Long ER waits in California prompt patients to leave against medical advice
Monday, June 03, 2019
The number of patients leaving California emergency departments against medical advice (AMA) has increased by 57% since 2012.
Not all the patients who left after seeing a doctor but before treatment had been rendered can be attributed to long wait times, but hospital administrators say most are due to overcrowded EDs.
"Most patients are sick but not critically ill," said Dr. Steven Polevoi, medical director of the ED at UCSF Helen Diller Medical Center at Parnassus Heights. "Emergency care doesn’t equal fast care all of the time."
Discontinuing care or leaving the facility AMA includes encounters where doctor explains the risks to the patient and requires the patient sign a form absolving the hospital from responsibility should a negative health event occur. It also includes cases where patients simply leave without telling anyone.
According to state statistics, men, people between the ages of 20 and 39 and the uninsured were most likely to leave an ER against medical advice. This patient group largely reported nonspecific symptoms, such as a cough or chest pain.
Hospitals in California experience some of the longest wait times in the country. The median wait time for patients from being seen to inpatient admission was about 5.5 hours. That wait time has increased by 15 minutes since 2012. Patients who were not admitted to the hospital saw wait times decrease by 12 minutes until around 2.5 hours from arrival to discharge.
The national median wait time from arrival to inpatient admission was 80 minutes shorter than California's wait time. Four states — Maryland, New York, New Jersey and Delaware — had longer wait times in 2017.
The number of patients leaving California's EDs without treatment can't be correlated to volume growth as the percentage of patients who prematurely is greater than overall patient encounter growth.
ED wait times has been a long-term issue for hospitals across the nation and various methods have been implemented to alleviate patient wait times. Variability is often cited as the key factor in creating snags in ED throughput.
Predictive analytics, innovative staffing models and cultural changes used to speed up care delivery. In some places, like Kaiser Permanente hospitals, ED patients are seen within 10 minutes of arrival. Some have suggested revising reimbursement models so providers who don't meet national benchmarks would be paid at a lower rate.
In California, hospitals are attempting to decrease patient wait times by changing the where the point of care occurs. For example, Community Regional Medical Center in Fresno utilizes what's known as "provider at triage." Registered nurses see patients in the lobby within five minutes of arrival. This process has made it possible for patients to be seen by a physician in around 30 minutes. The hospital sees less than 2% of patients leaving AMA.
"When patients bring themselves into the ED, they are seen in about five minutes by a qualified registered nurse and, on average, are seen by a provider within 30 minutes of arrival," said ED Medical Director Dr. Jeffrey Thomas.
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