ER vs. Outpatient Center Wait Times: A Research Proposal

Introduction

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. Until a few years ago, the traditional emergency room was the only option available. Over the past 20 years or so, however, 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 has resulted in 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 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 of 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 study setting is followed by a summary of the research and important findings in the conclusion.

Characteristics of the 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 — 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 rates of suboptimal clinical outcomes. 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 statistics reported by the U.S. Centers for Disease Control. According to the National Hospital Ambulatory Medical Care Survey (2011), there were 136.3 million emergency department visits in the United States that year, including 40.2 million injury-related visits (44.5 visits per 100 persons). Of those visits, 16.2 million resulted in hospital admission and 2.1 million in admission to a critical care unit. Only 27% of patients were seen in fewer than 15 minutes, and 2.1% of visits resulted in transfer to a different hospital.

Just over one quarter (27%) of the 136.3 million emergency room patients treated in 2011 were seen within 15 minutes of their arrival. 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 also noteworthy that approximately 29% of emergency room visits were injury-related, indicating that a significant percentage of healthcare consumers seeking care at emergency rooms do so for other reasons. For example, studies have shown that 13% of emergency room patients are malingering, with secondary objectives most often including obtaining food, shelter, or prescription drugs, seeking financial gain, or avoiding jail, work, or family responsibilities (Brady, Schur & Newman, 2013).

There are additional factors that can create inordinately long waiting times at emergency rooms. As Hsia, Kellermann, and Shen (2011) note:

In the U.S. health care system, hospital emergency departments 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 emergency room care when they face inordinately long waits for appointments with their primary healthcare providers. As Kovner and Knickman (2005) point out, "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 patterns 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.

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. These issues are discussed further below as they relate to the burgeoning outpatient clinic industry.

The majority of surgeries performed in outpatient clinics in the United States today involve the eye, ear, nose/mouth/pharynx, and skin (Wier & Steiner, 2015). 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, with just 2.3% performed in outpatient clinics (Wier & Steiner, 2015). Likewise, cardiovascular and respiratory surgeries were performed in outpatient clinics only 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).

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 is complicated by a number of factors. 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 be seen faster in outpatient clinics because the services offered are more specialized and limited (Urgent care center vs. emergency room, 2016). Waiting times in either venue can also 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 regardless of whether the setting is an emergency room or outpatient clinic (Urgent care center vs. emergency room, 2016). One industry analyst notes 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).

The likelihood that individuals will be seen and treated more rapidly in outpatient clinics compared to traditional emergency rooms is, however, clear: "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 worsen. 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 available statistics confirm shorter waiting times in outpatient clinics compared to traditional emergency rooms. Despite the unpredictability of waiting times for any given visit, an average of just 27% of patients are seen within 15 minutes of arrival in an emergency room — most likely the most severe, life-threatening cases — while more than half (57%) of patients are seen within 15 minutes of arrival at an outpatient clinic (Urgent care center vs. emergency room, 2016). The implications of these statistics are significant. Because there are far more visits to emergency rooms each year than to outpatient clinics, lengthy waiting times at the former may discourage some people from seeking medical care when they need it most (Reime & Tu, 2007).

Proposed Sampling Strategy: Strengths and Limitations

Formulating an effective sampling strategy that accurately compares waiting times at traditional emergency rooms with those at outpatient clinics is complicated by a number of factors. As one industry analyst notes, "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). Emergency room and outpatient clinic usage rates also vary depending on the time of day and the season of the year, with weekends and holidays typically seeing heavier usage (Kilcoyne & Dowling, 2010).

Therefore, a purposive sampling strategy would be the most suitable approach to collect the minimum number of data points needed to compare waiting times between these two venues. According to Trochim (2006), a purposive sampling strategy is one in which "we sample with a purpose in mind" (para. 4). The proposed purposive sampling strategy would employ a modal instance sampling approach that regards any patient visiting an emergency room or outpatient clinic as a "typical" patient. Although there are some constraints to this approach, modal instance sampling can be "very useful for situations where you need to reach a targeted sample quickly" (Trochim, 2006, para. 5).

Conclusion

The research showed that although emergency rooms and outpatient clinics provide some of the same types of urgent healthcare services, the former are legally required to accept all patients irrespective of their ability to pay and will treat virtually any type of healthcare emergency, while the latter are more specialized and limited in their offerings. It is not surprising, then, that waiting times in emergency rooms tend to average far longer than those in outpatient clinics. The most recent statistics indicate that a majority of outpatient clinic patients will be seen within 15 minutes, while just over one quarter of emergency room patients are seen within this time.

In any case, waiting times for either venue are unpredictable and may be longer or shorter depending on the time of day, time of year, or countless other factors relating to the human condition. The research also showed that calculating average wait times for emergency rooms and outpatient clinics is a challenging enterprise for these reasons and others, including most especially the potential reluctance of individuals to participate in research following a traumatic experience involving urgent healthcare.

Despite the challenges involved, the findings that emerge from the proposed study will provide a valuable benchmark concerning current average waiting times in traditional emergency rooms compared to outpatient clinics, and will serve as the basis for future research in this area.

References

Alijani, G. S. & Kwun, O. (2015, July 1). The effect of emergency waiting time on patient satisfaction. Journal of Management Information and Decision Sciences, 18(2), 1–4.

Brady, M. C., Scher, L. M. & Newman, W. (2013, October). "I just saw Big Bird. He was 100 feet tall!" Malingering in the emergency room: Four instruments can help you make a rapid assessment of a patient feigning symptoms. Current Psychiatry, 12(10), 33–39.

Emergency room. (2015). In Merriam-Webster dictionary. Retrieved from http://www.merriam-webster.com/dictionary/emergencyroom.

Hsia, R. Y., Kellermann, A. L. & Shen, Y-C. (2011, May 18). Factors associated with closures of emergency departments in the United States. Journal of the American Medical Association, 305(19), 1978–1985.

Kilcoyne, M. & Dowling, M. (2010). Working in an overcrowded accident and emergency department: Nurses' narratives. Australian Journal of Advanced Nursing, 25(2), 1–5.

Kovner, A. R. & Knickman, J. R. (2003). Jonas and Kovner's health care delivery in the United States. New York: Springer Publishing Company.

National Hospital Ambulatory Medical Care Survey: 2011 Emergency Department Summary Tables. (2011). Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/nchs/fastats/emergency-department.htm.

Reime, B. & Tu, A. W. (2007, May/June). Factors associated with reluctance to use an emergency department in a multi-ethnic community: Results of a telephone survey. Canadian Journal of Public Health, 98(3), 222–225.

Trochim, W. M. K. (2006). Sampling. Social Research Methods. Retrieved from

Urgent care center vs. emergency room. (2016). Urgent Care Locations. Retrieved from https://www.urgentcarelocations.com/urgent-care-101/faq/urgent-care-center-vs.-emergency-room.

Wier, L. M. & Steiner, C. M. (2015, February). Surgeries in hospital-owned outpatient facilities, 2012. Agency for Healthcare Research and Quality. Retrieved from