By Rhonda Malone​​​​ Wyskiel, RN, MSN, EDAC, LSSGB
HORD COPLAN MACHT

It was a Wednesday night in a bustling urban hospital when Sarah, a young mother, rushed her feverish toddler into the emergency department (ED). The waiting room was packed, parents with crying children, elderly patients clutching their chests, and others staring at the clock, frustration etched on their faces. Sarah’s child was eventually seen, but not before hours passed in uncertainty and growing fear. This scene isn’t unique to one hospital or city—it’s a daily reality in EDs across the United States.

ED wait times are more than just numbers on a spreadsheet. They represent moments of anxiety, missed opportunities for timely care, and, in the worst cases, preventable harm. The problem isn’t new, but it’s growing more urgent. With EDs acting as both the safety net and the front door to healthcare, solutions require more than temporary fixes—they demand systemic change, innovative thinking, and a commitment from healthcare leaders, designers, and policymakers alike.

The Scope of the Problem Nationally, EDs serve as both the safety net and the front door of healthcare. With over 130 million annual visits to U.S. emergency departments, the demand has far outpaced capacity (CDC.gov). Key contributing factors include:

• Increased Patient Volumes: Aging populations, rising chronic disease prevalence, and limited access to primary care drive more patients to EDs.
• Staffing Shortages: Workforce challenges, including nurse and physician burnout, exacerbate capacity constraints.
• Behavioral Health Crisis: EDs are increasingly serving as default care sites for patients with mental health and substance use issues due to insufficient behavioral health resources.
• Boarding Delays: Patients awaiting inpatient beds often occupy ED resources for extended periods, causing bottlenecks.

Innovative Models for Improvement Despite these challenges, hospitals across the country have implemented innovative models to reduce wait times and improve patient flow:

1. Vertical Care Models: By treating lower-acuity patients in seated areas rather than traditional beds, EDs can increase throughput and reduce bottlenecks.
2. Discharge Lounges: Dedicated spaces for patients awaiting final steps in discharge free up valuable ED bed space.
3. Observation Units: These units provide short-term care and monitoring for patients who may not require full inpatient admission.
4. Real-Time Data Monitoring: Advanced analytics platforms offer real-time insights into patient flow, helping teams anticipate and address bottlenecks proactively.

A Design-Driven Approach Physical design plays an often-underestimated role in addressing wait times, but it’s not a silver bullet. While thoughtful layouts, flexible treatment spaces, and efficient wayfinding can improve throughput and reduce bottlenecks, they cannot fully address the systemic issues driving ED overcrowding. Challenges like staffing shortages, limited inpatient capacity, and behavioral health crises require operational and policy solutions. Hospitals can’t simply ‘build their way out’ of these problems—design must work hand-in-hand with broader systemic reforms to create meaningful, lasting change. Thoughtful ED layouts that incorporate clear wayfinding, flexible treatment spaces, and separate zones for high- and low-acuity patients can significantly impact efficiency.

• Triage Redesign: Implementing rapid triage protocols reduces initial assessment time.

• Private and Secure Spaces for Behavioral Health Patients: Creating dedicated environments reduces risks associated with overcrowding and patient agitation.
• Family-Friendly Waiting Areas: Enhancing waiting room comfort reduces perceived wait times and improves patient satisfaction.

System-Level Reforms Are Essential While operational and design improvements are critical, broader system-level changes are equally necessary:

• Investment in Post-Acute Care: Increasing capacity in rehabilitation and skilled nursing facilities can reduce ED boarding.
• Telemedicine Integration: Virtual consults for non-emergency cases can alleviate physical ED overcrowding.
• Community Partnerships: Collaborations with local health services can provide alternative care pathways for non-acute patients.

Personal Insights and Reflections Early in my career, while working on ED improvement initiatives across multiple healthcare systems, I witnessed firsthand how small operational changes could lead to significant improvements in patient flow and staff satisfaction. These experiences shaped my understanding of the interconnected factors driving wait times in emergency care. I’ve observed that the most successful interventions share three common threads:

1. Leadership Commitment: Executive sponsorship ensures initiatives are prioritized and resourced appropriately.
2. Frontline Staff Engagement: Empowering nurses, physicians, and support staff to co-create solutions fosters ownership and sustainability.
3. Continuous Improvement Culture: ED performance must be monitored, and interventions adjusted based on real-time feedback.

One example I encountered was the implementation of a discharge lounge at a mid-sized hospital. The space, staffed by nurses, allowed patients cleared for discharge to wait comfortably while final paperwork and transportation arrangements were completed. This intervention reduced bed occupancy times and improved overall ED throughput.

The Road Ahead Sarah’s story isn’t just about one mother’s anxious night in an overcrowded waiting room—it’s a reflection of a healthcare system straining under immense pressure. Every delayed diagnosis, every frustrated patient, and every overburdened healthcare worker is part of this narrative.

Addressing ED wait times isn’t about quick fixes—it’s about reimagining how we design, staff, and operate our emergency departments. Hospitals, architects, policymakers, and communities must collaborate to implement sustainable, thoughtful solutions that put patients and providers at the center.

The time to act isn’t tomorrow—it’s now. For Sarah, her child, and the countless others who walk through those ED doors every day.