A broken hip, a high-grade fever, heart attacks, stroke, or stitches; any number of injuries, illnesses and concerns bring nearly 150,000 patients to the emergency departments (EDs) at London Health Sciences Centre every year. You may have been one of them. And unless your need was critical, chances are you spent some time waiting to be seen and treated. The reasons for wait times at the University Hospital, Victoria Hospital and Children’s Hospital EDs are many, varied, and complex. We asked two hospital and two community health-care leaders to sit down and discuss the issues from their unique points of view.
From LHSC, Dr. Gary Joubert is the chief of emergency services and treats thousands of patients each year, and Carol Young-Ritchie is a long-time health-care administrator who has spent many years working with staff and leaders to improve ED care. Sandra Coleman is the CEO of the South West Community Care Access Centre, a key community partner in improving patient access and wait times, and Neal Roberts is chief of Middlesex-London Emergency Medical Services, overseeing the paramedics who bring patients from across the city to LHSC’s emergency departments.
1. Why do some patients face such lengthy wait times?
Carol: Care that’s provided in the emergency department takes time. Initially on arrival a registered nurse will perform a quick triage assessment to sort patients into acuity categories to help prioritize who needs care urgently. Once into the department, another nurse performs a more in-depth assessment and possibly initiates investigations approved by emergency physicians. A physician will then do an in-depth medical assessment. Frequently there’s a diagnostic work-up including blood work and diagnostic imaging (which can take one to two hours), administration of medications and sometimes medical procedures. It’s like putting pieces of the puzzle together to see what’s wrong with the patient and that takes time.
Sandra: There’s also another answer in here which is that people show up that shouldn’t; who shouldn’t be there and don’t need emergency care. The emergency department becomes the last option when people have nowhere else to go, such as having no family physician. You can be guaranteed that if you show up at one of LHSC’s EDs, it’s there 24/7. It’s become the front door to the health care system, which should not be the case.
Gary: I think Sandra’s made a good point, and that is: what is an emergency department really built for? EDs are designed to care for those patients in extreme need. The impetus of having an ED wasn’t to become this social safety net for medical care. The other component that affects us is that the ED has finite space. There are a certain number of beds in that space, and when the beds are occupied, there’s no opportunity to flow additional patients.
Neal: There is a greater demand on a service within our community while at the same time the community isn’t able to keep up with that demand. It means patients are not being able to get into a bed right away and they’re seeing a delay.
2. What common themes are you hearing from patients, families and visitors?
Carol: The feedback I get from patients is that when they are informed of why they’re waiting, it’s OK and they can appreciate the sickest patient needs to be seen first. So when we tell people it’s going to be a four-hour wait, people know what to expect and can make choices around that. Unfortunately, sometimes as we get very busy we fail to communicate as well as we should and that is perceived as uncaring so one of our challenges is to keep patients and families informed of why they are waiting.
Gary: I empathize with the patients because they are scared, worried, concerned about whatever the issue was that brought them into the ED, but at the same time there’s a mismatch about their expectations and what we can accomplish in a certain amount of time. The expectation of the public is that, “I watched House last night, and they cured a disease in an hour. How come you can’t do the same thing?”
Sandra: The emergency department has become the front door and one of the main sources of access to the health-care system. What we hear is that many of these patients don’t have a family doctor and they don’t know about the Community Care Access Centre (CCAC). They have no idea that the CCAC is free, accessible, and a phone call away. By no means do I want to over-state that we’re the magic bullet to eliminating everybody out of the ED, but we need to be part of the solution.
Neal: Those patients who are coming in to the emergency department, as well as what we’re seeing in EMS, are patients who are older and much sicker than they were years ago, and we’re also seeing an increase in demand of these sicker patients.
3. What do you find most frustrating and the biggest challenge in regards to ED wait times?
Neal: It’s really not an emergency department problem; it’s what’s above emergency: the various departments that have patients in beds who should be in another location outside the hospital. It’s been talked over the years about increasing ALC* beds and making sure that patients have the ability to move from a hospital bed into a long-term care bed, but I don’t think there’s a magic solution to this.
*ALC: “Alternate Level of Care” refers to when a patient is occupying a bed in a hospital and does not require the intensity of resources or services provided in that care setting.
Sandra: I totally agree with Neal that we have a long way to go, but there have been some huge improvements like the Home First program. The challenge is that there are new innovations like that coming out all of the time and it’s hard to keep all members of the hospital and primary care* team aware of that. So sometimes by the time the CCAC case manager connects with a patient in the emergency department, there will have already been discussions about needing to be admitted or the potential need for long-term care. At that point, our case manager has no hope of being able to then try to counsel and support a client and family that they can go back home and there are supports in the community to make that happen. If we can do a better job of all of us being on the same page about that, then I think we can continue to make incremental improvements here.
*Primary care: Your first point of contact for health care, usually provided by a family doctor.
Carol: The community has always relied on the fact that our EDs will be open 24 hours a day, seven days a week for whatever happens. And I think we have over-relied on that as a point of entry and that’s where we start to see our back-ups and our wait times. We want to maintain good quality care and nobody likes long wait times, so it’s very frustrating for patients, families as well as care providers. Unfortunately, one of the things we’ve done — whether it’s an advantage or disadvantage to primary care — is that when people come to the ED they typically get all their testing and results done the same day. So yes it is a long wait but people are leaving the ED knowing their diagnosis and what’s wrong with them.
Gary: One of the things that occupies a lot of my time is ensuring that we get patients moved, and there are a lot of factors that affect this. For example, there are patients tying up beds who are discharged but can’t leave until late in the day because they have family members who need to pick them up. There are patients we have who are ALC and they occupy beds that are really for acute care space.
4. What solutions are working best now?
Sandra: Through the Home First program, since November there have been about 60 clients who have been brought home instead of staying in hospital waiting for a long-term care bed in the community. These people would have otherwise stayed at LHSC on average more than 50 days, so all of those hospital days have been saved. In addition, the number of ALC patients at LHSC has dropped to 77 in April, down from 116 in December. So care is truly shifting from hospital to home, and slowly but surely I think that this is going to ease the congestion in the ED.
Neal: One of the programs we use with some success is the provincially funded off-load nurse program which basically helps get EMS out of the ED and back on the street. I’ve also noticed that there tends to be a lot of patients within the ED that are requiring mental health services. I’d like to see a program where we can work harder in the community to help mental health patients so that the emergency departments aren’t as over-loaded with these cases.
Gary: There’s just never one solution, it’s a multitude of factors. And there are no easy answers. If there were, we would have figured it out already. We have a number of solutions that we’ve imposed and brought to the forefront in our ED such as the RAZ [Rapid Assessment Zone] system, where the idea is to try to pinpoint those higher-acuity CTAS-3* populations more quickly to give them a better opportunity for getting treatment sooner.
*CTAS refers to the Canadian Triage and Acuity Scale which ranks the severity of each patient’s injury or illness from one to five, with one being the most severe.
Carol: We’ve done a lot of work looking at our processes to be more efficient and reduce wait times. We have also added specialized nurses in geriatrics and mental health to perform in-depth assessments for patients. Externally, we’ve been partnering with agencies such as CCAC, but also looking at how we can improve communication between our hospital and long-term care so we can try and alleviate an emergency visit as well as getting information back to our primary care partners so they can help support patient follow-up in the community. Overall I think there’s a real recognition that the emergency department is a pressure point, and certainly a lot of good work is being done to try to make things better.
5. What final message do you have about wait times in the EDs?
Gary: There’s no question, we will see every patient who comes to our door, regardless of how long they wait. But it may be more productive for them to ask “do I really need to be seen today? Or can I be seen by a family physician or maybe at a walk-in clinic or urgent care centre tomorrow?” I realize a lot of people may not have the medical expertise to necessarily make that decision and if that’s the case, then obviously default to the ED. But I’d like to see the public ask themselves if they would be best served by going to the ED.
Neal: At the end of the day it’s about providing the best quality patient care by excellent staff. Whether the medics, the ED nursing staff, or the physicians, we’re all there for their care. We have their best interest at heart, they just need to understand that we are dealing, at times, with a sicker patient.
Sandra: I would just add the piece around if you are receiving CCAC services, please remember we are there to help and the case manager is just a phone call away. If we could be part of the solution, we are very much wanting to do that.
Carol: Our staff and physicians are very skilled in emergency care. And it’s really not their intention to make people wait longer than they need to wait. Please be patient. We are there to see everybody, we will see everybody, but we do need to see the sickest patients first and quality care takes time.