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