1. Group 4:
Jade Bedell
Chiao Chin
Esther Densmore
Joshua Frisbie
Stephen Yeboah
1. Introduction
The hospitals in Dallas, Texas serve over a million citizens, with a variety
of socioeconomic levels, meaning that in many circumstances, patients cannot
pay for their care. The Emergency Medical Treatment and Labor Act (EMTALA)
is a US law delegating emergency departments’ requirement to treat all patients
regardless of their ability to pay. This law has a huge impact on the number of
patients that hospital emergency rooms (ER) see every day that are unable to
pay for their care, which in turn, can affect the quality of care given and patient
outcomes. Four quality measures, used in determining care given in emergency
departments (ED), were chosen to facilitate the analysis of five Dallas hospitals
to show that despite being in a similar geographic and demographic area, quality
of emergency care can vary substantially.
Table 1
Indicators
1. Average time patients spent in the emergency department before they were seen by a
healthcare professional
2. Average time patients spent in the emergency department before being sent home
3. Average time patients spent in the emergency department, before they were admitted to
the hospital as inpatient
4. Percentage of patients who left the emergency department before being seen
Literary Review
Emergency Care
Emergency rooms (ER) are an indispensable factor of America’s health
care. Unfortunately, overcrowding in ER is a common issue for many providers.
Overcrowding in ER settings decrease the quality of care that patients receive,
as their issues are not being tended to in an effective and timely manner.
The federal and state governments are aware that intervention is
necessary in order to reduce overcrowding in the ER. As a result, the Health
Care Financing Administration (HCFA) strictly enforces the Emergency Medical
Treatment and Active Labor Act (EMTALA), making ER services the first priority
and the only health care in the U.S. to be guaranteed by law.
According to a 2002 national U.S. survey by the Lewin Group, nine out of
ten large hospitals indicate ER operating above capacity (2002). Overcrowding
ERs have contributed to delays in diagnosis, delays in treatment, decreased

2. quality of care, and poor patient outcomes (Lynn and Kellermann, 1991). One
study correlates ER overcrowding to delays in identification and treatment of time
sensitive conditions like acute myocardial infarction, acute stroke, acute surgical
emergencies, and severe sepsis (Derlet RW, Richards JR, 2002). Another study
published, focuses on the main reasons that people visit ER, such as the
aforementioned acute conditions of stroke, myocardial infarctions, traumatic
injuries (shock and organ damage), and severe sepsis (Capp, 2014). This can
then result in patients sometimes leaving the ER without seeing a clinician if the
wait is too long (Capp 2014). Other than treatment for severe conditions, a large
majority of patients resort to the ER for seeking care if they do not have the
means (insurance) to access a primary care physician (PCP) (Lucas, 2009).
Emergency care research frequently indicates that inappropriate time
usage in care delivery is one of the primary reasons for decrease in quality of
care (Lucas, 2009). Not having adequate time in the care delivery process also
results in the patient being uninformed about their situation which can lead to
further complications (Lucas, 2009). When patients that are seeking emergency
care services for traumatic injuries are informed of their situation and are aware
of the best evidence based outcome, the healthiest outcome will be produced
(Silow-Caroll, 2007). We can reduce unnecessary time loss in ER care delivery
by focusing on communication and patient understanding. This focus can be
applied to all emergency care services to yield the best outcome (Silow-Caroll,
2007).
2. Data and Methods
Indicator Selection

3. Quality indicator 1 measures the length of time that a patient has to wait to
be seen, from the time they arrived in the ER to the time that they were sent
home. This measure only applies to patients who were sent home after being
seen. The high average for a hospital could mean that their ER does not have
enough employees or that they are seeing too many patients.
Quality indicator 2 shows the average time patients were in the ER from
arrival to the time they were sent home. Lower numbers reflect efficiency of an
ED, as it indicates that patients were being both seen then treated in a timely
manner.
Quality indicator 3 shows the average time patients spent in the ER but it
doesn’t count the patients who just arrived the ER and went home. Long stays in
an ER prior to a patient being admitted can be a clue that the ER are
understaffed, beds are not available, or they are overcrowded.
Quality indicator 4 shows that hospital ER that have a high volume of
patients who leave without being seen usually do not have the resources to
provide timely and effective ER care. This is important because patients who
leave the ER without being seen may be seriously ill, putting themselves at
higher risk for poor health outcomes; and these patients could return to the ER
with a more serious illness or worse, die.
Table 2
Quality Indicators
Hospitals
1. Average
time patients
spent in the
emergency
department
before they
were seen by
a healthcare
professional
2. Average
time patients
spent in the
emergency
department
before being
sent home
3. Average
time patients
spent in the
emergency
department,
before they
were
admitted to
the hospital
as inpatient
4. Percentage
of patients
who left the
emergency
department
before being
seen
*Nationwide data 26 min 134 min 274 min 2%
*Statewide (Texas)
data
26 min 127 min 270 min 3%
Texas Health
Presbyterian
52 min 200 min 352 min 1%
Baylor University
Medical Center
50 min 239 min 405 min 4%
Methodist Dallas
Medical Center
43 min 212 min 369 min 5%
Parkland 106 min 356 min 442 min 8%
UT Southwestern 43 min 219 min 374 min 4%
For quality indicator 1, “Average time patients spent in the ER before they
were seen by a healthcare professional,” the national, and Texas statewide
averages are both 26 minutes. Parkland hospital has the worst average time, at

4. 106 minutes, while Methodists Dallas Medical Center (MDMC) and UT
Southwestern University Hospital (UTSUH) have the best times, at 43 minutes.
The other two hospitals, Texas Health Presbyterian (THP) and Baylor University
Medical Center (BUMC), have average times of 52 and 50 minutes, respectively.
Quality indicator 2 found the average time that patients spent in the ED before
being sent home. The national average time is 134 minutes and the Texas
statewide average time is 127 minutes. All of the hospitals analyzed had
average times above, both, the national and state average, with THP, MDMC,
and UTSUH having the three lowest times, at 200,212, and 219 minutes. While
Parkland hospital and BUMC had the longest times of 356 and 239 minutes,
respectively. The third quality indicator found the average time patients spent in
the ER before being admitted as an inpatient. The national average time is 274
minutes and the statewide average is 270 minutes. Patients at Parkland hospital
have to wait an average 442 minutes, while BUMC patients have a 405-minute
average wait time. UTSUH, MDMC, and THP have the lowest average times of
374, 369, and 352 minutes, respectively. The fourth and final quality indicator,
which found the percentage of patients who left the ED before being seen, THP,
at 1%, was the only hospital with a percentage below the nationwide and
statewide averages of 2 and 3%, respectively. BUMB and UTSUH both had 4%
of their patients who left before being seen, while Parkland and MDMC had the
highest percentage of patients who left, at 8 and 5%, respectively.
3. Results
THP has twice the national and state average length of time spent in the
ER before a patient was seen by a healthcare professional. However, they had
the lowest percentage of patients who left before being seen. THP and MDMC,
the only non-level 1 trauma centers of the 5 hospitals analyzed, both had the
lowest average time spent in the ER before being sent home. This could be due
to the fact that they are treating patients with lower level of trauma compared to
the other 4 hospitals, meaning that even if takes more time for patients to be
seen, less time to be actually treated.
BUMC and Parkland hospital both have wait times substantially longer
than the national average wait time in the ER before a patient is seen and they
have the two highest average times spent in the ER before being admitted to the
hospital. Both hospitals have the largest ER patient inflow as well as a low
patient volume to number of patient room ratio, suggesting the possibility that
overcrowding could be an issue.
Though BUMH and UTSUH are level 1 trauma centers and have similar
outcomes for most of the quality measurements, BUMH has over 3 times the ER
patient volume. This could indicate that UTSUH is less efficient than BUMH.
Based on the data collected for MDMC, it is determined that they are
consistent in being average, relative to the other hospitals analyzed. Their
quality outcomes matched what would be expected based on their organizational
information.

5. Table 3
Organizational Information
Hospital # of
patie
nt
room
s
Location Trauma
Level
Ownership # of ER
visits
# of
employees
in clinic
Texas Health
Presbyterian
56 Dallas III Non-Profit 42,000 3000+
Baylor
University
Medical Center
74 Dallas I Non-Profit 115,239 4,750
Methodist
Dallas Medical
Center
59 Dallas II Non-Profit 60,259 2,828
Parkland
Hospital
108 Dallas I Government 142,000 10,000+
UT
Southwestern
Medical Center
28 Dallas I Government 36,000 13,800+
Table 4
Hospital Mission
Texas Health Presbyterian “To improve the health of the people in the communities we
serve”
Baylor UniversityMedical
Center
“Baylor Scott & White Health exists to serve all people by
providing personalize health and wellness through
exemplary care, education and research as a Christian
ministry of healing.”
Methodist Dallas Medical
Center
“To improve and save lives through compassionate quality
health care.”
Parkland Hospital “Dedicated to the health and well-being of individuals and
communities entrusted to our care.”
UT Southwestern “To improve health care in our community, Texas, our
nation, and the world through innovation and education.”
4. Discussion
Conclusion
Overall the data collected and analyzed verifies the hypothesis that
hospitals in the same geographic area serving the same population can have
varying degrees of quality. Of the five Dallas hospitals assessed, Texas Health
Presbyterian had the best quality outcomes in comparison to the national and
state averages. Some ways for hospitals to improve their quality outcomes in ED

6. could be more effective communication between clinicians, clerical workers, and
patients, as well as improvements to their structure and processes in the ER.
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