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The crisis in ER Add to ...

Long waits in the emergency department are a problem that has seemingly bedevilled the health-care system for time immemorial.

The public, to a large extent, has come to grudgingly accept that every ER visit will be a marathon of pain and frustration, with some humiliation thrown in for good measure.

Only rarely do ER woes make the news any more, and even then it takes a monstrous failure, such as the Winnipeg man who died after waiting 34 hours to be seen for a severe bladder infection.

The latest flare-up to pique the interest of reporters has occurred in Edmonton, where Paul Parks, president of the emergency medicine section of the Alberta Medical Association, warned of the "potential catastrophic collapse" of emergency care.

Dr. Parks backed up the strong words with some blood-curdling examples of "sub-optimal encounters" - a patient with a brain aneurysm waiting six hours in the lounge before being seen; another patient with a broken back spending six hours strapped to a board in the waiting room.

So what is the solution?

The simple - simplistic, even - response is to expand emergency rooms and hire more ER docs. People always want more doctors and nurses hired. If only it were so simple.

Anyone who has pondered the issue - and, in fairness, many have tried to tackle this persistent problem - knows that throwing staff bodies into the ER will bring little more than temporary relief, and at great expense.

Most of the measures required to ease overcrowding and reduce waiting times lie outside the ER.

This is well articulated in a new report by John Ross, Nova Scotia's provincial advisor on emergency care. While his prescription was written for that province, many if not all of his observations and recommendations apply to other jurisdictions.

Dr. Ross begins his report with a quote from the late management guru Peter Drucker, who was once hired to come up with a mission statement for a hospital emergency department. Their mission, he concluded, is to "give assurance to the afflicted. ... The doctors and nurses give assurance."

While that may seem self-evident, emergency care has strayed far from this fundamental goal. The only proper way to give assurance in times of crisis is promptly - and in the medical setting that means patients being seen almost immediately.

A good starting point is medically acceptable waiting times. These standards do exist (the Canadian Triage and Acuity Scale, for example), but there is no incentive for respecting the standards and no consequences for failing to meet them.

If you tie funding to performance, performance will improve.

That said, most of the problems we see in emergency departments are not their own doing. One key to cleaning up the mess is making sure they are used appropriately.

You need to get patients in and out of ER quickly. The longer they linger, the greater the failure.

With few exceptions, gravely ill or severely injured patients are seen promptly in the ER and then moved to critical-care or intensive-care units. But only about 10 per cent of patients are admitted to hospital.

Of the other 90 per cent, far too many have ended up in the ER by default, because they don't have access to primary care.

It's easy to point an accusing finger at the public and blame them for their wasteful ways, but it can take six weeks to get an appointment with a family doctor, if you have one. So where do you turn? Many walk-in clinics are a joke: They will treat the most mundane matters, but refer anything even moderately time-consuming to emergency rooms. And they make you wait, too.

So off to ER Canadians trudge. The ultimate irony for some patients is that they'll be treated there by the very family doctor they couldn't see by appointment - a striking example of the perverse incentives that exist in our health system.

Many ER docs like having patients with minor problems because it's more lucrative - especially when paid on a fee-for-service basis. So in some respects they are protecting their turf (and in particular their income) by arguing we need more ER docs rather than saying we need to keep minor cases out of ER.

Many ER docs insist on the need to treat patients with minor problems there because it helps ensure they have a reasonable income - something they wouldn't have if they handled only trauma cases.The fee-for-service pay model is ill-suited to the ER.

So, get ER docs working on salary.

Then, as Dr. Ross recommends, establish fast-track areas in emergency departments for the treatment of minor injuries and illnesses. These can be staffed by nurse practitioners, mental health workers and physicians.

In smaller hospitals, overcrowding is rarely a problem; rather, the public has to cope with on-call doctors and sporadic closings. Dr. Ross recommends transforming many of these inefficient ERs into community health centres that provide chronic disease management and primary care.

There is a subset of patients - generally the frail elderly with chronic conditions such as dementia - who spend countless hours (and often days) in emergency before moving to a hospital bed. This adds to the bed shortages and back-ups in ER.

The fundamental problem here is lack of nursing-home and long-term-care beds and, in many cases, a lack of home-care services.

"Many seniors land in emergency departments when what they really need is care provided in their home or nursing home. Improving access to these services should be a priority," Dr. Ross writes in his report.

Similarly, he notes that many people with severe mental health and addiction problems, known as "frequent flyers" in ERs, could be better cared for with mobile crisis teams and in psychiatric facilities.

In short, we need to reserve emergency rooms for emergencies. But to do so we need to bolster access to primary care and long-term care: solutions that are not simple, but urgent.

Follow on Twitter: @picardonhealth

 

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