To reduce ER wait times, hospitals must stop using them as in-patient warehouses

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James Worrall and Paul Pageau are emergency physicians at the Ottawa Hospital. Dr. Pageau is also a former president of the Canadian Association of Emergency Physicians.

Wait times for emergency department (ED) care have ballooned across Canada. At the ED where we work, patients who arrive in the evening are routinely not seen by a doctor until after 8 o’clock the following morning. As we move through the winter, with continued high levels of respiratory illness, we will likely see the situation worsen.

But the standard explanations for long wait times are wrong. We repeatedly hear that there is nowhere else for patients to go because they do not have a family doctor. Patients are also often criticized for inappropriately using EDs. The scientific research, however, shows that we can blame neither the breakdown in Canada’s primary care system, nor our patients, for overcrowding. It is ineffective patient-flow practices that unnecessarily increase wait times.

Research by the Canadian Institute for Health Information has shown that only 20 per cent of emergency patients who are ultimately discharged have a condition that could be managed in a family doctor’s office. Research also shows that these patients are the least complex and least time-consuming of all those we see in the ED. Patients with minor issues only modestly affect wait times for patients with more serious problems. So, even if they could be diverted to other clinics, overall waits and volumes are unlikely to improve.

Even patients who do have a family doctor often choose to come to the ED. Why? Studies show there are several reasons. Often, patients perceive their problem may be serious or dangerous, i.e., an emergency. Or they believe they require a test or treatment that can only happen in the ED.

Since the early days of emergency medicine, the medical establishment and politicians have derided patients for using the health care system inappropriately. This is nonsense. The great majority of ED patients are rational people who put up with terrible waits because they have real concerns that need to be addressed. Sometimes, patients think they are having a health emergency, such as a heart attack or appendicitis, but they are not. To sort that out, of course, requires a medical assessment and testing. How can we expect patients to be able to determine what is a health “emergency” on their own?

Demand for unscheduled care is normal. Emergencies, both major and minor, will not stop happening. Trying to solve ED wait times by diverting patients elsewhere will never make a meaningful impact. It is time to stop blaming patients and a lack of family doctors. Instead, we need to tackle the real cause of overcrowding: ED beds are filled with admitted patients.

The majority of stretchers and resources in most Canadian EDs are used to care for patients who have already been seen and treated in the ED, but who require admission to the hospital and are simply waiting for an in-patient bed. Despite regional variations in funding and patient demographics, every large hospital in Canada suffers from this malaise. It is the natural byproduct of ineffective patient-flow procedures.

All hospitals experience fluctuations in their in-patient census. The problem is that we use the ED as a buffer zone to handle this variation. In effect, it has become the waiting room for in-patient care. In-patient units also struggle to discharge patients, particularly the elderly, who need posthospitalization services such as long-term care, rehabilitation or community care. We clearly need to improve access to these services.

Leaving admitted patients in the ED in the meantime is not, however, a safe or logical solution, as it has unintended consequences. When ED stretchers are being used by patients better cared for in an in-patient unit, they are not available for new patients waiting to be seen. Holding admitted patients in the ED has been shown to increase in-hospital mortality, lengthen stays and increase costs. This evidence is ignored, because change is perceived to be too difficult. It would require hospitals to adopt dynamic staffing and operations models.

But this is possible. Britain, Australia and New Zealand have all implemented rules that ensure admitted patients are moved to in-patient units within hours. While not perfect, such rules do free up critical space in the ED, reduce wait times and may reduce mortality. ED wait times will not improve in Canada until governments have the courage to make similar rules. This will require political mettle, and hospitals will have to make difficult modernizations to their age-old patient-flow strategies.

So let us dispense with the fiction that long waits in the ED are due to patients presenting with minor problems, and that fixing primary care will solve things. People will always need emergency care, and they cannot get it if hospitals continue warehousing admitted patients in the ED.