Hospitals vary widely in ER waiting times

If you show up to the Hospital of the University of Pennsylvania's emergency room but aren't in serious trouble, get ready to wait.

New federal data show that the prestigious university hospital has the highest median ER wait times in the city at 81 minutes to see a doctor.

The Centers for Medicare and Medicaid Services, which publish the data from hospital submissions, say long waits can be a sign of understaffing or gridlock elsewhere in the hospital. And they can lead to lower quality care and more stressful stays for patients and families.

Jill M. Baren, chair of the Department of Emergency Medicine at Penn, said the database isn't complete enough to capture all the factors involved in ER waits. "No single data source can provide a clear picture of how each individual hospital defines the 'door-to-doctor' concept and what the patient population in any single emergency room is comprised of, a factor which is a key contributor to wait times," she e-mailed. She also noted that patient outcomes exceed national standards at HUP's emergency room.

Patients there tend to be very sick, and spent close to seven hours from when they stepped through the ER doors until they made it to a hospital bed, fifth highest in the area, data show.

Another major academic trauma center, Temple University Hospital, said it took 54 minutes to see a doctor and five hours and 20 minutes to get a bed although the North Philadelphia center was diverting ambulances to other centers far more often, city records show.

The suburban Abington Memorial Hospital posted the region's shortest waits at 11 minutes.

In Philadelphia-area South Jersey, Virtua Memorial Hospital of Burlington County had the longest waits to see a doctor at 60 minutes, while Kennedy University Hospitals - with campuses in Cherry Hill, Stratford, and Washington Township - collectively posted the lowest at 18 minutes.

The results covered the first nine months of 2012.

ER crowding can certainly be a nuisance for patients. And to be sure, those who show up with serious problems such as heart attack or stroke are pushed to the front of the line. But research has shown waits to be a serious problem.

A study of nearly a million admissions from the ER at 187 California hospitals, published in June in the Annals of Emergency Medicine, found that patients admitted during high crowding were 9 percent more likely to die within three days than those admitted through a calmer ER. Overall, crowding led to 300 additional deaths in just a year.

"We used to think that crowding just affected those non-acute patients; patients with sore throats, for example, would have to wait 12 hours instead of 6 hours to be seen in the ER. But now we see that there are very real, and measurable, negative effects of ER crowding on our ability to care for sick patients," said Renee Hsia, associate professor in Emergency Medicine at the University of California, San Francisco, and co-investigator of the study.

Another study, published in 2009 in the journal Academic Emergency Medicine, focused specifically on HUP and showed that patients arriving with chest pain during the highest level of crowding experienced adverse outcomes - such as death and heart attack - up to five times more often than those admitted when it was calmer.

"Things tend to get missed more frequently when it's crowded," said Jesse Pines, a professor of emergency medicine and health policy at George Washington University and author of the 2009 study. "Like a patient who comes in with a gunshot wound to the chest or is obviously having a heart attack, those are not the ones impacted by crowding. But it's really patients with conditions that may still be time-sensitive like someone with pneumonia or sepsis."

ER wait times across the country have been trending up over the last decade as more patients seek emergency care.

The Centers for Disease Control and Prevention last year found a 32 percent rise in ER visits over the last decade and the median wait to see a physician rose from 27 minutes to 33 minutes from 2003 to 2009.

A recent survey of medical directors and ER heads in Pennsylvania showed that 83 percent of respondents viewed crowding as a problem, with three-quarters saying it had worsened in the last two years.

ER visits are expected to rise again after January when millions more people will get insurance under the Affordable Care Act.

Still, it's not just the surge in patients that's causing the long waits. It's also hospital-wide inefficiencies, experts say.

Boarding - where a patient sits in the emergency room until a hospital bed opens up - is often caused by backups elsewhere in the hospital. "Right now we have a lot of ER crowding because sick patients are waiting for an open bed upstairs," Hsia said of hospitals generally. "A combination of a little bit of operational engineering using already-collected hospital census data - along with the hospital leadership to direct these shifts in hospital culture - could go a long way in reducing ER crowding."

Urban hospitals tend to have longer ER waits. But in the wider Philadelphia area, Holy Redeemer Hospital and Medical Center in Meadowbrook, Crozer-Chester Medical Center in Upland, and Delaware County Memorial Hospital in Drexel Hill were well above the 62.4-minute urban hospital average to get evaluated by a doctor.

"There is a large discrepancy with the data you have and the data we run every month for all the departments," said Bruce Nisbet, chairman of the emergency departments at Crozer-Chester Medical Center and Springfield Hospital, both part of the system that includes Delaware County Memorial Hospital. Nisbet said internal metrics over the same period showed median waits at 55 minutes, compared with the government's 83 minutes.

He added that the hospital has since streamlined its triage system by opening a rapid assessment unit in May, adding six beds. "There have been significant steps forward," Nisbet said.

Philadelphia hospitals fared slightly better than other urban areas with average wait times across the city's 13 reporting acute care centers at 53 minutes. In Chicago, it took an average 57 minutes to see a doctor; in New York City it was 63.5. Los Angeles ER waits were much lower at just under 40 minutes on average.

But data did show that patients were often willing to endure the long waits. Only 4 percent of patients at Crozer-Chester Medical Center and HUP - and even fewer at Delaware County Memorial and Holy Redeemer - left before being seen.

Laura Burke, a clinical instructor of medicine at Harvard Medical School, also noted the poor outcomes that overcrowding can cause. But she said that a hospital's reputation and quality can outweigh long waits in a patient's mind.

"I might be willing to accept a higher wait time if I know they offer better services or specialties," Burke said.