Mid-Missouri hospitals try to cut down on emergency room wait times
COLUMBIA, Mo. (KMIZ)
It's not uncommon to walk into an emergency department waiting room full of people, so many that some have to sit on the floor. Patients waiting hours in emergency departments is becoming a more familiar story across the nation.
Two hours. Three hours. Five hours. Six hours. Twelve hours.
This is how long some people in Mid-Missouri have had to wait in the emergency department before being sent home. It can be nerve-racking.
"Whenever you show up to the emergency room, you believe that this is a dire situation," said Boone Hospital Emergency Department clinical educator Jesse Godec.
According to the University of Michigan, for safety and quality reasons, national hospital standards say no patient should wait in an emergency department for more than four hours.
That doesn't always happen.
According to data from the Centers for Medicare and Medicaid Services, average emergency department wait times in Missouri can range anywhere from 2 hours and 5 minutes up to 3 hours and 31 minutes. This is considered high compared to other states, where many departments are also struggling to cut down time.
Many factors contribute to the problem.
"It's not fair. It's not fair, and how do we fix this? We have to fix this," said Godec. "This is not what we signed up for, to watch sick people sit on the floor."
The problem has persisted for at least a decade now, and so have the concerns, according to Godec.
Wait times vary by state. For example, the Washington D.C., area is clocking an average of 5 hours and 14 minutes in its emergency departments, while North Dakota's average wait time is 1 hour and 50 minutes.
The reasons include limited space, but also things outside of hospitals' control, like primary care provider shortages and closures of rural hospitals.
"Over the years, the appropriate use of emergency rooms has become harder and harder for patients because there are less options," said Godec. "Urgent cares often are very busy. Getting into primary care in a timely fashion if something has just arisen that day can be difficult."
| Emergency Department | Number of rooms/beds in the Emergency Department | Average number of patients seen per month |
| Boone Hospital | 20 beds | 3,200 patients |
| University Hospital | 63 exam rooms, four trauma beds | 6,787 patients |
| SSM St. Mary's Health | 28 beds | 2,600 patients |
| MU Health Care's Capital Regional Medical Center | 29 beds | 3,000 patients |
| Lake Regional Hospital | 36 beds | 3,250 patients |
The provider squeeze
From 2014 to 2023, 12 Missouri hospitals in rural communities closed, according to the Department of Health and Senior Services. This leads to patients needing to travel longer, prolonging care.
"There's this huge path in the center of the state that has nowhere else to go," said Godec. "Once we cross that threshold of 20 in the department, there are no more places to put people, so that's when the wait starts."
Many residents in rural Missouri are forced to travel long distances for emergency care. For example, an Audrain County resident would have to drive about a 45-minutes to get to an emergency department. And if it's life-threatening, like a heart attack, getting emergency care in time is crucial.
"We saw overnight, about 15 to 22%, somewhere in that range, an increase in patient volumes, almost all from Audrain," said Godec.
A shortage of physicians is also causing a bottleneck effect on emergency departments. Matthew Nusbaum, executive director of critical care and emergency services for Boone Health, said the shortage of primary care doctors ends up causing people to visit the ER for care they should get in a clinic.
According to previous reporting from July, Missouri is short almost 500 primary care physicians. Experts project that by 2026, Missouri will have a shortage of 2,000 primary care providers.
Not having access to a primary care provider can lead people to prolong their health needs, whether it be not going to an annual check-up or keeping up with treatment for a chronic illness.
"What you'll see is a lot of folks don't have PCP or primary doctors, and so a lot of times the emergency department is their primary care," said Nusbaum.
This is especially true for people using Medicaid, who are underinsured or do not have insurance. According to research from the National Library of Medicine, Medicaid expansion increased emergency department wait times by about 10%.
Hospitals, by law, cannot turn away a patient because of their financial or insurance status.
Urgent care clinics can also be costly for those without insurance. According to GoodRx, a typical visit can cost between $125 and $300, with an average of $180. Urgent Care clinics are also limited in what testing and care they can provide compared to an emergency department.
"Urgent cares are often very busy. Getting into primary care in a timely fashion can be difficult," said Godec. "About half our patients don't really need the emergency room, but they're still here and they're still in distress, and if we don't deal with the problem now, in a week from now, it could get worse."
Another prevalent factor playing into emergency department wait times is staff burnout. A study done in South Africa in 2023 found that 50% of emergency department doctors and nurses are experiencing burnout.
Emergency department wait times could get even longer with the newly passed Big Beautiful Bill, as almost 12 million people across the nation face the loss of health care coverage. The bill reduced subsidies for insurance providers and imposed stricter rules for eligibility, pushing more sicker people to the emergency department. Lacking insurance causes patients to delay their health care and hospitals to figure out how to foot the bill when the revenue stream is lower.
Creating solutions
MU Health Care's Capital Regional Medical Center in Jefferson City has implemented a direct-bedding system to minimize wait times in the emergency department.
"We really move that wait time down to essentially minutes," said emergency department medical director Dr. Gale Osgood. "When someone checks in, if we have an open bed, they get brought right back."
Osgood says the department recognizes that people are safer in the emergency department than in the waiting room, so by implementing direct-bedding and avoiding the triage process, it gets patients right in, regardless of their condition.
However, if the department is full, hospital staff will triage patients and rearrange beds if more life-threatening, high-acuity patients arrive.
"A lot of literature that says the triage process is fundamentally flawed and some people are just not good at it," said Osgood. "Sometimes people come in with jaw pain and perhaps it's a heart attack, so you have to really be careful by saying this is a non-high-acuity complaint."
| ESI Index Level | Condition | Seen time | What could classify | No. of tests or procedures needed |
| Level 1 | Resuscitation | Immediately life-saving intervention | No tests or procedures needed | Needs all resources available |
| Level 2 | Emergency | High risk of becoming life-threatening | chest pain, stroke, fever in an infant, shortness of breath, major fracture/break | Needs all resources available |
| Level 3 | Urgent | Non-life-threatening but requires care | abdominal pain, CT scan, swelling, persisting pain, blood test | Needs two or more resources |
| Level 4 | Semi-urgent | Non-life-threatening, but requires resources | sprained ankle, small cut, simple fracture, UTI, eye irritation | Needs one resource |
| Level 5 | Non-urgent | Non-life-threatening, could need resources | sore throat, cold, minor rash, earache | No tests or procedures needed |
The department also has an emergency room observation unit for patients who need more help or testing than what can be provided in the department and who doctors suspect will be there less than 24 hours.
"We can move them up there and have our providers watch them," said Osgood. "It's been extremely helpful."
Osgood says the state average of patients leaving the emergency department before being seen is around 4%. Over the last year, his department's rate sits at 3%.
The department switched to a new product that gave them strong, reliable data and the ability to track how many people sign in and leave the emergency department. The data showed they weren't doing as well as they wanted. They also listened to their patients' feedback.
"We would see stuff on social media, which we obviously took as a large consideration," said clinical nurse manager for MU Health Care's Capital Regional Emergency Department, Tyler Silvey. "Whenever we went to work on this project, there was a lot of different data and things that we looked at, not just the numbers, but also our net promoter score, which showed what our patients thought about our facility and the care they received."
They are also still looking to expand their number of beds.
Nationwide, more than 25% of patients who come to emergency departments that use boarding procedures during non-peak months waited four hours or more for a bed, according to the University of Michigan Institute for Healthcare Policy and Innovation. During the winter months, that number rose to 35%.
"You could have 100 beds and they're all full, and you can still have a six-hour wait, so let's fix the processes that can lead to more success," said Godec.
In mid-October, Boone Health fully implemented a new method called the Rapid Care Path to get patients into and out of the emergency department quickly and efficiently. The method was developed about 18 months ago, as the department has seen a record number of patients in the department this year, according to Nusbaum. This has helped them treat about 500 to 600 more patients each month.
"We see lower acuity patients during our higher-volume times, that way you're saving the beds for the sicker patients, and so you can see the lower acuity or vertical patients that are walking, talking through there," said Boone Hospital Emergency Department manager Nick Woods.
The Rapid Care Path method uses an area for 12 hours a day, every day for patients dealing with non-life-threatening conditions during busier times.
"You check in and your first clinical contact will now be a clinical person, so a medical tech or a nurse will check you in and you get your wristband," said Woods.
What used to be a triage space is now an exam room space for providers to see patients, assess them, give orders for tests and medication, blood work, etc. Woods says the goal is to have a patient in there for 20 minutes or less.
At any point after you check in, a provider will come to the patient and start assessing them, decreasing door-to-doctor time.
"It should decrease your total length of stay, so from the time you got here, to the time you're discharged, should decrease significantly," said Woods. "Having that provider sooner in the patient's care, it really helps cut down that time and kind of focus on what we really need to order and to figure out what's going on with the patient."
The main waiting room will be split into sections for patients who are checked in with a provider, patients who haven't been seen yet, and a third area for patients waiting for results.
"Essentially, this will keep your less sick patients, but also seeking care and need care, up in this area, and you save your back rooms, for the more acutely ill or patients who are less mobile," said Woods.
As Boone Health implements the new system fully, the hospital is also looking to expand the emergency department with the help of a strategic partner. Boone Health has a set of finalists selected. It will be another several months until an executive agreement is signed.
The project is likely to cost about $30 to 35 million, said Boone Health spokesman Christian Basi.
"So that is one of the reasons why we are searching for a strategic partner to help us is because we're doing well, but we don't have the additional resources to invest that much," Basi said. "If we don't find the right fit, we will continue to grow, and we will find a way to do this; it will just be a little slower."
MU Health Care's University Hospital Emergency Department uses a process called FastER to streamline patient care. You first see a triage nurse, explain your health concerns, and they take your vitals. During busier times, providers will come to you in the waiting room with results and medication to speed up care. The goal is to get patients what they need in under an hour, according to MU Health Care's website.
In September, Phelps Health broke ground on a new emergency department expansion project, which will add 21,000 square feet and include 32 medical beds.
In addition to hospitals, urgent and quick care clinics are trying to do more. In May, MU Health Care's Quick Care clinic in Jefferson City expanded its hours to 7 a.m. to 7 p.m. Monday through Friday and 8 a.m. to 4 p.m. on weekends.
The Medical University of South Carolina implemented a Virtual Provider in Triage method, which doctors say has cut the time it takes a patient to see a provider in half, while also reducing their left-without-being-seen rate by 80%. The initiative uses telehealth to connect patients with a doctor as soon as they arrive at the hospital, so if a patient needs something simple, like a medication refill, they can get it done right then and there. If they need more care, the virtual meeting can lead to imaging, testing and further examination.
"This isn't just an ER-based problem; it's a hospital-wide problem," said Silvey.
While emergency departments and health professionals try to tackle this, wait times continue to go up, putting Missourians' health, patience and trust in the system in limbo.
