I entered the field of Emergency Medicine because of its fast-paced, adrenaline-inducing environment where I’d be able see a wide array of medical problems and still make a tremendous impact on patient care. As an Emergency Physician I would become an expert in resuscitating the critically ill and managing acute undifferentiated patients. I quickly learned that this actually encompassed a small segment of the patient population served in our tertiary care Emergency Department (ED), with a large proportion of the patients being of the non-urgent variety.
My experiences thus far as a senior resident, just over the halfway mark in my five-year training program, have been remarkable, but I have also encountered many challenges. One of the biggest challenges has been dealing with the ever-looming issue of ED crowding, specifically patient wait times, and the subsequent declines in patient satisfaction and ultimately, patient outcomes. The large numbers of the aforementioned “non-urgent” patient presentations are simply the tip of the iceberg when approaching the multifaceted problem of departmental congestion.
Emergency Department Overcrowding
ED overcrowding has become a frequent and significant occurrence nationwide and in many departments, has become a chronic issue with a substantial impact on patient care. According to the Canadian Agency for Drugs and Technologies in Health Assessment Series on Canadian Emergency Department overcrowding, ED overcrowding is defined as “a situation in which the demand for emergency services exceeds the ability to provide care within a reasonable time” (1). This problem can impact both ED staff and patients in a variety of ways. It is unfortunately a system-wide issue with no clear, simple solutions. As our focus grows more and more on how to improve the system and provide more timely care, we need to take a step back and reassess the cost of such an endeavor – not merely in terms of monetary value, but more specifically, by the impact on the quality of the care we are able to offer our patients.
Waiting in the emergency department
In all realms of life, we must wait. We wait in line for our caramel macchiato at Starbucks. We wait, bumper to bumper, in horrific traffic during rush hour. We wait through, what sometimes feels like hours, of commercials to see what happens next on Grey’s Anatomy, or Walking Dead, if that’s more your flavour. Bottom line, waiting is a fact of life – we do it every day. The important distinction, when discussing waiting times in the ED, is that sometimes, these long waits can be detrimental to one’s health. Hence the creation of the triaging system! Laypeople unfortunately have difficulty comprehending our triaging system, where their needs are based on assessment of medical complexity and urgency rather than the sequence in which they have shown up to the ED. This then causes increased frustration and a decline in overall patient satisfaction, projection of these displeasures on the health care team and subsequent frustration among the nurses and physicians caring for the patient. It’s unfortunately become a small yet significant cycle of stress and discontent, which simply compounds the problem.
Canadians make approximately 16 million visits to EDs each year, and more than 1 million of these result in inpatient hospital admissions (2). In ED patient satisfaction surveys, waiting time is one of the most frequently stated concerns of patients and their families. Interestingly, in most studies waiting time ranks above any concerns with the actual treatment the patient has received or any problems encountered with staff communication or behaviour (3). In the recent international health survey sent out by the Organization for Economic Cooperation and Development (OECD), Canadians were found to wait longer than most other countries when it comes to receiving medical care (4). We pay more, yet wait longer. Many strategies have been employed to help address this issue but it still remains in the forefront as one of the top issues of our health care system.
Most of us are familiar with the nationwide media coverage surrounding the 41 year old male from West Kelowna BC who drove his truck into the Emergency Department due to his growing frustration in waiting to receive care for his complaints of mental illness. Most are also familiar with the horror story of the man who died in the Winnipeg ED waiting room after waiting for over 34 hours to see a physician. These are extreme examples but the frustration surrounding these cases resonates with many who have had the misfortune of waiting countless hours in one of Canada’s overstressed EDs.
Addressing the issues
Several factors need to be considered when attempting to tackle this problem. Everything from the first encounter at triage, movement into the department, time to actually see a physician, time to diagnostic imaging and various testing, time to consultation and then disposition – each step needs to be examined individually. Patients cannot move up to a ward bed if there aren’t any available. They can’t get that ultrasound right away if the porter is held up elsewhere or if the technician is unavailable. A patient cannot physically be moved to an ED bed if they are all occupied. Every step is just as important as the previous and the next. All are possible barriers to accelerating patient disposition.
An interesting notion is rerouting the patients to different hospitals that perhaps have not yet exhausted all of their personnel and resources. Our technological era has given rise to a new approach of consumer choice in the realm of healthcare. Websites and cell phone applications have been developed to provide patients with “up-to –the-minute” updates on ED wait times. This is truly a novel and interesting concept: let the patients know ahead of time what to expect before they show up at our doorstep. Since this is a new endeavor, there are certainly many anticipated problems with this system. First, the wait times posted do not take into consideration a possible surge in patients presenting to the ED. Jouriles and colleagues specifically addressed this problem in their article looking at correlation between posted and actual patient wait times (5). They found that EDs that saw over 2000 patients a month, which our hospital certainly does, could not accurately predict patient wait times. Additionally, the wait times do not take into account triaging. What I mean by this is that the wait time posted gives an average time and is not based on the urgency of the complaint. The patient with chest pain will likely be seen sooner. And the patient with a small hand laceration will logically wait longer. Many hospitals across Canada have employed these websites and apps in an attempt to provide their communities with more information and hopefully decrease the number of patients in their waiting rooms. Whether this has made any impact on our system or even patient perceptions of our system is yet to be determined.
Our population is aging and expectations of the health care system are growing. Patients are demanding faster care, easier access to imaging modalities and prompt diagnoses. ED overcrowding has been an issue in Emergency Medicine in Canada for over 20 years and the problem continues to grow. The Canadian Association of Emergency Physicians (CAEP) put together a position statement and set of national benchmarks on waiting times in a hope to provide manageable goals for patient care across the country (6). In addition, they put forward a list of potential solutions that can be utilized as needed by each individual hospital system. Despite media coverage demonstrating the “real” problem is in dealing with the number of patients in the waiting room that need to get past our pearly gates, the CAEP position statement notes that our biggest issue is in securing beds for patients admitted through the ED, thus producing a situation we call “access block”. With our hospitals increasingly facing the situation where more patients require admission than there are beds in the hospital to accommodate them, the ED is inappropriately being used as a kind of “patient warehouse” or storage facility. This issue then, like a rippling effect, translates down to the waiting room because there simply is nowhere for these patients to go. The Ottawa Hospital has created a taskforce to identify all potential barriers to patient assessment and disposition and then to implement strategies to improve the flow and quality of patient care delivered in our department. This is certainly not an easy venture and I can’t say that I envy the long and arduous road ahead as they attempt to tackle this problem. What’s important to remember, however, is that the accountability for patient care extends well beyond the walls of our EDs. Other players, such as primary care doctors, long term care homes and our elected representatives must all do their part as well. There are many examples in our international community of systems overcoming this problem. The time to act is now as the health of our patients and the sanity of our ED staff depends on it.
- Emergency department overcrowding in Canada: What are the issues and what can be done? http://www.cadth.ca/en/products/health-technology-assessment/publication/621
- Canadian Institute for Health Information. Health Care in Canada 2012: A Focus on Wait Times. https://secure.cihi.ca/free_products/HCIC2012-FullReport-ENweb.pdf
- Bursch B, Beezy J, Shaw R. Emergency department satisfaction: What matters most? Ann Emerg Med. 1993;22:586–91.
- OECD. Waiting Time Policies in the Health Sector: What Works? February 2013. http://www.oecd.org/els/health-systems/waitingtimepolicies.htm
- Jouriles N. et al. Posted emergency department wait times are not always accurate. Acad Emerg Med. 2013; 20(4): 421-3
- Affleck et al. Emergency Department Overcrowding and Access Block. CJEM. 2013; 15(6)