taken back to [the treatment] information is captured and entered into a system area, an EKG [electrocardiogram] was done and to generate a medical record, the rest of the patient myocardial infarction noted. The patient was treated registration information can be captured at any point emergently. . . . during the ED stay.17 Combining registration and [A patient was] triaged, but not in lobby [several triage into parallel rather than serial processes can hours later]. The patient had complaint of chest increase department efficiency. heaviness, noncardiac reasons. . . . Using Midlevel Providers or Physicians in Triage The patient was triaged but was not in the waiting Many alternative triage strategies are described in the room when called [about four hours later]. . . . literature. One of the most successful strategies is to elevate the level of education and experience of the ■ While waiting for physician assessment: staff member in triage by placing a midlevel provider The patient was not seen in the litter area. [The (e.g., advanced nurse practitioner, physician assistant) patient] was observed in a sitting position with a cord or a physician in triage. This intervention alone wrapped around the neck. [The patient was] assisted has been shown to reduce throughput time, reduce by ED staff in removing the cord . . . assisted by staff waits, and reduce the LWBS population.24 One study back to bed. [The patient was] placed on direct shows that emergency medical technicians can predict observation. . . . whether patients would need to be admitted from the ED 62% of the time.25 Other studies show that The current state of crowding in many EDs has threat- physicians can accurately predict patient outcome and ened patient safety and placed an increased focus on disposition with 85% to 95% accuracy.18 triage. Using a reliable triage scale such as ESI and implementing promising new triage strategies can help Midlevel providers are typically stationed close to the EDs improve on the data metrics outlined previously, triage station and receive patients to initiate the plan while simultaneously safeguarding patient safety. of care and order diagnostic testing. The patient’s care is then transferred to the ED physician for a definitive diagnosis and completion of treatment through patient disposition. Midlevel providers are frequently used Walkaway Population during times of high acuity or volume. The success of “Walkaways” are patients who leave the emer- this model depends on the competence of the midlevel gency department (ED) before treatment is providers and their ability to quickly begin treatment. completed, patients who leave against medical When this model is used successfully, it has improved advice, and patients who leave without being patient satisfaction scores, reduced the LWBS popula- seen (LWBS). While the Centers for Medicare and Medicaid Services is collecting data related to the tion, and improved the door-to-doctor benchmarks at a LWBS population, many EDs realize the benefit relatively low cost. The disadvantages are that midlevel of tracking all walkaways from the ED. Not only providers tend to order more diagnostic tests and the is it a patient safety issue when patients requiring number of patient handoffs is increased.18 medical treatment leave a facility before treatment is rendered, but this population also potentially Another successful model is the placement of a board- increases facility liability and contributes toward certified emergency physician in triage. In addition to lost revenue. Rapid patient assessment and triage being able to accurately predict admission status, emer- is the most effective way to decrease the LWBS gency physicians have both the knowledge and authority patient population. to make broad-based decisions, including those related Source: Welch SJ. Quality matters: solutions for a safe to earlier patient admissions when warranted. and efficient emergency department. Joint Commission In the triage rapid initial assessment by doctor Resources. Oakbrook Terrace (IL); 2009:11. (TRIAD) study, the average patient wait time was reduced by 38% and the average processing time by Vol. 7, No. 4—December 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 129 Pennsylvania Patient Safety Advisory physicians, nurses, and ED technicians meet in the Table 5. Comparison of Australian Triage patient treatment area to perform the patient triage System (ATS) and the Canadian Triage and assessment and formulate the diagnostic plan of care. Acuity System (CTAS) Benchmark Times The emergency department at Vanderbilt University ACUITY ATS DOOR-TO- CTAS DOOR-TO- Medical Center, a Level I trauma center in Tennessee, LEVEL DOCTOR TIME1 DOCTOR TIME2 established a program in which patients are quickly Level I Immediate Immediate assessed in a triage area by a team consisting of a phy- Level II 10 minutes 15 minutes sician, a nurse, and a paramedic. Patients with urgent Level III 30 minutes less than 30 minutes problems are promptly moved to a treatment room. Level IV 60 minutes less than 60 minutes Patients with nonurgent problems are tested and Level V 120 minutes 120 minutes treated in the team triage area and then released or Notes returned to the waiting area until test results and 1. Western Australian Centre for Evidence Based Nursing and a treatment room become available. Because of this Midwifery. Triage in the emergency department: general program, most patients see the triage doctor within principles [online]. 2004 [cited 2010 May 25]. Available from 10 minutes of arriving, the percentage of LWBS Internet: http://wacebnm.curtin.edu.au/workshops/Triage.pdf. patients has decreased from 5% to less than 1%, and 2. Jimenez JG, Murray MJ, Beveridge R, et al. Implementation of patient satisfaction has increased markedly.27 the Canadian Emergency Department Triage and Acuity Scale (CTAS) in the Principality of Andorra: Can triage parameters No Triage serve as emergency department quality indicators? CJEM 2003 Sep;5(5):315-22. Another strategy being successfully used by a number of EDs involves directing patients immediately to an open bed in the ED and performing bedside registra- tion while simultaneously triaging and treating the 23% without adding extra staff. Benefits highlighted patient. In this model, the primary nurse performs the in this study included the following:26 initial patient assessment, often with the ED physician ■ Many simple medical conditions could be treated in attendance performing a parallel medical evalua- and patients discharged directly from triage. tion, thereby decreasing the amount of time spent by ■ Patients were admitted faster when a physician the triage professional and improving communication identified an appropriate medical condition dur- between healthcare providers. Where it can be imple- ing triage. mented, this model has led to reduced patient wait times, decreased overall length of stay, and reduced ■ Treatments for symptom control (e.g., pain numbers of ED patients waiting to be seen.24 management) were initiated in triage, leading to symptom relief by the time a patient was evaluated Advanced Triage Protocols by an attending physician, eliminating the time- Advanced triage protocols are order sets that include consuming need for reassessment before discharge. diagnostic and therapeutic orders that are locally ■ Prompt and succinct communication between a developed and are driven by the patient chief com- triage physician and other attending ED physicians plaint. Most EDs have approximately 20 medical streamlined care in complicated cases. conditions, which are responsible for about 50% of ED patient visits.18 For example, protocols for treat- Physicians in triage can decrease the LWBS patient ing patients presenting with chest pain may include population, because patients are more apt to stay in immediate electrocardiogram and administration of the ED once a physician has assessed their condition aspirin followed by physician assessment. Developing and explained the plan of care.18 Patient satisfaction evidence-based treatment protocols with regard to scores tend to be higher with early physician assess- particular medical conditions can increase medical ment and care. Finally, board-certified emergency care reliability and patient safety and decrease medi- physicians tend to order fewer unnecessary diagnostic cal errors and costs. Additionally, if diagnostic tests tests because of their knowledge and experience. are ordered early in the triage process, results can be Disadvantages to this model include the difficulty accessed by the treating ED physician as the patient in recruiting board-certified emergency physicians enters the treatment room. to work in this triage model, the high cost of labor, and the reluctance of some physicians to hand off Patient Flow Managers care to a subsequent emergency physician for care posttriage.26 Many EDs are using patient flow manager positions to expedite patient treatment and to provide real-time Team Triage troubleshooting of patient flow problems. Staten Island Rapid triage can increase patient safety by decreasing University Hospital in New York City uses a high-level bottlenecks in the front end of ED treatment because manager, an administrator on duty, to directly escort of shorter cycle times and because patients are guided patients to treatment areas. In addition to monitoring to treatment areas immediately, decreasing the time the progress of patient care, the administrator increases to treatment.20 Team triage is one way to expedite the direct-to-bed patient flow process and significantly patient evaluation and treatment. In this model, decreases patient wait times for care.28 Page 130 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 4—December 2010 Pennsylvania Patient Safety Advisory Environmental Design of ED Waiting Rooms registration system or as complex as a comprehensive Facilities that have the opportunity to design or emergency department information system (EDIS). redesign the ED can use design principles to improve EDISs are electronic health record systems designed patient flow and communication among staff mem- specifically to manage data and workflow in sup- bers. Considerations include embedding departments port of emergency department patient care and like radiology in the ED to reduce turn-around time; operations. The EDIS patient tracking component dedicating space for specialty staff (e.g., phlebotomy, is either patient- or department-centered and takes radiology, high-demand consultants) in the ED; build- into account both clinical course and physical loca- ing pods of services for adults, pediatrics, and levels tion tracking. Clinical course tracking follows the of “fast track” patients; and clustering registration and patient’s care throughout the ED process, providing triage areas to facilitate parallel processing. Pod-type information such as patient status, completed and design structures allow teams of providers to work anticipated events, order status, vital signs, and other closely together and to keep benchmark and trigger clinical information. Physical location tracking follows information regarding ED census and turn-around the patient through the physical space in all phases time, as well as patient-specific clinical informa- of the ED visit, from prearrival to disposition, and tion, easily accessible.29 Conversely, pod-type models can be accomplished manually through data entry require a higher level of staffing and may be designed into the system or through the use of radio-frequency for a specific patient population that may or may identification (RFID) or other similar technologies.32 not materialize at any given point in time. Designing Standard ED operational metrics are tracked and space for needed equipment and supplies at the bed- displayed in a dashboard fashion, proving practitio- side and designing “universal” treatment rooms may ners with access to real-time departmental status. significantly increase staff productivity and decrease In order to receive the optimal benefit of EDIS, it the time-to-treatment for patients. should be fully integrated and interfaced with other critical information technology systems, including the Authority reports and local news stories highlight electronic medical record, pharmacy, radiology, labo- the importance of maintaining keen awareness of ratory, registration/admitting, billing, and medical activity in ED waiting rooms. In addition to specific record systems.17 For smaller departments without suf- triage strategies, it is important to configure existing ficient funding for EDISs, manual tracking of patient ED waiting areas so that ED staff can easily track and status and department operational metrics is neces- monitor patients. Optimally, there is line of sight sary. (The Authority hosts a toolkit of sample tracking awareness of the waiting room patient population tools on its website; for more information, see http:// by the ED staff. If the waiting room is out of sight, patientsafetyauthority.org/EducationalTools/ EDs may elect to station a healthcare provider within PatientSafetyTools/Pages/home.aspx). or near the waiting room or use video monitoring technology. If medical staff is unavailable, specially Customer Service Culture and Communication trained volunteers or paraprofessionals can be used to facilitate information exchanges regarding patient While it is unrealistic to believe that all wait times condition to the triage professional. However, instead in the ED could be eliminated, preparing for and of performing and documenting repeat assessments explaining wait times to patients is important from of patients in waiting rooms, many organizations both a patient safety and a customer service point recommend that patients be assessed and moved of view. Previous Authority reports have shown that expeditiously from waiting area to treatment area. If unmonitored patients in the initial phase of ED treat- waiting must occur, it is best that patients wait on the ment can quickly become a liability. Patients who back end of an ED visit, after assessment has been spend more than two hours in the ED report less completed and diagnostic evaluation begun.18 overall satisfaction with their visit than those who are there for less than two hours.28 Since much of the time Fast-Track Service Lines in the ED is spent waiting (e.g., to see a physician, for Urgent care or fast-track service lines can improve consults, for tests and test results), understanding the front-end ED patient flow by routing low-acuity psychology of waiting can lead to innovative solutions. patients to separate treatment areas where they are Consider the following principles of waiting:33 evaluated and treated separately from acutely ill ED ■ People want to get started. patients. In this model, either a physician or a mid- level provider can treat patients in the fast-track area. ■ Anxiety makes waits seem longer. This allows the more acutely ill patients to receive ■ Uncertain waits seem longer than known, treatment in closely monitored areas. Two studies finite waits. have shown that dedicated fast-track service lines can decrease ED length of stay,30 decrease door-to-doctor ■ Unexplained waits seem longer than explained waits. time, and lower the ED walkaway rate.31 ■ Unfair waits seem longer than equitable waits. Information Technology ■ The more valuable the service, the longer the cus- tomer will wait. Information technology used within most ED depart- ments can be as simple as an electronic patient ■ Solo waits feel longer than group waits. Vol. 7, No. 4—December 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 131 Pennsylvania Patient Safety Advisory While decreasing delays in the ED would certainly having physicians determine whether any patients improve customer satisfaction, Press Ganey data can return for diagnostic testing at another time shows that keeping patients informed about delays in (offloading); or creating an express admissions the department and having a caring attitude toward team to expedite admissions out of the ED.18 patients can mitigate the negative effects of patient ■ Adopt an accurate and reliable triage methodology, wait times in the ED.28 Some innovative strategies and ensure that staff are trained in its use.18,23 that hospitals have implemented to decrease wait times include the abbreviated triage model, the paral- ■ Consider alternative triage strategies to expedite lel processing of registration and triage, bedside triage, patient door-to-registration time, including the patient involvement in progress tracking throughout following: the ED stay, shifting patient waiting to the end of the — Abbreviate patient registration: collect only as ED visit (after receiving the diagnostic evaluation), much data as needed to generate the medical designing ED waiting areas with patient comfort in record and create the patient wristband. All mind, and providing activities to occupy both patients other data can be collected at any point dur- and families while they wait for ED disposition. ing the ED stay.20 Communication is important throughout the ED — Elevate the level of experience or education of visit, both between healthcare providers and patients the triage personnel: consider using midlevel and their families, and also between healthcare pro- staff (e.g., physician assistant; nurse practitio- viders themselves in the ED. Handoffs are a known ner) or ED physicians in triage.18,24,25 risk factor for increased medical errors; in a busy ED, — Implement team triage: use a team of nurses handoffs can become even more dangerous. Bedside and physicians to perform triage at the transitions during shift change, when possible, can bedside in order to decrease front-end cycle help facilitate the transfer of information from one time and decrease patient time to treatment. practitioner to the next in busy ED environments. This model helps pull patients directly into Customer satisfaction surveys can provide the ED treatment rooms—a much safer place for ED with cost-effective feedback regarding patient percep- patients to wait for treatment.20,27 tions of timeliness and quality of care in the ED. — Bypass triage completely, and place patients in Risk Reduction Strategies for Front-End available beds immediately. Abbreviated reg- ED Processes istration and bedside triage combine to make this model efficient and safe for patients when Consider the following strategies to simultaneously beds are available.24 decrease the amount of time patients spend in the “patient arrival in the ED to physician assessment” — Use evidence-based advanced triage proto- phase of ED treatment and to enhance patient safety: cols for the department’s common ED chief complaints.18 ■ Implement a predictive model of staffing in the ED and staff accordingly. Analyze a minimum of four ■ Assign a patient flow manager to facilitate patient weeks of volume, key metrics, and admissions (see arrival in, and flow through, the ED department.28 sample “Emergency Department Census Tracking ■ Implement fast-track or urgent care treatment areas Tool” available on the Authority website). Deter- where low-acuity patients receive separate but paral- mine the average daily demand for each day of the lel care from dedicated practitioners. This practice week and for time periods throughout the day.2,18,28 helps preserve beds for acutely ill patients who ■ Use strategies to optimize low-census/low-utiliza- need closer oversight and monitoring services.18,30,31 tion times in the ED, and prepare for busier times. ■ Consider environmental design principles in ED Ensure that staffing is adequate during the busiest areas:18,29 parts of the day. Expedite patients early in the day — Look for and decrease waste and non-value- (or during less busy times) so that beds are open added steps. Observe patient flow processes, during the busier times. During shift changes, have and redesign staff work areas to be closer to practitioners do bedside transitions to facilitate patients. Stock needed items in each room or accurate flow of information.7, 18-20, 28 by each bed. ■ Monitor ED capacity in real time. Develop early — Consider embedding high utilization person- warning systems (e.g., number of patients wait- nel (e.g., laboratory, radiology, consultants) in ing to be seen, capacity) to alert staff to large the ED department. fluctuations in demand or capacity (see sample “Emergency Department Front-End Process — Maintain line-of-sight and situational aware- Measures Threshold Tool” on the Authority web- ness of all patients in ED waiting rooms. site). When an ED is at 80% capacity, initiate a — Redesign the ED to ensure that the majority variety of actions to prevent increases in capacity of patient wait time occurs at the back end of such as sending boarders to units; assembling a dis- the ED visit, after the patient has received the charge team to quickly discharge waiting patients; diagnostic evaluation. Page 132 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 4—December 2010 Pennsylvania Patient Safety Advisory ■ Develop a culture of customer service that takes 8. Sprivulis PC, Da Silva JA, Jacobs IG, et al. The associa- into account the psychology of waiting.33 Realize tion between hospital overcrowding and mortality among that parallel processes are better than serial pro- patients admitted via Western Australian emergency cesses whenever possible.18 Create and maintain a departments. Med J Aust 2006 Mar 6;184(5):208-12. way to inform patients about probable wait times 9. Chalfin DB, Trzeciak S, Likourezos A, et al. Impact of and potential delays.33 Collect and use information delayed transfer of critically ill patients from the emer- from patient satisfaction surveys.18 Consider creat- gency department to the intensive care unit. Crit Care ing comfortable patient waiting areas, preferably at Med 2007 Jun;35(6):1477-83. the back end of the ED visit, equipped with room 10. Pines JM, Hollander JE, Localio AR, et al. The associa- for family, and find ways to keep patients and fami- tion between emergency department overcrowding and lies occupied.27 hospital performance on antibiotic timing for pneu- monia and percutaneous intervention for myocardial Conclusion infarction. Acad Emerg Med 2006 Aug;13(8):873-8. EDs in the United States provide a critical service for 11. Schull MJ, Vermeulen M, Slaughter G, et al. Emer- patients in need of urgent, often life-saving medical gency department crowding and thrombolysis delays care. Additionally, the role of the ED has evolved in acute myocardial infarction. Ann Emerg Med 2004 from providing primarily life-saving treatment to pro- Dec;44(6):577-85. viding urgent unscheduled care to patients unable to gain access to their primary care providers, to provid- 12. Pines JM, Hollander JE. Emergency department crowd- ing care to Medicaid beneficiaries, and to providing ing is associated with poor care for patients with severe care to patients without insurance. These factors pain. Ann Emerg Med 2008 Jan;51(1):1-5. contribute to crowding in the ED. Timeliness of care 13. Table 20: Proposed clinical quality measures for elec- in the ED is a matter of patient safety, and it starts tronic submission by eligible hospitals for payment year with the period of the patient’s arrival through to the 2011-2012. In: Centers for Medicare and Medicaid Ser- diagnostic evaluation segment of the patient visit. vices. Medicare and Medicaid programs; electronic health This treatment phase can influence the timeliness of record incentive program; proposed rule. Fed Regist 2010 care for the remainder of the visit and has been con- Jan 13;75(8):1896. nected to clinical outcomes and patient safety issues. 14. National Quality Forum (NQF). NQF endorses measures Standardizing front-end operations not only improves to address care coordination and efficiency in hospital important time metrics, it also directly contributes to emergency departments [press release online]. 2008 Oct the safety of patients in this phase of ED treatment. 29 [cited 2010 May 12]. Available from Internet: http:// Notes urgentmatters.org/media/file/NQF%20Press%20 Release.pdf. 1. Centers for Disease Control and Prevention. Emergency department visits [online]. [cited 2010 May 12] Available 15. Loftus J. State report slams Aria Health handling of from Internet: http://www.cdc.gov/nchs/FASTATS/ man’s death in the ER [online]. NE Times 2010 Jan 27 ervisits.htm. [cited 2010 May 26.] Available from Internet: http:// www.philly.com. 2. Pitts SR, Niska RW, Xu J, et al. National hospital ambulatory care survey: 2006 emergency department 16. Pennsylvania Department of Health. Aria Health: health summary. Natl Health Stat Report 2008 Aug 6;(7):1-39. inspection results [12/16/2009 survey results]. [cited 2010 Jun 16]. Available from Internet: http://app2. 3. QualityNet. Reporting Hospital Quality Data for health.state.pa.us/commonpoc/content/publiccommon- Annual Payment Update (RHQDAPU). Measure com- poc/QAsurvey.asp?FACID=061801&PAGE=1&NAME= parison (inpatient hospital quality measures) [online]. ARIA+HEALTH&SurveyType=H%20&COUNTY. [cited 2010 Apr 29]. Available from Internet: http:// www.qualitynet.org/dcs/ContentServer?c=Page& 17. Wiler JL, Fite DL, Gentle C, et al. Optimizing emer- pagename=QnetPublic%2FPage%2FQnetTier3& gency department front end operations [information cid=1138900298473. paper]. Irving (TX): American College of Emergency 4. Bernstein SL, Aronsky D, Duseja R, et al. The effect of Physicians; 2008 Jan. emergency department crowding on clinically oriented 18. Welch SJ. Quality matters: solutions for a safe and efficient outcomes. Acad Emerg Med 2009 Jan;16(1):1-10. emergency department. Oakbrook Terrace (IL): Joint Com- 5. Joint Commission. Sentinel event statistics [online]. mission Resources; 2009: 131. 2010 Mar 31 [cited 2010 May 12]. Available from Inter- 19. Garcia TC, Bernstein AB, Bush MA. Emergency depart- net: http://www.jointcommission.org/SentinelEvents/ ment visitors and visits: who used the emergency room Statistics. in 2007? NCHS Data Brief No. 38 [online]. 2010 May 6. Joint Commission. 2009 Comprehensive accreditation [cited 2010 Jun 27]. Available from Internet: http:// manual for hospitals: the official handbook. Oakbrook www.cdc.gov/nchs/data/databriefs/db38.pdf. Terrace (IL): Joint Commission Resources, 2008. 20. Emergency Excellence. Intuitive and rapid emergency 7. Pines JM, Pollack CV, Diercks DB, et al. The association department intake increases safety. Newsl Emerg Excel between emergency department crowding and adverse [online]. 2010 Mar [cited 2010 Jun 1]. Available from cardiovascular outcomes in patients with chest pain. Internet: http://www.emergencyexcellence.com/ Acad Emerg Med 2009 Jul;16(7):617-25. newsletter/march_2010.htm. Vol. 7, No. 4—December 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 133 Pennsylvania Patient Safety Advisory 21. Centers for Medicare & Medicaid Services. Regulations 27. Vanderbilt University Medical Center Emergency and guidance: EMTALA [online]. 1986 [cited 2010 Oct Department. Team triage reduces emergency department 18]. Available from Internet: https://www.cms.gov/ walkouts, improves patient care [online]. 2008 Apr 14 EMTALA/Downloads/CMS-1063-F.pdf. [cited 2010 Jun 2]. Rockville (MD): Agency for Health- care Research and Quality. Available from Internet: 22. Centers for Disease Control and Prevention. National http://www.innovations.ahrq.gov/content.aspx?id=1735. hospital ambulatory medical care survey 2005 emer- gency department patient record [online form]. 2007 28. Press Ganey Associates, Inc. 2010 emergency depart- May 31 [cited 2010 May 24]. Available from Internet: ment pulse report:patient perspectives on American http://www.cdc.gov/nchs/data/ahcd/ healthcare [online]. 2010 [cited 2010 Sep 8]. Available NHAMCS-100(ED)_2005.pdf. from Internet: http://www.pressganey.com/galleries/ default-file/2010_ED_Pulse_Report.pdf. 23. Gilboy N, Tanabe P, Travers DA, et al.. Emergency severity 29. Redesign helps EDs improve patient flow. Ed Manag index, version 4: implementation handbook [online]. Rock- 2009 Apr;21(4):41-2. ville (MD): Agency for Healthcare Research and Quality. 2005 May [cited 2010 May 24]. Available from Internet: 30. Rodi SW, Grau MV, Orsini CM. Evaluation of a fast http://www.ahrq.gov/research/esi/esihandbk.pdf. track unit: alignment of resources and demand results in improved satisfaction and decreased length of stay for 24. Chan TC, Killeen JP, Kelly D, et al. Impact of rapid emergency department patients. Qual Manag Health Care entry and accelerated care at triage on reducing emer- 2006 Jul-Sep;15(3):163-70. gency department patient wait times, length of stay, and 31. Sanchez M, Smally AJ, Grant RJ, et al. Effects of a rate of left without being seen. Ann Emerg Med 2005 fast-track area on emergency department performance. Dec;46(6):491-7. J Emerg Med 2006 Jul;31(1):117-20. 25. Patel PB, Vinson DR. Team assignment system: expedit- 32. American College of Emergency Physicians. Policy state- ing emergency department care. Ann Emerge Med 2005 ment: health information technology. Ann Emerg Med Dec;46(6):499-506. 2008 Nov;52(5):595. 26. Choi YF, Wong TW, Lau CC. Triage rapid initial assess- 33. Maister D. The psychology of waiting lines [online]. ment by doctor (TRIAD) improves waiting time and 2005 [cited 2010 Jun 28]. Available from processing time of emergency department. Emerg Med J Internet: http://davidmaister.com/pdf/ 2006 Apr;23(4):262-5. PsycholgyofWaitingLines751.pdf. Page 134 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 4—December 2010 PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 7, No. 4—December 2010. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2010 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.