ER wait times worth cheering about
Ontario has made real progress in reducing crowding and waiting in emergency rooms
By Dr. Howard Ovens Director of the Schwartz/Reisman Emergency Centre, Mount Sinai Hospital, and co-chair, Ontario ER/ALC Expert Panel
A couple of weeks ago, Health Minister Deb Matthews announced that St. Michael's Hospital had lowered its emergency room times from 26 hours in April 2008 (inception of the Ontario "ER/ALC" strategy, a program to reduce ER crowding and waiting) to 10 hours in June of this year.
The public and media reaction was muted, reflecting widespread confusion about what exactly was measured and whether this was anything to cheer about.
I'd like to explain the announcement and tell you why many in the emergency medicine community are indeed cheering the service improvements we are making.
Ontario measures and publicly reports total length of stay in the ER as part of its "wait time strategy." Most people would think of their wait time during an ER visit as the time you spent in the waiting room or in a cubicle in the ER, waiting for the doctor to see you.
But once you've been seen, many patients continue to have waiting interspersed with care: waiting for tests to be done and reported; waiting for a consultant to see you; waiting for a bed to be ready to receive you if you are admitted.
Much of this time can't be helped; analyzing blood tests, completing careful assessments and many other elements of care just take time. Ontario wanted to capture all those contributors to waiting by measuring total length of stay in the ER from arrival to departure home, or in the case of about one in seven patients, until leaving the ER for your in-patient bed.
Ontario set targets for total length of stay in the ER: four hours for non-complex patients who go home - sore throats, sprained ankles, simple cuts - and eight hours for more complex patients who go home or are admitted - such as chest pain, strokes, shortness of breath, etc.
Ontario also decided to track these measures at something called the 90th percentile, rather than the average or median. The 90th percentile is the maximum time at which nine of 10 patients will have been cared for and released (only one in 10 will stay longer), while the median would be the maximum time for five of 10 patients - half stay shorter, half stay longer.
Experts advised that judging ER performance at the median would leave potentially long waits by too many patients unapparent in the data, but reporting at the maximum times (99th or 100th percentile) would include exceptional cases where patients need to stay longer - over 24 hours in many cases, because of complexities in their medical or social circumstances that can't or shouldn't be avoided. Thus the 90th percentile was just right for our purposes.
So the St. Michael's announcement highlighted the fact that in 2008 their ER length of stay was 26 hours at the 90th percentile; that is, it took a maximum of 26 hours to get nine out of 10 patients fully assessed, treated and released or admitted, while in June of this year they are getting to the same point in a maximum of 10 hours (their average length of stay went from 10.3 hours to 4.6 hours in the same period, while the median went from 5.6 to 3.6 hours).
Accomplishing this improvement with a modest investment of resources, while maintaining the quality and accuracy of diagnosis and care, is a major achievement. It does not mean that I, or anyone involved in this program, thinks "waiting" 10 hours is acceptable, but 10 hours to get the more complex patients seen, scanned, treated, counselled and admitted (or released) is pretty good.
With respect to what you consider wait times, this year the median wait to see a doctor in Ontario ERs is one hour (and coming down). However, I have to emphasize that the response on your arrival to an ER varies with the acuity of your problem; the sickest patients will always be seen first, less serious cases may have to wait. But in Ontario this year, almost nine out of 10 patients with non-complex problems receive all their care, complete their visit and are released within the four-hour target.
Individual experience is important, especially if it's you, your loved one or neighbour. But judging the program based on a few anecdotes is dangerous - ER times, whether waiting or total length of stay, are highly variable.
As I've stressed, the sickest patients go to the front of the line, and there remains a lot of variability from day to day and from hospital to hospital in waiting times (although decreasing variability is a measure of the effectiveness of improvement, and in Ontario, variability is decreasing).
Ontario is the first province in Canada to have the courage to tackle ER overcrowding and waiting. We are the only province to have set targets for length of stay and to report publicly on performance, and we have made major improvements over the last two years.
This leads not only to less patient frustration, but is safer also, as some patients will be at risk from delays in care. Patients who are less angry or frustrated also make for happier ER docs and nurses, which helps us keep our best people practising in the ER - a high-stress environment that burns out a lot of staff. Good ER care will always depend on having good staff, so happier staff ultimately means better care for you and your family.
Health care in Canada is highly political and it's easy to get caught up in that. My personal interest is in improving the quality of care, and getting the facts right.
But before you come to your own conclusions on our performance, it may be helpful to put Ontario's experience into an international perspective. The United Kingdom was the first major jurisdiction to tackle ER wait times. It set a firm four-hour limit for length of stay and expected it to be achieved 98 per cent of the time. It got there but had to make major changes in the way care was organized and delivered.
Ontario was emboldened by the U.K. success but deliberately decided to go with softer targets for a more evolutionary, rather than revolutionary change.
This spring the U.K. announced it was giving up on the four-hour target because of major concerns about the quality of care being delivered.
I think the Ontario approach, and resulting improvements to care, are indeed something to cheer about.