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Now is the Time to Fix Your Emergency Department: The Business Case for Change

Emergency departments (EDs) are a mess right now. Omicron is surging. Nurses are in short supply. Hospitals are at capacity with admitted patients boarding in the ED for days. Patients wait many hours to be seen. There is a sense of despair and apathy developing among ED staff. What’s the point of trying to do anything? Everyone is in the same boat. We don’t have the staff. We don’t have the beds. The patients can go somewhere else but will still have the same wait.

COVID-19 has been with us for two years now. Though not official, it’s no longer a pandemic. It’s now endemic for all practical purposes. This is the new norm. Adapt and survive, or don’t and die.

With exceptionally long waits, a patient somewhere will die in a waiting room. This has happened before and will happen again. (ref. 1, 2) Nurses will continue to burn out and leave the field. Physicians are beginning to show signs of burnout and talk about leaving as well. (ref. 3) Without nurses and physicians, hospitals will be unable to function. Without the ability to care for patients, hospitals will close.

Crowding causes stress. Going to the emergency department is stressful under normal circumstances. Put lots of people together, make them wait for hours, and emotions escalate. I am aware of one ED where the charge nurse had to call the police to respond to an increasingly unruly crowd in the waiting room. Triage nurses fear for their safety when they face a mob of angry patients in the waiting room. This contributes to nursing burnout and turnover.

Match Demand to Capacity to Improve Flow, Reduce Burnout

The current situation is a classic demand to capacity mismatch. Too much demand and not enough capacity. Matching capacity to demand entails a quantitative assessment of both:

  1. Demand: Are you performing services in your ED that can be better handled elsewhere?

  2. Nursing Capacity: Do your nursing resources match your patient demand? Are you using your nurses efficiently? Have you considered using RN extenders?

  3. Room Capacity: Are you maximizing your room use? Are you employing a vertical patient concept for lower acuity patients?

  4. Physician/APP Capacity: Does your clinician mix support the number of nurses, rooms and predicted patient arrivals at your facility? Are you flexing your providers when boarders are tying up beds?

Matching demand to capacity is very doable, but it requires time and commitment.

The ROI for Fixing Your ED

Fixing broken processes is rarely free. If nothing else, there is a time commitment—time that could be spent on something else. The good news is that there is a very positive return on investment (ROI) for fixing the ED.

Let’s look at patients who’ve left without being treated (LWOTs), for example. Assume the following: (ref. 4)

  1. You have 10 LWOTs per day.

  2. The average hospital collection for a discharged patient is $395 (not including diagnostic testing).

  3. The average contribution margin for an ED admit is $13,500.

  4. The average professional services collection for each ED patient is $160.

  5. Lastly, 5% of LWOTs would have resulted in an admission. (There is a false assumption that LWOTs are all low-acuity patients that don’t need to be in the ED. However, a percentage of LWOTs wind up getting admitted after leaving an ED.) (ref. 5).

$4.5M in additional revenue for LWOT reduction alone! If you increase your capacity and see more patients, the financial outlook is even better.

For example, assume that your ED has 50,000 annual visits with an average admission rate of 20% and a current length of stay (LOS) of 4 hours. If you can reduce LOS by 30 minutes:

That’s $22 million in additional revenue!

In addition, consider the costs associated with nursing turnover and recruitment. It costs $37,000 to $58,000 to recruit and replace a nurse. (ref. 6) How many nurses have you lost this year? Then think about the downstream effects of short staffing -- patient satisfaction, community perception, reputation, goodwill. Taking steps to fix your ED can produce an ROI that’s worth millions.

As bleak as things may look now, it won’t stay this way forever. The healthcare system will come out of this latest Covid surge, just as it has with the others. There may even be another; this is the new norm. So give yourself a competitive advantage by fixing your emergency department now, before your competition beats you to it.


  1. “Suit: 'Abandoned' Man Dies in Hospital Waiting Room,” U.S. News and World Report, Aug. 5, 2021

  2. “Woman, 25, upset by emergency room wait heads to urgent care but dies,”, Jan. 16, 2021

  3. “The Great Resignation: Why Physicians are Quitting and How Administrators can Mitigate the Impact on Care Delivery,” Healthcare Business Today, Dec. 12, 2021.

  4. Split Flow Success-Avoiding Pitfalls & Getting Up to Speed, ACEP21 Scientific Assembly, Boston, MA, Oct. 25, 2021.

  5. Rowe, et al., Characteristics of Patients Who Leave Emergency Departments without Being Seen. Academic Emergency Medicine, 2006: Aug. 848-852.

  6. 2016 National Healthcare Retention & RN Staffing Report, NSI Nursing Solutions, Inc.

Joe Twanmoh, MD, MBA, is the President and Founder of Queue Management. At Queue Management, demand to capacity matching and modeling is at the heart of what we do. To learn more, visit

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