A considerable effort has been made in recent years to improve emergency department performance, by the Ontario government and by hospitals across the province.

In 2008, the government launched its Emergency Room Wait Times Strategy to reduce lengths of stay in the province’s emergency departments. That strategy was expanded in subsequent years and has included:

• Measuring and reporting on patient time spent in the emergency department, and measuring patient satisfaction
• Setting targets by acuity for emergency department lengths of stay:
  • at a maximum of eight hours at the 90^th percentile for high-acuity discharged patients or admitted patients (meaning nine out of 10 patients should complete their visit within eight hours)
  • at a maximum of four hours at the 90^th percentile for low-acuity discharged patients (meaning nine out of 10 patients should complete their visit within four hours)
• Implementing a Pay for Results program that provides financial incentives to hospitals for continued performance improvement and high sustained performance in emergency department patient length of stay
• Implementing the Emergency Department Process Improvement Program to help emergency departments reduce patient length of stay, based on “Lean” methodologies aimed at identifying and removing unnecessary steps in a work process
• Expanding alternatives to emergency department services by improving support for patients with chronic conditions, creating more urgent care centres and working to increase public awareness of other places to receive immediate, unscheduled health care
• Supporting faster discharge from hospital of patients requiring an alternate level of care, by increasing home care and community care services and developing long-term care beds

The provincial government’s Patients First: Action Plan for Health Care also includes funding and measures to reduce emergency department length of stay.

Ontario hospitals and long-term care homes, as well as other parts of the health system, have worked in concert with the government to make changes aimed at addressing some of the challenges that affect emergency department performance. Hospitals have adopted process improvement programs, worked to meet targets and worked to take advantage of Pay for Results incentives.

Some of the quality improvement measures undertaken by hospitals include:

• Rapid referral clinics to get patients referred quickly to specialists outside the emergency department when appropriate
• Setting up “medical directives” under which nurses can order certain tests and procedures for certain conditions to speed up the diagnostic process
• Streaming patients to specialized zones for treating particular types of health issues such as heart problems or mental illness
• Streaming low-acuity patients to separate urgent care centres inside their emergency departments to free up resources for high-acuity patients
• Establishing medical assessment units to accept and monitor some emergency patients before they may be discharged or admitted
• Extending hours for diagnostic imaging services so fewer patients have to occupy emergency beds for hours while waiting for ultrasound or CT scans
• Bringing other health professionals such as orthopaedic technicians, medical lab assistants and physiotherapists into emergency departments to allow doctors and nurses time to deal with more patients
• Using patient flow coordinators and discharge planners to improve the movement of patients through hospitals and their emergency departments

Health Quality Ontario has launched an Emergency Department Return Visit Quality Program to monitor return visits to hospital emergency departments to identify adverse events and quality issues. The program is mandatory for all 73 high-volume emergency departments participating in the Pay for Results program, but all Ontario hospitals are encouraged to participate.

Programs in the community have also been developed to keep patients from needing to go to the emergency department. They include:

• Having “advance practice paramedics” monitor patients with chronic health issues in their own homes
• The establishment of Health Links to better coordinate the care of patients with chronic or complex health conditions
• The adoption of the Home First strategy to help hospital inpatients be discharged to their own homes with home care in place, rather than remaining in hospital to wait for a place in a long-term care home
• Participation by long-term care homes in programs to reduce emergency department visits by their residents

Given all that has been done, it’s difficult to know precisely how and to what degree each of these initiatives has helped reduce emergency department length of stay and wait time to see a doctor, or improved performance in other quality measures. What’s needed now is careful evaluation of the actions that have been taken to determine which have been most effective and how they should be carried into the future.

But that won’t likely be enough. As Ontario’s population grows and ages and emergency visits continue to increase, the pressure on emergency departments to handle more and sicker patients with greater efficiency – and on the health system to help keep patients from needing emergency care – will likely continue and even intensify.