The emergency department is a major point of access to health care for all Canadians. Fourteen million Canadians visit the emergency department (ED) on an annual basis but for many, regrettably, their visit to the emergency department is an unsatisfactory experience. Being the proverbial ‘canary in the coal mine’, the problems and pressures that beset the emergency department are a reflection of a health care system in trouble; the patient who waits for eight hours in a crowded ED waiting room, who watches their elderly loved ones ‘warehoused’ in a brightly lit and noisy ED corridor while waiting for a hospital bed to become available or who arrives at their community ED to find it closed because of a lack of sufficient physicians or nurses to properly staff the department knows only too well that something terribly wrong has happened to our national belief in universal access to timely and quality care.
Underlying all of these difficulties, I believe, is a lack of clearly defined and articulated minimum operational performance standards for Canadian emergency departments and this underscores, therefore, the extremely important work currently being undertaken by Accreditation Canada.
ED overcrowding is widely regarded by Canadian emergency physicians and nurses as the number one impediment to quality care. More than a matter of mere patient inconvenience, ED crowding is clearly associated with increased patient morbidity and mortality, system gridlock and increased costs to the system. It would simply not be allowed to exist if there were mandated standards with respect to occupancy, timely patient assessment and appropriate access to hospital ward beds.
Indeed, in February of 2008 , the Office of the Fire Marshall in New Westminster, British Columbia was able to articulate, in common sense terms, what those of us who work in the emergency department understand is nonsensical and unacceptable. The fire marshals declared the congested and dysfunctional ER at the Royal Columbian Hospital as an unsafe fire hazard and ordered it cleared. (1) Some Canadian emergency physicians called for a national Fire Marshal’s Day to call attention to the perennial problem of ED overcrowding.
In rural Canada, a shortage of physicians and nurses who are willing and able to staff the emergency department is leading to service disruptions and community anxiety. In Nova Scotia this became an election issue and in Ontario has led to controversial attempts at regionalization of emergency services by regional health authorities. Defining, once and for all, a standard for the training requirements and staffing levels for a given level of emergency facility would oblige governments to facilitate adequate training opportunities for their province’s EDs and force hospital boards and regional health authorities to review their unique circumstances with a view to regional co-operation in order to guarantee regional access to emergency services.
System issues would not be the only beneficiaries of articulated and enforceable minimum operational performance standards. Direct patient care, at the bedside, would also be subjected to scrutiny and improvement.
In 1991, the Ontario government surveyed the two hundred emergency departments in the province and found that more than 50% of those departments surveyed were lacking in essential life saving equipment. (2) The issue was not one of access to CT scanners and angiography but rather laryngoscopes and resuscitative drugs. Surprisingly, nothing tangible has been done to address the identified deficiencies.
A 2000 study of the Canadian emergency departments demonstrated that essential pediatric resuscitation equipment was “unavailable in a disturbingly high number of EDs across Canada”. Fifteen per cent of Canadian EDs did not have access to intra-osseous needles, pediatric oximeters were unavailable in eighteen per cent of ERs and sixty percent did not have infant warming devices. (3)
A 2001 study of 179 hospitals in Ontario revealed that only 0.6% were adequately stocked with antidotes for poisonings. The authors concluded that “most acute care hospitals in Ontario do not stock even minimally adequate amounts of several emergency antidotes, possibly jeopardizing the survival of an acutely poisoned patient.”(4)
The findings, with respect to processes of care and the adoption of evidenced based medicine, are equally discouraging.
A 2004 study of the compliance of teaching centre compliance with guidelines for the emergency management of asthma revealed that overall compliance with guidelines was only 70%.university. Compliance with management guidelines for severe asthma was only 41%.(5)
A 1999 study of compliance with the internationally acknowledged Ottawa Ankle Rules showed a disturbing lack of impact from an active process of dissemination of the guidelines developed to reduce the use of unnecessary radiography of sprained ankles. Following an intensive educational program, the number of x-rays taken for obviously sprained ankles remained the same. (6)
Clearly, for both the patient on the emergency stretcher and the emergency system as a whole, much more needs to be done to define minimum performance expectations. Regrettably, however, precious little time or energy has been devoted to articulating a national vision for minimum standards of emergency care.
The first attempt at defining a standard was with the release of the federal National Health and Welfare document entitled Emergency Units in Hospitals in 1981 and again in 1988. Hospitals were subdivided into four broad categories (A,B,C,D) that defined departments from the academic, tertiary care center to the rural small community emergency department. Recommendations were made with respect to space requirements, staffing, credentialing, equipment, diagnostics, inter and intra-hospital relationships and quality assurance mechanisms. Unfortunately, none of these articulated expectations had the power of enforcement and were largely ignored at the provincial level.
In 1989 the Ontario government was the first provincial government to introduce minimum ED standards with the release by the MOHLTC of their “Guidelines for Emergency Units”. This was a comprehensive document that reviewed all aspects of emergency service delivery in Ontario and made hard, tangible recommendations to guarantee an acceptable level of care for all Ontarians.
As noted above, two years later a survey of the 199 hospitals in Ontario with emergency departments revealed that only 50% of Ontario ERs met a disturbingly minimum standard. Curiously, nothing was done at the time to rectify these apparent deficiencies and the report was lost in a bureaucratic maze. In the late 1990’s a physician advisor to the MOHLTC attempted to revise and restore the concept but after ten drafts, the guidelines remained as only a draft discussion document. (2)
In 1997, the Rural Section of the Canadian Association of Emergency Physicians called for minimum standards of care for all rural emergency care facilities, from the basic industrial aid station to the northern nursing station to the rural community hospital. Experts in rural medicine and emergency medicine developed tangible recommendations with respect to staffing, education and credentialing, departmental equipment and supplies, necessary pharmacological agents, diagnostic imperatives, quality assurance and inter-hospital transfers for all levels of rural health care facilities. The document, unfortunately, gained no traction with the nation’s health ministries.
The issue, however, refuses to die.
In Ontario, the Report of the Hospital Emergency Department and Ambulance Effectiveness Working Group, the Schwartz report, (2005) highlighted “the differing practices and expectations for hospital EDs across Ontario”. (7) The report called for “a consistent standard which can be monitored and enforced”. Similarly, in 2006, a tripartite committee of the OMA, OHA and MOHLTC reviewing access to emergency services called for the “immediate development of standards for emergency departments setting out best practices and establishing minimum operational performance standards for every classification of emergency department in Ontario.”(8)
Four years later, still nothing has been done to fulfil these recommendations in the only province that has acknowledged the need.
It was, therefore, with a great deal of satisfaction that the Canadian Association of Emergency Physicians was advised that Accreditation Canada was willing to take a leadership role in the development and promotion of national standards for emergency care.
Over a number of subsequent years, with funding from Health Canada, and with broad national representation from representatives of emergency medicine and nursing, emergency medical services and hospital administration, an articulated, and albeit minimum, standard was developed for emergency departments on a national basis.
The standards document is admittedly a modest, early attempt at capturing processes of quality care in the highly complex world of the modern Canadian ED. Much more needs to be done to refine the necessary parameters of care to guarantee that Canadians expectations are met when they present to their local emergency department. It is, however, a welcome start and the leadership of Accreditation Canada is to be applauded.
In this issue of Qmentum Quarterly, the experience of Accreditation Canada in the initial use of the survey instrument in 2008 and 2009 is highlighted. One hundred and twenty five client organizations had on-site surveys using the new ED standards. Of the 125 hospitals surveyed, there were close to fifteen hundred unmet criteria with an average of 12 unmet criteria per surveyed facility. Among the top twenty unmet criteria, medication reconciliation ranked the highest, followed by the lack of use of evidenced-based guidelines and the promotion of safety. This is an important finding and given the blunt nature of the survey instrument highlights that with further and more in-depth analysis that other, equally important issues with respect to the processes of cares will be highlighted and dutifully corrected.
While these initial findings are important, what is even more important is that Accreditation Canada has done what all other health care jurisdictions have failed to do; they have started an irrevocable process towards the development of a minimum operational performance standard for all Canadian emergency health care facilities.
Thanks to their vision, their commitment to direct accountability and their hard work, all Canadians will be the ultimate beneficiaries.
(1) Globe and Mail; February 14, 2008: “Fire Inspectors shut down crowded waiting room”
(2) S. Sublett; Is it time to close your hospital’s ER?
CMAJ 1991 145: 1489-1492
(3) McGillivray D, Nijssen-Jordan C, Kramer MS, Yang H, Platt R. Critical pediatric equipment availability in Canadian hospital emergency departments. Ann Emerg Med. 2001;37 :371 –376
(4) Juurlink, DN., McGuigan, MA., Paton, TW., Redelmeier, DA. Availability of Antidotes at Acute Care Hospitals in Ontario CMAJ 2001; 165(1):27-30
(5) Krym, VF, Crawford, B., MacDonald, R. Compliance with guidelines for emergency management of asthma in adults: experience at a tertiary care teaching hospital CJEM 2004;6(5):321-326
(6) Cameron, C., Naylor, CD., No impact from active dissemination of the Ottawa Ankle Rules: further evidence of the need for local implementation of practice guidelines CMAJ 1999; 160 (8): 1165-1168
(7) MOHLTC: Improving Access to Emergency Services: A System Commitment: The Report of the Hospital Emergency department and Ambulance Effectiveness Working Group Summer 2005
(8) Improving Access to Emergency Care: Addressing System Issues; Physician Hospital Care Committee (MOHLTC; OMA; OHA) August 2006