The risks of emergency department overcrowding
Each year one in five Ontarians visits one of the province’s 163 emergency departments.
A recent study has shown that those who present to emergency departments when waiting times are longer have worse outcomes.
Since 2008, Ontario has spent a lot of money and effort to reduce waiting times and improve the quality of care in emergency departments. Although significant progress has been made, much more remains to be done.
Emergency departments offer an essential service to the population, providing episodic care and treatment to people who are injured or require emergency care for other illnesses. Each year, there are over 5 million visits to Ontario’s emergency departments. Emergency departments are sometimes used as an alterative to primary care providers when people cannot see their family doctor or nurse practitioner, or do not have one. Overall, about 90% of patients who visit Ontario’s emergency departments are discharged after receiving care, with only about 10% admitted to hospital.
Emergency departments are often referred to as the canary in the coal mine of the health care system, because how well they appear to perform is affected by the rest of the system. For example, when there aren’t any available hospital beds into which to admit sick patients from the emergency department, or if patients do not have access to a primary care provider, emergency departments fill up and become overcrowded. Because of this, there are no easy solutions to reducing emergency department wait times.
Long waiting times for emergency department care are an issue across Canada – and in many other countries too – and emergency department waiting time has been identified as a priority for the Ontario government. Waiting time for emergency department care are not just an inconvenience; they have also been found to have an impact on patients’ outcomes.
Longer waiting times impacts patient outcomes
A new study by Ontario researchers has demonstrated that long waiting time not only affect patient satisfaction, they increase the risk of death and hospital readmission for patients who have been discharged from the emergency department. This study, published in the British Medical Journal looked at 22 million patient visits to Ontario emergency departments over a five year period, and found that the risk of death and hospital readmission increased incrementally with the degree of crowding at the time the patient arrived in the emergency department. The authors estimate that if the average length of stay in the emergency department was an hour less, about 150 fewer Ontarians would die each year.
The study findings imply that when emergency departments are full or overcrowded, processes of care change and quality declines. Howard Ovens, an emergency medicine specialist and director of the Mount Sinai Hospital emergency department says that the study findings “confirm what emergency department staff have always known, that an overcrowded, backed up emergency department is dangerous.” Ovens says that “doctors will spend less time with patients when there is a long queue, as they are trying to get caught up.” The authors of the study also speculated that spending less time with patients can mean time-consuming but important tests may not be ordered, observation times may be shortened and arrangements for follow-up after discharge may be incomplete.
What is Ontario doing about emergency department waiting times?
Michael Schull, an emergency medicine specialist and researcher, and a co-author of the study, says that the Ontario government has been a leader in Canada in “aggressively working to reduce emergency department waiting times” through a variety of different programs and policies.
One way that policymakers try to improve waiting time is through setting targets for the time patients ought to spend in emergency departments – this indicates to those working within the health care system that this is an important issue. Astrid Guttmann, the lead author of the study notes that setting targets for time spent in emergency departments was started in the United Kingdom, and has been controversial as “some say that waiting times are not clinically relevant.” In fact, the British government recently announced that it will abandon waiting time targets in favour of “more clinically relevant indicators.” These indicators, however, have not yet been identified.
Ontario is one of the first jurisdictions to implement system-wide targets for time spent in emergency departments. In 2008, the Ontario government introduced targets – they expect that 9 out of 10 patients will spend 4 hours or less in the emergency department if they have minor or uncomplicated conditions, and 8 hours or less if they have more complicated conditions and may need additional care and services, including hospitalization. It is important to note that this “wait time” is not the time a patient should wait before being seen, but the time from arrival in the emergency department to discharge. Hospitals have used a number of different approaches to help achieve these targets, says Ovens, including “the creation of rapid assessment units for less ill patients,” providing coaching to emergency department teams that want to perform better as well as “better matching staffing to patient arrival patterns,” to ensure that emergency department capacity can more appropriately meet demand.
The most recent waiting times for Ontario’s emergency departments are publicly reported online, and updated on a monthly basis. Since this information became available, emergency department waiting times have improved across the province. However many hospitals are still not meeting the targets.
Ovens says that “there is still a lot of work to be done [in Ontario], and that maintaining emergency department access and flow is a continual process.