Should hospitals post emergency department waits online?
A number of Canadian hospitals have started publishing live emergency department wait times online in an effort to provide patients with expectations on how long they will have to wait to be seen for non-urgent issues.
These efforts are all innovative pilot projects, but there is little evidence available on whether this information makes any difference to patients.
Every year Canadians make over 14 million visits to hospital emergency departments. However, not all patients who enter an emergency department have the same level of need to access immediate care – they range from immediate, life threatening conditions, to those with relatively minor complaints, and everything in between.
Given how often Canadians use the emergency department, reducing waits and improving the patient experience is top of mind for policy-makers. In fact, reducing emergency department wait times is one of the current Ontario government’s top two priorities for health care in the province.
Alberta hospitals, as well as St. Mary’s Hospital in Kitchener, are starting to provide live wait time information online. These hospitals provide continuously updated information about how long most patients – not those who need immediate care – can expect to wait to see a doctor or nurse practitioner in their emergency department.
While some say that this information is not helpful for improving the quality of emergency department services, those leading the charge to provide more information to the public about waiting times say that people have a right to know how long they might wait when they arrive at an emergency department.
Why do we wait in the Emergency Department?
The Canadian Triage Acuity Scale, developed in 1998 through the Canadian Association of Emergency Physicians, and endorsed by the National Emergency Nurses Affiliation, classifies patients entering the emergency department into five levels of need.
The highest level of need is for those patients who are severely injured or acutely ill and should be seen by a medical team immediately for aggressive medical intervention. These patients include those who have suffered a cardiac arrest or major trauma. The fifth, and lowest level of need includes patients who have relatively non-urgent medical complaints, but nevertheless require medical care such as stitches or care for a sore throat. In fact, the guidelines note that some non-urgent patients could be “referred to other areas of the hospital or health care system” for care provided by a family doctors’ office, urgent care centre or clinic. The table below details the definitions, and some conditions, which are within each level of the scale.
|Canadian Triage Acuity Scale*||Level of Care||Examples of conditions/symptoms|
|Level 1: Immediate||It includes conditions that are threats to life or imminent risk of deterioration, requiring immediate aggressive interventions.||
|Level 2: Emergent||It includes conditions that are a potential threat to life or limb function requiring rapid medical intervention or delegated acts.||
•newborns with jaundice
|Level 3: Urgent||It includes conditions that could potentially progress to a serious problem requiring emergency intervention.||
•mild moderate asthma or shortness of breath
•vomiting and diarrhea in patients younger than 2 years
|Level 4: Less Urgent||It includes conditions related to patient age, distress, or potential for deterioration or complications that would benefit from intervention or reassurance within 1 to 2 hours.||
•mild abdominal pain
|Level 5: Non Urgent||It includes conditions in which investigations or interventions could be delayed or referred to other areas of the hospital or health care system.||
•a sore throat
•conditions related to chronic problems
•psychiatric complaints with no suicidal ideation or attempts
*Table adapted information from Ontario Wait Times page of the Ontario Ministry of Health and Long-Term Care
For those patients who are assessed as requiring immediate or emergent care, there are generally no, or very short waits for care. However, for those with concerns in line with CTAS levels 3, 4 and 5, there will typically be a wait, because emergency departments have a limited number of staff who are able to provide care and meet patients’ needs.
Samuel Vaillancourt, an emergency medicine resident in Toronto notes that “the bottom line is that the emergency department sees as many patients as those who walk through the door, except for those patients who leave the emergency department without being seen, which is about 2-5% of those who present in Canadian emergency departments” and that the concept of triage and “medically acceptable wait times” is important to managing the demands of a busy emergency department.
However, Vaillancourt suggests that “people don’t understand triage that well.” Edmund Kwok, an Emergency Medicine specialist at The Ottawa Hospital agrees, saying “most patients who come to the emergency department think that they are in need of urgent care … and that their needs are the number one priority.”
The Canadian Triage Acuity Scale is mostly used by health care providers who work in emergency medical services or emergency departments. Aurelia Cotta, a Toronto mother of three who frequently uses emergency departments when her children have required urgent care suggests that concepts of triage are not well known amongst the public, saying “it was news to me … and to every average citizen I have ever met “ that emergency departments triage patients based on severity and need. She suggests that beyond knowing that a patient rushed into the emergency department with a major trauma or cardiac arrest is going to be seen more quickly, “we all think its ‘first come, first served’ and that frankly fuels a lot of anger and resentment among patients” as they wait. She thinks that emergency departments could do a better job explaining the concept of triage to patients, and that “at a minimum, I just want to know that there is a system in place, with equitable criteria, which determines when I am going to be seen in the emergency department.
The Psychology of Waiting
Emergency department waits have been shown to have an impact on patient satisfaction. A study conducted over 15 years ago, which is frequently cited, surveyed patients who had recently visited an emergency department to determine whether actual wait times, or perception regarding waiting times, influenced overall satisfaction. The study concluded that “managing waiting time perceptions and expectations may be a more effective strategy to achieve improvement in patient satisfaction … than decreasing actual waiting time.”
Alberta Health Services launched a pilot project in July 2011 which provides average wait times for patients in Calgary’s four emergency departments through a website and smartphone app. In the first ten months of this pilot project, there were about 30,000 hits to the website. To put this number in context, there were around 250,000 visits to Calgary emergency departments during this time period. The program expanded in June 2012, with Edmonton emergency departments reporting wait times as well.
However, some critics have argued that providing patients with this kind of information could lead to ‘hospital shopping’ or patients choosing to avoid visiting an emergency department when they need care.
Michael Schull, an emergency medicine specialist and researcher at Sunnybrook Health Sciences Centre in Toronto says “how long you are going to wait should not be a driver of going to the emergency department to access care” and that “the evidence of how publicly reporting on emergency department waits influences patients’ behaviour is not yet known.” Schull raises concerns that providing wait time information “could send a dangerous message to the public to stay away from busy emergency departments.”
Tom Briggs, VP of Health System Priorities at Alberta Health Services, however, sees these services as providing a different message to the public. He suggests that this information is about “setting expectations for the wait and presenting other options.” The websites that report on wait time information also include a list of urgent care centers in the area, and their wait times.
Edmund Kwok argues that posting an average wait time, which may not reflect how long the majority of patients are waiting, “is not the way to alleviate patient anxiety.” While Kwok believes that “the more information patients have, the better… but that we need to get patients the right information that provides a more accurate picture of how long they can expect to wait, rather than an average.”
Alberta Health Services has not yet formally evaluated their initiative. Although the number of website hits has been publicly released, no information has yet been provided about whether the information provided accurately reflected wait times, and whether patients are changing their behaviour based on the published information. However, evaluations are underway, and the Health Quality Council of Alberta has added questions to its regular surveys of patients who recently visited Calgary or Edmonton’s emergency departments to see if they accessed online wait time information.
In fact, Alberta Health Services is pushing ahead with plans to provide wait time information for emergency departments across the province, including those located in smaller towns where there may only be one hospital. Rather than ‘shop for hospitals’ that have the shortest waiting time, Briggs says “this information plays into the psychology of waiting … if you’re choosing to go somewhere and you know how long you’re waiting, you’re happier to wait with some information, rather than no information.” Dave Brewin, Executive Director of the Provincial Access Team of Alberta Health Services adds to this, noting “in one hospital cities, it is not about which emergency department to choose, it is about setting appropriate expectations for their wait and/or providing the public with more information about [other] options.”
Real-Time Wait Time Reporting in Ontario
While Ontario has not made public any plans to launch similar province-wide real time reporting initiatives, St. Mary’s General Hospital in Kitchener is pioneering this approach in Ontario by reporting on wait times through their website. The hospital relies on a real-time data reporting system, powered by a company set up by St. Mary’s that takes data previously used for internal monitoring of hospital processes and patient flow, and develops it into emergency department wait time forecasting information.
Don Shilton, President of St. Mary’s General Hospital in Kitchener notes that Ontario hospitals are required to report on wait time information to the Ministry of Health and Long-Term Care, and that their hospital used these internal, existing data sources to answer “the number one question we hear from people waiting in the emergency department … which is how long will my wait be?”
Shilton notes that the wait times shown on the website and in the emergency department at St. Mary’s are for CTAS 3, 4 and 5 patients. They have refined the data so that 90% of patients will have a wait of less than or equal to the posted wait time.
While Shilton says that the feedback from patients, as well as staff, has been very positive since the website went live in April 2012, “the ideal situation would be if all hospitals and urgent care centers in the region had their data available, so that people could decide what is best for themselves.” He notes that this information is not intended for patients who are acutely ill, rather it is targeted at those who may be able to wait to see their family doctor or else visit an urgent care centre, rather than an emergency department.