… — … LWBS …—… ER inpatients …—… EMS park …—… Overcapacity

In Commentary, Opinion by Nadim Lalani2 Comments

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We had our inaugural residency retreat last month! Our guest speaker was Dr Paul Parks – a humble affable family man and Emergency Physician who was unwittingly thrust into the public eye after Emails were leaked documenting failures in the Alberta Health Care system resulting in ER “suboptimal outcomes”.

Dr Parks and colleagues documented what they felt were deleterious outcomes in patients in the waiting room of  the University of Alberta Hospital ER in Edmonton. They sent these to the ‘higher ups’ [click on link above to see them for yourselves] to try and advocate for better care of ED patients. The emails got leaked to the media and the outcome was a veritable sh#t-storm.

The topic couldn’t be more topical given that overcrowding in our hospitals made the newspaper headlines. I didn’t need to read the newspaper article – I worked  that day. We did in fact have 3 docs on and 3 capable residents, but nowhere to place the patient so that we could examine them – the result was painful waits. But I digress …

Paul wanted to share some of his experiences in Alberta in order to help us learn about ED Overcrowding [EDOC]. Here’s the main thing … The name itself implies that the problem is with the ED – THIS IS WRONG.

EMERGENCY DEPARTMENT OVERCROWDING IS NOT AN EMERGENCY DEPARTMENT PROBLEM.

EMERGENCY DEPARTMENT OVERCROWDING IS A SYMPTOM OF THE SYSTEM NOT FUNCTIONING.

TINKERING WITH THE ER ISN’T GOING TO FIX THINGS

We should stick to the proper term and call it like it is … ACCESS BLOCK [for more info you can download this PDF on ACCESS BLOCK]. Access Block is what causes EDOC and it’s NOT the ER’s Problem. That is the ER is not to blame, but simply the place where the problems manifest themselves. Tinkering with the ER is only treating the symptoms NOT the underlying disease.

For example … lets assume that you go to your favourite steak-house. On this day, the kitchen is short one cook and there’s a bunch of large tables that are taking their sweet time. Moreover two other popular steak-houses in town have also just closed. The result is that the waiting area [by the hostess-stand] is overflowed and people are lined up out the door. It’s going to be a 1 hour wait minimum to get seated.

Do you think that the cause of the problem is that there’s not enough space by the hostess-stand for people to wait?

Do you think that you can reduce the wait-time for your meal by making the hostess see you faster to record your name?

I think not … There’s one last bit.  You get your name down successfully and while  you’re waiting for tables to open up, you keep getting bumped by V.I.P’s [EMS traffic, strokes, heart-attacks, trauma cases] … So your ‘1 hour wait’ turns into a nightmare! But wait! … this isn’t a meal!  – like most people in the ED… you’re actually sick, you NEED to be there [get the Canadian Association of Emergency Physicians Position Statement here]… you can’t just pack it  in and go to the burger drive-through.

ED Overcrowding is like the area by the hostess stand. We are the hostesses and waiters who try and serve you as best we can.

BUT… if we’re short a cook [no inpatient beds to admit people] that means it takes longer for people to admitted [in Alberta it was as long as 72 hours – I worked there]

AND if people need to see specialists and are waiting in ‘your’ bed for the consult [like those people taking their sweet time] … there’s NO TABLES to seat you at. That means you wait. Like the steak house , we can’t guarantee when tables open up. And when VIP’s come in  … you wait longer.

You can’t fix this by tinkering with the hostess stand [In truth – ER’s have been adapting all along – things would be way worse if we weren’t making these constant changes].

You need more cooks [i.e freeing up acute care beds – read the CJEM paper on this here] and you need to clear out the customers that are ‘camping out’ [more efficient through-put for consulted and admitted patients]. It would help if there were more steak-houses in town too [access to GP’s offices and walk-in clinics] – but this is a small part of the problem.

For a comprehensive review of ED Overcrowding in Canada by some very smart people [actually published in 2006- [i.e. pre-sh#t-storm]] Click Here

You know – we get it. There’s not infinite money in the system. But it’s not more money the ER needs, its to have the rest of the system realize that the ER is everybody’s responsibility. The system needs to work so that we can do what we do best – save lives, seek out a diagnosis and treat your symptoms.

What can you do to change things?

1) Educate. Your top brass [and consultant colleagues] might have no clue about access block and how lack of access to long-term care and inpatient-flow-inefficiency has down-stream effects. DO THIS IN WRITING [showing stats is good]. Educate your patients/friends so that they can carry the message.

2) Try and get a commitment for local/provincial government for benchmarks. Again –DO THIS IN WRITING AS A GROUP [Less easy to target than a lone doc]. The CAEP benchmarks are a good start for legislating wait times  6-8 hours for those coming in- this is the most important benchmark. Ask your patients/friends to put pressure on government too.

3) MOST IMPORTANT – WE NEED TO PUSH FOR MORE PUBLIC LONG-TERM CARE BEDS. [More private care homes are NOT the answer]. The real problem behind ED OVERCROWDING IS NO ACCESS TO LONG-TERM CARE. These patients choke up beds on the medical wards [at three times the cost of a public long-term care bed] … when there’s no beds upstairs … your granny waits in the ER … when she waits in the ER … there’s no room to see other patients. This is only going to get worse … Grey Tsunami is coming!

Nadim Lalani

Nadim is an emergency physician at the South Health Campus in Calgary, Alberta. He is passionate about online learning and recently made a transition into human performance coaching. He is currently working on introducing the coaching model into medical education.