The topic of wait times in the Emergency Department (ED) has been well documented and discussed since the early 1970s, with the amount of time people spend in EDs continuing to be a topic of interest to patients, policy makers, health care providers and health system planners.2, 3 One of the many possible explanations for overcrowding is the use of EDs for conditions triaged as non-urgent, which contributes to increased demand for ED services. Health professionals have labeled use of the ED for non-urgent problems that could be cared for in other settings as “inappropriate use”. 4 Inappropriate ED use may result in increased health-service costs, overcrowding and can compromise care for true emergencies.4
Emergency Department wait time is a multi-factorial issue. There are many different factors that cause overcrowding, resulting in longer wait times. The commissioner recently made a point that wait times in the ED are not the fault of the ED; the bottlenecks are the result of problems upstream and downstream.1 There are several different hypothesized reasons for this issue, but for the purpose of this blog we will only be focusing on two; the upstream cause being issues with primary care, and the downstream cause being a discharge issue in other areas of the hospital.
A recent report stated that 60 percent of patients who go to the emergency room should not be there at all; they should be treated in primary care settings.1 Many people do not have a primary care physician, and those who do often are unable to get same day appointments.1 14.6% of patients reported that they could not get a timely appointment with their primary care physician, and 42.9% were referred to the ED by their primary care physician’s office.3 The usual time frame for available primary care appointments was 1-3 days, with over 17% of patients reporting that they are not able to get an appointment for over 7 days.3
One of the solutions to this upstream cause of ED wait times is getting patients to the right places. We don’t need bigger EDs, we need to shift the resources into primary care to alleviate some of the pressure in the EDs. Over 50% of patients mentioned that they would be comfortable seeing a primary care physician for their present complaints.3 That said, one recommendation for addressing the issues of wait times, as well as not being able to access primary care in a timely manner is to introduce a General Practitioner (GP) into EDs, to either work within or alongside the ED. The GPs may provide comprehensive resource-effective care for patients with non-urgent problems. In theory, the GPs would reduce wait-times and patient’s length of stay by seeing non-urgent patients quickly, and allowing Emergency Physicians to attend to more urgent problems.4 Overall, they would increase the flow and efficiency of the ED, and eliminate some of the problems associated with non-urgent patients who do not need to see an Emergency Physician.
There are a few suggestions on how to implement this recommendation. GPs can be introduced within the ED, where patients who enter the ED are immediately triaged into separate streams – non-urgent and urgent. GPs could work alongside the ED, where care is available next to the ED and patients can self-select which service they think they require. In this system, non-urgent patients may be redirected to the primary care service if they choose the ED. There is also the option to have GPs fully integrated, providing care jointly with Emergency Physicians, on the full range of urgent and non-urgent cases.4 So far, there are a few different options mentioned, however it is not yet known if this intervention results in better care for non-urgent patients.
Delays in some door-to-treatment times have been found in recent studies associated with ED overcrowding and longer ED wait times.2 One of the downstream causes of longer ED wait times is the lack of beds in the various inpatient departments of the hospital. 4% of patients waited over 24 hours in the ED for a bed once the decision to admit had been made.2 One of the solutions to this problem is to maximize the rate at which patients are being discharged. Studies have shown that ED wait times, patient volumes and discharges fluctuate throughout the week. Fewer discharges occur on weekends, resulting in a potential backlog in the EDs, especially come Mondays.2 One recommendation for this problem is to increase the rate of discharging. For example, increasing the amount of discharges on the weekends would free more beds on both of the two days, as well as alleviate some of the pressure come Monday.
The amount of time people spend in the EDs continues to be an issue throughout the country. Factors such as the convenience offered by the ED, lack of timely appointments with primary care physicians affect ED wait times. The issue of lengthy wait times is not solely the responsibility of the EDs; there are upstream and downstream causes that also need to be addressed.
- André P. Seniors on stretchers: a healthcare disgrace. The Globe and Mail. 2014:9:23. http://www.theglobeandmail.com/globe-debate/seniors-on-stretchers-a-health-care-disgrace/article20736757/. Accessed September 29th, 2014.
- Canadian Institute for Health Information. Understanding emergency department wait times: access to beds and patient flow. CIHI. 2007. 1-58. Accessed October 1st, 2014.
- Jaspreet, K. Gerd, F. Rafael, P. Brian, HR. Sasha, S. Primary care professionals providing non-urgent care in hospital emergency departments. The Cochrane Collaboration. 2012:4:28. (11) 1-82.
- Michael, FK. Minal, J. Anunaya, RJ. Sandra, MS. Emergency department waiting room: many requests, many insured and many primary care physician referrals. International Journal of Emergency Medicine. 2013. (6) 35.
Paige is currently studying Health Science at Western University and is expecting to graduate in the spring of 2015. She is currently working as a Research Analyst for the Ivey International Centre for Health Innovation in London, ON. Paige is passionate about all things health, and is interested in pursing a Master’s of Health Science in Health Promotion.