ICES Report: Benchmarking Patient Delays in Ontario's Emergency Departments: What Are We Waiting For?
|Table 1. Time to First Physician Assessment and Total Wait Time after Patient Registration in an ED, by Triage Acuity Level, in Ontario, 2003-2004|
|Triage acuity level*||Time to first physician (90th percentile, hours)||Total wait-time† assessment (90th percentile, hours)|
|*Canadian Triage and
Acuity Scale assigned when patient registers.
†Time from patient registration to discharge from ED.
Data source: Canadian Institute for Health Information - National Ambulatory Care Reporting System.
Total wait times in EDs vary substantially throughout Local Health Integration Networks (LHINs) in Ontario (see Figure 1). Compared to a provincial average of 6.6 hours (within which 90% of patients are seen), there is a 2.6-fold difference between the fastest-performing LHIN, at 4.2 hours (South West), to the slowestperforming LHIN, at 11.2 hours (Toronto Central). Such wide variation needs to be considered in the context of local differences among LHINs such as patient case-mix, availability of inpatient beds and existing alternatives to EDs for care of patients with minor complaints.
Various solutions to the ED wait problem have been proposed, including increasing inpatient bed capacity, increasing ED physical space, speeding up test turnaround times and reducing patient inflow by diverting patients with minor illnesses or injuries elsewhere for care. In the right context, all of these initiatives might work to reduce waittimes for some patients. However, solutions must be tailored to resolve predominant local causes of wait times, as it is unlikely that a "one size fits all" remedy is the answer.
So where do we go from here? One way forward is to examine the approaches of other jurisdictions that have successfully reduced ED wait times. The best-documented example is the National Health Service (NHS) in the UK, where dramatic reductions in ED wait times were achieved following the adoption, in 2001, of a country-wide target of four hours or less total wait-time for 98% of ED patients (Alberti 2005). In 2005, the NHS reported that less than 4% of ED patients spend more than four hours in an ED (Alberti 2005), compared to about 23% in Ontario and about 28% in the US (McCaig and Burt 2004).
Target-setting alone is unlikely to produce meaningful results. The UK strategy included several key components, such as financial incentives, accountability measures and additional investments such as enhanced access to afterhours alternatives to EDs (Alberti 2005). However, despite the substantially improved performance reported by the NHS, 20% of EDs in the UK have not attained the target, and some have complained of inadequate involvement of senior hospital administration in the effort (British Medical Association [BMA] 2005). In addition, a singular focus on achieving the wait-time target has been blamed for reduced attention to quality of patient care, inappropriate admissions, overly hasty discharges and "creative accounting" or manipulation of data to attain the target (BMA 2005; House of Commons Public Accounts Committee 2005).
However, the process of moving toward a benchmark may be as important as achieving it, and likely deserves equal emphasis. The NHS has adopted a more balanced strategy for another key quality-of-care indicator. The NHS measures the "call-to-needle" time for eligible patients with acute myocardial infarction (period from 911 call to delivery of clot-busting thrombolytic drugs) in terms of the absolute proportion of patients treated within the recommended benchmark time and the annual incremental improvement in that proportion (Department of Health 2003). Both measures can be used to gauge performance; two hospitals with differing absolute performance but similar incremental improvements could each be considered good performers. Implementation of performance targets may be more successful if there is allowance for some degree of variation in recognition of regional differences, and by ensuring that measures designed to help hospitals achieve the targets are appropriate to the local context.
Implementation of benchmarks has led to improved care in other contexts (Jha et al. 2003; Rogers et al. 2000), and Canada is now beginning to define target wait times for several medical procedures (Wait Time Alliance 2005). The UK experience suggests that wait-time benchmarks can be successful in EDs. If such efforts to reduce wait times are adopted in Ontario, it is critical to ensure that quality of care is not compromised and potentially improves. Good performance should include regular incremental improvement as opposed to the sole attainment of an absolute target. Local input into benchmark-setting and investment of new ED system resources are important, and close involvement of senior hospital administrators is required. Taken together, these may lead to substantially improved patient care in Ontario's EDs.
About the Author(s)
Michael Schull, BA, MSc, MD, FRCPC, has been a scientist at ICES since March 2000. He is an Assistant Professor in the Departments of Medicine (Division of Emergency Medicine) and Health Policy, Management and Evaluation at the University of Toronto. He also holds a faculty appointment in the Clinical Epidemiology Unit of Sunnybrook and Women's College Health Sciences Centre. Dr. Schull sits on the Research Advisory Committee of the Ontario Ministry of Health's Emergency Health Services Branch. He is a practising staff emergency physician at Sunnybrook & Women's and supervises the clinical and research training of residents in the Royal College Emergency Medicine program.
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