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Ask the doctor: Why are waits in the emergency department so long?

Q. I sprained my ankle pretty badly a few weeks ago and was taken to the emergency room. It took three hours before I saw a doctor. Why are emergency rooms so crowded and the waits so long just to be seen?

A. The reasons for emergency department waits are complicated; our entire health care system is implicated. It is impossible to explain every aspect here, but one place to begin thinking about the problem is to separate waiting to be evaluated from waiting to be admitted to the hospital, if an evaluation shows that to be necessary. The reasons for each differ, although there is some overlap.

You waited to be seen, so let's focus on that. Almost every emergency department in this country is overcrowded. About 50 million Americans lack health insurance, and for them, the emergency department may be the only way to get health care: doctors there see all patients who arrive, regardless of their health insurance status. Meanwhile, the number of emergency departments is decreasing. In 1991 there were about 2,500 departments in urban and suburban areas. Now there are about 1,800. Some additional staffing can help, but there's a fundamental problem of too many patients being funneled into too few departments.

Lack of access to primary care is another factor contributing to the overcrowding. There are too few primary care physicians, and the ones who are practicing have full schedules that make it difficult to see emergency cases. Some primary care physicians are experimenting with open-access scheduling, so more of their patients can be seen on an emergency basis. Others hold evening hours, which may also help some.

And apart from the overcrowding issues, I think waits have gotten long because the nature of emergency medicine has changed. The main focus used to be on resuscitating people and treating major trauma. We still do that, of course, but now the emergency department has become, de facto, a diagnostic center as well. And the evaluation of patients has gotten incredibly complex. Blood and imaging and other kinds of tests have to be ordered. That can create backlogs and longer waits.

Finally, patients in the emergency department are triaged: sicker or more seriously injured people get seen first. So someone like you, with an ankle sprain, will often wait a long time, because patients with, say, serious bleeding or chest pain that could be a life-threatening heart attack receive attention right away.

Enough on causes. What is being done about the situation, short of a massive overhaul of the health care system? Some hospitals are moving patients out of emergency departments into observation units for eight- to 24-hour stays. That can open up emergency department beds and help with overcrowding, which may translate into shorter waiting times for evaluation. Another approach is rearranging the hospital's schedule for elective procedures, so more beds are open and emergency patients can be admitted to the hospital faster.

Nurses have traditionally been in charge of triage. In the emergency department at Massachusetts General Hospital, where I work, we've adopted a system in which a physician helps with triage. I think it's a good change. Patients get seen faster. Tests are ordered earlier. But smaller emergency departments at community hospitals may not be able to afford to have a physician working in triage.

If you're having a true emergency, you obviously can't time a trip to the emergency department. Still, if it's a minor problem that needs medical attention but not right away, going to the emergency department fairly early in the morning may cut back on your waiting time. The peak period for emergency departments, when waiting times are longest, tends to start in early afternoon and end around 10 p.m.

Also, if possible, bring a list of your medications — and any supplements you're taking — with you to the emergency department, as well as the names and contact numbers of your doctors. Having such a list doesn't mean you'll get seen any sooner, but it may help doctors decide which tests to order and speed up the evaluation process. Of course you should put this list together before there's an emergency.

Unless it is an obvious emergency, I also highly recommend you contact your primary care physician or specialist, if you have one. Sometimes even a brief conversation can lead to advice that will spare you a trip to the emergency department. I love to see patients, but no one should go to the emergency department unless they really need to.

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