Stretchers are seen in the reflection of in an emergency room. Winnipeg’s health authority is investigating after two patients were sent home in taxis and died on their doorsteps in the dead of winter shortly after being discharged from hospital.Kevin Van Paassen/The Globe and Mail
No more ER waits.
That is the bold promise made by the Jewish General Hospital at the unveiling of its spiffy new emergency department, which will open officially on Feb. 16.
To be more precise, Dr. Marc Afilalo, head of emergency medicine at the venerable Montreal hospital, said every patient who walks into the ER will be seen within 20 minutes.
That is not a typo: 20 minutes. No more interminable waits to see a doctor.
But, be careful, the average wait in Quebec's ERs is currently 17.5 hours. That is the time from arrival at the seemingly-always-unfriendly registration desk to disposition (to use the bureaucratic jargon), meaning you are either sent home or admitted to hospital.
That average will not necessarily change appreciably no matter how fast patients are seen initially. That's because emergency department overcrowding is not an input problem, but an output problem.
The reason most people linger forever in the ER is that there are no beds available in hospitals; that problem is due, in turn, to the large number of patients who have been discharged but have nowhere to go because of shortages in homecare services and lack of affordable nursing home and long-term care beds.
The Jewish General initiative is not unique – a similar transformation is taking place at Mount Sinai in Toronto – but it is nonetheless important. They are making a commitment to efficiency, something that is often sadly lacking in our health system.
In fact, what is being promised is prompt triage. Rather than sit in a grim waiting room (there will actually be no central waiting room in the new ER), patients will be seen quickly and, depending on their health problem, triaged to one of five areas. (You can take a visual tour of the new facilities, courtesy of CTV Montreal.)
Patients who arrive by ambulance will be seen quickly (as they are now) and cared for in five resuscitation suites.
The most intriguing innovation is the creation of a "rapid assessment zone" (RAZ) where patients who need time-consuming treatment – but not admission to hospital – will be cared for. Patients needing intravenous antibiotics, blood transfusions and so on will sit in La-Z-boy style chairs rather than tying up stretchers and rooms.
Others who arrive in ER under their own steam (the vast majority of patients), will be assigned to one of three colour-coded areas :
- The green pod will be reserved for people with minor health problems like simple fractures, gastro-intestinal woes and influenza. They will wait in individual rooms, including some negative pressure rooms rooms that reduce the risk of infectious diseases spreading. In theory, this class of patients should be treated more quickly than they are now but, of course, more serious cases take priority with staff;
- The yellow pod will be reserved for people with chronic conditions – mostly seniors – the clientele that tends to spend the most time in ERs, usually as workers search for services for them outside the hospital. Now, at least, they will have somewhere quiet and calm to wait, rather than lying on a stretcher in the hallway or wandering confused in a large waiting room. (Because there are no hallways, there will be no more hallway medicine at the Jewish General);
- The orange pod will be reserved principally for psychiatric patients, another group that tends to visit the ER regularly. The sight of someone handcuffed to a chair can be off-putting, and the hubbub in the ER can often exacerbate the problems of someone in crisis, so these patients will have a separate, secure area. Hopefully, the isolation will not result in their being ignored.
This all sounds wonderful. Utopian even.
But changing the dynamics in Canada's emergency departments, and use of primary care services more generally, is much easier to do in theory than in practice.
History tells us when there are changes are made in Canadian health care there are always unintended consequences.
The biggest worry of administrators at the Jewish General Hospital is that when word gets out of their "no wait" policy, the new ER will simply be overwhelmed with patients and the waits will be worse than ever. The hospital's ER already sees at least 200 people a day.
After all, faced with the prospect of sitting in another grungy emergency room for 3, 6 or 12 hours, why wouldn't you drive a little further to the Jewish General?
Quebec's Health Minister Réjean Hébert played down this issue, saying vaguely that other hospitals will also introduce efficiencies in ER.
Politicians and policy-makers, however, shouldn't be blinded by the promise of shiny new emergency rooms.
The fundamental question that needs to be addressed is: How can we best treat patients who need urgent care – those who can't wait days or weeks to see a doctor but don't have a life-threatening condition?
Some provinces like Alberta are building urgent care centres away from hospitals; others, like Ontario, are bolstering family health teams so patients can get same-day appointments or, like Nova Scotia, sending paramedics to treat minor conditions in the home rather than transport people to hospital. Saskatchewan, for its part, has vowed to eliminate ER waits by 2017, largely be focusing on the bed blockage problem.
Is building bigger, faster ERs in hospitals the best approach to meet the health care needs of Canadians? That's not a given.
What is essential though is that we learn from these experiments and share best practices so the system can be improved on a large-scale rather than celebrating isolated Band-Aid solutions.
André Picard is The Globe's health columnist.
André Picard