I always approach my Emergency Department (ED) shifts with mixed emotions.
It is a rewarding and privileged opportunity to be an ED doctor but it is also an experience laced with uncertainty.
As I drive in to start my shift, my mind works through the various scenarios I may encounter: pediatric patient without a heartbeat, trauma patient who needs an emergency airway, severe anaphylactic shock, violent patient, etc. The broader scenario also weighing on me is the volume of patients I will see that night; how long some of them will already have been waiting and how I might help those seeking care as efficiently and safely as possible.
High quality care in the ED means many things. One of the key elements is timeliness. The first thing I do when I arrive is check 'the board' to see how long the longest patient has been waiting and check with the nursing team to see how the pace of the day has been.
Emergency departments are often the canaries in the coalmine when it comes to the health-care system -- early indicators of broader trouble looming ahead. But while canaries grow silent in a dangerous atmosphere, voices of patients, physicians, and other health care providers grow louder when there are problems with emergency care.
When the system comes under stress because of reduced capacity (e.g. full hospital beds, no access to imaging tests) or increased demands (e.g. flu outbreak, trauma), emergency departments become a crucible of long waits that leave patients in waiting rooms and on stretchers for longer than anyone would want.
My feelings when starting my own shift at the ED echoes some of the key findings outlined in a new report on emergency care in Ontario released by Health Quality Ontario (HQO). This deep dive into a crucial part of our health-care system highlights areas of success but also primes us with knowledge of the issues that must be addressed in order to improve the work done in emergency departments in the province.
There is good news: the HQO report Under Pressure: Emergency Department Performance in Ontario finds that people are seeing doctors more quickly when they arrive in Ontario's emergency departments and overall their visits are shorter. This is occurring even though more people are coming to the emergency departments and tend to be sicker than in the past.
Given this, overall care in the emergency departments met provincial wait-time targets. Between 2008/09 and 2014/15, the proportion of visits completed within the four-hour target for non-admitted low-acuity patients increased and the proportion of visits completed within the eight-hour target for high-acuity patients and admitted patients, taken together as a group, rose.
Importantly, Ontario residents are often satisfied with the care they receive, with a 2014-2015 survey showing 73 per cent of respondents visiting emergency reporting having received excellent, very good, or good care.
However what should concern policy makers, hospital administrators, and the public are the steadily increasing pressures on emergency departments: More visits, older patients, and sicker patients with no end in sight. And these warnings don't take into account the impact that a major potential issue, such as a 'bad flu season,' or other infectious disease outbreak could have.
Over the past seven years, the number of annual visits to Ontario's emergency departments increased 13.4 per cent -- more than double the 6.2 per cent increase in the province's population.
Patients are also sicker overall, with visits by these "high-acuity" patients who were not admitted to hospital increasing by 44.1 per cent, while visits by patients who were admitted rose 17.5 per cent.
The data also show that urban residents spend longer in the emergency department and wait longer to see a doctor than people living in rural areas. There is also wide variation in wait times across the approximately 140 EDs in the province. Overall, the provincial average hit wait time targets -- but this was not true of every hospital.
A previous Ontario Minister of Health once remarked that the Emergency Departments of the province were touchstones for Ontarians -- a guarantee that critical services will be there when they are needed most. Tremendous hard work by many, including those on the front line 24/7, has helped yield sizable improvements and ensure that promise is kept -- but the pressure is only growing.
I know I can provide assistance to the people I see during my own shift in the ED, but addressing the bigger issue of providing the capacity to see everybody who needs care in the ED in a timely fashion is going to require approaches that improve the system as a whole to ensure the canary keeps singing.
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