The ISMP, Dangerous Abbreviations....and You!

The ISMP, Dangerous Abbreviations…and you.

 

What is the ISMP?

The ISMP is the “Institute for Safe Medication Practices” – and is based in the United States.

In Canada, we have the Institute for Safe Medication Practices (ISMP) Canada.

As per ISMP Canada,

The Institute for Safe Medication Practices Canada is an independent national not-for-profit organization committed to the advancement of medication safety in all healthcare settings. ISMP Canada works collaboratively with the healthcare community, regulatory agencies and policy makers, provincial, national and international patient safety organizations, the pharmaceutical industry and the public to promote safe medication practices. ISMP Canada's mandate includes analyzing medication incidents, making recommendations for the prevention of harmful medication incidents, and facilitating quality improvement initiatives.

 

What is the “Dangerous Abbreviations List” about?

As per ISMP Canada,

The use of some abbreviations, symbols, and dose designations has been identified as an underlying cause of serious, even fatal medication errors.

The list can be found here:  http://www.ismp-canada.org/download/ISMPCanadaListOfDangerousAbbreviations.pdf

 

What is the difference between the United States ISMP list of dangerous abbreviations and the ISMP Canada list?

The ISMP list of dangerous abbreviations in the United States is somewhat more extensive in its list of abbreviations, and also gives numerous additional examples of dangerous abbreviations for medication names – where the ISMP Canada list only gives three examples of dangerous abbreviations for medication names. (Sadly, some Canadian hospitals haven’t even mastered not using those three!)

The ISMP list of dangerous abbreviations from the United States can be found here:  https://www.ismp.org/tools/errorproneabbreviations.pdf

 

Why might the list in the United States be longer?

Both the ISMP and ISMP Canada formulate their lists based on events that have already occurred (i.e. where the error has already reached and possibly harmed the patient), as well as “near-misses” – if they feel it warrants an addition to the list.

In the United States there are various federal and state mandatory reporting requirements for medication and other medical errors – providing a significant pool of data for the ISMP to use in gathering this information.

The same cannot be said for Canada – where reporting of errors is strictly voluntary.

-  This dearth of Canadian data can seen in Accreditation Canada’s Required Organizational Practice (ROP) entitled “Dangerous Abbreviations”, where only data from the United States is used when discussing the cost and extent of medication errors.  (http://www.accreditation.ca/sites/default/files/rop-handbook-2014-en.pdf )

 

Are there other dangerous abbreviations that should be added to both the ISMP and ISMP Canada lists of dangerous abbreviations?

I propose the following should be added to both lists:

-  “GM”, “Gm”, “G”, or “gm” for gram(s)

-  The metric (or SI) abbreviation for gram(s) is “g”.

-  In the metric system - gram, meter, and litre are all abbreviated as single lower-case letters (“g”, “m”, and “l” respectively), and prefixes such as kilo-, milli-, micro-, etc. are added to further quantify them.

-  When typing, transposition errors (i.e. accidently switching the order of letters) can and does occur.  Accidently switching “gm” with “mg” (or visa versa) would result in a 1000 times dose difference!

-  Having “GM” or “Gm” as an abbreviation for grams in a menu in electronic documentation or medication dispensing systems can lead to confusion.

-  I have on many occasions seen nurses accidently select the incorrect unit and document “2mg” (2 milligrams) as the dose given when 2 grams was ordered.  Having “g” for grams also sets it apart from “mg” – as a single letter is difficult to confuse with two letters.

-  In the metric system, the upper-case “G” is used for the prefix “Giga-“  - so the abbreviation “Gm” would refer to “gigameter”.

-  (As an aside, it may be appropriate to use the uppercase "L" for litre in written orders and documentation - as the lowercase "l" may easily be confused with the number "1".)

 

- “w/”, “w/o”, or “w” with a line above it for without

- There are so many variations of abbreviations for “without” that it can lead to confusion.

-  Arguably, an acceptable medical abbreviation for “without” has historically been “s” with a line above it (with “s” referring to the Latin word “sine”).

-  [“c” with a line above it has historically been used as the medical abbreviation for “with” (with “c” referring to the Latin word “cum” - pronounced “coom”)].

 

-  “NAC” for the medication acetylcysteine (an antidote for acetaminophen overdose).

-  Although this abbreviation is somewhat dated/archaic, it is still used on orders and documentation at some hospitals.

-  This abbreviation is used in academic literature and research, but should not be used in the clinical setting.

-  If a patient was transferred from a hospital using “NAC” as an abbreviation to another hospital, or another hospital requests records from a hospital that uses “NAC” as an abbreviation – many at the other facility would not likely know what this abbreviation refers to.

-  Abbreviations for the names of medications should never be used!

-  “GTN” for the medication nitroglycerin.

-  Although this abbreviation is somewhat dated/archaic, it is also still used on orders and documentation at some hospitals.

-  If a patient was transferred from a hospital using “GTN” as an abbreviation to another hospital, or another hospital requests records from a hospital that uses “GTN” as an abbreviation – many at the other facility would not likely know what this abbreviation refers to.

-  Abbreviations for the names of medications should never be used!

-  “cc” (for cubic centimetres) for millilitres (ml)

-  [Clarification of existing item on list] – I have seen the handwritten “cc” after the dosage (i.e. 10cc) mistaken for zeros – making it a 100 times dose difference!

-  I have seen this error occur in practice settings where I have worked in both the United States and Canada – yet neither the ISMP nor ISMP Canada have picked up on this.

-  [This is not an exhaustive list by any means!]

-  The only exception for the use of an abbreviation for a medication is “ASA” for aspirin (aka acetylsalicylic acid) – as “ASA” is universally understood as referring to aspirin in healthcare in North America.

 

Are there other problems with the lists?

As stated earlier, both the ISMP and ISMP Canada formulate their lists based on events that have already occurred – meaning that these lists are reactive in nature instead of proactive.

-  In Canada this presents an additional problem since (as was stated earlier) reporting of medication incidents is completely voluntary – so the data, more often than not, never reaches ISMP Canada for consideration and possible inclusion on this list.

-  I have seen multiple errors associated with all of the aforementioned additional abbreviations suggested in this blog entry, in practice settings in both the United States and Canada.  These occur in orders, written documentation, electronic documentation, and medication dispensing systems in both countries – yet have somehow escaped the notice of both the ISMP and ISMP Canada (as well as Accreditation Canada and the Joint Commission).

-  Sadly, with their reactive mandate, we will have to wait for a patient to be harmed or die from an error related to these abbreviations before they are added to the list(s).

 

Where do we go from here?

 

Hospitals and other healthcare organizations:

-  The aforementioned list(s) of dangerous abbreviations from the ISMP and ISMP Canada are minimum standards.  In Canada, it would be wise for hospitals to adopt the additional items in the ISMP list from the United States, the additional examples given in this blog post, and any additional problematic abbreviations that are found within your organization.

-  Share these additional problematic abbreviations with ISMP Canada.

-  Regularly audit your order sets, written documentation by physicians and staff, electronic documentation systems, automated medication dispensing systems, and pharmacy systems for use of dangerous abbreviations.

-  Inform ISMP Canada of common or unique medication incidents – as other organizations and individual healthcare professionals can learn from these and further increase patient safety.

-  Other problems with medications (i.e. formulations that cause difficulty with administration, faulty containers, problems with syringes or needles, etc.) can and should also be reported to ISMP Canada.

-  Think about unique abbreviations used in orders and documentation at your facility – and whether staff at another facility would understand those abbreviations if your patient were transferred there or presented there and that other facility is requesting patient records from your facility.

-  ( FYI.  The Joint Commission makes an excellent point about certain exceptions to the “Trailing zeros” rule – for non-medication documentation.  That can be found in this document:  http://www.jointcommission.org/assets/1/18/Do_Not_Use_List.pdf )

 

Healthcare professionals:

-  Even if your hospital or other healthcare organization does not adopt these additional dangerous abbreviations into their “Do NOT Use” list – you should not be using them.  This is your professional responsibility!

-  Many of you have not even mastered the ISMP Canada “Do Not Use” list of dangerous abbreviations yet.  Get on board!  This is your professional responsibility!

-  You too can and should report common or unique medication incidents to ISMP Canada – as other organizations and individual healthcare professionals can learn from these and further increase patient safety.  (This is a confidential process and does not involve identifying a patient – so there is no violation of privacy legislation.  You do not need your employer’s permission to do this.)

-  Other problems with medications (i.e. formulations that cause difficulty with administration, faulty containers, etc.) can and should also be reported to ISMP Canada.  (This is also a confidential process and does not involve identifying a patient – so there is no violation of privacy legislation.  You do not need your employer’s permission to do this.)

-  Think about unique abbreviations you use in orders and documentation at your facility – and whether staff at another facility would understand those abbreviations if your patient were transferred there or presented there and that other facility is requesting patient records from your facility.

 

ISMP and ISMP Canada:

-  Are you really going to wait for a patient to be harmed or die from an error related to the additional abbreviations suggested in this blog entry before they are added to the list(s)?

- ISMP Canada:  Are you really going to wait for a patient to be harmed or die from an error related to the additional abbreviations on the ISMP list of dangerous abbreviations from the United States before they are added to the ISMP Canada list of dangerous abbreviations?

 

System Administrator for electronic documentation and automated medication dispensing systems:

-  Electronic documentation systems (i.e. Eclipsys Sunrise Clinical Manager (SCM), Meditech, etc.), automated medication dispensing systems (i.e. Omnicell, Pyxis, etc.), and Pharmacy Department systems.- all need to ensure that the dangerous abbreviations from the ISMP list from the United States, as well as the additional abbreviations suggested in this blog entry are not utilized.

-  “GM’, “Gm”, and “G” used erroneously for “grams” (g) is a common error in many of the aforementioned systems.

 

Patients, patient family members, and the lay public:

-  You can also report medication errors or other concerning issues with medications via http://safemedicationuse.ca/index.html

-  There are also plenty of other useful and informative resources on this website.

 

Patients, patient family members, the lay public, media, and healthcare professionals in Canada:

-  Ask your MP, MPP, and federal and provincial ministers of health to require reporting of medication and medical errors (without patient identification) – to improve patient safety.

 

Links:

 

ISMP Canada – http://www.ismp-canada.org/index.htm  (Large variety of information for healthcare professionals.)

SafeMedicationUse.ca - http://safemedicationuse.ca/index.html  (Large variety of information for consumers.)

ISMP - http://ismp.org/  (Large variety of information for healthcare professionals.)  (Based in the United States.)

 

Other things we do that place your health at risk.

Other things we do that place your health at risk.

 

1)  All vaccines and temperature-sensitive medications that require refrigeration should be stored in refrigerators with continuous temperature monitoring that alarms and records when temperatures fall out-of-range - and for how long.

-  A digital or manual log of out-of-range temperatures needs to be reviewed on a regular basis by the Pharmacy Department and maintained.

-  This log should also include actions taken for each out-of-range temperature.

-  Some vaccines require frozen storage, but the aforementioned requirements should also apply.

-  Deviation from the required storage conditions for any medication or vaccine can reduce or eliminate their effectiveness.

-  Not all hospitals follow these important principles of maintaining AND monitoring storage conditions for medications and vaccines – especially outside of the central Pharmacy where medications and vaccines are stored at the point-of-care.

 

2)  Hospitals should maintain policies and procedures that outline actions to be taken for deviations from the required storage conditions in both the central Pharmacy Department and point-of-care areas.  These actions should include all possibilities up to and including the disposal of medications and/or vaccines.

-  Many hospitals do not have these policies and procedures.

 

3)  Food and food products should never be stored in a medication refrigerator.  Foods, and even the outside of food containers, provide an ideal environment for the growth of bacteria.

-  Some hospitals and/or point-of-care areas store drinks, pudding, yogurt, applesauce, etc. (that are used to administer medications to certain patient populations) in medications refrigerators for the sake of convenience.

 

4)  Refrigerators used for the storage of microbiology specimens (and other specimens) in the central Laboratory and in point-of-care areas must be separate and have the same requirements for maintaining and monitoring storage conditions, as well as policies and procedures outlining actions to be taken for out-of-range temperatures – up to and including the disposal of specimens.

 

 

5)  Refrigerators used for the storage of blood or blood products (for transfusion) in the hospital’s Blood Bank and in point-of-care areas must be separate and have the same requirements for maintaining and monitoring storage conditions, as well as policies and procedures outlining actions to be taken for out-of-range temperatures – up to and including the disposal of blood or blood products.

 

 

6)  Hospitals need to have a process for monitoring and auditing compliance with required storage conditions for medications, vaccines, microbiology specimens, and blood/blood products.

 

- Public Health Departments, government/regulatory agencies, and Accreditation Canada all need to audit these practices during their inspections.

 

-  Logs need to be reviewed spanning back to the previous visit (i.e previous Public Health inspection or Accreditation Canada survey).

 

And on a slightly different note….

 

7)  All intravenous (IV) lines attached to a central venous line (CVL) must run via an infusion pump to prevent the risk of (life threatening) “air embolus”.

-  IVs connected to CVLs should never be run via gravity.

-  Sometimes an infusion pump is not in the room when a CVL is inserted in an emergent situation.

-  Simply bumping an IV bag around can let air into the tubing – that you may not notice during a crisis situation.

-  Infusion pumps need to be considered part of the equipment necessary for central line insertion.

-  Infusion pumps have air-detectors and will alarm and stop infusing if air is detected.

Thoughts on Quality in Healthcare

Thoughts on Quality in Healthcare

(Someone shared these with me a while back....and now I share them with you.)

• Quality does not live on a proverbial island or in a silo - nor is it proprietary.  It should be shared among departments, disciplines, and organizations.
• Quality is multi-disciplinary.
• It does not need to “reinvent the wheel” simply for the sake of having one’s own “wheel”.  Many sources of research, best practices, evidence-based practices, etc. already exist which can be utilized without drastically increasing the cost of analysis and implementation.
• Quality does not limit itself nor hold allegiance to a single source or discipline.  Safer Healthcare Now, the Public Health Agency of Canada (PHAC), the Centers of Disease Control and Prevention (CDC) in the United States, the Department of Health in the United Kingdom, and the Cochrane Collaboration are just a few of the example of entities which provide meta-analysis of quality initiatives, best-practice and evidence-based practice.
• Quality is not afraid to reinvent itself.
• Quality starts, and ultimately ends, at the bedside.
• Quality needs the knowledge, means, and motivation to succeed.
• Quality initiatives require adequate policies & procedures, equipment, and education to be effectively implemented.
• Quality should be a natural part of the culture in healthcare.
• Quality incorporates safety and efficiency.
• Efficiencies in product/supply management can improve quality, patient safety, and increase cost savings.
• Patient safety and reduced risk flow out of quality.
• Quality is logical.
• Quality is achievable.

Waiting in the Emergency Department

Waiting in the Emergency Department:

Why do I have to wait so long to see a doctor in the ER?

Besides the number of other patients also waiting to see a doctor, and the severity of your condition - there are things that hospitals and the government do that contribute to the problem.

1)  Anything that slows down the discharge of admitted patients elsewhere in the hospital affects Emergency Department wait times.

(As discussed in the previous blog post, patients who are admitted to the hospital but who are unable to get an inpatient bed in the hospital, remain in the Emergency Department and take up Emergency Department beds that cannot be used to see new patients.)

-  Physicians are notorious for allowing admitted patients to remain in hospital for an extra day or two just to have a test that could just as easily be booked as an out-patient test.

-  They do this for several reasons:

a)  It is more convenient for them to follow-up with the patient if they are still in hospital.

b)  They feel that the patient may get the test faster if they stay in hospital.

c)  They don’t want the patient to “have to drive all the way back to the hospital for one test”.

-  None of these are a good reason to stop the efficient flow of patients – yet it happens quite frequently!

2)  Surgeons (i.e. General Surgery, Orthopedics, etc.) in many hospitals are notorious for both less-than-timely assessments of non-critical Emergency Department patients that are referred to them, and timely dispositions (i.e. making the decision to admit you to hospital).  This can be worse in large, high-volume hospitals and teaching hospitals.

-  Patients that have to wait for assessment and/or admission block Emergency Department beds – thus preventing the efficient flow of patients through the system.

-  In Ontario, where Emergency Departments have to report wait times and are paid-for-performance, the Emergency Department and the hospital can lose funding due to these delays.

-  Some hospitals have charged nursing hours, medications, etc. to the admitting service once a “no-bed” admitted patient is held in the Emergency Department for more than a certain number of hours (i.e. 8 or 12 hours) to provide incentive to the services to increase the efficient flow of patients, and to recuperate costs.  Perhaps they should be doing the same for these patients.

-  It is NOT right for the patient!

3)  In Ontario, some Emergency Departments and Community Care Access Centres (CCACs) feel that if a patient presents to the Emergency Department needing a crisis placement in a nursing home, long-term care facility, rehabilitation centre, etc. – that they will have a higher priority for placement if they remain in the Emergency Department (thus taking up an Emergency Department bed) rather than admitting them to an inpatient bed while they await crisis placement.

-    The Ontario Ministry of Health and Long-Term Care/CCAC document on “Category 1A Crisis” status indicates that the patient’s location does NOT determine their priority – yet the fact that the patient is taking up space in the Emergency Department and “impedes operations in the emergency department” and therefore contributes to “systemic pressure” is used as justification for prioritizing these patients.

-  Patient who have to wait for days in the Emergency Department whether they are “no-bed” admitted patients or patients awaiting crisis placement tend to do poorly for a host of reasons.  In many cases, patients awaiting crisis placement in the Emergency Department may be there for over a week!

-  Patients awaiting crisis placement that are kept in the Emergency Department, block Emergency Department beds – thus preventing the efficient flow of patients through the system.

-  In Ontario, where Emergency Departments have to report wait times and are paid-for-performance, the Emergency Department and the hospital can lose funding due to these patients being kept in Emergency Department rather than an inpatient bed.

-  It is NOT right for the patient!

4)  In Ontario, where Emergency Departments have to report wait times and are paid-for-performance, the Emergency Department and the hospital can lose funding due to “no-bed” admitted patient remaining in the Emergency Department.

-  Shamefully, some hospitals have become creative by having holding areas for these “no-bed” admitted patients that are physically outside of the Emergency Department (usually across the hall) and classifying that holding area as “inpatient beds” just to improve their wait time numbers and retain funding.

-  These areas, while perhaps somewhat quieter, are physically no better than keeping a patient in the Emergency Department (and in some cases even worse).

-  These areas do NOT have the same access to amenities and support services that would be available on an in-patient unit; and likely have no windows and limited natural light to orient patients – despite assurances by the hospital otherwise.

-  It is NOT right for the patient!

5)  A lack of mental health services in hospitals and the community results in additional “no-bed’ admitted patients in the Emergency Department who are awaiting admission to an in-patient mental health bed, or metal health patients awaiting “crisis placement” in a facility outside the hospital.

-  In many cities, the lack of services for both the pediatric and geriatric mental health populations further worsens the situation.

-  (Issues related to mental health patients will be expanded on in a later blog post.)

Final Thought:

Many Emergency Departments in Ontario start the day with over 50% of their beds taken up by admitted inpatients for whom the hospital has not beds.

There is a good chance that the real reason you wait so long to be called from the waiting room is that there is simply no space to see you.

Links:

The Ontario Ministry of Health and Long-Term Care/CCAC document on “Category 1A Crisis” status:  http://www.health.gov.on.ca/english/providers/pub/manuals/ccac/cspm_sec_12/12-3.html

Canadian Association of Emergency Physicians (CAEP) – “Position Statement:  Emergency Department Overcrowding and Access Block”:  http://caep.ca/sites/caep.ca/files/caep/PositionStatments/cjem_2013_overcrowding_and_access_block.pdf

Canadian Association of Emergency Physicians (CAEP) – “Position Statement on Emergency Department Overcrowding”:  http://caep.ca/sites/caep.ca/files/caep/PositionStatments/2009_crowding_ps.pdf

American College of Emergency Physicians (ACEP) – “Policy Statement:  Boarding of Admitted and Intensive Care Patients in the Emergency Department”:  http://www.acep.org/Clinical---Practice-Management/Boarding-of-Admitted-and-Intensive-Care-Patients-in-the-Emergency-Department/?__taxonomyid=117952

American College of Emergency Physicians (ACEP) – “Policy Statement:  Crowding”:  http://www.acep.org/Clinical---Practice-Management/Crowding/?__taxonomyid=117952

Ontario's ALC problem...and you.

Ontario’s ALC problem…and you.

 

What is ALC?

Short answer:  Alternate Level of Care

(Note:  This post will only be discussing ALC as it applies to beds in acute care hospitals.)

Ontario’s Ministry of Health and Long-Term Care (MOHLTC) defines ALC as, “When a patient is occupying a bed in a hospital and does not require the intensity of resources/services provided in this care setting…”

To paraphrase, a patient designated as ALC has recovered to a level where they no longer require the services of the acute care hospital, but occupy an acute care hospital bed due to the lack of available services and supports in the community or home;  or lack of available beds in a nursing home, long-term care facility, rehabilitation hospital, or other assisted-living facility.

How many ALC patients are there in Ontario?

As per the Ontario Hospital Association (OHA):

-  On September 30, 2014, there were 2,547 patients designated ALC waiting in an acute care bed in Ontario.

-  In August 2014, ALC-designated patients were occupying 14.7% of acute care inpatient beds in Ontario.  (That is almost 1 in 6 acute care beds!)

 

Why is this a problem?

1)  Hospital beds taken up by ALC patients cannot be used for new patients requiring admission to hospital, meaning they wait on a stretcher in the Emergency Department (ED) – sometimes for days.

-  The beds taken up by admitted patients in the ED cannot be used to see new Emergency Department patients – resulting in longer waits to get into the ED to be assessed by a physician and receive the treatment you need.

 

2)  Hospital beds taken up by ALC patients cannot be used for new patients requiring admission to hospital after surgery – so surgeries are often cancelled or delayed.

-  Most times patients will find out that their surgery is cancelled on the day it was to happen.

 

What can be done about the ALC problem?

1)  In the short-term, with lack of resources in the community and no nursing home beds, long-term care beds, etc. to send patients to, hospitals are left with little options.

-  One option is to apply for “Category 1A Crisis” status for their ALC patients  - if the beds taken up by ALC patients are preventing acute care admissions, causing cancellation of surgical cases, preventing admissions to critical care beds, or the number of “no-bed” admitted patients in the ED is affecting the operation of the ED.

There are a couple of issues with this:

-  Some hospitals are in “gridlock” situations, with all of the above affecting them so often, and on an ongoing basis that after a while the effect of frequently declaring “Category 1A Crisis” status would make little difference if there is still not a way to decant this pressure off the hospital.

-  The provincial agency responsible for arranging ALC services and placements (the regional Community Care Access Centres - CCAC) can go through the lengthy process of arranging appropriate placement for ALC patients – and then the patient (or their Substitution Decision Maker – SDM) can refuse the bed arranged for them for any (or no) reason, and continue to take up an acute care bed.  We have many patients that have been ALC in acute care hospitals across the province for over 2 years for this reason.

(-  Hospitals should charge patients for the full costs associated with their stay if they refuse to be discharged.)  (They should consider doing this at the acute-care rate – as they would be preventing an acute-care patient from occupying that bed.)

2)  Address the problem!

a)  The Ontario Government under the leadership of Liberal Dalton McGuinty “unfunded” (aka closed) numerous beds in almost every hospital across the province to pay for other Ministry of Health projects at the time that needed funding – i.e. renovating existing hospitals, new hospital buildings, and the creating of the regional Local Health Integrated Networks (LHINs) (aka another level of government bureaucracy), etc.

- Hospitals cannot admit patients to these unfunded beds without incurring the cost themselves – as they will not be reimbursed by the government, or only receive partial reimbursement.

b)  During that same period, the government closed nursing homes and long-term care facilities whose buildings required costly upkeep due to their age before having new facilities built to absorb these patients.

-  The government promised new facilities, but these never materialized in many regions.

-  Ultimately some acute care beds in hospitals had to be re-designated as “complex continuing care” due to the lack of appropriate beds in the community.

-  This re-designation of beds at one hospital then places further pressure on surrounding hospitals.

 

c)  CCAC needs to adequately fund home and community supports to get patients out of hospitals.

-  CCAC has strict limits on the amount of support that can be provided to any single patient.

-  There have been numerous similar cases where a patient remains in hospital simply because CCAC will not provide funding for 24/7 personal support workers (PSWs) for that patient.

-  As a result, these patients not only have to remain in hospital, but often have to be kept in “step-down” units where the nurse to patient ratio can be 1-to-1, or 1-to-2.

-  Maintaining this staffing ratio is quite expensive, but if the hospital does not (or cannot) designate the patient as ALC, there is no motivation for CCAC to provide the additional level of care at home – as the CCAC and the LHIN are not as directly accountable for how the hospital spends their money on admitted, non-ALC patients.

 

Links:

Ontario Hospital Association (OHA) - information on ALC and ER wait times - http://www.oha.com/CurrentIssues/Issues/eralc/Pages/eralc.aspx and

http://www.oha.com/CurrentIssues/Issues/Documents/OHA%20ALC%20September%202014.pdf

Ontario Ministry of Health and Long-Term Care (MOHLTC) - ALC definition - http://www.health.gov.on.ca/en/pro/programs/waittimes/edrs/alc_definition.aspx

MOHLTC/CCAC – information on “Category 1A Crisis” status - http://www.health.gov.on.ca/english/providers/pub/manuals/ccac/cspm_sec_12/12-3.html