With the resurgence of the flu this winter, the media has focused in on patients with viral illness flooding the emergency departments across Canada.
To be sure this is a problem for everybody. High volumes in the emergency departments and prolonged waits for miserable people in crowded and congested waiting rooms can hardly be considered ideal.
It should be noted that flu season is limited to a few weeks or months in any given year and yet emergency department crowding is a chronic, non-seasonal problem.
The unstated inference from the media reporting is that patients with non-urgent problems contribute significantly to the chronic and entrenched daily problem of ED crowding in Canada.
This mythology has certainly been supported by provincial governments of all stripes who cannot seem to understand that non-urgent patients do not cause crowding. Crowding is a problem of bed availability for boarded sick people in the emergency department causing a lack of treatment capability in the emergency department.
As a result, historically most provincial health authorities have focused their efforts on resolving crowding by promoting policies that divert patients away from the ED. No wonder crowding is still amongst us!
The rallying cry seems to have been “keep those snotty, coughing, puking, myalgic people from the ER” or “Emergency departments are for really sick people.”
It would be wise to remember however that for some, influenza is not a benign illness and has a significant mortality and morbidity in those with chronic illness.
We should also be quick to debunk the mythology of the non-urgent problem as being the scourge of the emergency health care system. Alllowing it to be propagated allows health authorities to continue to go down the wrong path in addressing the ED crowding issue.
Every emergency physician will be able to tell you of the CTAS Level V patient (non-urgent) who ended up being admitted to hospital. In fact, from 5 to 10% of CTAS V patients end up being admitted.
The emeregncy department raison d’etre is to look after acutely ill and injured people but they have NEVER been exclusively there for the CTAS Level I and IIs.
Look at our Ontario provincial volumes by CTAS Level:
CTAS I (really gravely ill): 1-5% of patient volumes
CTAS II (sick): 15-20% of annual patient volumes
CTAS III (might be sick, might not, hard to be sure at first glance): 40%
CTAS IV ( minor problems perhaps but not to the person willing to endure a six hour wait): 30-35%
CTAS V (just what the hell are you doing here?): 5-10% (greater % in rural hospitals)
So emergency departments in Ontario, all 150 of them and indeed in Canada, all 850 of them, give or take a few, on a really bad day see a very small per centage of seriously ill or injured. It is not “Emergencies only”; not now and likely not ever.
Indeed, in those departments that don’t have the wisdom to be on a salaried basis (and there are a lot), high volumes of low acuity patients allows the presence of a full time emergency medical staff to be available to see those occasionally really sick patients who come througfh the swooshing doors. Think about it!
Lastly, we have Dr. Michael Schull of Toronto to thank for his landmark paper on the effect of low complexity patients on ER wait times to put the final nail in the coffin:
The effect of low-complexity patients on emergency department waiting times.
Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada. firstname.lastname@example.org
The extent to which patients presenting to emergency departments (EDs) with minor conditions contribute to delays and crowding is controversial. To test this question, we study the effect of low-complexity ED patients on the waiting times of other patients.
We obtained administrative records on all ED visits to Ontario hospitals from April 2002 to March 2003. For each ED, we determined the association between the number of new low-complexity patients (defined as ambulatory arrival, low-acuity triage level, and discharged) presenting in each 8-hour interval and the mean ED length of stay and time to first physician contact for medium- and high-complexity patients. Covariates were the number of new high- and medium-complexity patients, mean patient age, sex distribution, hospital teaching status, work shift, weekday/weekend, and total patient-hours. Autoregression modeling was used given correlation in the data.
One thousand ninety-five consecutive 8-hour intervals at 110 EDs were analyzed; 4.1 million patient visits occurred, 50.8% of patients were women, and mean age was 38.4 years. Low-, medium-, and high-complexity patients represented 50.9%, 37.1%, and 12% of all patients, respectively. Mean (median) ED length of stay was 6.3 (4.7), 3.9 (2.8), and 2.2 (1.6) hours for high-, medium-, and low-complexity patients, respectively, and mean (median) time to first physician contact was 1.1 (0.7), 1.3 (0.9), and 1.1 (0.8) hours. In adjusted analyses, every 10 low-complexity patients arriving per 8 hours was associated with a 5.4-minute (95% confidence interval [CI] 4.2 to 6.0 minutes) increase in mean length of stay and a 2.1-minute (95% CI 1.8 to 2.4 minutes) increase in mean time to first physician contact for medium- and high-complexity patients. Results were similar regardless of ED volume and teaching status.
Low-complexity ED patients are associated with a negligible increase in ED length of stay and time to first physician contact for other ED patients. Reducing the number of low-complexity ED patients is unlikely to reduce waiting times for other patients or lessen crowding.
- If you want to fix crowding, start by fixing your hospital. [Ann Emerg Med. 2007]
There you have it. The non-urgent patient does not cause crowding. As such they are not the problem. They are a problem in that they are frustrated, miserable and are denied timely access to care but they didn’t cause it.
So let’s not get caught up in the madness of the moment. Yes it is chaos but it will still be chaos come June!