ER Mismanagement Can Be Fatal

Lengthy waits, failure to adapt cause morbidity and mortality.
Published on September 30, 2008

Early on Sunday, a Winnipeg man was found dead in a waiting room at the Health Sciences Centre, 34 hours after he arrived at the hospital’s ER. The details have not all been made public yet. What is known is that he arrived at HSC after being seen at the Health Action Centre clinic four blocks away, and that there is no record of his being seen by a triage nurse.

The spokesman for the Winnipeg Regional Health Authority has already described this death as shocking and unprecedented and an inquest has been called. When its findings are published, after a federal election and a month’s worth of news have passed, we will all be tempted to view this tragic and likely avoidable death as an isolated incident. In fact, it is symptomatic of widespread mismanagement of ERs.

The Wait Times Alliance, an association of Canadian physicians concerned with accessible health care, has identified emergency medicine as a priority, and with good reason. Patients who pass through the ER are either admitted to hospital or discharged after being seen by doctors. Among those who are hospitalized, half are transferred from the ER to a bed in about two hours, a very reasonable standard. However, 10 per cent wait for 17 hours or more, and one patient in 20 spends more than 24 hours in the ER.

There are two factors contributing to long waits in ERs. The first is the high volume of unnecessary visits to the ER. The triage process, which occurs upon arrival, ranks how urgently patients need care on a scale from I, assigned to someone needing immediate resuscitation, to V, for a patient not requiring urgent care.

The majority of patients coming to Canadian ERs are in categories IV and V, meaning that their problems can safely be addressed by family doctors on a non-urgent basis. Demand for emergency care is so high because of a shortage of family doctors, as well as the lack of GPs providing after-hours coverage for their patients.

The second aspect of the problem is effective hospital management in the face of this high demand. St. Paul’s Hospital, a major teaching centre in downtown Vancouver, has made significant progress is reducing waits and streamlining the whole ER process. Recognizing that it is not economical to staff the whole department for peak demand levels, for example, appointments and elective procedures in the rest of the hospital are scheduled around ER peak hours, so that overflow can be directed to other departments.

The greatest innovation at St. Paul’s, though, is the way in which traffic in the ER waiting room is handled. Nurse-practitioners, who have a level of autonomy and responsibility somewhere between RNs and MDs, have been integrated into the system, and doctors are involved in the triage process. Patients have contact with doctors and nurse-practitioners immediately upon arrival at the hospital, and not only after being screened by a nurse.

Rather than wait until a bed is free before moving a patient out of the waiting room, stretchers are used for quick assessments to give a more accurate, and faster, picture of how urgently each patient needs care.

Most notably, physicians work in the waiting room itself when demand peaks, beginning and sometimes completing care for level II and III patients before they are even admitted to the ER. Non-urgent patients awaiting admission can sometimes be treated successfully on the spot, or can be directed to more appropriate care providers.

Needless to say, a physician working in the waiting room increases the chances that a patient who slipped through the cracks in triage will be caught in time to prevent a bad outcome.

We likely will never know decisively whether a more efficient or less crowded ER would have prevented this particular death. It is damning, though, that a man nearing death could be in a hospital waiting room for 34 hours, whether or not he formally presented himself to triage, without attracting notice.

It is also disturbing that there was no communication between the provider at Health Action Centre who directed the patient to the ER, and HSC. Continuity of care and access to primary care are recognized weaknesses of our health care system.

St. Paul’s has been lauded for its ER innovations for over five years, but such changes have not been broadly implemented elsewhere in Canada. This death may be the catalyst for real reforms in the WRHA, but it should not require such a drastic failure to bring about long-overdue changes in how our health care is managed.

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