title: Bottlenecks in the emergency department: the psychiatric clinicians' perspective.
abstract: OBJECTIVE
  To ask psychiatric clinicians for their perspectives on the rate-limiting steps (RLS) in patient care in the Emergency Department (ED) and to compare them to the patient's actual length of stay.
  
  
  METHODS
  Prospective cohort study of clinicians' perspectives on the RLS among 1092 adult ED patients. Medical records were abstracted for ED time and other data.
  
  
  RESULTS
  Clinicians identified five RLS: limited availability of staff, limited availability of beds after discharge, need for clinical stability, need for additional history and patient's financial issues. The last RLS was the only one not associated with increased wait times in the ED. There were significant differences in the patterns of RLS by trainee status and hospital. For example, significantly higher proportions of trainees reported that RLS in patient care were due to the need for clinical stability and additional history and lack of bed availability. In contrast, non-trainee clinicians were more likely to cite problems with the availability of ED staff as an RLS.
  
  
  CONCLUSIONS
  Most of the RLS in patient care identified by clinicians were associated with actual increases in ED wait time for their patients. Next steps include asking clinicians for possible solutions to the delays their patients experience.
authors.affiliation: Division of Health Services Research, Partners Psychiatry and Mental Health, Boston, MA 02115, USA. grace.chang2@va.gov
authors.forename: Grace
authors.initials: G
authors.lastname: Chang
authors.forename: Anthony P
authors.initials: AP
authors.lastname: Weiss
authors.forename: E John
authors.initials: EJ
authors.lastname: Orav
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: Smallwood
authors.forename: Stephanie
authors.initials: S
authors.lastname: Gonzalez
authors.forename: Joshua M
authors.initials: JM
authors.lastname: Kosowsky
authors.forename: Scott L
authors.initials: SL
authors.lastname: Rauch
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D015331:Cohort Studies; D003441:Crowding; D017598:Efficiency, Organizational; D004637:Emergency Services, Psychiatric / Q000458:organization & administration*; D005260:Female; D006748:Hospital Departments / Q000458:organization & administration; D006801:Humans; D007902:Length of Stay; D008297:Male; D008485:Medical Audit; D008505:Medical Staff, Hospital / Q000523:psychology*; D009511:New England; D011446:Prospective Studies; D013997:Time Factors