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Jack Jones
HESP 157 – Clinician
Professor Ciccolella
31 March 2015
Fixing Crowded Emergency Department Waiting Rooms: A Critical Issue Analysis
The emergency room was established for medical emergencies. What someone defines as
an emergency is subjective, ranging from something as minor and nonurgent as a sore throat, to
something as critical as an episode of unknown syncope. High acuity patients come to the
emergency department (ED) via ambulance, while some enter through the waiting room. The
amount of patients being seen through the waiting room for non-emergent medical problems has
been increasing exponentially, especially since setting an appointment and being seen by their
primary care physician is deemed a grueling and tedious task. This is largely due to ED’s being
the only sector of healthcare that cannot turn patient’s down, regardless of their current status of
insurance (Okeke, Morganti, Vesely Smith, Kellermann, Bauhoff and Iyer. 2013). “From 1995 to
2009, annual ED visits in the US increased by 41%,” (Sayah, Rogers and Devarajan, 2014). This
stigma that the ED is the “safety net” of the healthcare system with regards to treating
noninsured patients has began to gain popularity within the medical community. Although those
with primary medical doctors (or PMDs) are able to be see for their medical issues, most
uninsured are using emergency departments as a means of their primary medical concerns, which
results in clogged patient flow and lead to an overwhelming patient volume. “An estimated 13%
to 27% of emergency department (ED) visits in the United States could be managed in physician
offices, clinics, and urgent care centers at a savings of $4.4 billion annually,” (Enard and
Ganelin, 2013). The physician assistants (or PA) have played a key role in increasing the rate of

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patient turnover, giving the emergency department physicians more time to focus on the high
acuity patients that need immediate and sepcialized medical expertise. Although PAs have been
able to provide their services to relieve the emergency room of this chaos, uninsured citizens still
are making their presence in the ED and contributing highly to the problem that exists today. A
further investigation of the trends in California emergency rooms and the detail at which
emergency rooms provide their services will be further evaluated throughout this analysis to
paint a picture of the problem and search for potential solutions.
A large proportion of the California population that visit ED’s is comprised of young
adolescents and children. The access to insurance with the help of the Affordable Care Act has
provided the population with more access to healthcare than ever before. Although it has allowed
patients to be seen, the amount of patients that are being seen in the ED as a source of primary
care is still a staggering amount. Through an analysis of California emergency department visits
by youth evaluated in 2014 by Hsia, Nath and Baker noted the following data:
“We grouped ED visits into 4 categories: Medicaid, private insurance, uninsured, and
other. To construct rates of ED visits per 1000 youths for insurance groups, we used data
from the State Health Access Data Assistance Center, derived from the US Census
Bureau’s current population survey […] The number of visits to California EDs by
youths increased from 2.5 million in 2005 to 2.8 million in 2010, a change of 11%.
Children covered by Medicaid accounted for 44% of all ED visits. The distribution of
visits across payer groups changed significantly between 2005 and 2010, with Medicaid
accounting for a larger share over time (P < .001). Uninsured youths living in California
exhibited the fastest increase in ED visit rates followed by those privately insured. The
rate of ED use among youths covered by Medicaid exhibited the slowest growth, with an

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increase from 341 to 366 visits per 1000 (7.4 %), but remained the highest in absolute
terms.”
As seen in this data, the amount of children and youth that are insured by Medicaid are still being
seen in California emergency departments, and those that are uninsured being seen in ED at
higher volumes than any other population based on insurance status. What the Affordable Care
Act thought it would provide is relief to the emergency medicine setting. This is till yet to be
seen in terms of absolute patient visits.
Health insurance was established in society due to the increasing rate of the
commercialization of medicine. While medicine began becoming its own entity with regards to
treating the public’s medical issues, the increase cost of medicine began to call for the people to
have coverage in the forms of insurance. Whether it is through a public, private, or welfare type
program, all individuals were urged to get medical coverage to protect them from the
preposterous costs of medicine. A primary care physician sees those that have insurance, while
those that do not have medical coverage are the “frequent flyers “ of the ED. According to
Hooker, Klocko and Larkin, ED visits are said to double by the year 2025 (2011). This increase
in ED visitation is due primarily for the lack of coverage in the United States. 49 million went
without coverage for most of 2010, with only about 84% of Americans being insured (U.S.
Census Bureau, 2010). This staggering number is causing these patients to flood the EDs to be
seen by a medical provider. Large sums of those that are uninsured are young adults (ages 20-
29), due in part from either being dropped from their parent’s coverage, or because they are
removed from public health coverage. According to a national health interview survey in 2008,
13 million young adults were uninsured, which is 30% of the 20-29 year old population. Almost
1 in 10 young adults were seen in the ED twice or more in the last 12 months (Cohen and Bloom,

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2010). Not only are the young having issues with obtaining reliable health insurance, so is
California’s large immigrant population, comprised largely of Mexican immigrants.
“In 2008, there were approximately 12.7 million Mexican immigrants living in the United
States, up from only 760,000 in 1970. Thirty-two percent of all immigrants living in this country
are Mexican, and of that number, more than half (55%) are undocumented,” (Akincigil, Mayers,
and Fulghum, 2011). This staggering number has lead to public reform of healthcare like
Medicaid. These publically mandated reformations have provided those within rural and urban
areas to receive healthcare for those practices like the ED. Some private practices choose not to
participate in these programs, which can cause patients to turn to the ED for their care. This is
different, however, for EDs. Thanks to the Emergency Medical Treatment and Active Labor Act
of 1986 (EMTALA), EDs must treat all patients that enter their doors, regardless of their ability
to pay or provide compensation from their insurance provider (Valenzuela, 2012). According to
Valenzuela, California’s expenditures on emergency Medicaid reached a shocking $941 million
(2012). Although this Affordable Care Act of 2009 tried to resolve the large noninsured
population, it did not include coverage for undocumented immigrants.
This current issue is particularly important to the taxpayer, and also the employed health
care practitioners within the emergency department. Emergency physicians and the amount that
will be licensed in the future are much less than that of the physician assistants. “The rate of ED
visits is predicted to double by 2025, while the rate of emergency physicians (EPs) entering the
profession is flat,” (Hooker, Klocko, & Larkin, 2011). With this increasing population in
urbanized cities comes the need for more practitioners, especially those of the urgent care setting.
Because of this huge volume of patients expecting treatment, waiting times have increased,
which results in patients leaving without being treated. This can result in increasing risk of the

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patient’s health, possibly leading to lawsuits and liability of the practice. Those that leave the ED
have been reported in the 3% to 5% range (McMullan & Veser, 2004). Although not high-acuity
pathologies, leaving the ED can cause problems, and often lead to exacerbation of illnesses and
potential lawsuits. These issues have become a problem in EDs across the nation; further
solutions will be investigated in the remainder of this analysis.
Although issues such as lack on insurance of the public, publicly insured patients, and
low socioeconomic status have become primary issues as to why EDs are overcrowded, there
have been a number of potential and already established solutions to these issues. There are a
variety of different mechanisms that have been implemented to assist in solving these everlasting
problems. Case managers, patient navigators, community health workers, investigation of ED
ergonomics and restructuring of EDs have provided some laxity with regards to patient volume
and patient flow. First, let’s examine the value and role of patient navigators within the ED
setting.
Patient navigators are used as a source of value to the patient during their visit in the ED.
While being seen for their presenting health problems in the ED, the patient navigator will assist
the patient in finding publicly funded insurance programs if the patient is uninsured, and aiding
the patient in finding a primary care physician. As investigated in detail in a 2013 study by Enard
and Ganelin, the roles of the patient navigator within and emergency department include, but are
not limited to the following:
“Advocate on behalf of patients/families during ED visit. Determine whether patient has
a PCP; if not, make referrals to physicians and/or community health centers on the basis
of patients’ needs/preferences. Schedule patient appointments with community-based
PCPs as needed. Discuss/address specific barriers to accessing primary care in the

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community. Explain eligibility requirements and assist with completing applications for
local, state, and federal services/ resources. Make referrals to community social and
support services. Coach patients/families on how to access healthcare and community
resources. Educate patients/families about the importance of finding and maintaining
medical homes/PCPs for nonacute conditions and accessing preventive care. Build
relationships with hospital staff and community-based organizations. Document patients’
sociodemographic and insurance information, health/social support needs, and all patient
navigation communication/activities.”
With intervention of the patient navigator, this study noticed a steep decline in the amount of
visits in the emergency department during a 12-month period after assistance through a patient
navigator. Those that visited the ED greater than 5 times a year seemed to decrease their number
of visits by approximately 3.4 times. It is clear that the involvement of the patient navigator in
establishment of future primary care visits outside of the emergency department shows huge
progress towards eliminating the amount of primary care related health problems in emergency
departments. In spite of the need for community health workers and health care administrators to
aide patients in finding primary care, the structure and layout of EDs have undergone many
changes throughout their initial establishment.
Ergonomics, or the study of people and their efficiency within the work environment,
have provided emergency departments with different methods of increasing patient flow while
still maintaining quality patient care. Crowding in the emergency department is likely caused by
two downfalls: a shortage of beds and a shortage of providers. For example, a simulation-based
algorithm created by Hurwitz, Lee, Lopiano, McKinley, Keesling and Tyndall have provided a
model showing that a variety of different parameters can help aide the flow of the patients based

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upon bed availability and amount of providers (2014). Other implementations of the rapid
medical examinations (or RME) have also seemed to provide some viable outcomes in patient
flow, while decreasing the amount of patients that leave without being seen. Through an
investigation done by Jarvis, Davies, Mitchell, Taylor, and Baker in 2014, they evaluated the
efficiency of the RME in completed their study in two separate phases. The first phase was
through the traditional nurse-led triage format, while the second phase was completed through
implementation of the rapid medical examination. In the RME portion, the patient was seen in
less than 30 minutes by a provider (either a physician or a physician assistant). During this time,
the provider gather pertinent information of their symptoms, and determines if the patient can be
either placed back in the waiting room for labs and/or radiology exams, or if they are of high
acuity and need to be placed in a ED bed. Through their findings, they discovered that in phase
1, the patient was ready to leave the ED in129 minutes compared to 76 minutes for phase 2.
Through the rapid medical examination, the providers are able to focus on getting labs ordered,
samples gathered, and radiology. Not only does the RME help with patient flow in the ED, but
also the establishment of fast track programs.
“The creation of a fast track (FT) programme staffed by mid-level practitioners has been
assumed to increase ED effectiveness for non-emergency patients,” (Aksel, Bildik, Demircan,
Keles, Kilicaslan, Guler, and Dogan, 2014). The fast track was established primarily to aid in the
overcrowding of ED patient by providing an urgent care type clinic for non-urgent patients. This
can be used as an adjunct to the RME program in order to discharge patients quickly to increase
patient flow. Not only does this help patient flow, but it also can decrease the amount of patients
that leave the ED without being seen (LWBS). Not only has there been a decrease in the LWBS
rate, but the quality of care remains constant. This is important to be noted because patient care

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is of the upmost importance for all medical departments. The fast track programs offer a decrease
in the length of stay and wait times. In the study by Aksel and other from 2014, they noticed that
the wait times of their patients decreased by a staggering 54.9%. (Aksel, Bildik, Demircan,
Keles, Kilicaslan, Guler, and Dogan, 2014). Shortening wait times and length of stay in the ED,
however, should be viewed as a problem in not only EDs, but through a system wide approach.
Part of the solution can also be evaluated not only inside the ED, but also through a
comprehensive view of the hospital as a whole. Although some patients in emergency
departments are seen and discharged quickly, others require specific and specialized medical
attention. A systematic view of the hospital and its resource can provide insight as to whether or
not the ED is the problem. As stated by Trzeciak and Rivers, “overcrowding was only alleviated
after hospital administration and the local department of health realized that system reform was
necessary,” (2003). Hospital administration should take a “whole picture” approach in solving
the ED waiting room crisis in order to come to a formal solution. The ED should not be the only
medical department to blame for the overcrowding; it should be seen as part of the problem, not
the entire problem.
The crowding of emergency department waiting rooms has been an everlasting problem
nationwide. Despite efforts by many healthcare administrators and managers, it seems as though
the problem is ever increasing. The solutions that have been implemented have shown to provide
some relief with respect to the length of stay for the patient, and decrease the amount of patients
that are leaving without being seen. There still needs to be an evaluation after implementation of
programs and legislature such as the Affordable Care Act. The next steps for researches of public
health and hospital managers should be to evaluate the total amount of patient being seen now
after said legislature, and the divergence of patients accordingly. Further solutions should be

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established to provide health services to those that cannot afford them. The ED should not be an
avenue for those without primary care to abuse. The future should be hopeful in finding solutions
to destigmatize the ED as a lower class gateway to healthcare. Our health is a huge component of
our lives within our given community, and should be seen as the upmost priority.

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Work Cited
Akincigil, A., Mayers, R. S., & Fulghum, F. H. (2011). Emergency Room Use by Undocumented
Mexican Immigrants. Journal Of Sociology & Social Welfare, 38(4), 33-50.
Aksel, G., Bildik, F., Demircan, A., Keles, A., Kilicaslan, I., Guler, S., & ... Dogan, N. O.
(2014). Effects of fast-track in a university emergency department through the National
Emergency Department Overcrowding Study. JPMA. The Journal Of The Pakistan
Medical Association, 64(7), 791-797.
Cohen, R. A., & Bloom, B. (2010). Access to and utilization of medical care for young adults
ages 20-29 years: United States, 2008. NCHS Data Brief, (29), 1-8.
Enard, K. R., & Ganelin, D. M. (2013). Reducing Preventable Emergency Department
Utilization and Costs by Using Community Health Workers as Patient
Navigators. Journal Of Healthcare Management, 58(6), 412-427.
Hamden, K., Jeanmonod, D., Gualtieri, D., & Jeanmonod, R. (2014). Comparison of resident and
mid-level provider productivity in a high-acuity emergency department
setting. Emergency Medicine Journal: EMJ, 31(3), 216-219.
Hooker, R. S., Klocko, D. J., & Larkin, G. L. (2011). Physician assistants in emergency
medicine: the impact of their role. Academic Emergency Medicine: Official Journal Of
The Society For Academic Emergency Medicine, 18(1), 72-77.
Hsia, R. Y., Nath, J. B., & Baker, L. C. (2014). Emergency department visits by children,
adolescents, and young adults in California by insurance status, 2005-
2010. Jama, 312(15), 1587-1588.
Hurley, R. E., Freund, D. A., & Taylor, D. E. (1989). Emergency Room Use and Primary Care

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Case Management: Evidence from Four Medicaid Demonstration Programs. American
Journal Of Public Health, 79(7), 843-846.
Hurwitz, J. E., Lee, J. A., Lopiano, K. K., McKinley, S. A., Keesling, J., & Tyndall, J. A. (2014).
A flexible simulation platform to quantify and manage emergency department
crowding. BMC Medical Informatics & Decision Making, 14(1), 1-20.
"Income, Poverty, and Health Insurance Coverage in the United States: 2010." U.S. Census
Bureau. Issued September 2011.
Jarvis, P., Davies, T., Mitchell, K., Taylor, I., & Baker, M. (2014). Does rapid assessment
shorten the amount of time patients spend in the emergency department? British Journal
Of Hospital Medicine (London, England: 2005), 75(11), 648-651.
McCaughey, D., Erwin, C. O., & DelliFraine, J. L. (2015). Improving Capacity Management in
the Emergency Department: A Review of the Literature, 2000-2012. Journal Of
Healthcare Management, 60(1), 63-75.
McMullan, J. T., & Veser, F. H. (2004). Emergency Department Volume and Acuity as Factors
in Patients Leaving Without Treatment. Southern Medical Journal, 97(8), 729-733.
Okeke, E. N., Morganti, K. G., Vesely, J. V., Smith, A. C., Kellermann, A. L., Bauhoff, S., & ...
Iy. (2013). The Evolving Role of Emergency Departments in the United States. Santa
Monica, CA: RAND.
Sayah, A., Rogers, L., & Devarajan, K. (2014). Minimizing ED Waiting Times and Improving
Patient Flow and Experience of Care. Emergency Medicine International, 1-8.
Trzeciak, S., & Rivers, E. P. (2003). Emergency department overcrowding in the United States:
an emerging threat to patient safety and public health. Emergency Medicine Journal:
EMJ, 20(5), 402-405.

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Wang, J., Li, J., & Howard, P. K. (2013). A System Model of Work Flow in the Patient Room of
Hospital Emergency Department. Health Care Management Science, 16(4), 341-351.
Valenzuela, A. (2012). Affordable health care coverage for Mexican immigrants in the
southwest: State-Initiated Reform in the Private and Public Sectors. Arizona State Law
Journal, 44(4), 1777-1805.