A Comparison of Waiting Times in Ers and Urgent Care Centers

Wait Times in Outpatient Centers Compared to Traditional Emergency Rooms

It is reasonable to suggest that many if not most people find themselves in need of urgent medical care at some point in their lives and until a few years ago, the traditional emergency room was the only option available. Over the past 20 years or so, though, there has been an explosion in the number of outpatient centers that provide a wide range of urgent medical care including various surgical procedures. This growth in the number of outpatient centers has resulted in an increased interest in determining how efficient these respective healthcare venues are in treating patients. To this end, this paper reviews the relevant literature concerning traditional emergency rooms and outpatient centers and proposes a strategy for recruiting and selecting a sample population to compare the average waiting times for each. An overview of the characteristics of the target and accessible populations is followed by a description of the proposed sampling strategy with its strengths and limitations. A discussion concerning the proposed recruitment plan is followed by a description of the inclusion and exclusion criteria that will be used for sample selection. Finally, an assessment of relevant contextual factors regarding the proposed setting of the study is followed by a summary of the research and important findings concerning the foregoing issues in the conclusion.

Characteristics of Target and Accessible Population

The scenario is probably familiar to any healthcare consumer who has sought medical care in a traditional emergency room. In all likelihood, there will be dozens of patients and their family members waiting for care and even if a consumer is fortunate enough to find an emergency room that is not crowded, the potential for new cases to arrive at any second means that waiting times can be extended indefinitely for non-life threatening cases. In this regard, Alijani and Kwun (2015) emphasize that, "Without a doubt, when looking at healthcare reform, we cannot overlook the problem of overcrowding and lengthy waiting times in most emergency rooms" (p. 2).

Lengthy waiting times in emergency rooms adversely affect the level of patient satisfaction (which is an area of quality concern for accrediting organizations such as the Joint Commission), but they also create a situation in which patients tend to experience higher levels of suboptimal clinical outcomes as well. For instance, Alijani and Kwun add that, "Long waiting times not only affect patient satisfaction, they increase the risk of death and hospital readmission for patients who have been discharged from the emergency department" (p. 2). Despite efforts to reform the healthcare system in the United States, most authorities agree that many Americans, especially those without health insurance, will continue to rely on emergency rooms as their primary source of medical care in the future (Alijani & Kwun, 2015).

Some indication of the extent of the problem can be discerned from the most recent statistics reported by the U.S. Centers for Disease Control which are set forth in Table 1 below.

Table 1

Emergency department visits in the United States: 2011

Category

Statistic

Number of visits

136.3 million

Number of injury-related visits

40.2 million

Number of visits per 100 persons

44.5

Number of emergency department visits resulting in hospital admission

16.2 million

Number of emergency department visits resulting in admission to critical care unit:

2.1 million

Percent of visits with patient seen in fewer than 15 minutes

27.0%

Percent of visits resulting in transfer to a different (psychiatric or other) hospital

2.1%

Source: National Hospital Ambulatory Medical Care Survey: 2011 Emergency Department Summary Tables. Tables 1, 4 at http://www.cdc.gov/nchs/fastats/emergency-department.htm

As can be seen from the statistical breakdown in Table 1 above, just over one quarter (27%) of the 136.3 million emergency room patients treated in 2011 were seen within 15 minutes of their arrival, and it is reasonable to posit that these cases were the most severe, arrived by ambulance and/or occurred during extremely rare periods of low demand. It is noteworthy that just around 29% of the emergency room visits shown in Table 1 above were injury related, indicating that the a significant percentage of healthcare consumers seeking care at emergency rooms do so for alternative reasons. For example, studies have shown that 13% of emergency room patients are malingering with secondary objectives most often including obtaining food, shelter, prescription drugs, financial gain, or the avoidance of jail, work, or family responsibilities (Brady, Schur & Newman, 2013).

There are some other factors that can create inordinately long waiting times at emergency rooms as well. For instance, Hsia, Kellermann and Shen (2011) report that:

In the U.S. health care system, hospital emergency departments (also known as emergency rooms [ERs]) are unique in their legal obligation to treat all patients in need, without regard for their ability to pay. As a result, emergency rooms often serve as the 'safety net of the safety net,' offering a place of last resort for uninsured and underinsured patients who lack other options for care. (p. 1)

In fact, even some insured patients may opt for medical care at an emergency room when they are required to wait inordinately long periods of time for appointments from their primary healthcare providers. In this regard, Kovner and Knickman (2005) point out that, "Medicaid patients have historically adapted to long wait times for appointments at some clinics and outpatient departments (60 days or more in many cases) by using emergency rooms for routine care" (p. 619). These statistics indicate that waiting times at virtually any emergency room are highly unpredictable and that treatment may be delayed for all but the most critical cases at any given time. A typical emergency room waiting room is depicted in Figure 1 below.

Figure 1. Representative emergency department waiting room

Source: http://cms.ipressroom.com.s3.amazonaws.com/173/files/20149/5436f6b6299b 50017f01d83d_pentup/pentup_mid.jpg

Against this backdrop, it is little wonder that healthcare consumers would be interested in a more efficient alternative, especially for urgent care needs that do not require tertiary healthcare services and these issues are discussed further below as they relate to the burgeoning outpatient clinic industry.

The majority of surgeries that are performed in outpatient clinics in the United States today involve the eye, ear, nose/mouth/pharynx, and skin (Wier & Steiner, 2015). In fact, the outpatient clinics were the venue for a majority of surgeries performed in the United States in 2011 on the ear (91.8%), nose/mouth/pharynx (86.7%) and skin (76.1%) (Wier & Steiner, 2015). By contrast, the majority of obstetrical surgeries (97.7%) were performed in inpatient settings and just 2.3% were performed in outpatient clinics (Wier & Steiner, 2015). Likewise, cardiovascular and respiratory surgeries were only performed in outpatient clinics 28.3% and 13.1% of the time in 2012, respectively (Wier & Steiner, 2015). At present, there are approximately 10,000 such outpatient clinics operating in the United States (Urgent care center vs. emergency room, 2016) compared to about 1,779 emergency rooms (Hsia, Kellermann & Shen, 2011). A typical outpatient clinic waiting room is depicted in Figure 2 below.

Figure 2. Representative outpatient center waiting room

Source: https://c.o0bg.com/rf/image_960w/Boston/2011-2020/2014/02/17/BostonGlobe.com / Lifestyle/Images/urgent-big.jpg

As noted above, the average waiting time for receiving emergency medical care can have a profound impact on the quality of clinical outcomes. Calculating the precise average respective waiting times for emergency rooms and outpatient clinics, though, is complicated by a number of factors. For instance, according to one industry analyst, "The average emergency room has a wait time of 2.4 hours, whereas urgent care centers are able to see walk-in patients within 15-45 minutes. However, that wait time does not express the time patients will spend waiting for services while in the doctor's office" (Urgent care center vs. emergency room, 2016, para. 4).

Nevertheless, ceteris paribus, patients will typically been seen faster in outpatient clinics because the services they offer are more specialized and limited (Urgent care center vs. emergency room, 2016). As also noted above, waiting times in either venue can vary depending on the exigencies of the day, and the potential for more urgent cases to arrive just as a patient is about to be seen exists irrespective of whether the setting is an emergency room or outpatient clinic (Urgent care center vs. emergency room, 2016). In this regard, one industry analyst emphasizes that, "Depending on the number of people waiting and the severity of sickness or illness, the wait can be as little as a few minutes or as long as a few hours" (Urgent care center vs. emergency room, 2016, para. 5).

As noted above, however, the likelihood that individuals will be seen and treated more rapidly in outpatient clinics compared to traditional emergency rooms is clear: "That said, most urgent care patients wait less than 15 minutes while the average emergency room patient waits over 2 hours" (Urgent care center vs. emergency room, 2016, para. 5). Moreover, the potential for adverse clinical outcomes in emergency room settings increases as overcrowded conditions increase. In this regard, Kilcoyne and Dowling (2010) stress that, "Overcrowded emergency departments are a high risk environment for medical errors and pose a threat for patient safety" (p. 3).

Other salient statistics that are available also confirms shorter waiting times in outpatient clinics compared to traditional emergency rooms. Despite the unpredictability of the waiting times for any given visit to these venues, an average of just 27% of patients are seen within 15 minutes of their arrival in an emergency room (and again, these are most likely the most severe, life-threatening cases) (National Hospital Ambulatory Medical Care Survey, 2011) while more than half (57%) of patients are seen within 15 minutes of their arrival at an outpatient clinic (Urgent care center vs. emergency room, 2016). The implications of these statistics are troubling. Because there are far more visits to emergency rooms each year compared to outpatient clinics, lengthy waiting times in the former may discourage some people from seeking medical care when they need it the most (Reime & Tu, 2007).

Proposed Sampling Strategy with Strengths and Limitations

Formulating an effective sampling strategy that accurately compares waiting times at traditional emergency rooms with outpatient clinics is also complicated by a number of factors. For instance, one industry analyst points out that, "The problem is most of these [outpatient] clinics are owned and operated by individuals, small physician groups and other independent operators making them difficult to find and obtain trusted information about" (Urgent care center vs. emergency room, 2016, para. 6). Likewise, emergency room and outpatient clinic usage rates both vary depending on the time of day and season of the year, with weekends and holidays typically being periods of heavier usage (Kilcoyne & Dowling, 2010). Therefore, a purposive sampling strategy would be the most suitable to collect the minimum number of data needed to compare waiting times between these two venues. According to Trochim (2006), a purposive sampling strategy in one in which "we sample with a purpose in mind" (para. 4).

As noted above, the purpose of the proposed study will be to compare waiting times in traditional emergency rooms with those experienced in outpatient clinics. Therefore, the proposed purposive sampling strategy would employ a modal instance sampling approach that regarded any patient visiting an emergency room or outpatient clinic as being a "typical" patient. Although there are some constraints to this approach, the model instance sampling approach can be "very useful for situations where you need to reach a targeted sample quickly" (Trochim, 2006, para. 5).

Recruitment Plan

In order to protect the privacy of adult (21 years+) healthcare consumers and their family members and to ensure that appropriate informed consent procedures are followed, approval for the recruitment plan will be obtained from the author's university as well as the emergency room and outpatient clinic selected for comparisons. Because of the data collection constraints described above, the proposed study will rely on the author serving as a field researcher stationed at the exit doors of the facility. In the capacity as a field researcher, potential respondents will be politely approached and requested to participate in the study and to indicate the amount of time they were required to wait before being seen by clinical staff. All respondents will be assured or their anonymity and that the only data needed is the amount of time they were required to wait. This data will be entered on a hard-copy spreadsheet and later entered into an Excel spreadsheet or SPSS database to calculate averages for comparison. A target of 100 total respondents from each venue will be recruited in order to have sufficient data for a valid comparison.