In search of the Rx for ER

Dr. Howard Ovens walks so briskly that it's hard to keep up with him. He's an emergency-department doctor, and speed matters.

But if you're waiting in ER, speed doesn't seem to matter. When I took my mom to the hospital a couple of weeks ago, she waited 10 hours to see a doctor. After 17 hours, the doctor decided to admit her. In all, it took more than a day to get her from her bed to a hospital bed. She wasn't in any danger. But it's hard, and her experience is far from uncommon.

Dr. Ovens is passionately determined to change that. He's head of emergency at Toronto's Mount Sinai Hospital, and he's also one leader of an ambitious three-year project that's tackling ER gridlock across Ontario. The rest of Canada is watching, and the stakes are high. "If people think the emergency problem is unsolvable, then they won't touch it for years to come," he says.

The primary problem in ER is not that too many people are showing up with the sniffles. The problem is that truly sick people wait too long to see a doctor and get a hospital bed. That leads to overcrowding, back-ups, and sometimes tragedies, to say nothing of headlines that are highly embarrassing to politicians. Politicians are extremely eager to fix ER wait times, which are a big sore point with the public and do nothing to improve their opinion of the system.

So what's the key to busting up the ER gridlock? Think like people who work in manufacturing. Measure everything. Gather data. Set standardized performance targets. Align people and systems with incentives. Analyze the data. Make the data public so that every hospital can see how it's doing compared to others. "People and systems respond rationally to incentives," says Dr. Ovens.

At the heart of Mount Sinai's emergency department is a big electronic display board that registers the status of each patient and the time remaining to meet the wait-time target. For example, the standardized target for treating simple cases (a broken arm, an earache) is four hours from the time the patient arrives until the time she goes home. For complex cases, it's eight hours. The staff can look at the digital board and see at a glance that in order to meet the target, they have 57 minutes left to finish treating Ms. X. All the performance stats are constantly updated and available by computer. This year, every hospital in Ontario is expected to discharge 80 per cent of the complex cases it sees in emergency within eight hours. Mount Sinai is currently achieving 85 per cent. The hardest nut to crack is wait times for people like my mom, who need a hospital bed. But beds are hard to find, so big urban hospitals like Mount Sinai are way behind on that one.

Last year Mount Sinai got an $800,000 incentive bonus from the government for improving its emergency department performance. The money went for extra staff and beds. There are intangible rewards as well - such as improved staff morale and fewer surly patients. "The greatest reward for staff is a better professional working environment," Dr. Ovens says.

The notorious problem with ambulance offloading has been fixed, too. Paramedics used to hang around for hours (frequently on overtime) waiting to turn their human cargo over to the hospitals. Hospitals were punished for success, because the faster they treated ambulance cases, the more ambulances would pour in. Now there's a dedicated nurse assigned to ambulance cases, who can take them over right away. All hospitals are obliged to share the ambulance load. At Mount Sinai, the turnaround time for ambulances is down to 18 minutes.

Then there's the dog that didn't bark. Last fall, emergency departments across the province were hit with record volumes during the H1N1 epidemic. They handled it. No bad-news headlines. Proof, says Dr. Ovens, that the system is markedly improving. The biggest enemy of progress is fatalism, he argues. "If we're fatalistic, we let the system off the hook." Then he says goodbye and strides away, fast.