The Canadian healthcare system is at its breaking point. Aging and rapidly growing populations coupled with a healthcare human resource crisis have outstripped our systems’ resources leading to historic wait times for care in every department. As the safety nets of the healthcare system, emergency departments (EDs) are the “canary in the coal mine,” the first signal when our system is failing Canadians. Most healthcare providers predominantly work office hours, with small amounts of additional after-hours coverage; however, the ED is always open, bridging the care gaps for every Canadian community. Despite this, closures of EDs – particularly in rural Canadian communities – is frequent, leading to worse outcomes and wider gaps for patients seeking local emergency care. Also problematic is the crowding facing most EDs, with higher volumes of patients leading to wait times ranging from two hours to over twenty-four hours. We also see admitted patients spending hours or days in the ED for in-patient beds, leading to worse outcomes and increased all-cause mortality from “hallway medicine.” 

When traditional approaches to alleviating patient flow fail our system, we must look to other industries for illumination. For our wait-time crisis, we examined innovations in consumer-driven services provision that are happening in the customer service industry. Today, you can book a service appointment for your car online and get regular text message updates about its progress. You schedule a ride from your cell phone and watch an icon as it approaches you. You can communicate digitally with almost everyone. However, the healthcare system has been slow to innovate; the often cited reasons of privacy, disconnected information systems and cost containment combine to limit digital innovation.

To address the dual challenge of escalating wait times and the realized loss of patient and community trust in our hospital’s ED, the Michael Garron Hospital (formerly known as the Toronto East General Hospital) researched ways to reduce wait times while smoothing ED attendance and improve experiences by co-designing an innovative strategy in the form of pre-booked same-day appointments for urgent but low-risk conditions presenting to our ED. Our goal was to allow patients who were safe to wait a few hours at home and come in at a time when the ED would be less congested, thereby providing lower wait times. We designed our program in four stages:

First, we examined our data on patient arrival times in the ED to identify “less busy” times for each day of the week. These time blocks were ideal for creating booked appointment slots for patients who intended on visiting the ED that same day. 

Second, we identified a list of the medical issues and injuries for which our ED team, based on their clinical judgement, believed that patients would be safe waiting a few hours before being seen. We were cognizant to include only those that required an emergency visit and an assessment within the next 24 hours. The purpose of the program was not to bring non-emergency conditions into the ED, but rather to improve the waiting experience of those who were coming anyway. The difference was that while the patient would have been waiting in the ED for those conditions previously, now they could wait at home. Given the risk in delaying care for patients requiring immediate emergency intervention, the scheduled visit pilot was limited to patients with acute low-risk musculoskeletal presentations (e.g., ankle injury).  

Third, we examined staffing patterns, wait times and problem lists for our patients and organized them by our EDs’ treatment zones. ED zones for patients requiring higher levels of care have longer waits than those where patients are able to walk, have lower care needs or can help themselves more readily. Therefore, coupled with the appointment blocks, the need to ensure that the appropriate level of staff and equipment (e.g., imaging) and a dedicated daily point of contact for the program (in our case the orthopedic technician) would be available during the appointment windows was key to achieving our goals. 

Fourth, our team created an online booking tool to allow for patients to complete a self-screen of their issue and injury using inclusion and exclusion criteria defined by the ED care team. If a patient screened “in,” they were able to book an appointment. If they screened “out,” they were advised to come to the ED. 

The ED booked appointment program for patients with acute issues requiring emergency care either the same day or the next was launched in June 2022. Since the program’s inception, uptake has gradually increased. The ED now sees an average of more than 200 appointments per month, with a service estimate of two hours total “in department” time. Initial apprehensions around the program attracting more patients (e.g., those for routine primary care) to the ED or delaying care for those needing it more urgently have not been observed.  

In the 18 months since implementation, the booked appointment program has been highly successful and has grown in popularity. A large proportion of the ED’s positive patient feedback is related to the booked appointment program. The program is also one example of an unconventional approach to addressing wait times that has been particularly successful in our setting and with our care community. Despite growing demand for ED services since June 2022, our ED’s wait times have remained low with an overall departmental trend toward stable or declining patient wait times for our hospital. 

Canada does not have the financial or human resources for all of healthcare to function outside business hours. We are fortunate to have EDs provide the safety net our population deserves for trusted and timely care for emergent conditions and medical issues happening at any time of day. Emergency medicine clinicians have long held true the belief that our job is to service all patient needs, regardless of the difficultly in doing so in our setting. Yet the narrative of “ED overuse” diminishes the recognition of the critical function that the ED plays within our fragmented and overtaxed healthcare system. Future innovations in digital technologies and drawing on practical examples from industries outside healthcare provide a path forward for EDs looking to bridge the gaps in our healthcare system in order to provide safe, reliable, effective and timely care to the communities we serve.   

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