Compass Clinical Consulting has encountered common problems in each Emergency Department (ED) through expert interim and consultant engagements in a variety of healthcare organizations.

Our Emergency Department expert and clinical consultant, Alisa Slimick, MBA, BSN, RN, provides insight into this area from her own experience working in a range of healthcare settings.

What “Red Flags” Should Hospitals be Examining?

Hospitals need to examine negative occurrences such as: extended Length of Stay (LOS), lengthy door-to-doc time, and high rates of left without being seen (LWBS). Anything that prevents the hospital from meeting the goal of decreasing these issues must be assessed. For example, the work-up time (the time patients arrive to when they leave) can oftentimes be decreased. One way to address this issue would be to closely examine turnaround times for all diagnostic tests.

Additionally, wait times in triage can be problematic. Look out for triage processes that are cumbersome and lengthy. Triage processes should be about 5-10 minutes long, rather than half an hour or more. When there are extended wait times in triage, patients end up in waiting rooms for hours. Staff need to be asking, “How often are patients reassessed?” They need to establish what their policy is for patient reassessments, and whether they are meeting it.


Excessive boarding is one of the most prominent trouble areas in hospital Emergency Departments. Hospitals need to examine overcrowding and what is causing it. For example, overcrowding can be caused by patients not moving out as quickly as they could due to extended inpatient LOS—many organizations exceed guidelines for inpatient LOS.

The standard for boarding in the ED is one hour. It is most important that an organization ensures patients that are boarding are being cared for appropriately and at the same level of care as the inpatient unit. Your hospital must look at processes and how you’re taking care of patients to ensure safe, quality care.

Staffing Inefficiencies

Reductions in staffing, caused either by the hospital’s choice or people leaving unexpectedly, result in open positions, but no reduction in patient volume. This leads to patient safety issues without proper attention being allocated to each new patient in the ED.

Hospitals can counteract this commonality by reallocating resources to make sure patients are safely cared for, which could involve looking outside of your ED for inpatient nursing staff members who can temporarily fill this gap to care for boarding patients in the ED, or move the boarding patients to an area outside the ED where they can receive care specific to their needs to allow for staff to utilize all of the department’s space for ED patients.

Inadequate Emergency Department Staff Training or Resources

Another concern that hospitals must be aware of is the lack of resources or specific training. The ED is not always included in training; inpatient floors often have training for new devices that may be implemented, but the ED tends to get overlooked as a separate entity, even though the patients with those new devices may very well seek care in the ED at some point. With proper training and resources, staff can provide better care, ultimately contributing to other goals such as improved throughput and reduced LWBS.

Assess Each ED’s Unique Culture

Although hospital Emergency Departments (EDs) share common problems, it is important to remember that each has its own unique culture and challenges. At one of my recent engagements, I spent time as an interim director at a hospital in the Midwest. Not long after I arrived, I diagnosed physician and staff relationships as a major setback in the Emergency Department, and this was an area I began to tackle.

The traditional physician culture of the hospital and hesitancy of the medical director made collaboration and subsequent, necessary departmental changes especially difficult. Additionally, the ED staff did not immediately trust new leaders due to feeling a former lack of visibility with previous leaders.

I counteracted these difficulties and barriers to transparency by proactively communicating changes to the staff, and working to fit into the culture. Once the staff understood how proposed changes would affect them and the associated benefits, they were much more receptive and developed a greater trust in leadership.

Employee morale may seem like a minor issue, but it remains equally important to how your ED is run. If staff are unhappy, there is the potential that this could escalate into a mass exodus of people leaving, which results in those staffing inefficiencies that affect quality patient care. If leadership is reticent to making changes, then there will be a barrier to establishing processes, and improving inefficient practices. My philosophy, second to achieving safe, quality patient care, is that the ED must be a good place to work.

Ultimately, staff in the Emergency Department need to understand: why you are there?; what are your plans?; why is something changing?; and why does it need to change?

To be successful, ED staff and leadership need to understand what needs to be changed and why, which means identifying the problems their ED is facing so they can help the department improve processes and provide safe, quality care. To do so may require looking outside of the Emergency Department – whether to another unit (inpatient nursing to provide additional care) or to a consultant or interim director.

If you would like to find out more about the successes our interims have had in the ED or other areas and how your hospital can maintain safe, quality patient care, contact us at or (513) 241.0142.


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