Finding creative ways to adapt

While some doctors may see emergency medicine as too hectic and devoid of opportunities to form the long-term relationships with patients that many doctors cherish, emergency physician Dr. Ian Chernoff (photo above) considers caring for 25 to 30 new patients every day to be an opportunity to do a lot of good.

“In terms of just having the potential to be a positive force in health care for a maximum number of patients, it is hard to match the opportunity that emergency medicine presents,” explains Dr. Chernoff, who works full-time in the emergency department at at Mount Sinai Hospital.

“Often we’re seeing people and families at absolutely pivotal and once-in-a-lifetime moments,” he notes. “I’ve always felt quite privileged to be able to be involved with people at those times of their lives. There’s just an immense opportunity there to try to be a good person and a good physician and provide compassionate care.”

Dr. Chernoff has been providing care to emergency patients for 19 years, and things have changed quite a bit over those years. Overall, he’s seeing more patients, more older patients, and more patients with complex health problems.

Emergency medicine has adapted to the pressures created by these changes in many ways that have actually improved care, says Dr. Chernoff. For example, there are more types of staff available – such as physician assistants, nurse practitioners, advanced practice geriatric nurses and physiotherapists – to provide care. And there is much more of a team approach, he explains, with doctors sharing important decision-making roles with these new staff members.

Staff also have more options other than admission to hospital available for patients whose needs can’t be completely addressed during their emergency visit, including home care and community health services.

But these kinds of changes haven’t relieved all the pressure. Dr. Chernoff says the two biggest barriers his emergency department faces in trying to deal efficiently with more patients, and patients with increasingly complex conditions, are the small physical space available to care for them, and a shortage of inpatient beds for patients waiting in emergency for admission.

When Dr. Chernoff started working at Mount Sinai Hospital’s emergency department 10 years ago, five extra beds in a hallway were used for patient overflow. Now there are five more in another hallway, and five more in a hall in the waiting area. And it’s still often not enough.

“I now routinely go out and assess patients in the waiting room, and that’s suboptimal in many ways,” says Dr. Chernoff, adding he does those assessments to at least get care started for patients when there are no emergency beds available.

Waiting room assessments are among the many “creative” adaptations he says emergency departments are making to deal with patient overflows. But he believes the crowding does affect quality of care to some extent. “For an elderly patient who is already ill enough that they’ve had to come to the emergency department, if they have to lie in a hallway and there’s bright light and there’s noise and they don’t sleep for a period of time, that is not good for their medical condition.”

An expansion of his emergency department is already in the works, and Dr. Chernoff believes such growth in capacity is sometimes needed in addition to innovation and adaptation.

“I think things need to move in concert. You can be the most efficient emergency department on the planet, but if there are not more inpatient beds and there is not more physical space to see patients, if nothing else changes and the pressures just get added upon, then ultimately, of course, there’s only so much you can do in such circumstances.”

Measuring performance

At a time when Ontario’s emergency departments are dealing with significant change in the numbers and types of patients coming through their doors, it’s important to look at the quality of care those patients are receiving.

One way to examine quality is through emergency department performance indicators that evaluate timeliness of care, such as “time to physician initial assessment,” “length of stay” and “left without being seen.”

Time to physician initial assessment measures the time from when a patient is triaged or registered (whichever happens first) to when they are seen by a doctor. Length of stay measures the time from when a patient is triaged or registered to when they are discharged from emergency to go home, are admitted to an inpatient bed, or are transferred to another acute facility. Left without being seen tracks how many people leave the emergency department before being examined by a doctor.

Emergency departments are doing better

The good news is that the performance of Ontario emergency departments in all three of these indicators has improved overall in recent years, despite increases in the volume, age and acuity of patients.

Between 2008/09 and 2014/15, the 90th percentile time to physician initial assessment – the maximum amount of time within which nine out of 10 patients saw a doctor – decreased by:

  • 16.2% overall for all patients, to 3.0 hours from 3.6
  • 18.7% for high-acuity discharged patients, to 3.2 hours from 3.9
  • 15.0% for low-acuity discharged, to 2.7 hours from 3.2
  • 19.6% for admitted patients, to 3.1 hours from 3.8 [2] (Figure 5)

Over the same period, the 90th percentile length of stay in the emergency department – the maximum amount of time within which nine out of 10 patients completed their visit – decreased by:

  • 10.6% overall for all patients, to 7.8 hours from 8.7
  • 18.1% for high-acuity discharged patients, to 6.7 hours from 8.2
  • 13.3% for low-acuity discharged patients, to 3.9 hours from 4.5
  • 8.4% for admitted patients, to 29.4 hours from 32.1 [2] (Figure 6)

Also over those seven years, the proportion of emergency visits completed within the province’s four-hour length-of-stay target for low-acuity discharged patients increased to 89.9% from 84.6%. The proportion of visits completed within the eight-hour target for high-acuity patients and admitted patients, when lengths of stay for those two categories of patients are counted together in a single group, rose to 85.7% from 79.8%.[11]

The annual number of emergency department visits that resulted in the patient leaving without being seen by a doctor decreased by 18.3% between 2008/09 and 2014/15, to approximately 3% of all visits from about 4%. Some research suggests the most common reason for leaving the emergency department is being “fed up with waiting.”[12]

Another important quality indicator is patient experience. The majority of people in Ontario appear to be satisfied with the care they have received in the province’s emergency departments. In a 2014/15 patient experience survey of Ontarians aged 16 and over conducted on behalf of the Ministry of Health and Long-Term Care, 72.6% of respondents reported receiving excellent, very good or good care. However, the other 27.4% – more than one in four respondents – rated their care as fair or poor.[13]

There were fewer positive ratings among people aged 16 to 44, at 68.8%, and more from people aged 75 and older, at 86.7%. Among rural residents, 83.5% rated their experience as positive, compared to 70.6% of urban residents.[13]

Improvement still needed in some areas

Even though lengths of stay and waits to see a doctor were shorter, and the majority of patients were satisfied, emergency departments were not necessarily performing as well as they should be for all patients.

High-acuity patients wait longer to see a doctor

The data showed that the 90th percentile time to physician initial assessment in Ontario was longer for high-acuity discharged and admitted patients, at 3.2 and 3.1 hours respectively, than for low-acuity discharged patients, at 2.7 hours, in 2014/15 (Figure 5). This is not necessarily the result most people would expect – since a major goal of triage is to have higher-acuity patients seen sooner.

However, the high-acuity discharged group includes a range of patients, from those who need to see a doctor immediately (CTAS Level 1) to those who have potentially serious conditions but can wait without suffering harm (CTAS Level 3). So the longer wait for the group as a whole does not necessarily mean patients triaged at the top priority level, for example, had to wait hours to see a doctor. In fact, the data showed that the wait was shorter for patients with the most urgent, life-threatening conditions.[2]

One reason low-acuity discharged patients as a group may see a doctor faster might be because many hospitals stream them to separate areas of the emergency department designed to handle lower-acuity patients more efficiently.

Low-acuity discharged patients can often stay in a chair to see a doctor and often don’t require much medical equipment for diagnosis and treatment. So, they may not have to wait for an emergency bed and other equipment to be available, as high-acuity discharged and admitted patients often do. Emergency departments often move low-acuity patients into rapid assessment zones designed for patients who don’t need to use a bed in emergency, so that all patients can be cared for more efficiently.

Admitted patients may spend a long time in emergency

Why the 90th percentile?

Time to physician initial assessment and emergency department length of stay are measured in this report at the 90th percentile – the amount of time within which nine out of 10 patients will have seen a doctor or completed their visit.

The 90th percentile indicator was chosen because it represents the maximum wait to see a doctor or length of stay for the vast majority – 90% – of patients. So, it’s a point of measurement that includes most extreme scenarios in which patients have to wait longer to see a doctor or stay longer in emergency than patients at the median or average time points.

Provincial and individual hospital targets for length of stay and time to physician initial assessment are also set at the 90th percentile, to more fully reflect what the emergency department experience may be like for a wide range of patients.

While the 8.4% decrease in the 90th percentile length of stay for admitted patients was a significant improvement, that still meant nine out of 10 admitted patients spent up to 29.4 hours in the emergency department in 2014/15. A large portion of that time – 22.5 hours – was spent waiting in the emergency department to go to an inpatient ward.[2]

There are several consequences that may arise from emergency patients having to wait such a long time for admission to an inpatient hospital bed. They include discomfort for the patient and possibly less than optimum care as a result of not being in the hospital ward a doctor has decided is best suited for their care.

As well, because they usually have to occupy a bed in emergency while they wait, sometimes for many hours, admitted patients may impede access to emergency beds, doctors, nurses and other resources for other patients still waiting for care.

A lack of available inpatient beds for patients from emergency may be linked to many possible factors. For example, a hospital may simply not have enough beds to meet the needs of the growing community it is serving;[14] inefficient inpatient bed management may lead to patients not moving in and out of hospital wards as quickly as possible; or, inefficient housekeeping practices may mean inpatient beds are not readied for the next patient quickly enough.[15]

Lack of inpatient bed availability is also frequently attributed to inpatient beds being occupied by patients who don’t require hospital care but are waiting for a space in a health care facility appropriate for their needs – such as a long-term care home or a rehabilitation facility. These patients are often identified as requiring an “alternate level of care.”

In 2014/15 in Ontario, 13.7% of “inpatient days,” or of all the days each individual hospital bed in the province was occupied by a patient, were used for patients identified as needing an alternate level of care.[16] That was an improvement, down by 14.3%* in 2011/12. The 2014/15 figure amounted to approximately 4,000 inpatient days being used at any given time that year for patients waiting to receive care elsewhere.

To whatever extent patients requiring an alternate level of care may affect emergency department lengths of stay, it is an issue for which at least part of the solution lies in other parts of the health system. Hospitals can certainly work on improving the flow of patients through their emergency departments and inpatient wards, but there is not much they can do to free up inpatient beds occupied by patients waiting for places in long-term care homes, for example.

*Incomplete fiscal year: July 2011 – March 2012.

Targeting improvement

Performance improvements over recent years have resulted in Ontario hospitals collectively meeting two of the province-wide targets set for emergency department length of stay in 2014/15: four hours for low-acuity discharged patients and eight hours for high-acuity discharged patients. The provincial target of a maximum eight-hour length of stay in emergency for admitted patients is not being met on a province-wide basis.

To drive improvements across the province, each hospital, locally, has its own set of individual targets related to provincial targets for emergency department length of stay. Some of those targets are incorporated into the Hospital Service Accountability Agreement each hospital has with its Local Health Integration Network.

Hospitals may also set improvement targets for their emergency departments in the Quality Improvement Plans they are required to draw up annually. These are submitted to Health Quality Ontario on April 1 of every year. The plans and their targets must reflect the province’s health care priorities, as well as locally relevant quality issues.

Health Quality Ontario reviews and analyzes the Quality Improvement Plans to produce reports that share consolidated data and observations with hospitals and the public. The reports spread knowledge about effective improvement strategies and help align quality improvement efforts – in emergency and other areas of care – across the province.