In a position paper released Wednesday, the Canadian Association of Emergency Physicians (CAEP) says that contrary to popular belief, emergency room overcrowding is not caused by inappropriate use or by patients without their own doctors.
The primary reason for overcrowding is due to "access block" within hospitals that prevents ER patients who need to be admitted from being transferred to a ward, leading to backups in emergency, CAEP says.
Access block can be caused by an inadequate number of acute-care beds in a hospital or beds taken up by patients waiting for transfer to long-term care or other alternative-care facilities within the community.
"This is truly an overall health-care problem, not just within the emergency department," said Dr. Andrew Affleck, a trauma physician at the Thunder Bay Regional Health Sciences Centre and a co-author of the paper.
When it comes to benchmarks, CAEP says most patients should wait no longer than three hours after arrival at an emergency department to be seen by a doctor and eight hours to be transferred to an in-patient bed for those needing admission.
"The one caveat is we do see patients not in the order they come in, but in the order of their acuity," said Affleck. In other words, patients are triaged based on the seriousness of their condition, with a heart attack taking precedence over influenza, for instance.
Dr. Howard Ovens, director of emergency medicine at Toronto's Mount Sinai Hospital and another co-author, cautioned that the term "wait time" shouldn't be confused with overall "length of stay" in the ER.
From the time of seeing a doctor to discharge or admission, "important interventions would have taken place to clarify your diagnosis and usually to start treatment," he said.
In the last five years, emergency departments have been doing a lot more investigations because of the increased availability of sophisticated diagnostic equipment such as CT and MRI scanners, added Affleck.
"So the time as you move through the emergency may be a lot more," he said.
Last year, about 16 million Canadians sought care at an emergency department, and about one million of them were admitted to hospital. But wait-time benchmarks, and public reporting on efforts to meet those targets, vary from province to province, CAEP says.
Ontario has had benchmarks and an online reporting database for several years, with 74 hospitals in the program given financial incentives to hit the targets.
Under the program, a patient with an uncomplicated health issue — a sore throat, sprained ankle or a simple cut, for instance — should spend less than four hours "from door to departure, 90 per cent of the time," said Ovens. "Only 10 per cent should take more than four hours."
He said the majority of hospitals, which vie for a share of the $93-million annual incentive package based on performance, are achieving that benchmark.
For those with more complex problems, such as shortness of breath, abdominal pain, vomiting or vaginal bleeding that require more investigation, Ontario's ideal ER visit time is no more than seven hours, and the hospitals are "achieving that almost all the time," he said.
Still, in hospitals across the country, it's not unusual to see patients languishing on gurneys in the emergency department, waiting for an acute-care bed to open up on a ward.
"There are times now where patients have waited after admission to the floor (for) 24 to 36 and even 48 hours, two days in the emergency department," Affleck said. "They'd be on a stretcher, not even a hospital bed.
"Those are our sickest patients. And what CAEP is advocating for ... is they shouldn't be staying in there any more than eight hours after the decision to (admit them) to transfer to the floor.
"That's the goal we want and that's what Canadians should expect when they come in."