Prior to the COVID-19 pandemic, EDs around the country were under strain. Seven million people waited more than 2 hours for care in 2017, with many waiting much longer than that. Emergency departments are routinely crowded, and the majority of hospitals report boarding patients in the ED while they wait for available treatment beds in a different part of the hospital.
Long wait times are not just inconvenient. When emergency care is delayed, there can be serious health consequences. There are numerous reports of patients dying while they wait for emergency care because they did not get treatment in time. Crowded EDs are also connected to increased stress on staff, poor adherence to protocols, and clinical errors. So, it may seem like decreasing wait times during the pandemic would be a good thing. But that is not the whole story.
During the month of April, ED visits across the country declined a staggering 42% from the same time in 2019. These declines were most profound in areas heavily affected by COVID-19. The decrease of patients may be due to multiple reasons. First, it may be a sign of effective strategies to streamline the health system in response to the pandemic. Second, some emergencies, such as injuries, may simply decrease as people stay at home more.
Unfortunately, ED visits for actual medical emergencies are declining as well. Independent of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections, emergency calls for cardiac arrests increased dramatically in March and many patients were declared dead at the scene. This suggests that people are waiting too long to seek care for true medical emergencies—a potentially lethal decision.
Fear of SARS-CoV-2 infection seems to be affecting the demand for emergency care. Many patients perceive a trip to the ED as a trip to a COVID-19 hotbed. A recent study on patients’ perceptions about EDs during the pandemic found that hospitals were seen as infection reservoirs and that patients were unaware of the steps that hospitals had taken to protect uninfected patients from COVID-19.
As fear over the COVID-19 pandemic decreases, ED wait times might increase again, perhaps becoming longer than ever. Delayed care and undermanaged chronic conditions as a result of the pandemic might trigger emergencies and lead to increased need for ED services.
The current, temporary decrease in ED wait times is an opportunity to optimize ED workflows to keep wait times manageable. There are 2 bottlenecks in EDs that drive up wait times—inputs and outputs—and there are also solutions deployed during the pandemic that should be maintained to keep wait times manageable in the future.
A significant part of why EDs are seeing decreased wait times during this pandemic appears to result from decreased demand. Some of this decrease may stem from effective ways to keep nonemergent patients away from the ED during the pandemic. Before COVID-19, many EDs already had fast-track clinics to divert nonemergent patients to a lower level of care. COVID-19 may have simply increased the importance of these clinics to keep EDs functional.
In addition, the increase in telehealth may be changing the way community-based health centers and independent practitioners deliver care. As COVID-19 spread, health systems implemented telehealth solutions to avoid in-person care. Many nonemergent patients are referred to the ED by outpatient clinics, often due to a lack of same-day appointments. Stay-at-home orders and expanded telehealth capability may be refocusing community-based clinicians to treat patients at home rather than referring them to an ED. Telehealth may be increasing the capacity of community-based clinics to provide timely care, which is linked to the number of nonurgent visits that EDs are used to seeing.
Thus, maintaining solutions such as fast-track clinics and telehealth might continue to divert nonemergent patients from EDs and help maintain the delicate balance between supply and demand for ED care. Even more important than input in achieving the delicate balance between supply and demand is output, which is an ED’s ability to discharge a patient, and the most commonly identified cause of ED crowding. Medical floor bed availability, psychiatric and substance treatment bed availability, or homeless shelter admitting schedules can all affect when an ED can safely discharge someone. When safe discharge options are not available, EDs have little choice but to keep patients in the ED.
The American College of Emergency Physicians has identified this as the major driver of ED crowding. When a bed is occupied by someone waiting to leave, new patients see longer wait times.
The surge in patients during the COVID-19 pandemic was met with increased planning in bed availability and organization. Active bed management is an important way to reduce ED wait times. Another potentially powerful tool is reverse triage, a system of ranking patients by risk for adverse events at the end of ED care and discharging those at low risk. Reverse triage can rapidly reduce bed occupancy and ED wait times but must be implemented with care to protect patient safety. Hospitals that successfully implemented these strategies to increase capacity for COVID-19 should maintain them even when the pandemic abates.
Emergency departments operate within the delicate balance of supply and demand. Decreased demand for ED services during the COVID-19 pandemic reflects both fear and avoidance. Patients who are experiencing an emergency should not be afraid to seek treatment, nor should the negative effects of crowded EDs be the norm. The COVID-19 pandemic may be the right time to reinvent emergency care delivery by keeping wait times manageable while treating patients with emergencies.
Alex Woodruff, MPH1,2; Austin B. Frakt, PhD1,2
Conflict of Interest Disclosures: Dr Woodruff reported receiving grants from the Laura and John Arnold Foundation. Dr Frakt reported receiving grants from the Laura and John Arnold Foundation.