Taking a drive through some states south of the border, you might notice a peculiar phenomenon: not only are there billboards showcasing the latest fashion or promoting certain consumer goods, but obscenely large billboards advertising the ER wait times of various hospitals. “Come to our ER! The wait is only 3 minutes to see a physician!”

You might laugh and even shake your head at this, but it certainly makes sense in their private healthcare system where the more patients are seen at a hospital, the more money it makes. Advertising is an obvious market strategy for this business model. You think to yourself, thank goodness for our public system where hospitals don’t have to worry about competing with others’ wait times, and focus on giving the best care to patients regardless of how busy certain days are (especially since volume in ER fluxes unpredictably).

Time to wake up, because reality has arrived.

A number of hospitals in Calgary (and 1 in Ontario) began publishing their ER wait times online last year, showcasing “real-time” expected time a patient will have to wait before being seen by a doctor. It’s no billboard on a busy highway, but it is publicly available and perhaps even more readily accessible to anyone who cares to look.

The argument for publishing ER wait times are these: online information like this will help patients better decide where to seek medical aid, and will also spur providers to improve service. Patients with minor ailments might defer a visit to a busy ER and go to their family doctor instead. Healthcare providers might work more efficiently when they see their own wait times are longer than another nearby ER. “Information is power,” reasons Don Shilton, the president of St. Mary’s General Hospital, the first institution in Ontario to implement this system.

Um, perhaps.

I have several issues with this new system they have. The first has to do with accuracy of the information, and the others are related to the unintended effects of having such information available to the general public.

This system only publishes a single estimated wait time for each hospital. It is not perfectly clear how they come up with this number, but from their site information it seems that “through a computer algorithm” they combine the total number of patients arriving into their department, relate that to the number of active staff/physicians, and spit out an average expected wait time. Anyone who works in an ER (or even been a patient there) will see a problem with this. The emergency room is not a first-come, first-serve environment. A single predicted wait time might work okay in a restaurant, but certainly not in a workplace where patients are triaged based on the severity of their illness or injury.  What this translates to is inaccurate and misleading information to the patients – someone who is suffering from a life-threatening condition would be seen immediately, whereas someone with a very minor complaint may wait well over the published wait times. And most patients at home looking up these times will likely be unable to accurately triage themselves on this huge spectrum, leading to misinterpretation of the information.

Not only do these published wait times inaccurately represent reality for most patients, they could also lead to many unintended consequences. Imagine this scenario: a 65 year old man is experiencing crushing chest discomfort, and looks up this wait time information. He sees that the closest ER has a 6 hour wait, while the ER 2 hours away only has a 2 hour wait. He chooses to get his wife to drive him to the far ER, since he doesn’t want the ambulance to take him to the ER with the long wait times. He ends up having delayed diagnosis of an acute heart attack, and worse, ended up at a hospital without a PCI-suite, and has to be rapidly raced back to the original hospital near his home.

While published wait times might dangerously push patients with high acuity away from seeking timely care, would it be too hard to imagine that patients with minor issues might bypass seeing their own family doctors/walk-in clinics and instead visit the ER with the shortest wait times? Or perhaps increasing referrals from other healthcare providers in the community, or specialists, or outpatient clinics, or… the list goes on. Would this in effect be putting an even greater strain on the emergency department’s role as a safety net for the rest of the healthcare system?

Ultimately, publishing ER wait times in and of itself is not a solution to anything, really. The backlogged hospital beds are still there. The insufficient convalescent support outside the acute care hospitals are still present. Potentially re-directing patients with minor complaints by alerting them of long wait times, or flogging the already over-worked ER staff to work faster in hospitals with 103% occupancy levels, might not be the answer.

For good or evil, publishing performance metrics such as wait times are here to stay, as we edge closer and closer to a performance-based renumeration system in Canadian healthcare. The key question is, however, which metrics should we be using and publishing – and how can we fully explore the consequences.

What do you think of publishing ER wait times? Are there better metrics?

 

Dr. Edmund Kwok is an Emergency Physician with special training and interest in performance management, quality improvement, and patient safety. He blogs at the Front Door to Healthcare.  Follow on Edmund on Twitter @FrontDoor2HC.