In 2004, I was approached by Health Canada to prepare a discusssion paper on wait times in Canadian emergency departments. The report never saw the light of day. Eight years later, on review of the paper, I was struck by the realization that many of my comments from that galaxy far, far away were still fairly valid today. I offer this up as a historical document and a reminder that though things are indeed improving, we still have yet to address the major issue that affects crowding: hospital bed capacity.
Wait Times in Canadian Emergency
Acute Care & Health Technology Unit
Alan Drummond MD
March 31, 2004
A recent Ipsos-Reid poll commissioned for the Canadian Medical Association has concluded that from a public perspective, the predominant health care issue in Canada is access. (1)
In the past year, two thirds of Canadian families had to wait longer than they thought reasonable for access for medical services. While long wait times for specialists (75% concerned), the shortage of health care professionals across Canada (75% ) and access to some diagnostic services such as MRI’s (73 %) were predictably highlighted, long wait times for emergency department services were also noted to be of significant concern for Canadians (74%). The majority of those polled believed that access to emergency services had deteriorated over the last couple of years. The pollsters concluded that the survey reflected a considerable amount of anxiety and suffering with respect to delays in access.
The principal cause of prolonged wait times in Canadian emergency departments is emergency department (ED) overcrowding.
ED overcrowding is defined as a situation in which he demand for service exceeds the ability to provide care within a reasonable time frame, causing physicians and nurses to be unable to provide quality care.
ED overcrowding has been documented in the Canadian medical literature since the mid-1980s and is known to exist in all provincial jurisdictions.
Though often characterized as an urban, teaching hospital phenomenon, overcrowding has been documented in both community hospitals and small rural hospitals.
While there tends to be heightened media awareness of ED overcrowding during the winter months, usually associated with outbreaks of respiratory illness, ED overcrowding is accepted by Canada’s emergency physician as an ever-present impediment to quality patient care.
More than a matter of mere patient inconvenience, ED overcrowding has numerous serious negative medical consequences including the potential for increased patient morbidity and mortality. It also places the general public at risk as a result of ambulance diversion and emergency service system gridlock.
In an era of heightened awareness of the public health consequences of new and emerging infectious diseases and concern with respect to bioterrorism, it is sobering to note that ED overcrowding has recently been implicated in the progression of the SARS outbreak in Toronto.(2)
Though multifactorial and complex in its causes, there is a clear understanding in the international literature that the principal cause of ED overcrowding is not the inappropriate overuse of the ED by patients with comparatively minor illness. Rather it rests with either an insufficient number of acute care hospital beds, the inappropriate utilization of same or reduced system flexibility to cope during periods of peak demand.(3)
As such, the cure for ED overcrowding lies not in the emergency department but rather in addressing the relative lack of acute care bed capacity in the hospital.
The problem of ED overcrowding can be solved. The tragedy is that rather than attempting to cure, we have applied mere management strategies.
As the president of the Canadian Association of Emergency Physicians has stated “we are allowing our patients to suffer unnecessarily”.
Wait times in Canadian Emergency Departments:
Acceptable wait times in Canadian Emergency Departments have come to be defined by the Canadian Emergency Department Triage and Acuity Scale (CTAS). (4)
The CTAS scale was developed by the Canadian Association of Emergency Physicians (CAEP) in 1998. The objectives of CTAS were to “more accurately define patients’ needs for timely care and to allow emergency departments to evaluate their acuity level, resource needs and performance against certain operating ‘objectives’.
Patients are assigned a triage level on initial registration in the emergency department based on the perceived urgency of their presenting complaint.
Patients are assigned to one of five categories according to level of urgency and, with each level, come an expected fractile response time indicating maximum waiting time for the type of complaint.
The five CTAS triage levels are as follows:
Level of Illness/Acuity
Nursing Response Time
Physician Response Time
In recognition of wide variations in demand for care and that ideals cannot always be achieved without unlimited resources, each triage level is given a fractile response objective. A fractile response is the proportion of patient visits for a given triage level where the patients were seen within the CTAS time frame defined for that level. Fractile response does not deal with whether the absolute delay for an individual is reasonable or acceptable.
This would mean that even though a Level 11 patient should be seen within 15 minutes it may only occur 95% of the time. Although Level V patients have been given a time response objective of 2 hours, the fractile of 80% means that patients may have to wait over 6 hours on occasion. Patient assessment errors may occur when waiting times are beyond the recommended response times.
The physician response time for CTAS Levels 1 and 2 are based on scientific evidence. The physician response times for all other levels is based on physician expert opinion and consensus and assumes ideal operational conditions.
The CTAS defined response times are, at present, guidelines only. There remain no articulated, enforced, minimum guidelines for operational performance for Canadian emergency departments.
CTAS is currently used in approximately 80% of Canadian EDs.
Causes of overcrowding: (3,5,6)
Lack of beds for admitted patients
a) the absolute shortage of acute care hospital beds
Increased waiting times for transfer to an inpatient bed has become the most important cause of ED overcrowding. (5,6)
An emergency patient who has been admitted to an in-patient clinical service must be “warehoused” in the emergency department until a ward or ICU bed becomes available. Such a patient, occupying a stretcher in the emergency department, denies, on average, four patients per hour access to the emergency department. Over an eight or twelve hour ER shift, thirty-two to forty-eight patients per hour are thus denied timely access to the emergency department. Multiply that one admitted patient by twenty or thirty patients, as is commonly the case in urban emergency departments and the real cause of overcrowding becomes readily apparent.
The Canadian Association of Emergency Physicians in their most recent position statement on overcrowding has stated that patients requiring hospital admission should be held in emergency departments, hallways or waiting rooms for more than 6 hours.(7)
Acute care bed capacity has been dramatically reduced in Canada over the past decade and this has contributed substantially to ED overcrowding.
Schull in his study on hospital restructuring in Toronto (8) concluded that hospital restructuring in Toronto resulted in a net reduction of acute care of beds with 30% of acute care beds closed between 1991 and 1997. No substantial increase in ED overcrowding occurred during that time presumably as a result of excess capacity, reduced demand or enhanced hospital efficiency. A further 14% were closed from 1998 to 2000 during which ED overcrowding worsened substantially.
In each year during the restructuring period, the occupancy rate of acute are beds in Toronto hospitals exceeded 90% and peaked at 96% in 2000.
A British study suggested that normal fluctuation in demand for emergency admissions will result in bed shortages and periodic bed crises if average acute care bed occupancy rises to 90%. (9)
CAEP in its position statement on ED overcrowding has suggested that hospital beds in Canada have been reduced by almost 40% nationally. (3)
b) the effect of the alternate level of care patient
Acute care bed capacity is also affected, in turn, by patients who require an “alternate level of care” (ALC) but due to shortages in home care resources or chronic care beds, must occupy an acute care hospital bed. These “bed blockers” contribute to the problem of ED overcrowding by preventing the admission of emergency patients to hospital beds. A recent Ontario Hospital Association survey of hospitals in Toronto revealed that ALC patients occupied an average of 10% of total staffed bed capacity. Some individual hospitals reported the percentage to be much higher, at 20-25%. (10)
c) the role of inappropriate bed utilization
Increasing acute care bed capacity or flexibility to respond to periodic fluctuations will have a have the greatest impact on reducing ED overcrowding.
Primary management strategies to improve operating efficiency and increase inpatient bed capacity in the face of overcrowding includes such administrative measures as the appointment of a bed management committee with definitive and broad-decision making capability. Efficiency measures to improve bed utilization include examining prolonged length of stay patients, implementing an “intent to discharge” policy, the development of discharge lounges, ensuring flexible bed designations and implementing a “30 minute rule” to improve the turnover of a recently vacated bed. (11,12)
Clearly, the adoption of appropriate bed utilization strategies should not be used only in a crisis mode. Hospitals, regional health authorities and government must begin to adopt and nurture a hospital culture that focuses on moving the “right patient” to the “right bed” within a reasonable time frame. (7)
2. Shortage of nursing and physician staff
Experienced and dedicated nursing staffs are considered to be the backbone of any emergency department.
There is a perception that there is a shortage of trained nurses to staff the nation’s EDs. This requires quantification. Many hospitals are choosing to staff the ED with par-time nurses to lower costs. This creates shortages within the ED as experienced personnel move into full-time jobs outside the ED. A corollary to this problem is the high staff turnover in some EDs, as a direct result of the frustrating working conditions associated with ED overcrowding. Both circumstances lead to a higher percentage of new, inexperienced emergency nurses who may not be as efficient in the delivery of emergency care. (5)
There is also a shortage of trained emergency physicians in Canada and the last decade has seen an increase in the number of media stories with respect to service gaps and ER closures on the basis of being short staffed.
Canada has less than 2,000 trained emergency physicians to meet the needs of 10 million Canadians who present to the nation’s EDs on an annual basis.
There are currently 394 Royal College certified specialist emergency physicians in Canada and 1198 family physicians who hold the Certificate of Special Competence in Emergency Medicine of the College of Family Physicians. (13) Given the significant attrition from the specialty with advancing age, there is concern that residency training programs, as currently structured, will not be able to fulfill future Canadian requirements.
Furthermore, it should be acknowledged that an estimated 4,000 family physicians provide emergency service to the significant number of Canadians who live in small urban and rural communities. Given the declining popularity of family medicine as a career choice, this may prove to be a significant negative factor in emergency service provision in the future.
Increased complexity and acuity of patients in the ED
As the population ages, there is a growing number of patients with chronic medical condition, such as diabetes, chronic obstructive lung disease and cardiovascular disease who require emergency services. These patients often require complex assessments utilizing advanced diagnostic technology to determine the need for hospital admission or further therapy.
Furthermore, the increasing proportion of ED patients with HIV/AIDS, drug abuse, homelessness and the de-institutionalization of the mentally ill have also had an impact on the complexity of cases encountered in the ED.
The increasing frequency of day surgery has led to increased visits to the ED for post-operative complications such as nausea and vomiting, poor post-operative pain management and wound infections.
Increasing home care availability should have an impact on this contributing segment of the overcrowding problem.
Intensive therapy in the ED
Advances in the scope of practice in emergency medicine have led to increasing lengths of stay in the emergency department. Thrombolysis for acute myocardial infarction, sedation for painful procedures and a new understanding of the need for more aggressive and prolonged therapy of asthma and migraine mean prolonged stays in the ED for some and denied access for those in the waiting room.
Many conditions that used to require admission for evaluation and treatment are now managed in the ED including chest pain evaluation (often 6 to 12 hours of observation and serial testing), evaluation of thromboembolic disease (deep venous thrombosis and pulmonary embolism), congestive heart failure, nephrolithiasis and infectious diseases such as pneumonia and pyelonephritis. This requires additional human resources, diagnostic utilization and prolonged occupancy of ED beds.
The disturbing corollary to this is that despite such knowledge physician compliance with clinical guidelines remains poor. (14) This leads to missed opportunities to improve bed utilization from the emergency department. (15,16)
Delays in service provided by reduced access to diagnostic services and specialty consultation
As a result of advancing technology and changing standards of care, more patients in the ED need ultrasounds, CT scans and MRIs, all of which lead to longer stays in the emergency department.
Specialist consultation is an integral component of emergency care. A shortage of specialists or delays in specialist response for consultation in the ED further contributes to prolonged stays in the department.
Do patients with minor illness contribute to ED overcrowding?
There is a well-entrenched myth that patients with comparatively minor illness are the cause of ED overcrowding. Indeed, influential health policy leaders, such as Romanow and Dechter have incorporated this myth into their ideology. (17,18)
It should be acknowledged that 42-55% of all emergency department visits involve nonurgent problems. (19) It is also well known that there is a shortage of family physicians in Canada and that orphaned patients often use the ED as a source of primary care. Given this knowledge and the enhanced media coverage of ED overcrowding during the winter season’s outbreaks of viral illness, there is a ready acceptance, by some, of the notion that patients with coughs and colds are overwhelming the system and should be treated elsewhere.
Furthermore, it is becoming increasingly apparent that declaring the nonurgent use of the ED as the “fashionable scapegoat for the ills of the health care system” (20) is not only misguided but can lead to inappropriate attempts to either restrict or divert access to the ED.
Emergency physicians, however, do not view nonurgent patients as the root of the overcrowding problem. To again quote the most recent CAEP position on overcrowding “non-urgent” patients “do not occupy acute care stretchers, require little or no nursing and typically have brief treatment times. They consume a fraction of ED resources, generate minimal incremental costs and do not displace patients who need emergency care”. (7)
The American College of Emergency Physicians report on overcrowding states that “non urgent emergency department use simply leads to overcrowding in the waiting room, not overcrowding in emergency department treatment areas.” (21)
To reiterate a basic truth, the problem of overcrowding is not an influx problem of large numbers of nonurgent patients who overwhelm the ED but rather an efflux problem of admitted patients who cannot leave the ED because there is no ward bed available to them. Their occupancy of an ED stretcher for prolonged periods of time denies others in the waiting room access to the treatment capabilities of the ED.
With respect to the role of minor patients in the ED, most experts in the field of emergency department administration discount the effect of the “inappropriate” emergency patient, the patient who seeks primary medical care from the ED, as contributing significantly to overcrowding. (3,5-7, 20-23)
Minor patients do not require an inordinate utilization of resources and require comparatively little physician time for assessment, diagnosis and treatment. Given the relatively fixed costs of ED operation, nonurgent patients do not cost the system more.
Furthermore, there is no agreement within the specialty of emergency medicine as to what constitutes an inappropriate visit. (24,25) There is even a danger in making judgments based on the perceived seriousness of the presenting complaint. Every emergency doctor has had the experience of the middle aged patient presenting with simple heartburn, only to eventually be diagnosed with a heart attack that leads to their death. It is accepted that patients who present within the lowest triage category will still have an admission rate of 5 – 10%.
There is also an increasing appreciation that the ED can provide acceptable primary care to segments of the population, with no additional cost to the system and equal healthcare outcomes. To the disenfranchised, homeless and de-institutionalized mentally ill, accessibility to care may be as important as continuity in assuring better health outcomes. (20,22,26,27)
Lastly, in those emergency departments funded on a fee-for-service payment mechanism (roughly half of the nation’s emergency departments), the nonurgent patient essentially provides funding to allow for physicians to continuously available for the critically ill.
Accepting the myth that nonurgent patients are the problem has led to considerable efforts to divert patients away from the ED in hopes of curing overcrowding. If these initiatives are aimed solely at solving overcrowding, they will ultimately be proven to be a tragic waste of health care dollars.
In Ontario, for example, ED overcrowding has been cited as the principal reason for provincial telehealth programs. This province wide initiative has an annual cost of $45 million. Its effect on ED overcrowding has never been evaluated.
Similarly, a universal influenza immunization campaigns was launched with a stated primary aim of reducing visits to the emergency department. The cost has been estimated at $38 million annually but recent reports have suggested no effect on ED visits. (28)
Lastly, many government leaders have suggested that primary care reform will, by providing more continuously available care, reduce unnecessary visits to the emergency department. Recent literature has suggested that even the much aligned “frequent flyer” patient, often felt to be the archetypical “orphaned” patient, in fact, usually has access to a designated and easily accessible family physician. The Canadian Medical Association in its document on primary care renewal has stated unequivocally that such initiatives will not impact on ED overcrowding. (29)
Though each of these public health initiatives may have merit in their own right, none have been proven to impact on ED overcrowding.
Effects of overcrowding: (3,5,6)
Overcrowding has a number of sequelae that negatively impact on patient care.
Poor patient outcomes
The overcrowded ED causes more than patient inconvenience; it places patients at risk of increased morbidity and mortality.
During times of overcrowding, emergency patients may experience prolonged pain and suffering unnecessarily because the ED staff is too busy to attend to them.
As physicians are seeing more complex, acutely ill patients, they often have inadequate time for proper patient assessments leading to an increased risk of medical error, poor outcomes and increased medicolegal risk.
There has been one study internationally that has observed a significant positive correlation between overcrowding and increased mortality. (30)
Canadians, however, do not have to scour the international literature.
The Canadian press archives have readily available, high profile stories that link untimely and unnecessary deaths directly due to ED overcrowding: Kyle Martin in Credit Valley Hospital, Mississauga in 1998; (31) Joshua Fleuelling in Toronto in 2000 (32), Vince Motta in Calgary in 2002 (33) and Dorothy Madden in Winnipeg in 2003.(34)
Long waits and patient dissatisfaction
An overcrowded ED will, by definition, lead to prolonged waits and increased patient dissatisfaction with the quality of care. The level of dissatisfaction is reflected in an increasing number of patients who leave without being assessed. In Ontario, in 1999, there was a 2% increase in the number of patients who left the ED without having been assessed by a physician.(Marion Lyver, EH Consultant, Ministry of health and Long Term care, Province of Ontario; personal communication, 2001)
The consequence of this is the potential for seemingly minor medical problems to become more serious from delays in care. The myth that patients who leave without being seen usually have minor, insignificant illness has recently been dispelled. (35)
Admitted patients in the ED utilize a disproportionate share of resources. They require 2.5 times more service from emergency physicians and nurses compared to the average ED patient. (36)
The overcrowding of EDs with inpatients results in an increased average inpatient length of stay with attendant increased costs per patient. (37)
The incidence of ambulance diversions has increased, especially in urban areas. The consequences are significantly increased transport times, limitations on system-wide response times, increased emergency health service costs and the potential for poor clinical outcomes. Patients suffer the inconvenience of discontinuity of care from their usual medical provider and separation from their medical record. Patients’ families often have to travel extra distances to visit. Paramedics may be tempted to misrepresent their evaluation of the patient in order to avoid a “redirect”. Of greater concern, when hospitals declare “redirect status”, the system relies on the field assessment by a paramedic that the patient’s condition permits the longer transport to another facility. (38,39)
The effects of ambulance diversion on clinical outcomes are studied and disturbing. Schull in his study of ED overcrowding and ambulance transport delays for patients with chest pain in Toronto has documented delays in treatment for myocardial infarction patients and suggested that there is a correlation with shortened survival of these patients. (40)
From a system perspective, system gridlock, with multiple hospitals in an urban area requesting ambulance redirects, limits the emergency health system to respond to public health emergencies and limits the effectiveness of any disaster response plan.
Contributing to infectious disease outbreaks
The recent experience of the Toronto EDs with the SARS outbreak has led some researchers to suggest that overcrowded EDs can contribute to infectious disease outbreaks. (2)
“The presence of one unrecognized SARS patient waiting for a ward bed in one crowded emergency department in Toronto created the epicenter of a city’s outbreak, which resulted in about 250 probable cases (about half in health care workers), 36 deaths, over 15,000 people quarantined (including large numbers of paramedics and hospital personnel), hospital and ED closures and a virtual shutdown of outpatient activity.”(41)
Violence in the ED is of increasing concern. A recent survey of health care workers in the ED revealed that 84% of respondents reported witnessing verbal abuse at least once per shift in the year before the survey. More than 20% recalled physical threats over 20 times in the year and over 50% had been physically assaulted.(42,43)
ED overcrowding, long patient waits, high stress illness and the noisy environment of the ED are felt to be factors that contribute to violence.
Decreased physician and nursing productivity
The many causes of overcrowding have had a contributory, cumulative and negative effect on emergency health care worker productivity. This leads to stress, burnout and the premature shortening of careers.
There have been a number of management strategies directed at ED overcrowding that have been developed and applied over the past decade.
Management implies an approach aimed at merely “managing” or containing a crisis rather than attempting to “cure” the root cause.
Management strategies have been in vogue in excess of a decade. Perhaps not surprisingly, in spite of the increasing use of such strategies, ED overcrowding continues to be an increasing problem in Canada.
Given the widespread acceptance of the myth that nonurgent patients are the major cause of ED overcrowding, most management strategies have focused on diverting the patient away from the ED.
In the community setting, this has led to such initiatives as public education campaigns, telehealth patient advisory hotlines, universal influenza campaigns and an almost religious belief that greater accessibility to primary care and its alternatives will lead to reduced utilization of the ED. There are no studies and little proof that suggests this to be the case.
In the emergency department sector, management strategies reflect surrender to the inevitability of overcrowded EDs. In the absence of a comprehensive, long term plan to increase hospital bed capacity, strategies have to be developed to cope with the never ending patient demand.
A number of management strategies have been employed:
Fast-tracking of nonurgent patients
The fast track system is an approach of treating both acutely and minimally ill patients in a parallel fashion within one geographic department. Fast track is thus an urgent care center within the confines of a hospital based ED.
They have been shown to decrease patient waiting times, increase patient satisfaction and allowing personnel who are involved in the care of acutely ill patients to dedicate their efforts to that group of patients while allowing the non-acutely ill to be seen and treated in the ED. (11,44-47)
Electronic patient tracking systems
Electronic computerized patient tracking systems are relatively newer innovations that monitor and track patients through their emergency department stay from registration, triage, assessment, investigation, treatment and discharge.
Individual patient location through the treatment process is displayed in real time on a central data board. Excess waiting times or delays in patient re-assessment are highlighted and allow such patients to be identified and re-assessed. (48,49)
This provides a safety factor to an overcrowded ED.
Studies have shown that a significant number of hospital admissions do not warrant acute care. As noted previously many conditions which used to require hospital admission can be managed through a period of observation and prolonged treatment in the ED.
The use of observation units allows the ED to reduce its number of admissions by creating a facility for observation of patients without formally admitting them to hospital. The observation is of short duration. Observation units may also be known as “clinical decision”, “short stay” or “chest pain” units. They provide the hospital the ability to determine if a patient who exhibits lower risk symptoms should be admitted on an in-patient basis and to evaluate and treat the patient in a timely manner. (50)
The ultimate goal is to improve the quality of medical care to patients through extended observation and treatment while reducing inappropriate admissions and health care costs.
Building bigger emergency departments
As emergency patient average lengths of stay increase, there is a natural inclination to want to increase emergency department stretcher capacity in order to maintain constant patient flow through the department. This has led to the suggestion that increasing emergency department size will solve overcrowding.
This strategy may be entirely appropriate for older departments where changing patient demographics (increasing population density, increasing patient volumes, the effects of aging) have overtaken the ability of the physical plant to meet patient demands. In others, however, increasing emergency department size is merely enhancing the “warehouse” capacity for admitted patients to spend further time in the ED.
All of these strategies are, in essence, crisis management. They accept the inevitability of overcrowded EDs and provide departments with coping mechanisms. They will not, in and of themselves, solve overcrowding.
Would there be a benefit to defining minimum operational performance standards for all ED?
ED overcrowding is caused by an insufficient number or inappropriate management of acute care hospital beds. The solution therefore rests beyond the confines of the emergency department.
Nevertheless, it would be beneficial to define and articulate minimum performance expectations to ensure the maximum operating efficiency and accountability of the emergency department.
No such performance standards exist. (51)
In the 1981 and 1988, Health and Welfare Canada published Guidelines for Emergency Units in Hospitals that outlined management issues for the broad spectrum of emergency departments that existed in Canadian Hospitals. (52,53) There were no performance parameters or benchmarks. There was no enforced compliance.
With the transfer of control of health care resources to the provinces, the issue of emergency department standards became a provincial concern.
In 1989, the Ontario Ministry of Health introduced a “standards” document entitled Guidelines for Hospital Emergency Units in Ontario. (54) They were, and remain, the only province to have attempted such an undertaking. As with the federal government, the guideline focused on broad management issues with no benchmarks or enforceable compliance factors mandated.
A 1990 survey of compliance with the recommended guidelines revealed that fully 50% of Ontario’s 200 emergency departments did not meet an admittedly minimum standard. (55, 56) There were deficiencies noted in administration, staffing, and equipment.
New standards for Ontario’s emergency departments have been considered since 1998 but six years since the initial draft, they remain incomplete, unpublished and not enforced.
In 1997, the Canadian Association of Emergency Physicians released its “Recommendations for the Management of Rural, Remote and Isolated Emergency Health Care Facilities in Canada”. (57) This document focused on the previously ignored rural emergency department but again had no articulated performance benchmarks. They were never implemented nationally nor endorsed by federal or provincial governments.
The Canadian Council on Health Services Accreditation (CCHSA) is responsible for hospital accreditation in Canada, and in every onsite review, the ED is considered a mandatory area for evaluation. The CCHSA, however, does not have a set of accreditation standards specific for the ED.
This raises the question as to whether any Canadian emergency department can truly be proven to be operating efficiently.
There remains no articulated common understanding across Canada as to the required number of physicians and nurses required of an ED based on patient census and acuity. There remains no universal acceptance that CTAS response times as an operating standard. There is no clear understanding as to what constitutes an acceptable level of overcrowding or ED wait times before the mandatory commitment of increased physician staffing. There is no consensus of the training requirements for emergency physicians and nurses for a given level of emergency department. The minimum equipment, formulary and diagnostic requirements remain ill-defined. Furthermore, there are no clearly articulated performance benchmarks for each level and type of emergency departments.
In order to be ultimately able to measure and compare the performance of one ED against another or a gold standard, there must be the uniform institution of electronic information systems and the development of a comprehensive ED data set that is standard for all EDs. (58)
What would be the performance expectations of a rural emergency department?
There can be no doubt that rural emergency departments must be judged differently with respect to their abilities to bring human resources and the required technology to bear on a defined clinical problem.
Rural EDs are not a uniform entity. The CAEP document identified five levels of rural emergency health care facility and outlined the expected human resources and diagnostic, therapeutic and formulary requirements for each level of facility. (57)
It should be noted, however, that emergency facilities should not be viewed in isolation. In Canada, the patient should, on registering in an ED, be entering a regionalized system of care, where the patient’s needs determine the most appropriate location for service delivery.
If a given clinical problem exceeds the capabilities of a given ED, the patient should be expeditiously transferred to the next most appropriate level of facility.
Most true emergencies however, do not have a high technological demand and can be stabilized and managed in the most basic of EDs.
ED response times for true emergencies should not be a matter of geography. Canadians have a right to a defined minimum standard of emergency care when they visit a facility that purports to be an emergency department. A heart attack victim should be assigned the same clinical priority and given the same access to thrombolysis in Moncton, Montreal or Moosejaw.
The acceptance of CTAS suggested response times, for all but Level V patients, has been accepted by the Society of Rural Physicians of Canada. (59)
Solving the problem of ED overcrowding:
ED overcrowding is a chronic, systemic public health problem that constitutes a threat to the safety and well-being of the 10 million Canadians who visit the ED on an annual basis. In its most extreme form, that of system gridlock with multiple city hospitals requesting ambulance redirect consideration, overcrowded EDs compromise the ability of the urban hospital system to disasters and other public health emergencies.
It is the belief of Canada’s emergency physicians and nurses that ED overcrowding can be solved and does not constitute a necessary evil. Curing overcrowding will require a willingness to look beyond the emergency department and examine system issues that lead to access block for acute care hospital beds.
Solving overcrowding will require political will.
The following is a proposed list of prerequisites to allow governments and health care providers to finally come to grips with a problem which has been allowed to exist for far too long.
Acknowledge that ED overcrowding is a national public health emergency
The prolonged waits associated with ED overcrowding cause more than mere patient inconvenience; overcrowding has direct negative effects on the well-being and safety of patients and is associated with increased mortality rates. Ambulance diversions, a direct effect of overcrowding, lead to inadequate system response to emergencies and threaten the ability of an emergency system to respond to disasters and other public health emergencies. Overcrowding may contribute to the spread of new and emerging infectious diseases.
It is time, indeed, well over due, to devote the appropriate time and resources to solving this threat to the well-being of the Canadian public.
Recognize that the cause of ED overcrowding generally lies outside the ED
ED overcrowding is a symptom of system failure. Solutions to ED overcrowding will require increasing the number and more efficient use of hospital beds, both acute and chronic; improving the community care options for the elderly and the chronically ill to ease the problem of “bed blockers” and provide better access to diagnostic, surgical and acute care services.
Increase the capacity of hospitals to provide in-patient, critical care and long term care beds
It has been acknowledged by international experts of ED administration and our national emergency physicians and nurses associations that ED overcrowding is primarily the result of a shortage of inpatient beds, not a lack of ED capacity.
Hospital beds in Canada have been reduced by approximately 40% over the past years. Overcrowding in EDs exists only when bed occupancy rates exceed 90%. Alternate level of care patients, the so-called “bed blockers” occupy about 10% of total hospital bed capacity. Providing sufficient acute care beds to allow average bed occupancy to 85% and reducing the number of ALC patients would go along way to solving overcrowded EDs.
The correct solution to overcrowding therefore is in increasing the number of in-patient beds, either absolutely or through improved utilization of same, to prevent the “warehousing” of admitted patients in the ED. It is these patients that lead to overcrowded ED waiting rooms and prolonged wait times in the emergency.
Increase the system awareness of appropriate bed utilization strategies and link hospital funding to compliance
There are well established principles for the appropriate utilization of acute care hospital beds. These strategies are often inconsistently employed and often only when a hospital is in a “crisis” mode. Hospitals should be made aware of appropriate bed utilization strategies and should have their funding linked to both compliance and length of boarding times in the emergency department.
Implementation of the Canadian Emergency Department Triage and Acuity Scale (CTAS) in all Canadian emergency departments.
CTAS guidelines are not universally recognized in all Canadian jurisdictions. CTAS response times should be accepted as a national standard and the dedicated funding should be linked in order for EDs to meet the recommended fractile response times.
Minimum operational performance standards should be articulated and defined for all Canadian EDs.
There are currently no defined, articulated or enforceable minimum performance operational standards for EDs in Canada. To guarantee their maximum operational efficiency and to enhance accountability, performance standards should be defined for Canadian EDs.
The Canadian Association of Emergency Physicians has identified the need for such standards and has clearly expressed a willingness to participate in the process of standards development.
7. Institute a national human resources strategy to define the requirements for trained emergency physicians and nurses for present and future needs
There currently is no clear understanding of the number and training of emergency physicians and nurses to meet both our current and future needs. There is an urgent need to study and quantitate the human resources component required of an efficient and effective emergency health care system.
8. Dedicate funds for research, development and promotion of clinical practice guidelines to guarantee maximum ED operational efficiency and the appropriate utilization of acute care hospital beds
Physician compliance with clinical practice guidelines is generally considered poor. It has been shown that some clinical practice guidelines lead to an improved quality of patient care, speedier and more efficient use of ED resources and cost savings to the health care system. Dedicated funding of research, development and implementation of clinical practice guidelines for emergency medicine may lead to efficiencies in both ED care and acute care bed utilization. (60)
9. Implement computerized data bases so that ED managers can analyze visit volumes, acuity profiles, admission rates, waiting times and boarding times in the ED.
Quantitative data is required to characterize the magnitude and extent of the overcrowding problem and in order to compare the efficiency of one ED to another.
The Canadian Association of Emergency Physicians has formed a national working group on Canadian Emergency Department Information systems (CEDIS) to address the issue of electronic information systems for EDs and to develop a comprehensive emergency department data set that is standards for all EDs. Their work should be supported.
Electronic patient tracking information systems, though not a solution to overcrowding, will lead to increased patient safety. The potential for their more widespread implementation should be evaluated.
Emergency department overcrowding is a national public health problem that threatens the well-being and safety of all Canadians.
Emergency department overcrowding is a symptom of a system failure. The health care system has failed to recognize and anticipate that the drastic reductions in acute care hospital bed capacity, over the past decade, without the simultaneous restructuring of home care services and chronic care delivery, would have a profound impact on the ability of the system to provide emergency care.
Rather than attempting to divert patients away from the emergency department, the solution lies in increasing acute care hospital bed availability either through increasing capacity, flexibility or through the adoption of appropriate bed utilization strategies.
Rather than attempting to manage the problem, efforts should be made to cure overcrowding. Above all this will require political will.
Canadians have a right to timely access to quality care when faced with an emergency. Canadians should wait no more.
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