Mitigate Risk in Your Emergency Department

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A version of this article was published in the January 2024 edition of Healthcare News.

In the post-pandemic world, the health care system remains at or over capacity, leaving many organizations struggling with how to meet patient demand.

Some of the primary issues plaguing the system include:

  • An aging population
  • Exacerbation of acute health conditions
  • Lack of access to primary care providers and urgent care
  • Staffing issues that includes shortages, turnover, and burnout

The emergency department (ED) is an open door for those in need of health care, and overcrowding has become the norm.

Overcrowding inside the ED causes additional risks for a health care organization, including lack of quality and safe care, regulatory violations, patient dissatisfaction, low staff engagement, physician dissatisfaction, and more.

Throughput and Left Without Being Seen

One key issue that causes EDs to be overcrowded is throughput within the department. Throughput in an ED is defined as time of arrival to time of dismissal—and the key driving metric within that timeframe is door to doctor. Simply, how long after a patient arrives at the ED does it take for the provider to perform their first evaluation?

The current national average for time patients spend in the ED prior to discharge is approximately 180 minutes, with leading practices closer to 150 minutes. This number can be slightly different based on the organization’s annual number of visits. However, often organizations that successfully manage their ED length of stay can mitigate some of the risk of overcrowding.

Another risk caused by overcrowding in the ED is patients that leave prior to being medically screened by a provider or before their treatment is complete. This can cause two issues:

  • The patient didn’t receive the necessary treatment and will likely return at a different time—possibly more acutely ill than on first arrival
  • The patient receives treatment at a different health care facility and left without being seen (LWBS) or evaluated by a provider

In addition to serious health implications and consequences to the patient, these scenarios can also have a significant financial impact to the organization if the exacerbated illness requires a longer length of stay (LOS) and potentially damage the organization’s reputation.

Solution: Evaluate Your LOS Metrics to Uncover Improvement Opportunities

One of the potential solutions to improving an ED’s LOS and LWBS rate is to evaluate the metrics related to LOS. Suggested data elements to review include:

  • Arrival to triage
  • Turnaround times for both laboratory and radiology
  • Length of time for other specialty consultants to arrive
  • Total time to complete the triage process
  • Arrival time to first provider order

Focusing on these improvement opportunities would also require a review of workforce and labor to ensure staff are scheduled appropriately at peak times. Additional workflows to consider include assessing use of provider in triage, nurse standing orders, and the fast track process.


Inpatient ED holds, or boarding, also plays a significant role in overcrowding inside the ED. Patients not yet admitted and waiting for an empty bed are often held in the ED. In some organizations, patients may wait longer than 24 hours and at times will be discharged from the ED, having never received a bed. Staffing, continuity of care, and space are the underlying risks when ED boarding issues occur in long intervals.


To mitigate boarding issues, organizations should review ED admission rates by specialty in their organization and compare those rates to the national rate—approximately 22%.

Organizations should also ensure their hospital has a surge capacity plan that proactively aligns nursing units and ancillary departments when the ED is at high volume. Some examples of the surge plan include:

  • Laboratory and radiology departments sending an additional staff member to the ED during times of high surge
  • Inpatient nursing units picking their admitted patient up from the ED instead of ED staff leaving the department to transfer patients

As throughput metrics within the ED improve, incidental improvements will also occur with patient satisfaction, staff satisfaction, and a decrease in number of patient grievances.

For long-term and sustainable success, ED physicians, hospital leadership, and staff within the ED all need to be involved to drive the solutions and implement change. Active team members should monitor these metrics closely and evaluate on a routine basis to ensure the organization is not at risk and able to provide timely care to those in need.

We’re Here to Help

To learn more about mitigating risk in your ED, contact your Moss Adams professional.

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