National Reporting of Emergency Department Length of Stay: Title and subTitle BreakChallenges, Opportunities, and Risks

In this issue of JAMA, Fee and colleagues¹ report data from the 2008 National Hospital Ambulatory Medical Care Survey evaluating the ability of emergency departments at safety-net hospitals to comply with parameters for time to disposition for both admitted and discharged patients. Based on analysis of nearly 25 000 patient visits, including 11 065 visits at safety-net hospitals and 13 654 visits to non–safety-net emergency departments, there were no significant differences for compliance with proposed length-of-stay measures for admitted patients (median, 269 minutes vs 281 minutes) or discharged patients (median, 156 minutes vs 148 minutes) for safety-net emergency departments and non–safety-net emergency departments, respectively. However, there were associations between longer emergency department length of stay and several subgroups examined, including patients of nonwhite race, those with lower triage acuity, and type of treating clinician (eg, resident/intern).

The question of length of stay as a performance measure is important because of concerns about disparity of care because safety-net hospitals serve a disproportionate share of minority, uninsured, or underinsured patients. The authors indicate that their aim was to evaluate the performance of emergency departments in meeting length of stay criteria. But it is here that concerns among emergency physicians begin. A common mantra among the emergency medicine community is that length of stay is a hospital problem and not an emergency department problem. There is evidence that this is partially true.

The modern emergency department faces challenges that exceed those of past years. On the one hand, beneficial improvements in medical knowledge have led to life-saving or life-changing therapies and interventions to treat patients with myocardial infarction, stroke, and trauma, and other acute disease processes. Some treatments are time dependent, leading to pressure on already-busy clinicians to prioritize the care of some complex patients over others. Public disclosure of time to treatment has led to improvements in some of these parameters but at a cost of hurried decision making. The pay for performance measures provide incentives for hospitals to improve services and demand rapid action by their emergency department staff. Yet some of these efforts may have unintended consequences. For instance, the increased use of antibiotics for pulmonary conditions other than pneumonia was hypothesized to have occurred so that clinicians could meet the time-to-treatment performance measure for pneumonia reported to Centers for Medicare & Medicaid Services.²

Both structural and clinical issues contribute to the complexity of measuring quality in the emergency department. Emergency department visits have continued to increase by an estimated 25% over a 10-year period,³ along with an estimated 5.6% increase more in 2008, the latest year for which estimates are available. The largest increase in emergency department visits occurred among middle-aged adults and patients insured by Medicaid.⁴ At the same time, the number of emergency departments has decreased by 27% over the 20-year period up to 2009.⁵ Although the proportion of patients requiring admission has remained stable, the absolute number of patients who require admission has increased, yet the number of staffed inpatient beds decreased by 1.2% from 2004-2009.^{6 - 7} Among the more challenging patients for whom emergency physicians must find a disposition are those patients with mental health symptoms, who now account for almost 12.5% of all visits.⁸ Pressures on throughput come from complex critically ill or injured patients who require extensive testing that is most expeditiously performed out of the emergency department. Additionally, the proposed financial penalties associated with readmissions will lead hospitals to expect greater efforts in the emergency department to avoid placing these patients back on the inpatient units.

As noted by Fee et al,¹ efforts in other countries to address emergency department overcrowding and length of stay have had mixed effects. The United Kingdom had failed experiments in reducing volumes through the use of nurse advice lines, walk-in treatment centers, or other alternative means to manage patients. This follows studies that have associated overcrowding not with low-acuity patients but with inpatient census and surgical schedules. In a study from the United Kingdom, organizational factors, including the organization and leadership in the emergency department, was associated with efficiency. The UK National Health Service mandated a 4-hour time to disposition rule with a resultant improvement in compliance with that goal. It is not clear, however, that institution of the “4 hour rule” translated to meaningful improvements in patient care.⁹ A similar government-mandated program in Ontario has had mixed success with some improvements in length of stay for patients discharged from the emergency departments. There seems to have been limited change in the time to place admitted patients into their inpatient beds (ie, boarding time), thought to be due to limited changes in practice on the inpatient units.¹⁰

Several US hospitals are now embarking on a similar federally mandated effort to report various measures of emergency departments performance. Pilot projects as part of the Agency for Healthcare Research and Quality Health Research & Educational Trust have provided some insight into the efforts that hospitals must make to comply with the new measures. These initial efforts indicate that substantial investment will be needed to collect the necessary data, and preliminary information shows that there are significant variations in performance measures.¹¹

What is the message from the study by Fee et al¹ for hospitals that will face increased scrutiny with the resultant transparency over their emergency department lengths of stay? There are 3 aspects to the complex issue of emergency department volume and overcrowding: availability of other sites for care aside from the emergency department such as improved access to primary care physicians, efficiency within the emergency departments, and inpatient processes that impede efficient management and discharge.¹² Hospitals will likely have the greatest influence on time to disposition for discharged patients through industrial processes for improving patient flow such as Six Sigma or Lean process methodologies.¹³ The Urgent Matters project sponsored by the Robert Wood Johnson Foundation has identified a tool kit of changes that can be used to improve hospital and emergency department throughput.¹⁴

Quality improvement mandates should be based on evidence that the measures will actually improve patient outcomes. Data supporting the notion that overcrowded emergency departments with long boarding times demonstrate some impairment in quality are inconsistent.¹⁵ It is unclear whether mandated reporting of length of stay or other metrics will lead to beneficial changes in patient outcomes. The gist of the available information indicates that meaningful efforts to alleviate emergency department crowding and optimize treatment times will require institutional culture change with a commitment to expediting hospital discharges and providing the necessary resources to ensure that emergency admissions are handled promptly. Relying solely on staff to sponsor change within the walls of the emergency department will be less successful.