I think it’s safe to say that more ink has been spilled on wait times in emergency departments than on any other health-related issue. Regardless of what Canadian jurisdiction you live in, chances are you’ll find an article or editorial every few weeks detailing a local crisis. And we aren’t alone in this. A quick glance across the pond shows that a similar story plays out regularly with the National Health Service in the UK, with backlogs part of expected daily life.
In my local paper (London Free Press), here’s a brief sampling of headlines over the past few months:
Emergency room wait times worsening in London – Sept 25/14
Bottleneck reaches record levels, with Victoria Hospital 125% full on Sunday and Monday -Dec 29/14
Hospital looks to biz to cut waits – Apr 3/14
UH ranks worst – July 1/14
“We need to do better” about wait times – Dec 15/14
Inspiring, no? Inevitably the crisis du jour is followed by buzz on talk radio, and the peanut gallery in coffee shops and Internet comment sections offer up their scapegoats, usually including a combination of CEO salaries, nursing cuts, bed-blockers, teaching hospitals, tertiary centres, ER frequent fliers, influenza, etc. (Andre Picard does a good job here countering the message that influenza is to solely blame for holiday backlog). So everyone is fired up, but nothing changes, and we wait for the next article decrying wait times. Wash. Rinse. Repeat.
I’ll start off by stating that more funding alone is not the solution to all of our ills. More funding will be a necessity for a few of the issues I will discuss, but throwing money alone at this problem won’t solve anything. The proposal by the Ontario NDP party during the last election to reduce ER wait times by 50% by adding nurse practitioners made for a great election sound bite, but would do nothing to change the fundamental flaws in the system.
There is a tremendous urgency to improve the ER system now. We are incredibly fortunate that our news isn’t littered with stories of patients suffering complications as a result of wait times. I have sent patients from my clinic to the ER on many occasions with urgent conditions, to be shocked when they had not been assessed hours later. And this is no fault of the ER physicians, who do their best to essentially survive one shift at a time. They were trained to treat emergencies, yet as a result of angry waiting patients, non-emergent presentations, and bed backlog with admitted patients, many are on the verge of burnout. Talk to an emergency physician and ask them whether they are satisfied with their jobs, and most will tell you the same story. Their dissatisfaction affects how they interact with nurses, staff, and admitting services, then those individuals become inevitably irritable, and the spiral of morale continues to descend.
So let’s start to fix it. I see our ER congestion as being a consequences of two main system flaws: a problem with access and a problem with flow.
Access is getting appropriate care to patients when medically necessary and when they feel they need assistance. As much as we criticize patients for visiting the ER for non-emergent issues, for whatever reason, they felt that their visit was appropriate. I will explore various strategies for ensuring that patients receive timely care, and increase satisfaction, without simply increasing ER resources.
Flow describes how patients move through the hospital system, and having patients in the most appropriate location at all times. Flow solutions are largely hospital-dependent, but there are a few principles that can be administered system-wide. It is no secret that the biggest barrier to flow is patients awaiting long-term care and patients who are ALC (alternate level of care). Funding is the issue. All levels of government know that funding new nursing homes is costly, and they want to put off the issue as long as possible. So either they’re waiting for the apocalypse or a repeat of the 1918 influenza epidemic, because I’m not sure how much more dire situations need to become in some jurisdictions before they act. Families and home care are looking after these patients at home as long as possible, until they inevitably decline, at which point they are admitted to hospital in crisis while they await a long-term care bed. It’s a situation that plays out across the country every day, and is a huge drain on our system.
1) Linking patients with a family doctor/primary care team
Yes, you’re probably thinking, “His first big idea for ER improvement is more family doctors? Thanks for stating the obvious, genius.” Of course it’s obvious. Which makes it even more frustrating that we still have so many patients without family physicians after years of this being an issue. The proposed cuts from the Ontario Ministry of Health to bonuses for physicians who take on new patients certainly won’t help things.
1a) Have retiring physicians provide mentoring to family medicine residents to take over practice
Every community has had retiring physicians close up shop and leave patients orphaned. These patients will inevitably seek fragmented care through walk-ins and emergency departments until they can find a new physician. I can speak personally of the advantages of this form of succession, as I have taken over from my own family physician. Family medicine residents I speak to are quite interested in this type of arrangement, as it helps to allay much of their anxieties about entering the real world. The retiring physicians would love to provide their patients with continuity. Health Force Ontario, the OMA and individual residency programs can work together to provide the initial contact between residents and physicians, elective opportunities as a sort of “trial period”, and a standard protocol for the business transition.
2) Some family doctors/primary care teams need to improve accessibility to patients
When new patient enrolment models in primary care were introduced in Ontario, they made some intuitive sense to the MOHLTC. Rather than be paid per patient visit, physicians in these funding models would receive the bulk of their funding based on the number of patients on their roster. The physicians within each respective group would be responsible for providing after-hours care to any patient of any physician within the group. From the ministry’s standpoint, they would be able to better predict their costs from year to year regardless of whether the number of patient visits increased. From the physician’s standpoint, they would be paid more than they received in a fee-for-service model. And while many physicians who currently work in these models work hard and still provide great access to their patients, some physicians have taken capitation payments as an invitation to cut back on hours and number of patient visits. The only instrument of accountability is that they have payments deducted if their patients attend walk-in clinics rather than seeing a physician within the group. While it may seem Draconian, I don’t think it would be unreasonable for the MOHLTC to work towards a strategy where physicians are expected to provide same-day appointments as part of their contract terms. I know that many family physicians have moved to a “Same-Day/Advanced Access Scheduling System” where most appointments are booked the day for the same day. Whatever means they use to ensure same-day appointments, there needs to be some teeth to the MOHLTC policy to ensure compliance, which may include a patient ombudsman. Patients then need to be clearly informed of these same-day policies, because right now the majority of patients assume they can’t get in the same day, and resort to the ER or walk-in clinics. If physicians find that because of patient volume they are not able to meet those targets, the MOHLTC ideally would be a resource to allow the physician to transition to a more reasonable roster size (moving patients to a new grad taking patients, etc.). There also needs to be procedures in place that guarantee that vacationing family doctors have physicians covering their patients for them (and that patients are aware of these procedures). Too many patients are bouncing back to the ER for non-urgent follow-up while their doctor is still on holiday.
3) Hours of operation for primary care clinics and walk-in clinics need to be easily accessible online.
This may be another point that seems obvious, but is often overlooked. All physicians who see any patients in primary care should be required to post updated hours and days of operation on an easily accessible public website. They should also include hours during which phones will be answered, and locations of after-hours clinics. This is easily achievable, as the CMA provides easy-to-create websites for physicians. I realize that physicians reliably state their office hours on answering machines, but having them available online would be much more easily accessible to patients. (Clearly posting updated holiday hours is another absolute must.) Providing easily accessible interactive maps of local walk-in clinics would also help to redirect patients. This walk-in list is available for London, but a map would be much easier to navigate for patients. This map could also be prominently displayed in ER waiting room entrances.
4) Complete visit records must be sent from the ER or the walk-in clinic to the family physician or primary care team within 24 hours
This serves two major purposes. One is to inform the family physician that the patient has sought care elsewhere. There is often an issue that needs follow-up, and if the family physician doesn’t even know the visit took place, follow-up can be difficult. The second purpose is to provide complete records to guide any further evaluation. This is pretty self-explanatory. The more information the family physician has, the fewer tests are duplicated, the fewer errors are made. Here in London we have a system called the LENS, whereby the physician is sent an email every morning detailing every patient of theirs who was in any local ER or admitted/discharged from hospital. If they ever discontinued this service, I would picket my local MPP’s office personally.
5) ERs and walk-in clinics should be required to report to MOHLTC names of patients who state they don’t have a family physician or primary care team
Some ERs have programs in place where frequent users are identified and underlying socioeconomic issues are addressed. My proposal would help the MOHLTC to identify patients who are attending any acute care centre frequently, and to match them to a family physician. Of course this proposal is contingent on point #1, whereby we have enough family physicians or primary care teams to make this happen.
6) Have accessible “Urgent” clinics across many specialties, and very clear hours and days that they run, and posted preferred contact information
Every primary care physician runs into this situation. The patient comes in with an urgent issue, we know which type of specialist we want them to see urgently, but navigating the system to get to that specialist is a maze. Finally we give up, and knowing that the patient can’t wait days to see the specialist, they are sent to the ER. Every community has success stories of urgent clinics that provide tremendous service to the community. The local LHIN should provide every primary care physician with the following (created in consultation with the head of each speciality): a list of urgent clinics in every discipline, the preferred means of contact (to call the specialist directly, the resident, secretary, etc), and the hours and days of operation.
7) Community radiology facilities should be required to have same-day appointments and reporting available for x-ray and ultrasound
Primary care physicians are happy to manage urgent conditions as an outpatient, provided that we have access to the necessary testing. This is especially true for physicians working in nursing homes. Quick guaranteed access to radiology and laboratory services could prevent numerous admissions to hospital for a “diagnostic workup”. Along similar lines, the government needs to continue to work urgently towards having all lab and imaging reports (from both community and hospital) available for access to any practitioner. ER docs should have access to view (not add to) the GP’s files, and vice versa. The amount of duplication and ER visits because of this lack of access would truly disgust the public. I know that the MOHLTC have information sharing on their radar, but this has to become reality ASAP.
8) National, provincial and local bodies need to design better patient education tools for self-management
Part of making our health care system manageable is to decrease unnecessary utilization. But what may seem like unnecessary utilization to a health care professional may seem like an unsolvable ailment to a patient. This education can take the form of waiting room resources, online tools or online evidence-based guidance. More often than not, patients are simply looking for either reassurance or very simple advice, which should be very simple to provide them for viral illnesses, MSK pain, non-urgent issues, etc. Scrap Telehealth (and other similar provincial programs), put their algorithms online for patients to interpret themselves, and put some of the money saved into online patient education (I’m a unabashed fan of the work being done at the Evans Health Lab by Dr. Michael Evans and his team). An easily accessible resource through the CMA, for instance, could be a patient’s go to resource for all acute illnesses. It won’t be an inexpensive project to complete, but the savings would be nationwide.
9) Continue to address the social determinants of health
This could be a 3,000 word essay onto itself, but we need to continue to provide funding to address poverty, homelessness and drug use, in order to curb emergency department use. The complexity of that solution is well beyond my expertise, but it needs to continue to be a top priority at all levels of government.
10) Continue to provide accessible home care
I know that the CCAC here in Ontario has come under fire at times for being top-heavy in terms of management, but over the past couple of months I have noticed the CCAC case managers doing great work in trimming unnecessary services to patients. Keep in mind that private companies are employed to administer the services, so without a case manager to oversee utilization, there would be very little accountability remaining. Physicians and other health professionals need to know that if they see a patient and make any home care recommendations, to call the case manager directly. Don’t just send a fax to CCAC and hope for the best. They’ll end up in crisis in the ER.
So there it is, my entire manifesto. I’d love to hear your feedback and suggestions, because I really do hope that we can moved forward in communities with some of these changes. The sooner we begin to work on local and provincial solutions, the sooner we can avoid any of the likely consequences of ER overcrowding in the future.