Group 2 ER Wait Times summary PDF

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ER Wait Times Global Video 

https://www.youtube.com/watch?v=t7lOXSKj7eI

Group 2 ER Wait Times Video Summary    

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Inside one of craziest ER’ in country(Peel) Brampton civic hospital Jamie lee Ball arrived and collapsed on the floor She had abdominal surgery 8 weeks before o Said she was in excruciating pain o Laid on a stretcher at first near nurses station o Noisy well lit area with no privacy o Then behind curtains  Small, thin curtains couldn’t even stretch arms from side to side o In that room with 20 different people o 5 days later she had enough o Never ended up in proper section for abdominal issues and never ended up with a room Her experience is an example of what is happening on a larger scale at hospitals around the country Hospitals are bursting at the seams o Called emergency room wait times doctors say real problem is moving patients out of beds in other parts of the hospital and into long term care so others can claim their space Blair Bigham: Canadian Association for Emergency Physicians o Patients in emergency dept who are sick enough to be admitted cant work their way into the hospital for treatment they stay in the emerg o NACRS chart:  0-4 years: 4.8 hours  5-19 years: 5.3 hrs  20-64 years: 7.6 hrs  65+: 17 hours o Latest report shows 90% of senior emerg visits  36.3 hours in 2016-2017 (NACRS)  31.4 hours in 2015-2016  5 hours longer o When they stay in emerg dept they are susceptible to delirium  Brain dysfunction where brain starts to hallucinate and have memory problems, cognition problems and can stay with patient weeks or months Funding for nursing home beds and better home care needs to come thru because no one should leave hospital sicker than when they came

Health Policy Issue 

Long emergency room wait times in Canada.

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Currently in Canada patients are waiting too loo long in wait rooms before being treated or assessed.

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Emergency room wait times in Canada are measured by researchers using surveys and asking people how long they would be waiting on average.

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Many people are hesitant on changing Emergency rooms as they are scared, they won’t be receiving the same quality of care as they are currently receiving. Some staff members are also hesitant as their pay and jobs might be affected.

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Chart shows wait times/measure of wait time and number of admitted patients

ER Wait Times 

The median Canadian will wait about 3 hours and the 90th percentile can wait 8 hours

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The median Canadian will wait 11 hours and the 90th percentile can wait 38 hours

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Chart shows breakdown between province wait times

Geography, Population and Economic State  As of 2016: o Canada's population = 35 151 728 o 5% growth between 2011 and 2016 o Ontario had the largest population of all the provinces and territories with a population 13 448 494 o Alberta experienced the largest population growth between 2011 and 2016 with a growth of 11.6% o Average age of 41.0 years o 16.9% of Canadians are 65 years or older  As of 2015: o Median income = $70 336 o Considered to have a stable economy and GDP Jurisdiction  Jurisdiction over the issue: o Provincial and territorial governments are responsible for establishing, maintaining, and managing hospitals as per the Constitution Act, 1867 o Federal governments are responsible for setting and administering national principles for the Canadian healthcare system as per Canada Health Act  There have been calls for collaborative involvement of both the federal and provincial/territorial governments: o The Wait Time Alliance (WTA) cites strong national political leadership and high levels of physician engagement as key elements of countries with high-performance healthcare systems (Wait Time Alliance, 2014) o According to the WTA, the federal government could be involved through supporting a review of existing wait-time benchmarks and the development of a pan-Canadian vision statement(Wait Time Alliance, 2014) Regulations and Stakeholders  Regulations: o Canada Health Act o Section 92, Constitution Act, 1867  There are many stakeholders in an issue as expansive as this: o Federal, provincial and territorial governments o Municipal governments o Physicians and other healthcare professionals o General public o Ontario Medical Association, Canadian Mental Health Association, etc. o Wait Time Alliance (WTA) o Health Council of Canada

Who is Affected by Long ER Wait Times?  ER Patients  Age, gender  Patients' families  ER Staff  Stress  Recruitment and retainment Gender Analysis  There is no statistically significant difference between frequency ofvisits between male and female(Canadian Institute for Health Information, 2007)  Women have longer lengths of stay than men (Morris, Zelmer & Johnson, 2006)  Median length of stay women = 176  Median length of stay men=161  -49% men/51% women

Age as a Factor  NACRS data shows that age affects the number of visits to the Emergency Department and the length of stay in the ED Trends: •The older patients are the more likely they will visit the Emergency Department •80-90 highest percentage of admitted ED visit •90-100 age group as the longest length of stay among all age groups ER Staff Long ER wait times have a negative impact on : •Stress Levels of nurses and physicians (Estey, Ness, Saunders, Alibhai &Bear, 2003) •Affects nursing and physician's recruitment and retainment (Rowe, 2006) •Job satisfaction among ER staff(Rowe, 2006) Scale of Issue •11.2 million people visited the ER in 2017-2018 (CIHI, 2019) •Many of the ED's in Canada run at capacity most days •Ten hospitals in Ontario regularly operate at close to or over 100 percent capacity and it is routine for hospitals in Onatrio to run at 90-95% capacity most days (Milne,Tepper & Petch, 2017) •89% of patients indicated a lengthy wait in theER (Wellstood, Wilson & Eyles, 2005) Long Standing Issue ("When to go to 'emerg',2000, p. R9) •Long ER Wait times have been an issue since the 90's(Milne,Tepper & Petch,2017) •Many account the rise of ER wait times to budget cuts that resulted in reduction of hospital beds •Globe and Mail article from 2000: "When to go to 'emerg' and when to wait until morning" •Informing public appropriate illnesses to seek ER treatment Further Evidence •Federal information

•Statistics Canada Census •Mandatory NACRS compliance

Causal Factors Associated with ER Wait Times 

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Staff shortages in the ED o Many people believe that emergency room wait times could always be improved by scheduling more staff to work. o Or could be improved by hiring different types of health care professionals to work in the ER. People not seeking appropriate care o Individuals will sometimes automatically revert to the emergency department in hospitals when they could be seeking better care somewhere else. o For example; family physician, LTC facility, mental health clinic, etc. Physicians having limited hours o Many people think emergency room wait times could be reduced if more people had a family physician. o Sometimes, people will have problems that a family physician can treat, but since they don’t have one, they go to the ED.

Outcomes Associated with Long ER Wait Times 

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High stress levels among ER staff leading to decreased quality of care o When there is a lack of health professionals in the ER, the staff is forced to move patients along rapidly (Bradley, 2005). o Exhausted physicians and nurses leads to a lower quality of care o Increases chance of burnout(Howlett et al., 2015) Low patient satisfaction o Unhappy patients make for a higher stress level in Emergency Rooms o When individuals do not have a family physician they resort to the ER causing a higher volume in the ER Public Safety Risk o The risk of contracting a virus or infectious disease increases dramatically. o A delay in care can lead it increased risk of morbidity and mortality (Guttmann, 2011)

Previous and Current Interventions Many stakeholders have aimed to help ease the burden of long emergency department wait times –whether through research, policy development or pilot programs. Three examples of interventions in Canada: •Newfoundland and Labrador's development of "Strategy to Reduce Emergency Department Wait Times" •Fraser Health Authority's pilot project at Burnaby Hospital •Guelph General Hospital's process improvement program (PIP) Notable example of interventions outside of Canada: •The Cleveland Clinic's use of split-flow in the emergency department at Medina Hospital 3 Alternatives  Increase Primary Care  Implementing PREVIEW-ED  Implement Split-Flow Process

Alternative #1-Increase Primary Care •Attempt to increase the number of family physicians in highly populated areas •Ensures that all patients have a place to go for acute illness and injury •15.3% of Canadians did not have a family physician in 2017 (Statistics Canada, 2019) •Reduces the chances of patients resorting to urgent care units •Increase the required hours that physicians need to work per week or month •Allows patients to see their physician in a timely manner •Potentially initiate incentives for family physicians to work more evenings and weekends •Better System to find patients a new physician when theirs retires •Often patients are unable to find a new doctor after theirs retires, creating a system to avoid this would decrease ER wait times Evaluation of Alternative #1 Resources Required: •Financial Investment, Political Support, Physician Support and Compliance Stakeholders: •Supporting:Emergency Department,General Public •Opposing:Government Funds, Current Family Physicians Potential Positive Outcomes: •Lowered ER wait times, less stress on hospital staff, increased patient satisfaction, lower risk of spread of infectious disease, less stress on patients to find care Potential Negative Outcomes: •Unhappy family physician, quality of primary care may decrease, increased cost of healthcare Do Benefits outweigh Costs?: •Yes Alternative #2-Introducing PREVIEW-ED Program to Long Term Care Facilities Nationwide •Screening tool to assist LTC staff detect illness early among residents. •Identify early symptoms of 4 treatable illnesses •pneumonia •urinary tract infections •dehydration •congestive heart failure Goal: Reduce preventable emergency department transfers by 25% for 4 illnesses in long term care facilities, Increase efficiency of ED, Protect security of LTC residents (Elbestawi & Kohm, 2018) ---PSW's followed a 1-paged PREVIEW-ED tool to indicate action taken upon monitoring a resident. If resident showed any signs of being not "normal", PSW report to registered staff who treats patient for symptom or performs close observations. If symptoms persist LTC resident is transferred to ED (Elbestawi & Kohm, 2018) ----Practical Routine Elder Variants Indicate EarlyWarning for Emergency Departments Evaluation of Alternative #2 Resources Required: ◦ Consensus among PSW's and LTC staff ◦ Managerial resources –train/adapt PSW and LTC management of illness symptoms and treatment

Stakeholders: ◦Supporting: Emergency Department Management, Residents in LTC ◦ Opposing: Personal Support Workers and other staff in LTC Potential Positive Outcomes: $6.2 ◦ million savings in Ontario annually,$9.85 million savings in B.C annually, Potential Negative Outcomes: ◦PSW's unhappy Do the benefits outweigh the costs?: ◦Yes Alternative #3: Implement Split-flow Processing •Using the Medina Hospital as an example, implement a pilot project using the split-flow process •Change in the meso-and micro-allocations to improve individual patient care and overall hospital performance statistics •By streaming patients into certain geographical areas of the ED based on their condition, it reduces wait times and keeps hospital beds open for the most serious patients •Provide education to employees to better meet the demands of their jobs in the ER Evaluation of Alternative #3 Required Resources: •Financial investment, support of staff and politicians, educational resources Stakeholders: Supporting: ◦ Public, hospital administration, political support ◦ Opposing: Potentially governments (due to up-front costs) Potential Positive Outcomes: •Reduced wait times and increased patient satisfaction •Higher quality of care because of more individualized treatment, with more beds are kept open for serious patients, while less serious patients can move through the system more efficiently Potential Negative Outcomes: •High initial costs –for renovations and reorganization of emergency departments and training for ED healthcare professionals •Public use of the ED as a primary care point may continue or even increase Do the benefits outweigh the cost?: •Yes

Chosen Alternative: Better Primary Care •We chose this alternative as it seemed the most realistic, affordable and efficient •By increasing the quality of primary care we are increasing the quality of patients visits by lower wait times, decreasing stress and lower the risk of disease Primary Care Pros

-decrease ER wait times -Efficient & Personalized -Medical History -Motivates doctors to work more

Long Term Care -Decrease ER wait times and the volume of patients -More organized

Implementation of Split-Flow -efficient -eliminate ER wait -increase satisfaction

Con s

-Decreases Stress -Lowers risk of disease -Increases patient satisfaction -Lower physician incomes which may affect quality of care

-Costly -Time Consuming

-costly -unsatisfied and hesitant patients

Implementation of Evaluation Strategy •In order to implement our strategy, the number of family physicians must be increased, at least in highly populated areas •Also, the hours a physician works will have to be increased •We would suggest to pay the physicians on a salary plus bonus •This way, physicians will most likely to be motivated to extend their hours of service so that the number of patients they see increase •The implementation process would use a top down approach starting with the ministry of health, and end up with the physician offices •The implementation would have to be done as soon as possible •This is a country-wide implementation Conclusion •Emergency wait times are a large issue in Canada •We purposed these 3 alternatives: •Better Primary Care •Implementing PREVIEW-ED •Implement Spit-Flow Process •Based on the evidence that we have found, we believe that better Primary Care should be implemented Question 1 Are there any other alternatives you could think of aside from those we have listed? -better organization -better patient reporting -more research -es Question 2 Which of the proposed alternatives do you feel would have the greatest impact and why? -most said split flow model

Question 3 What questions and/or indicators do you think could be examined to evaluate the effectiveness of the implemented alternative? -wait time decreased? -measure entire time spent at hospital not only wait times -types of conditions being treated -overall conditions -ask doctors own perspective to improve Question 4 What financial, political, technical, or managerial resources do you think are needed?

-managerial: primary care physicians in private practices(secretaries etc) -political: allowing more international practitioners -what people are going to ER for Teacher Question   

Applying from other communities Difficult dealing with two levels of gov Many actors involved not everyone will be happy...