Located in Middletown just south of Hartford, the hospital forms a geographic triangle with its two satellite EDs at Middlesex Hospital Marlborough Medical Center in Marlborough and Middlesex Hospital Shoreline Medical Center in Essex. Roughly 50% of the hospitals’ patients live within that triangle, notes Michael Saxe, MD, Chairman of Middlesex’ Department of Emergency Medicine, which places all three EDs within reasonable driving range of that population. Realizing that distance did not need to be the principal determinant of which ED their patients visited, Saxe and his colleagues decided to see if they could use some other factor to influence where people sought care — and make patient volume more manageable in the process. In September of 2009 they began posting the waiting times of each ED — updated every five minutes — on the hospital’s website.

“When we launched, the program was so far ahead of its time that we had the area’s biggest television channel here filming us,” he says. The story got picked up by four other TV channels as well as newspapers in 26 communities. Johnson recalls being shocked by the attention, largely because the initiative had required so little effort and so few resources.

“The data we needed was digitized and available,” he said, “since we had a comprehensive ED information system with triage and tracking components already in place.” The only thing Middlesex needed to purchase was a program that could read the triage file, determine the ED wait times, and then transfer information to Middlesex’s Web server. Wait times are available both in both Flash and HTML formats, which allows users to access information from computers and smartphones. Altogether, Johnson said, the entire cost associated with posting the times was about $3,000.

Saxe says he determined from the start that the EDs would not post “optimistic” wait times or even average wait times, but “the longest time of any patient in that ED who has not yet seen a physician. The result is that we often beat the posted time.” Posting conservative times, he says, gives greater credibility to the EDs and leads to exceeded expectations for patients.

Upon arrival at the ED, each patient is quickly triaged by a nurse who inquires about his or her condition and determines what care will be needed. The nurse then enters this information into the ED information system, at which point the patient’s wait time begins to be calculated. The

clock stops once a physician is available. That person’s wait time is posted, soon to be replaced by the wait time of the next patient.

He says the three EDs’ left-without-being-seen rates “have always been extremely low” — one half of one percent at Shoreline and Marlborough and under one percent at Middletown — but that overall quality has improved considerably since last year. Smoother distribution of patients between EDs “minimizes patients’ wait times and improves their care. The staff can work at a steadier pace all day long, be more efficient and do better work, and they’re less likely to make mistakes.”

There’s a greater level of accountability, also. “Simply knowing the times are available to the public means that everyone in the ED is more aware of them,” Saxe says. “Our administrators can click in and say, ‘Hey — I noticed the ED wait time was two hours. What happened?’ We want them to care and be aware. We may need resources or equipment or technology, so we want them to know when times are good or bad.”

Moreover, Saxe says, the fact that 50% of the hospitals’ revenue begins with ED visits at the three sites means that being “aware when patients are being inconvenienced and responding to that” makes good business sense.

Johnson says administrators should expect some trepidation among staff when they decide to post ED wait times.

“Before implementation, our staff had anxiety about this concept,” he says. “They felt that posting these times was going to put us under the microscope for the community and the administration [to scrutinize], and that we would be held to higher standards and be blamed if we didn’t meet our goals.” But the staff is now “very accepting,” he says. “No one gives it a second thought anymore. In fact, we find it useful to check the times before coming in to work so we know how busy we’ll be.”

For EDs with information systems already in place — by far the most expensive component of posting Web sites — “there’s no down side to posting times,” says Saxe, who says Middlesex is implementing plans to post wait times in ED waiting rooms and nurse stations as well. “Any ED that wants to be modern should do it. Any upfront technology costs are offset by the time your staff saves not having to answer questions about wait times and the revenue that’s not lost by patients leaving without being seen.”  

 

 

Ludwig Johnson, Vice President, Information Services, Middlesex Hospital, Middletown, CT