Complex factors at play when it comes to emergency department waits
Patients with more minor cases could see shorter waits at urgent care centres, walk-in clinics
Inside the belly of the emerency department at St. Catharines hospital, a patient freshly off-loaded from a Niagara Emergency Medical Services ambulance lies on a gurney. Nearby in a room, one of the paramedics sits with registered nurse Maureen McCreadie as they go over thee patient's vital signs and McCreadie inputs the information into a computer. Depending on how serious the patient's condition is, she could end up seeing a doctor before the 20 or 30 other patients sitting outside in the sunlit waiting room, some of whom may have been there for more than an hour. It's called triaging, and it's a backbone of emergency medicine in Niagara and across
Canada: those with the most serious injuries or illnesses are seen first, regardless of when they arrive at one of the three hospital ERs that Niagara Health operates in St. Catharines, Niagara Falls and Welland.
When it comes to emergency medicine, first-come, first-served does not apply.
It’s also one reason why people with less serious medical needs often have to wait longer than they’d like to at ERs, said Derek McNally, Niagara Health’s executive vice-president of clinical services and chief nursing executive.
“Often we hear, ‘Why do you look at him before me? I’ve been here for hours,’” he said. “It does get frustrating for patients and their families.”
But Niagara Health, like operators of hospitals across Canada, uses a five-level triage and acuity scale to assess who needs care most quickly. Level 5 is non-urgent, while Level 1 is the most serious, such as a heart attack or someone needing resuscitation.
“It’s life and death and we need to see you right away,” said McNally, himself a former emergency department registered nurse.
To help patients make informed decisions on where to seek care, Niagara Health has for the past several years posted real-time wait times at its three emergency departments and its two urgent care centres, in Fort Erie and Port Colborne, reflecting the estimated time it will take between being assessed by a specially triage nurse and being seen by a doctor or nurse practitioner. Screens inside the ER waiting rooms also display the same information.
For instance, during a recent glance at the hospital system’s website, the ER in St. Catharines had a wait of 2.5 hours with 31 patients being treated and 16 waiting, Welland’s ER had a wait of three hours with 14 people treated and 10 waiting, and the ER at Greater Niagara General Hospital had a wait of 1.5 hours with 19 patients being treated and six waiting.
But for those showing up to ERs with minor ailments such as sprains or looking for a prescription renewal, triage may push them back in the queue to make way for more serious cases.
Niagara Health said people may actually be seen faster by going to urgent care centres for problems such as nausea and vomiting or the flu; coughs, colds and fever; ear, nose and throat problems; cuts needing stitches; sprains and strains; or minor asthma attacks and allergic reactions.
Heading to the ER seems to be the first impulse for many Niagara residents, even for more minor cases: Niagara Health, which had just less than 200,000 ER and urgent care visits last year, said about 32,000 ER visits last year were for minor concerns.
In this fast-paced world, waiting in an ER can seem like an eternity. But McNally said waits are inevitable because of the various steps that an ER visit can entail: the initial assessment, registration, consultation, diagnostic lab tests such as blood work, X-rays or ultrasound if ordered, the actual diagnosis, treatment, and the decision to either discharge the patient or admit them.
That can take hours and can entail a dizzying series of interactions with such hospital staff as lab assistants, medical imaging technologists and respiratory therapists.
The decision to admit a patient can be greatly complicated by what’s going on in other areas of the hospital, with Niagara Health frequently dealing with many patients taking up in-patient beds who don’t belong there. These are people who can’t be safely discharged, but who are waiting for beds in places such as longterm care homes or retirement homes, said McNally.
Niagara Health, which operates about 900 beds in total, had no less than 140 patients waiting for so-called alternate level of care placements during an interview with Niagara This Week.
That leads to backups in the ER and what’s commonly called hallway medicine, with patients needing to be admitted waiting on cots, requiring ER staff to monitor their conditions and leading to delays overall.
The hospital system continuously works to keep those number of clogged in-patient beds down by working with the province’s Ministry of Health and the local health integration network that Niagara is a part of, said McNally.
For instance, Niagara Health recently opened a number of beds not yet funded by the province, and a couple of years ago launched its integrated comprehensive care (ICC) program that provides discharged patients with congestive heart failure or chronic obstructive pulmonary disease access to support 24 hours a day for 60 days.
That program, which helps people to manage their chronic conditions at home, has decreased the average length of stay in hospital by three days and reduced readmissions and unanticipated ER and urgent care visits by more than 10 per cent, Heather Paterson, Niagara Health’s director of patient care and ICC project lead, said earlier this year.
Unforeseen circumstances such as a multi-car accidents resulting in patients being rushed to the ER can also create longer waits for other patients because the newcomers must be seen first, said McNally.
The length of ER visits can also be increased if the doctor or nurse practitioner requires consultation with specialists such as a cardiologist if a patient has heart issues, or an orthopedic surgeon for a serious bone break.
“We do the best we possibly can to get everyone through with the least wait and the least frustration as possible,” he said. “(But) sometimes people are disappointed.
“The reality is, every step of your (ER visit) takes time,” said McNally. “There’s a wait for everything.”
Niagara also faces the challenge of having one of the largest populations of seniors — who on a per capita basis tend to consume much more ER resources than younger people — in Canada, said McNally.
“You see a lot of older people with recurring, coexisting conditions,” he said.
As Niagara heads into full-blown flu season and the inevitable stress that places on ERs, urgent care centres and walk-in clinics, McNally said Niagara Health is also seeing a noticeable spike in the number of kids showing up with flu symptoms this winter.
While the hospital system continuously stresses that less serious cases are best suited for urgent care centres, walk-in clinics or in a family doctor’s office, where patients are more likely to be seen more quickly, McNally said people should err on the side of caution and either head to the ER or call 911 if they think they have a true medical emergency.
“We will never turn anyone away,” he said “You’re not going to be criticized.”
While admitting Health Niagara sometimes misses the mark on timely visits to the ER, McNally said everyone from the housekeeping staff and porters to nurses, volunteers and doctors are passionate about safe quality care in a timely manner.
“We have amazing staff and volunteers,” he said. “We’re very proud of the work they do and the care they provide.