Ryan Chiao, Senior Photographer

In an emergency room, the difference between health and harm can come down to how quickly a patient is seen by a provider. 

But according to a Yale study published this summer, patients who were Black, Hispanic or Latino, Spanish-speaking or insured by Medicaid were more likely to be skipped in emergency room lines. Those patients also had a higher likelihood of being treated in hallways and leaving before treatment was complete.

The study looked at over 90,000 cases of queue jumping at the Yale New Haven Hospital’s emergency department between 2017 and 2020 and adds to a growing body of research pointing out disparities in the timing and quality of care received in the emergency room. 

According to Hazar Khidir, instructor of emergency medicine at the School of Medicine and a co-author of the study, these disparities are often rooted in systemic problems like individual bias, structural racism and economic inequality.

“It’s not just a triage nurse being racist toward a patient,” Khidir said. “There are issues at the structural level.” 

The queue

When a patient first enters the emergency room, they go through a screening process to ensure that they will receive the appropriate level of care.  

According to Rohit Sangal, lead author of the study and the associate medical director of Yale New Haven Hospital’s adult emergency department, emergency rooms typically use a metric called the Emergency Severity Index, or ESI, to triage patients. 

The ESI scale is ranked from one to five, with the most ill patients, such as those experiencing a stroke or heart attack, categorized as ESI 1. The least sick patients, such as those requiring a medication refill, are categorized as ESI 5.  If there is no space in the emergency room — which can happen when there is a shortage of staff, a shortage of beds or when many patients arrive at once — a line forms. This line, said Sangal, is known as a “queue.” 

Patients in a queue are seen by a doctor according to how sick they are and when they arrive. But still, unexplained queue jumps — the term the researchers used to describe people being skipped in line — might occur. The data used in the study do not specify why someone was jumped. 

But queue jumps can happen for a variety of reasons, said Lesley Meng, a professor at the School of Management and co-author of the study.  One legitimate reason for a queue-jump occurs when a waiting patient’s condition worsens. For example, if a patient experiences a seizure or another emergency situation in the waiting room, according to Sangal, they would be jumped in line. 

“The waiting process is dynamic,” Sangal said. “A patient’s clinical status may change, which changes where they need to be in the queue.” 

Even without the possibility of being skipped in line, patients frequently avoid the emergency room if they are worried they might have to wait for several hours, said Caitlin Donovan, a spokesperson for the National Patient Advocate Foundation. 

If a patient experiences long wait times, they might be reluctant to return to the hospital to treat their health problems.

Ignoring health problems can have serious consequences for both the patient and the system, Donovan said, including “worse health outcomes and ultimately higher costs.” 

“Ideally, there’s a treatment space for everyone when they come in,” Sangal told the News.

However, Meng also noted that it is often difficult for patients to tell if they are being skipped over for medical reasons or for other ones — including socioeconomic privilege.

For example, Khidir explained, a privileged patient might have their primary care doctor call the emergency room ahead of their visit to make sure they are seen quickly. Someone without a primary care doctor might have to wait longer. 

She also pointed to one of the study’s findings: patients insured by Medicaid are more likely to be queue-jumped, even though emergency room providers are typically unaware of a patient’s insurance status. 

According to Khidir, this is because Medicaid and insurance status can affect the triage process through indirect means. 

For instance, patients on Medicaid might have a more difficult time finding a doctor who accepts their insurance. If they don’t have a regular doctor, they might not receive a diagnosis for conditions they have, Khidir explained. By the time they are seen in the emergency room, they would appear to be less sick than they actually are.

“A triage nurse doesn’t need to see if a patient has Medicaid for that to have an effect on the triage process,” Khidir said. 

Addressing inequalities 

The Yale queue-jumping study is far from the first research to point out disparities in the emergency room. For example, a study published last September found that non-white patients received less urgent ESI triage scores than white patients, while another study from Boston University found that Black and Hispanic patients experience longer emergency-room wait times than white patients.

Once emergency room inequalities are documented through studies like the queue-jumping study, hospital administrators then decide how to address disparities. 

Howard Forman, a professor of radiology at the School of Medicine and the director of Yale’s healthcare management program, said that there is one obvious solution to the problem.

“Queue jumping wouldn’t matter at all if there were no queues,” Forman told the News.

In addition to getting rid of wait times, Forman said the healthcare industry should prioritize repairing structural inequalities that disadvantage patients from low-income and marginalized backgrounds. Though he acknowledged that those issues are difficult to correct immediately, removing queues and structural inequality should remain on “our short list of problems we’re working on,” Forman said. 

In the short term, other solutions could include changing the triage system, said Chris Chmura, the current manager of clinical projects and education at YNHH, who previously worked as a triage and trauma nurse in the emergency department. 

The ESI system, developed in 1999, is now over 20 years old. Chmura believes that it is not well equipped to handle today’s patients with more complex health needs.

“We’re using tools that were designed in a totally different healthcare setting,” said Chmura. 

Over the past year, YNHH has shifted to a machine-learning tool that uses electronic health records to make more informed triage decisions. 

Chmura said that this tool can help patients receive triage rankings called acuity scores, which are based on the algorithm’s predictions of their health outcomes and the risk of an adverse event. 

“We’ve optimized our front-end flow and our triage process and physician processes,” said Beth Liebhardt, the executive director of emergency services at YNHH, and a co-author on the study. 

Liebhardt said that the data used in the queue-jumping study were collected before 2020. Since then, YNHH has begun to shift away from ESI rankings to a hybrid triage system that uses machine learning to rank patients. 

Liebhardt believes that the study’s findings might change if repeated today.

“With a different timeframe, I think those numbers would look different,” Liebhardt said. 

In addition to machine learning, other triage strategies, such as a split-flow model where patients are separated by the severity of their health needs, might help reduce bias in the emergency department, said Sangal. 

Another solution, according to Forman, is for hospitals to hire multilingual patient advocates to staff emergency department waiting rooms. These advocates could translate for patients who are uncomfortable with English and alert the triage nurse if a patient’s condition worsens.

For Forman, it’s also important that any new solution for addressing inequalities in the emergency room is thoroughly researched. He said it “would be best” to test each idea one by one to see which are meaningful and which are less so.  

Meng confirmed that she and other researchers from the medical school, the School of Management and YNHH are investigating changes made in the YNHH emergency room and their effect on patients. 

“We’re essentially studying every little piece of a patient’s journey through the ED to try to understand whether there are inefficiencies, whether patients are harmed during their waiting, and to come up with ways to make things better,” Meng said.

The study was published in July in the scientific journal JAMA Network Open and

conducted by researchers from the School of Medicine, the School of Management and Yale New Haven Hospital.