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AD-A278 806




August 1993



Final Report (07-92 to 07-93)












& 199









13. ABSTRACT (Maximum 200 words)
This study attempts to identify the variables which contribute to patient waiting
time in the emergency room.
There are 10 independent variables that have been identiThese variables are patient
fied from previous studies found in the literature.
volume, patient acuity, laboratory tests,
radiology procedures, consultations,
admission, physician staffing, nurse staffing, physician assistant staffing, and shift.
Time and motion studies were conducted to quantify these variables for analysis.
Correlation and stepwise multiple regression analysis were used to analyze the data and
determine which variables made a statistically
significant contribution toward patient
waiting time.
The analysis identified laboratory tests,
radiology procedures, and consultations
as the variables having the strongest relationship to and predictive ability
of patient
waiting time.
The results of these analyses will be used to make recommendations for
changes in the emergency room or related services that would improve the efficiency and
quality of services provided in the emergency room.

patient waiting time,

patient volume,



NSN 7•01-@2l-0-SS00



patient acuity


Standard Form 298 (Rov. 249)
Pmcnrbptd by ANSI Std. Z39-1e









A Graduate Management Project
Submitted to the Faculty of
Baylor University
In Partial Fulfillment of the

for the Degree

Master of Health Administration
Captain Rolando Castro Jr.,


May 1993


94 5 02


................ 5.......... Discussion ........ 3.... 16 Chapter II... 1 1 3 3 11 Methods and Procedures ............ 4..... ii I................. 21 Conclusions and Recommendations ................... Table Table Table Table 2.................. Regression Coefficients ....... Introduction ............................ i .......... Means and Standard Deviations jpca "*l~~ ard#......... 13 Results ........ IV..... Dist ................. 17 18 19 20 20 Loogsslon For NTIS Qua& DTIC TAB Uuzmonoved Justiticatloz 0 Availability so............ VI.......................... Stepwise Multiple Regression ... III.. List of Tables Table 1.......Table of Contents Page Acknowledgements Abstract ....... 24 References 27 .... Purpose ....... V.................... Demographics of the Sample Population .. Conditions Which Prompted the Study Statement of the Management Problem Literature Review ........................ Correlation Coefficients .....

and children. MC. to my wife. the grammatical Colonel and patience Finally.Acknowledgements I extend my sincere below for their study. mentoring. Ann Dobbs. to . for their whose editorial and structural Herbert K. Ambulatory Care Services. gratitude their Captain of to the ER and and support this project individuals during listed the course would not have of this been help. greatly document. last two years. skills quality Reamey III of for his contributed the final guidance. Ms. Emerd-ncy for allowing in collecting and complete the data. Kevin D. during my residency. and understanding during the Maria and David. and the ER staff for their cooperation Chief. access to the Lokkesmoe. support Julie. assistance The completion possible without First.

studies for radiology time assistant regression significant waiting variables laboratory physician the from previous admission.Abstract This which study contribute room. staffing. staffing. analysis which in radiology analysis. Time There literature. the in time. patient to to patient emergency in attempts The to make emergency the and room or efficiency emergency and room. consultations patient stepwise waiting laboratory strongest analyses found to were used and of studies Correlation toward the variables and conducted identified the staffing. procedures. quantify and to made patient a analyze statistically as waiting changes would provided be in used improve the to time. . variables having predictive ability results of these recommendations related services quality of services variables for that patient volume. these are These consultations. identify 10 identified acuity. the relationship will the tests. and determine are physician were variables independent tests. nurse shift. that been have the and motion variables multiple data contribution The analysis procedures.

Castro Introduction Patient flow and long patient important aspects of efficiency The efficient use of emergency a significant impact hospital variables in this analyzing and improving this total study. containment.38 times greater than 1. 1992. patient amount of emergency emergency and emergency room unit time in from the has set a goal time the patient disposition. at Martin Army Community the status daily basis. . MACH averaged per day with waiting 10. waiting waiting The hospital of no more presents Over of patient than three hours to the ER until the period from January 1992. final and cost Which Promted the Study monitors the ER on a commander time are used The administration (MACH) have in (ER) . the patient the front desk to the terms room resources and quantifying waiting time times are the emergency quality Understanding involved in upon patient public relations. process room from the time room. interchangeably. emergency (EU) can can be beneficial efficiency. patients the For the purpose of is defined as spends in the patient final the the registers at disposition The department (ED). to November 30. satisfaction. time of Conditions Hospital of care.

more than 28%. there were 81 patient complaints filed against the MACH emergency room. long waiting times may delay the initiation of treatment for genuine emergencies. or slightly involved patient waiting time. waiting times in the emergency of patient dissatisfaction Long room are often a source and give negative perceptions of the quality of patient care rendered. making waiting time An understanding of how patients flow through the system and the multiple factors basis that affect patient waiting time may provide a for improving efficiency and the quality of patient services in the emergency room. More importantly. (MTF) with the beneficiary population The current budgetary constraints DoD medical treatment use of resources continues to reduce the DoD medical treatment will see reductions little (DoD) As the in facilities on require more efficient order to operate within the annual . This perception impacts on the reputation of both the emergency room and the hospital.Castro three hours. in their annual or no decrease in they must serve. Department of Defense force structure. a quality assurance issue. facilities budgets. Twenty-three of these complaints. During the first 10 months of 1992.

to determine the causes These factors can be into three general areas: and process variables. classified patient. relations. Structural variables include size and/or type of emergency department. play an The ER averages 48.000 emergency for approximately room will room visits 25% of inpatient per year and hospital admissions. structural. For MACH.Castro 3 budget. and skill The primary patient variable . the staffing levels. important role approximately accounts in the emergency this effort. Statement of the Management tProblem Patient flow and long patient waiting times in emergency room are important aspects of efficiency impact upon patient satisfaction. time in that hospital public and cost containment. layout or unit design. quality of care. are the factors which contribute the What to patient waiting the emergency room and how can these factors be addressed to improve the quality and efficiency of patient services? Literature Review A review of the literature on waiting time in emergency room shows numerous factors in that past studies have examined an effort inherent to this problem. levels of providers.

31. it takes to complete records compared of physician (1990) testing. Process variables look at the time triage.6 minutes 13. December and December During phase 1.7 minutes during . of datient time periods: hospital flow and registration. treatment. admission. 17. Burrow. Torma.028 emergency The study departments. and Huang (phase and beneficiary or discharge. consultation. include age. study by Howell. two-tailed significant with A t-test difference to be seen by a physician during phase to see a physician compared 1988 from other and time waited for discharge between phase 31. 1987. Patients 2. patient acuity or classification. 1987 gender. (phase I). EPs and supplemented using a time waited to March to March emergency from other hospital statistical two methods emergency department with five experienced with six experienced room looked at two staffed staffed Teneyck. 2). and was supplemented with physicians physicians comparison revealed (p< a statistically 0. physicians was (EP) the ER was departments.Castro 4 studied is patient variables status. 1 the 1. 1986. waiting times with staffing. involve patient diagnostic A retrospective distinct Other to phase 1 waited 1 and 25.00001) in During phase 2.

discharge. from 0 to radiology (1986) acuity in for correcting to determine in and Curtis and awaiting an acuity code to cardiac arrest).Castro 5 phase 2. urgent an attempt 171 to in the patient time each patient was assigned (least analyzed inefficiencies examination/treatment. A time and mo~ion study by Saunders in I was the ER with more experienced reduced 1. waiting time to discharge and 59. ranging Each They reviewed the amount of patient 6 They also noted whether procedures. Saunders of the emergency of tracked to waiting times patient when diagnostic EPs found that encounter. Howell patient waiting through the emergency sources patients of high acuity had the shortest stages the patients waits. the patients consultations. low acuity experienced especially (1987) department identify all et time. of delay. The 71.9 minutes al.5 minutes concluded significantly staffing in phase in 2. They found the average waiting time to be 150. had laboratory or or were admitted to the hospital.568 patients phase the tests while longest had to be performed. records spent triage.16 . h study by Smeltzer process variables and patient establish criteria emergency department.

was awaiting discharge The average 10.Castro 6 minutes. Of the latter 28 out of 45 patients had waiting times greater than four hours. group. 15. and/or consultations. conditions or Smeltzer and Curtis found that there was no correlation between acuity and patient waiting time. They concluded that long waiting times appear be related to diagnostic testing. 25% discharged between two and three hours.12 hours. Approximately 6% of the patients presented with life-threatening cardiac arrest (acuity codes 5 and 6). radiology Eleven of the 28 patients were admitted to the hospital. laboratory procedures. to and but were not able to directly assess the contribution to long waiting time since the amount of time taken for these procedures was . and 26% discharged after three hours. consultations. admission to the hospital.03 minutes.38 time spent Approximately 49% of the patients were discharged within the first two hours. Most of the patients (91%) that presented to the emergency room were classified as acuity code 2 or 3 (minor or major care). The average time spent in the examination or treatment room was 2. All but two of the 28 patients had some combination of procedures. The average time spent in triage was minutes.

This second study time for ordering a test and receiving the results was 77. An analysis of admissions showed that the average waiting time in room for patients the emergency who were admitted was 4. An analysis of variance showed that only 15% of the variation in waiting time . The average waiting time from when the admissions office was notified until the patient was transported to the ward was 1.55 hours. patient and mean patient waiting time.6 The average length of time for a radiology exam was 69.36 minutes. speculated days.Castro 7 not recorded. In 1987. Smeltzer and Curtis conducted a subsequent study of patient waiting time.02 minutes. Consultations required an averaged of 63. study involved factors The second time and motion studies to determine the that contributed to the long waiting times discovered revealed in the previous that the average laboratory minutes. arrival rate. DiGiacomo and Kramer (1982) investigated the relationship between daily patient census. study. They that patients had to wait longer on busier Using Spearman's Rho.5 hours. they found that there was not a significant correlation between waiting time and patient volume (ER census).

level of physicians as patient visits and the educational factors affecting the length of to the emergency room.Castro 8 was due the patient volume. resource availability time by 12%. the regression equation indicated that 59% of the patient's time was spent being processed through the system and the remaining 41% was the time spent waiting between the various steps of the process. that delay patient but did not attempt to quantify these After these problems were identified. This study also identified staffing levels and patient acuity as other factors waiting time. Comparisons between waiting time and hourly patient arrival rates showed no significant correlation and a 22% variance time attributable in waiting to hourly patient arrival rates. to show any statistically in The study failed significant relationship . modifications were made in patient waiting time. an attempt to improve The authors conducted two more studies of waiting time after the changes were implemented and found that the modifications staffing and illness-related reduced the total visit Wilbert (1984) diagnostic tests. conducted a study identifying consultations. Based on an average waiting time of 78 minutes. variables.

facilities p< 0. Only 5% reported average waiting times over three hours. Schloss (1991) Hayes Army Community discovered that patient .9 minutes. Reed.005) in the waiting times between with a fast-track system and those without such systems. Goss. the mid-Atlantic region which reported two hours. A statistical analysis of the survey results revealed a significant difference (Chi-squared.4 Castro 9 between patient acuity and total visit week. the but less than Fifteen percent had average waiting times two and three hours. (1991) these facilities Total visit conducted a survey of 185 hospitals that 62% of had average waiting times in emergency room of greater between to 126. However. and Ready New York Hospital (1971) in their survey of found that there was no significant relationship between patient volume and patient waiting time. or shift. Hospital. they did discover a significant correlation between median waiting time to see a physician and patient volume per shift. time. or between time from arrival physician contact and total visit time averaged Purnell in time. In a retrospective study of 895 admissions from the emergency room at Silas B. day of the than one hour.

. 90. and urban hospitals. The study showed that the mean total time for admission was minutes.C.Castro 10 acuity. statistically and admitting service were significant contributing factors to the total (p< 0. patient volume. suburban. were performed on approximately X-ray examinations 40% of the patients with a mean turnaround time of 44 minutes. Their analysis of these turnaround times indicated only a . and obstetrics-gynecology were grouped as having the highest mean total times. Patients triaged as 'emergent" mean total times and patients had the highest mean total 183 had the lowe- triaged as "non-urgent' times. and laboratory turnaround times. surgery. respectively. Psychiatric admissions had the lowest mean total times and pediatrics. design. and They found that total patient waiting time varied significantly among small community.0001) time required for a patient to be admitted through the emergency room. with mean times of 67. Laboratory tests were performed on less than 30% of the patients with an average turnaround times of 55 min es. in 20 Washington. area The study analyzed treatment times. and 133 minutes. x-ray staffing levels. facility D. Cue and Inglis conducted a study of the emergency departments hospitals. In 1978.

(2) conduct time and motion studies to quantify the variables affecting patient waiting time. Purpose The purpose of this study was to determine which factors contribute to patient waiting time in the emergency room and how these factors can be addressed to improve the quality and efficiency of patient services. significant are the statistical Despite these inconsistencies most of the studies identified consultations. waiting These studies reveal a wide variance in significance of these factors and in some cases even contradictory in findings. summary. factors and admission as influencing patient waiting time.Castro I I slight correlation In with waiting time. numerous past studies factors that affect have shown that there patient time. the literature. diagnostic tests. The objectives of the study were: (1) analyze patient flow in the emergency room to identify the key variables affecting patient waiting time. (4) use the results of and the analysis as a basis for . (3) conduct statistical analyses of the resulting data from the time and motion studies.

procedures. staffing. The alternate hypothesis in this study states that patient waiting time does vary as a volume. physician encounter. admission. staffing. patient radiology physician physician assistant The null hypothesis in this study states that patient waiting time does not vary as a function of patient volume. However. procedures. laboratory tests. consultations. this study are time time from triage to time from physician encounter to and total patient waiting time. The dependent variables in from registration to triage. or shift. or . shift. nurse staffing. patient acuity. function of patient laboratory tests. admission. patient acuity. final disposition.Castro 12 recommending changes in to improve efficiency and quality the emergency room. laboratory tests. There are 10 independent variables identified: volume. staffing. consultations. only the aggregate measure waiting time) will be used in (total patient the hypothesis test. consultations. radiology procedures. admission. patient acuity. and shift. radiology staffing.

registration. The data collection yielded an initial 1806 subjects. time when patient was time of initial physician or and time of final disposition. work schedules. P. (SF Data collection for this study took place during a two week period from January 15.Castro 13 Methods and Procedures This study employed a quantitative. Time and motion data were collected on each patient that presented to the emergency room during this period. Times were recorded for initial time of triage. As the patient was processed through the times were recorded on SF 558 for each step of the process. These times were recorded by the ER staff or the researcher as the patient moved through were recorded in minutes. sample of 25 subjects were randomly selected for each day of the two week period for which data was collected. yielding a final sample The alpha probability level was set at p(0. taken to treatment room. contact. non- experimental research design using data collected from ER logs. From this sample. Emergency Care and Treatment. 1993. 1993. and Standard Forms 558 558) . All times Data were also collected on . ER system.A. of 350 subjects (N=350).05. through January 28. the system.

mutually exclusive and categorically and 3) The and were exhaustive. The stepwise regression allows reexamination. consultations. data for patient acuity nonurgent) and shifts (emergent. for each treating the variable were the most recent one entered. total patient waiting time. consults. was regressed upon each of the predictor variables. in of the variables included previous steps. In the first step. 2.Castro 14 patient acuity. regardless . x-rays. procedure. variable with the highest significant correlation added to the model. and admissions were coded as dichotomous data using binary notation. and shift. and correlation coefficients Those variables showing a high correlation were analyzed using stepwise multiple linear regression. patient volume. and the patient volume were coded as continuous variables. The dependent variable. (shifts 1. the staffing numbers. admissions. program. Each time period. The data obtained from this collection process were entered into the MICROSTAT statistics Descriptive statistics were calculated. entries for labs. in the model at each step. staffing levels. as if it is At each step of the regression a partial F test is variable currently in the conducted the model. The urgent.

It was stressed to the ER staff that no attempt would be made to associate any of the staff with delays in patient treatment. in because the This process continues until no more variables can be entered or removed and the variables remaining in the model provide the best prediction of the dependent variable (Afifi & Azen. Variables earlier step may in that were incorporated at an later steps become needless of their relationship with other variables model. This was done to . 1972). The process is repeated at each step on the basis of each variable's ability to improve the prediction of the dependent variable. form used on a daily basis by the ER The issue of the reliability of the data was addressed using the following measures. smallest nonsignificant partial exists) is The variable with the F statistic (if such removed from the model and the model is reworked with the remaining variables. The content validity of the SF 558 as a data collection is instrument was assumed due the fact that it a standard staff.Castro 15 of when it was actually entered. The ER clocks were used as the sole source for recording times to reduce inaccuracy from use of individual watches. The clocks were checked on a daily basis to ensure mutual agreement.

monitor the and ensure accurate and complete recording of the data. descriptive statistics. and inferential statistics.19 minutes with a standard deviation of The mean for total patient waiting .Castro 16 avoid any bias in the recording of times by staff might be fearful of being identified with delays. who in The the ER as the process. The largest beneficiary category was active duty dependents. representing 53% of the sample population. author of the study spent as much time physically possible to observe recording of data. The demographic characteristics sample are shown in patients seen in category Table 1. of the population the 17 to 64 age there is percentage of pediatric patients also a significant (35%) . time was 143. utilization patterns. All data identifying either patients or health care providers were omitted to protect their right to privacy. Results The analysis of the data set yielded the following information on demographics. The majority of the the ER were in (60%) . descriptive statistics were calculated The for the data set and the relevant means and standard deviations are shown in Table 2. however.

Table x-rays. Twenty-nine percent laboratory work. patients The data set presenting as nonurgent. additional consultation.Castro 17 80. hospital these categories time of 62 minutes. 1 Demographics of the Sample Population Age Percent Beneficiary Percent Category of Sample Category of Sample 0-16 35% Active 26% 17-64 60% AD Depn 65 and 5% Duty 53% Retirees 8% Ret Depn 12% older Others 1% the time . was required 3% required and 3% were admitted to The average for an x-ray the patients 24% required (note: exclusive).41 minutes. also shows triaged as that 79% room were urgent. of are not mutually lab procedure while the average had a turnaround turnaround 55 minutes. to the emergency were 20. and of the triaged 1% were triaged as emergent.

78 350 0.46 Radiology Procedures 350 0.41 Emergent Category 350 0.99 10.58 52.02 0.11 Urgent Category 350 0.79 0.17 * Physicians 350 1.03 0.50 NAME * Physician Assistants .D.49 Shift 1 350 0.91 Laboratory Procedures 350 0.96 0.24 0.A.50 Shift 3 350 0.03 0.70 Time from Registration to Treatment Room 350 61.41 Patient Volume 350 129.Castro 18 Table 2 Means and Standard Deviations N MEAN S.20 0.44 0.94 Total Waiting Time 350 143. Contact 350 88.13 0.43 Consultations 350 0.85 * Nurses 350 2.39 0.28 68.01 0.00 18.61 Time from Registration to First Physician/P.34 Shift 2 350 0.43 0.40 Nonurgent Category 350 0. Time from Registration to Vital Signs/Triage 350 11.19 80.29 0.18 Admission 350 0.

10 using stepwise resulted in three being removed from the regression The three variables equation were laboratory procedures. tail.15 Note. Coefficients Variable Laboratory r Procedures 0.18 Shift 2 0. were £<O. Critical value (2 These six variables multiple regression. remaining procedures.05) +1- = analyzed The regression '. of the six variables equation.28 Consultations O.16 Shift 1 -0.41 Radiology Procedures 0.28 Shift 3 -0. in the radiology The statistical test . Table 3 Correlation.. that waiting The correlation with the had a time to coefficients Table 3. and consultations.Castro 19 of The correlation predictor strong meet are variables the dependent identified six variables enough relationship the critical listed in variable to patient value.

10 Total 2276047. standard error of the estimate. and level of significance The regression coefficients.9 614838.39 Adjusted R Squared = 0. Table 4 Stepwise Multiple Regression Dependent Variable .Castro 20 value. and Table 5.50 Consultation 36.51 Residual 1661209.Total Patient Waiting Time Source Sum of Squares Regression df Mean Square F 31. are degrees of listed in freedom. Table 4.04 4 153709.26 R Squared = 0.27 .17 Radiology 33. r squared are given in adjusted r squared.82 345 4815.67 Standard Error of the Estimate = 69.98 Constant 115.0001 .85 349 Table 5 Regression Coefficients Variable Regression Coefficient Laboratory 61.

radiology exams.Castro 21 These results demonstrate support of the alternate hypothesis. radiology exams. The statistically significant relationship between patient waiting time and laboratory tests. tests. The 143 minutes and the (66 minutes) and x-ray are also consistent with the . The results of this analysis are consistent with the findings of previous studies. in that patient waiting time does vary as a function of at least three of the independent variables. Discussion The stepwise multiple regression analysis identified laboratory consultations time. the variance independent these three variables account for 27% of in patient waiting time. The remaining variables did not have a statistically significant affect on patient waiting time. When all the independent variables are taken into consideration. consultations has been substantiated Smeltzer and Curtis (1986) turnaround times for lab tests (55 minutes) in and Wilbert average patient waiting time of exams and studies by (1984). and as the best predictors of patient waiting These variables had the strongest statistically significant relationship with the dependent variable.

1978). combination. These three variables. & Ready. Reed. interesting statistics disproportionate One of the more on utilization was the number of nonurgent patients that presented to the ER. and staffing also found in & Curtis. Wilbert. the literature (Smeltzer DiGiacomo & Kramer. 1986. (Smeltzer & Curtis. Almost 80% of all ER patients are These patients are using valuable and expensive ER resources for conditions that might very well be handled more appropriately in other . radiology examinations. such and are going to have longer stays in the ER than those patients who do not require these procedures. 1971). time of day (shift). and Goss. triaged as nonurgent. of a significant correlation patient acuity. 1984. 1982. Wilbert. 1984. singly or in therefore increasing steps to the total waiting time. and Cue & Inglis.Castro 22 findings of other studies 1987. as laboratory tests. The results also provided valuable information on utilization and demographics. will add one or more additional the treatment process. is 1986. consultations. The lack between waiting time and patient volume. These results can be logically explained by the fact that patients who require ancillary services.

data collection phase of the study. Patient volume might have been more accurately represented by either the number of patients seen .Castro 23 primary care settings. This information may indicate a need to expand pediatric clinic hours to accommodate the needs of these patients. it limitations to this study. This resulted in a high percentage of cases having incomplete or missing data for these variables and required that they be coded using binary notation. Another interesting statistic shows that 35% of the patients in on demographics the ER are pediatric patient between 0 and 16 years of age. and consults as continuous data. limitation to the study is A second the patient volume variable. The turnaround times for lab tests and x-rays that were presented earlier were the averages for those cases that did have adequate documentation. during the the ER staff failed to adequately document the times for these variables. There are several First. This variable represented the total number of patients seen in the ER during the 24 hour period of each day. x-ray exams. However. was one of the original intentions of the study to capture the data on lab tests.

There are times when orders for lab tests or x-rays will stay on the counter of the nurse's station waiting for someone to carry them to the lab or to escort the patient to radiology.ur mark. Conclusions and Recommendations The results of this study provide the hospital and the managers of the emergency room with additional information to assist them in provided in improving the services the ER. The information on lab tests. and even though the mean times for these procedures approximate the orye h'o.Castro 24 during the shift or the hourly patient arrival rate. there is still room for improvement. Finally. x-ray exams. there are times when the completed lab results remain in the lab waiting for . caution should be exercised when attempting to generalize these results to other hospital emergency rooms. and consults provides a basis for assessing these services and procedures for possible improvement. The data collected in this study represent a two-week snapshot of the patients who presented to the ER of a military hospital with a unique patient population. Orders for lab tests and x-rays coming from the ER are processed as STAT requests (one hour turnaround time). Likewise.

Castro 25 someone to phone the ER. The information on patient acuity indicates the hc-pital. A pediatrics after-hours clinic during the evening and on weekends might be a more appropriate way to treat this portion of the population. that may need to look at alternative methods of treating the disproportionate number of nonurgent patients that are accessing system through the ER. and specifically the ER. result the results Improving in decreased to the ER or efficiency patient in carry these areas them to would waiting time and would probably improve patient satisfaction. in the is usually staffed There may be a need to expand this program order to more efficiently handle these patients. initiatives These would free valuable ER resources the more urgent cases. The demographic information on pediatric patients indicates that there may be a need to expand these services also. The ER currently runs a fast- track for nonurgent patients. but it by one physician and operates limited hours on weekdays. The fast-track and the pediatrics after-hours clinic could both operate out of the Outpatient Clinic adjacent to the ER and could share any clerical or nursing support that might be required. to treat This would probably increase .

Castro 26 of care the quality for risk medico-legal the hospital. patient affecting should consider Greater effort x-rays. research Additional in area may provide this conclusive data on the variables waiting time. of limitations made to Future studies this incorporate continuous data. more the should be and consults as Patient volume might be represented more accurately as the number of patients the hourly patient arrival rate. per shift or . and reduce given to the patients study. lab tests.

& Azen. 30-33. 04 Castro 27 References A. W. time spent by patients in at the New York Hospital. Goss. Torma. Improving the operations (1978). L. E. 52.. training. Reed. J. facilities. Burrow. analysis: Academic Press. emergency unit waiting time. classification systems. R. & Reader. department in triage in 185 hospitals: fast-track systems. V.J. T. A study of (1982). & M. Cue. Huang. (1971).. A survey of emergency (1991). & Inglis. E. Teneyck. E. Purnell.. R. 8. Hospitals. M. Statistical (1972). The impact of dedicated physician staffing on patient flow and quality assurance parameters department.. Medicine.. 155. the emergency room: Survey New York State Journal 1243-1246.4. D. 71. P. E. R. J. J. DiGiacomo. M. New York: A computer oriented approach. (1990). Bulletin.. & Kramer. an Air Force emergency Military Medicine. F. Howell. Quality Review 10-13. J. Afifi. A. 110-119. of the emergency department. L. and skills and of triage of . S. I. Physical patient- waiting times.. qualification. D.

Journal of Emergency Nursing. Smeltzer. 10.. (1984). 13.Castro 28 personnel. emergency department. (1986). Schloss. Pre-admission patient treatment the emergency room. Timeliness of care in the Quality Review Bulletin. Unpublished manuscript. & Curtis. Sources of delay (1991). 99-108. Time study of patient movement through the emergency department: in relation to patient acuity. E. 402-407. E. for . 16(11). Saunders. (1987). times in Annals of Emergency 1244-1248. H. & Curtis. Analyzing the emergency department. C. H. Wilbert. patient time in Review Bulletin. C. L. Quality Review Bulletin. Smeltzer. 240-242. 17(6). (1987). C. C. 12. L. C. H.. An analysis of emergency department time: Laying the groundwork efficiency standards. Quarterly 380-382. Medicine.