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Does texting for wait times compromise emergency care?

327582On our recent road trip I was amazed by the number of billboards (from several health care systems and hospitals) advertising texting for emergency room (ER) wait times. My first thought was if you can text, how emergent is it? This was quickly followed by the concern that the option/advertising of texting about wait times might make the ER seem, well, less for acute care and more for convenient care.

Should I be concerned?

There are about 130 million ER visits a year in the United States accounting for 4% of health care spending. The total number of ER visits has ballooned since 1995 when there were 97 million visits. A 30% increase is pretty significant, especially when you realize emergencies have not increased by 30%. Then factor in the fact that the number of emergency departments has declined by 11%.

The math only means one thing, 11% fewer places to go but 30% more visits = longer waits. The averageUnknown wait time to be seen in an American ER is about 55 minutes, which seems long at first blush (and really long if you have a broken leg or have appendicitis) so it is easy to see why texting to find the shortest wait might be attractive.

But let’s back up a bit. Not everyone who goes to the ER needs (medical speaking) to be seen emergently. According to the CDC this is how visits to the ER break down acuity wise (2010 data):

  • Level 1: Should be seen in < 1 minutes – 1% of visits
  • Level 2: Should be seen in 1-14 minutes – 10% of visits
  • Level 3: Should be seen within 15-60 minutes – 43% of visits
  • Level 4: Should be seen within 61-120 minutes – 33% of visits
  • Level 5: Should be seen within 121 minutes to 24 hours – 7% of visits

(The numbers don’t add up to 100% because 5-6% of ER don’t have a triage system so can’t contribute to the stats this way)

What is most important to know is that 25% of patients presenting to the ER are seen within 15 minutes but 11% meet the criteria of needing to be seen within 15 minutes, so that is good math. Another 42% are seen between 15 minutes and an hour, matching up nicely with the level 3 needs. Basically, ERs are currently doing a good job at what they are designed to do. Care for people who have emergent and urgent needs in a timely fashion. (Of course there are stories of people waiting and dying, but that is typically because they were triaged incorrectly and no one realized how sick they were. That is a different, albeit still serious, issue).

But 40% of people who go to the ER do not medically speaking need immediate care and many could be seen elsewhere. Many health care systems, doctor’s offices, and hospitals have weekend and evening hours as well as injury centers and urgent care clinics for this very purpose. A bleeding diaper rash does need to be seen and an ear infection probably needs treatment and that ankle you twisted pretty badly probably should be evaluated to make sure it’s not a break, but the doctor’s office or an urgent care clinic would do just fine. These are medical issues, but they are not emergent issues. Even if you cut your finger and need stitches an injury clinic and in many cases your primary care doctor is a great option.

Just speaking with a nurse or doctor can help. Many people also just don’t know what can wait. There are many times when my kids were sick that I received invaluable advice from the amazing 24 hour nurse line at the Children’s Hospital in Denver. I didn’t even know there was an acute care clinic until I called the advice line.

waittimesPhone advice and other options for care could probably prevent many unnecessary ER visits. In fact 48% of people who go to the ER do so because their doctor’s office isn’t open and 46% because they had nowhere else to go. This tells us that many people know the ER isn’t the best place, but their options are limited. The answer to that problem seems to be improving access to the needed services, not to offer texting as a work around.

So does advertising about texting increase non urgent use of the ER? If the wait is short might it give someone the idea of just getting things checked out in the ER instead of waiting until the next day? Will it encourage people to just go to the ER when it’s clearly not emergent (because if you can text, it’s not likely a true emergency) instead of calling to speak with the doctor on call or the advice nurse? And what if you really are emergently sick and instead of heading to the closest ER because the texting service gave you a 40 minute wait there (but in reality you would have been seen much sooner because you are urgently ill), you drive further away for a presumably shorter wait but your condition deteriorates en route? Average wait times are just that, average. A true emergency will (if triaged correctly) almost always have less than a 15 minute wait.

Texting is clearly aimed at non-emergent and urgent patients, people who could probably (and many who should probably) be seen in less acute/more appropriate settings. The cynic in me wonders if this texting option it’s just another way to artificially boost Press Ganey scores (I fear many hospital administrators care less about the quality of care and more about the survey results). I’m all for satisfaction, but if it comes at the expense of sending more non urgent cases to the ER then it’s a concern. Wouldn’t a better solution for ER wait times be more advice nurses/doctors and after hours clinics?

Just a thought.

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Discussion

4 thoughts on “Does texting for wait times compromise emergency care?

  1. Wouldn’t it be great if all the ERs had associated after hours clinics and could triage people to them instead?

    Posted by Donna | February 28, 2014, 11:53 pm
    • Not only that, but note that half of those patients went because the doctor wasn’t open. Such patients could self-triage to the after hours clinic. My one visit to an ER was just such a case–the problem wasn’t an ER-level problem but neither did I want to wait from Friday evening to Monday morning to get some help. This was before the quick care clinics had appeared, there were no in between options.

      Posted by Loren Pechtel | March 1, 2014, 8:21 am
  2. numbers don’t add up to 100% because 5-6% of ER don’t have a triage system

    Wait, what? How the hell does any ER function without a triage system? That pretty much defeats the object of a place to treat emergent conditions.

    How do they assess need without triage, how do they determine who gets priority?

    Posted by boostick | March 3, 2014, 1:43 am
  3. I agree with most of your points, that it’s useful to have after-hours triage&care that is separate from emergency. I think shopping around for an ER is ludicrous, and if you *were* to choose an ER from several options, I don’t think wait time is necessarily a smart criteria to use.

    But isn’t the increase in ER visits mostly explained by the increase in population? in 1995 there were 97 million ER visits for 266 million people(0.36 visits per person). Now there are 130 million visits for 316 million people(0.41 visits per person). That looks pretty close to me, maybe ERs are a little busier but not 30% busier as you’re implying.

    Posted by reddressgnome | March 4, 2014, 6:09 am

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