Publishing ER wait times – for good or evil?

Taking a drive through some states south of the border, you might notice a peculiar phenomenon: not only are there billboards showcasing the latest fashion or promoting certain consumer goods, but obscenely large billboards advertising the ER wait times of various hospitals. “Come to our ER! The wait is only 3 minutes to see a physician!”

You might laugh and even shake your head at this, but it certainly makes sense in their private healthcare system where the more patients are seen at a hospital, the more money it makes. Advertising is an obvious market strategy for this business model. You think to yourself, thank goodness for our public system where hospitals don’t have to worry about competing with others’ wait times, and focus on giving the best care to patients regardless of how busy certain days are (especially since volume in ER fluxes unpredictably).

Time to wake up, because reality has arrived.

A number of hospitals in Calgary (and 1 in Ontario) began publishing their ER wait times online last year, showcasing “real-time” expected time a patient will have to wait before being seen by a doctor. It’s no billboard on a busy highway, but it is publicly available and perhaps even more readily accessible to anyone who cares to look.

The argument for publishing ER wait times are these: online information like this will help patients better decide where to seek medical aid, and will also spur providers to improve service. Patients with minor ailments might defer a visit to a busy ER and go to their family doctor instead. Healthcare providers might work more efficiently when they see their own wait times are longer than another nearby ER. “Information is power,” reasons Don Shilton, the president of St. Mary’s General Hospital, the first institution in Ontario to implement this system.

Um, perhaps.

I have several issues with this new system they have. The first has to do with accuracy of the information, and the others are related to the unintended effects of having such information available to the general public.

This system only publishes a single estimated wait time for each hospital. It is not perfectly clear how they come up with this number, but from their site information it seems that “through a computer algorithm” they combine the total number of patients arriving into their department, relate that to the number of active staff/physicians, and spit out an average expected wait time. Anyone who works in an ER (or even been a patient there) will see a problem with this. The emergency room is not a first-come, first-serve environment. A single predicted wait time might work okay in a restaurant, but certainly not in a workplace where patients are triaged based on the severity of their illness or injury.  What this translates to is inaccurate and misleading information to the patients – someone who is suffering from a life-threatening condition would be seen immediately, whereas someone with a very minor complaint may wait well over the published wait times. And most patients at home looking up these times will likely be unable to accurately triage themselves on this huge spectrum, leading to misinterpretation of the information.

Not only do these published wait times inaccurately represent reality for most patients, they could also lead to many unintended consequences. Imagine this scenario: a 65 year old man is experiencing crushing chest discomfort, and looks up this wait time information. He sees that the closest ER has a 6 hour wait, while the ER 2 hours away only has a 2 hour wait. He chooses to get his wife to drive him to the far ER, since he doesn’t want the ambulance to take him to the ER with the long wait times. He ends up having delayed diagnosis of an acute heart attack, and worse, ended up at a hospital without a PCI-suite, and has to be rapidly raced back to the original hospital near his home.

While published wait times might dangerously push patients with high acuity away from seeking timely care, would it be too hard to imagine that patients with minor issues might bypass seeing their own family doctors/walk-in clinics and instead visit the ER with the shortest wait times? Or perhaps increasing referrals from other healthcare providers in the community, or specialists, or outpatient clinics, or… the list goes on. Would this in effect be putting an even greater strain on the emergency department’s role as a safety net for the rest of the healthcare system?

Ultimately, publishing ER wait times in and of itself is not a solution to anything, really. The backlogged hospital beds are still there. The insufficient convalescent support outside the acute care hospitals are still present. Potentially re-directing patients with minor complaints by alerting them of long wait times, or flogging the already over-worked ER staff to work faster in hospitals with 103% occupancy levels, might not be the answer.

For good or evil, publishing performance metrics such as wait times are here to stay, as we edge closer and closer to a performance-based renumeration system in Canadian healthcare. The key question is, however, which metrics should we be using and publishing – and how can we fully explore the consequences.

What do you think of publishing ER wait times? Are there better metrics?


Dr. Edmund Kwok is an Emergency Physician with special training and interest in performance management, quality improvement, and patient safety. He blogs at the Front Door to Healthcare.  Follow on Edmund on Twitter @FrontDoor2HC.

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  1. Ryan Herriot

    Windsor Regional Hospital has started doing something similar, right on the front page:

    I don’t really have anything further to add; I agree with you completely. This sort of metric might be useful if all hospitals measured it in the same way and compared it internally in order to help steer things towards best practices, but it could be dangerous to share with a public that can’t necessarily put the information in context.

  2. Catherine Richards

    I don’t think publishing ER wait times is helpful to a patient at all. As a patient the only thing that concerns me about visiting an ER in terms of wait times, based upon past experiences, is how one is assessed and treated and/or mistreated while waiting to be seen by a doctor.

    Not all ERs inspire confidence and if one is truly suffering in an emergency situation (the only legitimate reason one should go there) one would like to think that the person (intake nurse or triage nurse) to whom the symptoms are first described would be reassuring that one’s emergency is understood and will be taken seriously. Somehow the staff seem better able to communicate that they care little about one’s circumstance unless I suppose one was having an obvious heart attack or stroke. Less obvious emergencies don’t command attention. There is unfortunately also a noted absence of empathy among many of the ER staff I have encountered.

    In my experience the moment one enters an ER it’s a gamble as to how the situation will be managed. Things can change in an instant in an ER and often they do. It’s very disconcerting when one is met with indifference or outright hostility by ER staff as if the patient is being a nuisance and there only to add to the roster and waste the precious time of the staff. The staff avoid eye contact, resist answering questions, make excuses about the delays, vent their frustrations with the system, and advise patients that they should not complain because there is a lack of staff and resources and it’s not their fault. “Be patient” is a common directive to patients approaching a desk to enquire about the wait time and one feels that what is really being said is, “Don’t be a patient on our shift!

    When my Mom spent four excrutiatingly long days in an emergency ward waiting for a bed and to be admitted, a nurse told me I should write a letter to my MPP about the funding cuts. When I reminded her that my Mom was dying and suggested she understand that writing a letter to the government was not high on my priority list in the moment, she got the message. My Mom finally got a room and a real bed in the hospital after those four days we spent in ER, she in a tiny cot surrounded by commotion and lights and me in a chair beside her. She died three days later.

    I and my family members have not often been greeted at an ER with warmth and compassion by staff even though obviously myself or a loved one was feeling anxious, in pain and distressed and would have welcomed a kind and empathetic attitude from staff. Those whom have been professional and genuinely caring stand out in my memory. Lives were saved over the years by some very dedicated ER staff and I will always feel deep gratitude for those people whose compassion and skill was evident.

    It never ceases to amaze me that we hear so often about overcrowded ERs filled with patients who are not in need of urgent attention and I wonder why anyone would willingly subject themselves to such a cold and traumatic experience if they did not feel it was a life or death situation.

    ER wait times are and will remain a reality. I wonder how many people die waiting.

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