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09-06-2011 | Article

Setting emergency department waiting targets ‘clinically justified’


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MedWire News: Patients who face long waits before being seen in and discharged from emergency departments have an increased risk for short-term death and admission to hospital, report Canadian researchers.

"Our findings provide strong support for policies in Canada, Australia, and England targeting reductions in length of stay in emergency departments," say Astrid Guttmann (Institute for Clinical Evaluative Sciences, Toronto, Ontario) and co-workers.

"Our study suggests that there is clinical justification to reduce lengths of stay, although taken alone it cannot guide specific policy interventions or targets to achieve this goal."

The researchers draw their conclusions from data on nearly 14 million patients who were seen in emergency departments in Ontario, Canada, and subsequently discharged, and on over 600,000 who left without being seen.

Overall, the risk for death or hospital admission within 7 days among patients who were seen and discharged rose incrementally with each additional hour of average waiting time, reflected in an increasing average length of stay, for patients seen during that shift.

Specifically, high-acuity patients (Canadian triage and acuity scale category 1-3) were 79% more likely to die and 95% more likely to require hospital admission if seen during a shift with long waiting times (average length of stay ≥6 hours), compared with during a shift with short waiting times (length of stay <1 hour).

The same association was seen among low-acuity patients (category 4-5), who experienced a 71% rise in death risk and a 66% increase in the likelihood of hospital admission. These relationships were independent of confounders including age, gender, calendar month, the time of day and week, and the presenting complaint.

In contrast, patients who left the emergency department without being seen had no increase in the risk for death or hospital admission, the team reports in the BMJ.

In an accompanying editorial, Melissa McCarthy (George Washington University, DC, USA) said: "The results of this study may come as a surprise to many people, including emergency department clinicians."

She noted that "most emergency departments do not routinely track patient outcomes, except for patient satisfaction, recidivism, and rates of leaving without being seen." Thus, their outcomes are rarely known.

"The results make a compelling case for the need to improve the operational efficiency of emergency departments," said McCarthy.

"Length of stay is an efficiency measure; the study shows that when emergency departments operate less efficiently, more deaths and hospital admissions occur in discharged patients."

She concluded: "Emergency departments must be redesigned to meet patients' needs more effectively and efficiently."

MedWire ( is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2011

By Eleanor McDermid