ABSTRACT

Advertising emergency department (ED) wait times has become a common practice in the United States. Proponents of this practice state that it is a powerful marketing strategy that can help steer patients to the ED. Opponents worry about the risk to the public health that arises from a patient with an emergent condition self-triaging to a further hospital, problems with inaccuracy and lack of standard definition of the reported time, and directing lower acuity patients to the higher cost ED setting instead to primary care. Three sample cases demonstrating the pitfalls of advertising ED wait times are discussed. Given the lack of rigorous evidence supporting the practice and potential adverse effects to the public health, caution about its use is advised.

By now, you’ve probably seen one – a billboard advertising a hospital, prominently displaying its emergency department (ED) wait time. The billboards have been adopted by hospitals around the country as a means of advertising their services. Often, the displayed wait time is short, and the billboards are designed to steer low-acuity, but insured, patients to the ED by demonstrating convenience. But are these ads truly harmless?

Proponents of this practice state that it is a powerful marketing strategy that can help steer patients to the ED, thus potentially increasing hospital revenue.¹ Likewise, the practice can decompress overburdened hospital systems, as patients with less acute problems are hypothesized to take the additional time to drive to a hospital that may not be closer to them, but has less wait time.² One hospital system reported posting wait times of other local EDs in its waiting room, so that if patents wish to leave and go to a nearby affiliated hospital with a shorter wait time they have that possibility.³ Supporters of this technology state that it smooths the “peaks and valleys” in ED volume that occur throughout the day.³

THREE CASES

A 60-year old man decides to leave work early because he experiences chest discomfort. He is a minimizer, and doesn’t share his symptoms with his colleagues apart from telling them that he feels unwell and is leaving early. While driving home, he notices a billboard for a local ED, which publishes a wait time of 60 minutes. Not wanting to wait that long, he proceeds to drive another 10 miles up the road where he knows that there is another hospital. His trip is cut short as he develops a ventricular fibrillation cardiac arrest, veers off the road, and dies.

A 25-year old woman sees a sign advertising a wait time of 30 minutes and decides to go to the ED for a sore throat and rhinorrhea she has had for the past 2 days. As soon as she arrives, a multi-car pile-up occurs on the adjacent highway, causing the ED staff to dedicate all of its available resources to multiple acute trauma victims that suddenly present. The woman is finally evaluated 2 hours after arrival, is diagnosed with a viral upper respiratory infection and over-the-counter medications are recommended. She leaves frustrated and unsatisfied.

A 50-year old man with hypertension ran out of his anti-hypertensive medication. The patient neglected to make a follow-up appointment with his physician because he remembered seeing the advertisement for the nearby ED that had a short wait time and did not require an appointment. When he goes, the emergency physician agrees to write a 10-day prescription for his medication, encouraging the patient to follow-up with his physician for routine care. The patient does just that, but his insurance is billed for the cost of his ED visit.

The first case is hypothetical and can never be proven. Still, advertising a single wait time can be misleading. There are no clear standards regarding what the advertised time represents. Is it time from arrival to seeing the triage nurse, to being placed in a room, to quickly saying “hello” to a physician, or to a comprehensive evaluation? Furthermore, advertised wait times represent an average number and defeat the purpose of triage, where patients are evaluated based on the time-sensitivity of their medical condition and not on the order upon which they arrive to the ED. This fact may not be immediately clear to a layperson that sees a number on a billboard.

Although it can be argued that the second patient should have sought primary care instead of the emergency department, this option is not always possible and it is difficult to determine if the patient had an emergent condition without actually being evaluated. Still, such a patient would undergo standard triage and would have to wait should a patient with a more emergent condition present in the interim. Given the dynamic environment of the ED, it seems impossible to predict a wait time knowing that sicker patients can present at any time.

For the third patient, primary care from the start would have been ideal. The CDC has reported that 7.9% of ED visits are non-urgent.⁴ If this patient presents with a request for a medication with normal vital signs and no symptoms, then this visit was probably not appropriate for the ED. Advertising wait times to attract patients such as this one may please the hospital administration and inflate revenue, but it fundamentally undermines the key mission of emergency medicine that predicates being available 24/7/365 for any concern of an emergent or urgent condition that a prudent layperson may have and wastes healthcare dollars.

In actuality, wait times mean little. A patient may be seen in an expeditious fashion, but the workup that the emergency physician orders may take a prolonged time if there are laboratory or radiology inefficiencies. The advertised number doesn’t explain that a patient might need to be transferred or have care deferred to a follow-up visit should a certain specialist (e.g. neurosurgeon) or imaging modality (e.g. magnetic resonance imaging) be unavailable. The wait time number does not describe the time a patient who is admitted may have to wait if there is ED crowding as a byproduct of lack of inpatient bed availability. Furthermore, the emphasis on clinicians becomes reducing initial door to first evaluation time, and not on more meaningful markers such as time to admission or discharge.

WHERE’S THE EVIDENCE?

There are limited peer-reviewed studies evaluating the advertising of ED wait times. Only 1 paper from England evaluated accuracy of predicted waiting times.⁵ Using a rigorous statistical process, there was a large difference in predicted vs. actual ED wait times. This is different than an ED simply publishing the maximum time a patient is currently waiting in their ED, but highlights that prediction modeling potentially used for advertising may be inaccurate.

GUIDELINES

No formal guidelines exist regarding adverting ED wait times, although the Emergency Medicine Practice Committee of the American College of Emergency Physicians recently published a white paper regarding this topic.⁶ This group cited the dearth of available evidence, the lack of standardization of the definition of reported times, and the argument that patients with emergent conditions may have delayed care secondary to seeing a long wait time. The paper recommends that until more evidence is available, advertisements should display the universally defined wait time as “time from door to qualified medical provider time”, that wait times contain a disclaimer that they do not apply to potentially life-threatening conditions, and that they should be updated at least hourly. Any such initiative should also be conducted in parallel to hospital initiatives that reduce institutional operational inefficiencies which also ultimately affect ED wait times.

CONCLUSION

Advertising wait times may encourage patients to self-triage in a dangerous way. Published times may be inaccurate based on the dynamic nature of the ED and lack of a standardized definition, and conflict with the core mission of emergency medicine by appearing to cater to low-acuity patients that might be better served in alternative environments. Pending more evidence, caution about their use is advised.

Footnotes

REFERENCES