Healthcare Quarterly

Healthcare Quarterly 9(2) March 2006 .doi:10.12927/hcq.2006.18133
Longwoods Review

Emergency Room Waiting: Not Really Necessary

David Levine


The review of wait-time issues in our emergency rooms is both timely and pertinent. Each of the nine solution elements for reducing wait times is a component of the overall solution to a greater or lesser degree. I would suggest regarding the solutions in two categories: avoiding emergency room visits and managing emergency room visits.
The Montreal Regional Health Authority has been particularly concerned with this issue, as emergency wait times are the barometer by which the work of ministers of health are measured by the population. Avoiding emergency room visits is the real solution, and to this end, Quebec is implementing a reform in healthcare that I hope will revolutionize the way healthcare is delivered.

Quebec has been divided into 95 territorial organizations, each containing a hospital, nursing home, rehab centre, home care and primary care services with a mandate to manage the healthcare of their population. This is a population-based managed care model relying on multidisciplinary primary healthcare teams registering a given population and managing their care and treatment. This model, used by the Kaiser foundation in California, has reduced by half the number of visits per capita to the emergency room. Ensuring accessibility 12 hours a day, seven days a week with on-call night coverage is the key to this reduction, as well the registering and direct management of all chronically ill patients. The Montreal targets are to reduce emergency room visits by 50% within five years.

The second approach is to manage the functioning of the emergency rooms, and six of the nine solutions reviewed refer to this approach. The regional management of emergency room functioning is another factor that is key to reducing waiting times. The Montreal Regional Health Authority has a team that monitors the 15 emergency rooms on the Island of Montreal. A report is submitted twice a day giving the occupancy rates, number of ambulances, patients awaiting hospitalization, patients waiting more than 48 hours and other pertinent data.

As the emergency rooms become more crowded, the agency can redirect ambulances, open more nursing home or rehab beds, provide more intensive home care coverage if required and prioritize admissions to nursing homes from overcrowded hospitals. These measures alleviate pressure points and smooth out the system. Each of Montreal's 12 territories has a home care specialist discharge planner in the hospital emergency room coordinating the movement of each patient. This close link to alternative solutions to hospitalization and discharge has allowed for a much more controlled emergency room environment. It enables all the emergency rooms to be connected and provides a level of security to emergency room managers.

These two approaches integrate the nine solution elements in the paper and provide a way to implement them in the broader context of a populational responsibility. Quebec produced a guide to better management of emergency rooms, and after many hours of training and reorganization, it became clear that the real secret to emergency room management is a change in culture of hospital medical staff, led by a dedicated, passionate physician in charge of the emergency room with full, unconditional CEO and board support. The hardest changes to implement are cultural ones, but with the right vision they are possible.

About the Author(s)

David Levine
President and CEO, Montreal Regional Health and Social Service Authority


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