The state of Emergency
Eastern Health ER data
January 26, 2013
Province’s strategy to reduce ER wait times could be better, experts say
“Many myths exist as to the causes of emergency department overcrowding, including overuse by non-urgent patients and seasonal outbreaks.”
— From the 2006 Ontario-based report Improving Access to Emergency Care: Addressing System Issues
An ashen-faced man lies loosely covered by a blanket on a gurney in the corridor of a hospital. His mouth hangs open slackly and his breathing is shallow. One arm is dangling down and has to be sidestepped by the medical personnel rushing by.
On a gurney behind him — there’s seven on this particular day, lined up on both sides of the hall like train cars — a jaundiced looking elderly woman is attended by two paramedics and a relative. There is barely room for them to stand next to her bed in this busy thoroughfare.
The people on the gurneys have been admitted and are waiting for beds in other units of the hospital. But those beds are scarce and they could be in the corridor for days, with no privacy, constant bright lights and scant opportunities to salvage their dignity.
There is nowhere to put personal items, clothes or toiletries, and a trip to the washroom can mean trying to clutch your hospital gown together for modesty’s sake as you navigate the maze of corridors, that’s provided you’re able to do so.
Welcome to the emergency department at the Health Sciences Centre, where this scene unfolds with unfortunate regularity.
It’s a problem this province is trying to tackle with a five-year strategy, but is it taking the right approach?
The Department of Health says its strategy was developed, in part, by working closely with the Canadian Association of Emergency Physicians (CAEP).
That came as a bit of a surprise to Dr. Alan Drummond, chair of CAEP’s public affairs committee and a past CAEP president.
He is an emergency physician and a hot-blooded advocate for addressing overcrowding in emergency departments and, indeed, he contributed to the Ontario report quoted at the beginning of this column.
He says his close working relationship with this province consisted of approximately an hour’s conversation.
“To say they had a close relationship with CAEP … I think that’s a bit misleading, to be honest,” he said.
Dr. Howard Ovens, the lead adviser to the Ontario Ministry of Health on its strategy for addressing emergency department wait times, says it was suggested by CAEP that the Newfoundland and Labrador government speak to him, but he was on vacation at the time and was never consulted.
Ovens contacted me after I wrote about emergency department wait times in last week’s column, as did Drummond, and both offered frank assessments of our provincial strategy.
Both were mystified that the Newfoundland Department of Health hired a Virginia-based consulting firm to review its two busiest emergency departments.
That consultant, X32 Healthcare, says on its website that it is in the business of “Creating World-Class Emergency Departments … through lean healthcare educational courses and consultation designed to improve throughput, quality, efficiency, and financial performance …”
“The people in Virginia, with all due respect, I don’t think would have had the experience that we’ve had here in Canada,” Ovens said. “The Americans don’t have a publicly funded health system to the extent that we do. They don’t speak the same language.”
Drummond was dumbfounded: “You go to America for advice when there are positive Canadian experiences that you can draw on?”
Doing it right in Ontario
One of those positive experiences is the province of Ontario, where Ovens said the key was “Taking responsibility for the problem, both at the hospital level and the government level.”
The focus there is on measuring the problem, collecting data and reporting it publicly, and offering incentives to emergency departments that make improvements.
As one example, The Toronto Star reported on Wednesday that St. Joseph’s Healthcare hospital in Hamilton “managed to cut the average length of stay for patients coming into the ER and who don’t require admission to an in-patient bed to 3.7 hours from 5.8 hours. And the time from arrival at hospital to initial physician assessment has dropped to 30 minutes from 3.7 hours.”
Still, Ovens acknowledges that the Newfoundland strategy contains “some steps in the right direction.”
The two biggest emergency departments in St. John’s — at the Health Sciences Centre and St. Clare’s — are now collecting wait time data and wait times have lessened in the past three years. Fewer patients leaving the emergency departments without having been seen. Physician hours and nurse practitioner hours have been boosted and patients are being fast-tracked. The emergency department at St. Clare’s is being expanded.
Newfoundland’s strategy also acknowledges that overcrowding in emergency departments is a complex problem that requires a multi-pronged solution.
But moving patients through the ER in a more efficient manner doesn’t matter much if there’s no bed to put them in if they need to be admitted.
We still have too many sick people on gurneys in the hall and too few hospital beds.
So there are flaws in the wait time strategy, as well — hopefully ones that won’t prove to be fatal.
For one thing, the Newfoundland strategy is big on diverting people away from the emergency department and it perpetuates the notion that “high volumes of low-urgency patients can create overcrowding in an emergency department and lead to longer wait times.”
Research says otherwise.
As the Ontario report notes, “Proportionately more patients with complex multi-system disease are being seen in Ontario’s emergency departments; the highest visit rate is now in the 75 and older age group.
“In order to relieve the burden on emergency departments and the health-care system as a whole caused by an aging population, it is imperative that access to care, including emergency care, be improved.”
We’ve got our own aging population here with the accompanying complex health problems. These are not “low-urgency” patients we’re talking about.
Drummond calls the theory that low-urgency patients contribute to overcrowding “total garbage,” and says it places the blame for poor service on the patients themselves.
“Does anyone in their right mind take a screaming child to Emerge to sit in a shitty patient waiting room for hours on end? … The whole notion of guilting the patient? I’m sick of it. It’s just rhetoric — hackneyed and old and tired. We’ve heard this all before.”
And Ovens cautions, “Encouraging patients to use alternatives to the (emergency department) is at best a small part of the solution.”
Drummond says overcrowding in emergency departments is about bed utilization and bed capacity.
He also disputes the idea that seasonal flare-ups of flu cause overcrowding in emergency departments.
“Crowding is a chronic, daily problem across this nation,” he said. “Crowding is a 52-week problem. Flu season lasts four weeks.”
Drummond said such myths lead to “the wrong diagnosis and therefore the wrong prescription.”
And so, until this province addresses the shortage of beds in other parts of the hospital, emergency department halls will continue to overflow.
Adding more physician spaces at the medical school and providing a tele-healthline, as we’ve done in this province, won’t solve the problem.
As Ovens points out, most people who call healthlines have no intention of going to the emergency department, but may wind up being urged to do so by the medical professional at the end of the line who is worried about liability issues.
“We can let people quietly suffer or we can do the right thing,” Drummond said.
“The reality is, if you really want to solve crowding, you’re going to have to address hospital bed capacity, and that costs a gazillion dollars. I think it comes down to dollars and cents.”
Patients at risk
Drummond says having people waiting on gurneys turns crowded emergency departments into something they’re not meant to be — makeshift wards where nurses trained specifically for emergency care are handing out meal trays and performing other unrelated duties.
“It becomes a ward and it becomes an inadequate ward,” Drummond said.
Too many patients and not enough beds can lead to emergency department situations where “pain is mismanaged, there’s an increased risk of complications and death, and increased costs to the system,” he added.
“You are forcing our elders — who we should be respectful to for the Canada they built — to suffer unnecessarily. There’s no toileting, no privacy, no dignity.”
But there are solutions and examples to follow.
Ovens, who’s the director of the Schwartz/Reisman Emergency Centre at Mount Sinai Hospital in Toronto, explained how some emergency departments in Ontario have implemented rapid assessment zone (RAZ) units — a development he calls “the most important strategy that’s emerged internal to emergency departments in the last five years.”
The old model, Ovens said, was that if you needed to lie down during an Emerge visit, you stayed lying down; you owned that bed or gurney for the rest of your stay.
“RAZ units have an internal waiting room and a couple of individual examining rooms,” he said, adding that ambulatory patients who require an examination and testing need not spend their whole visit lying down, but can be examined and then take a seat to await the results. That frees up valuable emergency department bed space.
We should be aiming higher
“I think we’ve had a very successful experience in Ontario,” Ovens said.
“We had the advantage, in 2008, of looking to the U.K. (for inspiration.) With all due respect to you in Newfoundland, you have an opportunity to do better than Ontario because of our experience.”
Ovens and Drummond were both perplexed as to why the Newfoundland government didn’t follow — and build upon — Ontario’s lead or other Canadian success stories when it developed its strategy.
Perhaps it’s not too late to make changes.
One thing’s for sure: blaming non-urgent patients for being part of the problem won’t solve anything.
Nor will being condescending to the people needing care.
As one of its goals, the Newfoundland strategy states: “Patients need to be educated that wait times are based on urgency and not the order in which they register. Patients also need to understand that unplanned and urgent events, such as a motor vehicle accident or a cardiac arrest, will impact their wait time.”
Is there anyone here who didn’t know that already?
This province needs to adjust its approach or the strategy ultimately won’t succeed — not in five years or 10. We have proven strategies in Canada that this province could adopt.
Ovens puts it best.
“It’s a public health priority to fix (emergency department) wait times,” he said, “and there is no excuse for failure, as there are examples of success.”
Pam Frampton is a columnist and
The Telegram’s associate managing editor. She can be reached by email at