American Journal of Emergency Medicine 56 (2022) 10–12

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American Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/ajem

The use of the word “quiet” in the emergency department is not

associated with patient volume: A randomized controlled trial
Jennifer E. Geller a,⁎, Pamela Ohman Strickland, PhD b, Joshua T. Bucher, MD, FAAEM c
a
Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
b
Rutgers University School of Public Health, Piscataway, NJ, USA
c
Robert Wood Johnson Medical School, Department of Emergency Medicine, Piscataway, NJ, USA

1. Introduction
The word “quiet” is a controversial term to use in Emergency Medi-
cine (EM) where unscheduled care is provided. It is believed by many
EM healthcare workers that if the word is said, a bearable shift gets
busier [1]. The chance of there being few patients in the emergency
department (ED) is low; so, the department will likely get busier re-
gardless of if the word is said. Biases in the human mind associate
pointing out the lighter load with the increase in patients, even without
evidence [2]. In 2019, a study in a microbiology lab found no evidence of
difference in the number of clinical episodes on days where “quiet” was
used versus the days it was not [3]. Our study hypothesizes there is no

Fig. 1. Flow chart of study design starting at the unblinded researcher randomly selecting whether a shift was intervention or control shift and how the participants participated in the
study at that point.

⁎ Corresponding author.
E-mail addresses: Jg1614@rwjms.rutgers.edu (J.E. Geller),
bucherjt@rwjms.rutgers.edu (J.T. Bucher).

https://doi.org/10.1016/j.ajem.2022.03.020
0735-6757/© 2022 Elsevier Inc. All rights reserved.

Descargado para Ronald Eduardo Lozano Acosta (loacro@yahoo.com) en Cayetano Heredia Pervuvian University de ClinicalKey.es por Elsevier en marzo 29,
2022. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados.
J.E. Geller, P.O. Strickland and J.T. Bucher American Journal of Emergency Medicine 56 (2022) 10–12

Fig. 2. Visual Analogue scale from “Comparison of anxiety and pain perceived with conventional and computerized local anesthesia delivery systems for different stages of anesthesia
delivery in maxillary and mandibular nerve blocks,” published in 2018 [4].

association between the word “quiet” and ED crowdedness; however,
those who believe the word “quiet” does cause the ED to become busier
will perceive higher levels of business compared to those who do not.
This study was a Rutgers IRB-approved, randomized control trial be-
tween June 9, 2021 and July 23, 2021 at the Robert Wood Johnson Uni-
versity Hospital ED — a level three tertiary receiving center and level
one trauma center with >70,000 adult patient visits per year. The 400
+ staff members of the ED were surveyed, with some responding mul-
tiple times for a total of 506 surveys collected.
A researcher carried out the trial on a convenience sample of 47
shifts spanning 30 days, including 13 morning, 20 afternoon, 11 eve-
ning, and three night shifts (certain days included more than one
shift). Each day, either the intervention or control was initiated by
that researcher with randomization from a random.org random number
generator. The intervention was asking “Has it been quiet in here?” and
the control was greeting any ED staff without saying the intervention
phrase. Randomization was blinded to the statistician and primary in-
vestigator. There were 14 days randomly assigned the word “quiet”
and 16 not assigned the word “quiet.” After randomization, the re-
searcher went into the ED and approached as many staff members as
possible following through with intervention or control. After the re-
searcher obtained verbal consent to do so, the staff member returned
three hours later to administer a survey. Fig. 1 shows the participant
flow through the trial.
The three questions on the survey were answered via visual ana-
logue scale [Fig. 2] [Fig. 3] [4]. Means and standard deviations were cal-
culated for all outcome variables (survey questions) and number of
visits per shift. Mixed linear models examined the effect of using
“quiet” on survey questions, adjusting for day of week (Sunday through
Saturday), shift (morning, afternoon, evening, night), and number of
patients using a random effect for date to account for the natural corre-
lation between respondents on the same day. Akaike's Information Cri-
terion indicated that a random effect for shift nested within a date did
not provide a better fit, and sensitivity analyses revealed similar test re-
sults when accounting for this nesting. Histograms of the survey ques-
tion surrounding the word “quiet” demonstrated a split in those who
considered the word disruptive versus those that did not, with modes
at 0 and 100. Therefore, we considered a stratified analysis by day to
see whether those who rated using the word “quiet” as playing a role
in how busy the rest of the day gets as 50 or above versus those who

Fig. 3. The survey the research team member gave toe staff three hours after saying the work “quiet” or not and only getting consent for the staff to take part in the study.

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Descargado para Ronald Eduardo Lozano Acosta (loacro@yahoo.com) en Cayetano Heredia Pervuvian University de ClinicalKey.es por Elsevier en marzo 29,
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J.E. Geller, P.O. Strickland and J.T. Bucher American Journal of Emergency Medicine 56 (2022) 10–12

Table 1
Means (SDs), 95% confidence intervals of the means, and p-values for comparing days with and without the word “quiet”

Overall (n = 506) With “quiet” (n = 240) Without “quiet” (n = 266) P-value

Survey Question 1 (crowded) 56.7 (25.5) 60.2 (24.3) 53.5 (26.1) 0.27
(54.4, 58.9) (57.1, 63.3) (50.3, 56.7)
Survey Question 2 (Patient number) 54.9 (26.1) 58.5 (25.7) 51.8 (26.1) 0.24
(52.6, 57.2) (55.2, 61.8) (48.6, 54.9)
Survey Question 3 (Word “quiet”) 54.0 (36.1) 51.3 (35.5) 56.3 (36.4) 0.32
(50.8, 57.1) (46.7, 55.8) (51.9, 60.8)

Table 2
Means (SDs), 95% confidence intervals of the means p-values for comparing days with and without the word “quiet”, stratified by high and low values of whether they perceived the word
“quiet” as affecting business for the rest of the day

With word “quiet” Without word “quiet”

Perception of word “quiet” on busyness: Perception of word “quiet” on busyness:

Lower (n = 94) Higher (n = 107) P-value Lower (n = 83) Higher (n = 142) P-value

Survey Question 1 (crowded) 56.2 (23.2) 68.6 (21.6) <0.0001 51.7 (27.4) 53.8 (25.9) 0.92
(51.3, 61.0) (64.4, 72.7) (45.6, 57.7) (49.5, 58.1)
Survey Question 2 (Patient number) 53.8 (24.1) 69.9 (22.2) <0.0001 51.1 (26.4) 52.0 (26.2) 0.87
(48.8, 58.9) (65.6, 74.1) (45.3, 57.0) (47.7, 56.4)

rated it below 50 were more or less likely to consider the ED crowded or
to have a large number of patients.
The average number of patient visits per shift was 199.9 (SD = 17.9;
min = 161; max = 233). Table 1 presents the means, standard devia-
tions and 95% confidence intervals of survey questions, along with the
mixed-model p-values for the effect of whether the word “quiet” was
used or not. Although the perception of crowdedness and number of pa-
tients increased with the use of the word, the effect was not statistically
significant. Table 2 presents comparisons of the first two survey ques-
tions (crowded, patient number) with respect to whether respondents
rate the word “quiet” as having an effect on patient volume or not, strat-
ified by whether the word “quiet” was used or not. Stratification was
justified by noting that the interaction between whether the word
was used or not and perception of the use of the word on busyness
was significant for both Survey Question 1 (crowded, p-value =
0.00008) and Survey Question 2 (number of patients, p-value =
0.0003). Further, on days the word “quiet” was used, those that believed
it to increase the sense of busyness rated the ED as more crowded and as
having more patients than those who did not (both p < 0.0001). The
mean for crowded for those who thought the word “quiet” increased
busyness was 68.6 (95%CI: 64.4,72.7) versus 56.2 (95%CI: 51.3,61.0)
for those who were less likely to think it increased busyness. Likewise,
the means were 69.9 (95%CI: 65.6,74.1) and 53.8 (95%CI: 48.8,58.9)
for Question 2 (patient number). The association was not significant
when the word “quiet” was not used. Qualitatively, the research staff
member using the word “quiet” was told shifts became “worse” such
as by causing patient cases of lice, severe traumas, and cardiac arrests.
This study did have limitations. The same researcher conducted the
study each shift, so that individual began to be associated with the word
“quiet.” Some staff members participated more than once, because as
many staff members as possible were approached on any given shift.
We did not collect staff identifiers and could not control for this in the
statistical analysis. However, the anonymity of responses potentially in-
creased participation and overall study power. This is a small, single site
study with a convenience sample of data. Therefore, data may not be
generalizable.
The use of the word “quiet” was not associated with increased pa-
tient volumes or the perception of increased patient volumes unless a
staff member had a pre-existing belief the word “quiet” does influence
your perception of emergency department volume. Future directions
include assessing if this perception affects staff state of mind such that
there are negative implications on patient care.
Funding
None.
Author Contributions
JEG and JTB conceived the study, designed the trial, and obtained IRB
approval. JTB supervised the conduct of the trial and data collection. JEG
undertook recruitment of participating subjects for the study and per-
formed all data collection. POS analyzed the data that was collected by
JEG with oversight by JTB. JEG drafted the manuscript, and all authors
contributed substantially to its revision. JTB takes responsibility for the
paper as a whole.
CRediT authorship contribution statement
Jennifer E. Geller: Writing – review & editing, Writing – original
draft, Methodology, Investigation. Pamela Ohman StricklandPhD:
Validation, Software, Formal analysis, Data curation. Joshua T. Bucher:
Writing – review & editing, Visualization, Supervision, Resources, Con-
ceptualization.
Declaration of Competing Interest
JEG, POS, and JTB do not have any conflicts of interest to disclose.
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Descargado para Ronald Eduardo Lozano Acosta (loacro@yahoo.com) en Cayetano Heredia Pervuvian University de ClinicalKey.es por Elsevier en marzo 29,
2022. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2022. Elsevier Inc. Todos los derechos reservados.