When patients come to a hospital emergency department, they are often anxious and in pain or distress. They want to receive medical attention fast. That can be a challenge for the medical staff who is coping with high volumes of patients, many with severe medical conditions. But a novel approach to managing patient flow in the emergency departments (EDs) at William Osler Health Centre is helping to speed up care for the patients who usually wait longest.
At Osler, a multi-site health centre in the west Greater Toronto Area, there are doctors and nurses on site in the emergency departments 24 hours a day, 365 days a year. When a patient comes into the ED, they are seen by a triage nurse, who determines the urgency of their condition using a 5-level assessment tool called the ‘Canadian Emergency Department Triage and Acuity Scale’.
Level 1 patients are those in critical and unstable condition, such as someone in cardiac arrest. These patients must be treated immediately. Level 2 patients are very ill and could become critical at any time. An example is someone suffering a severe allergic reaction. These patients need to be seen within a very short time. Level 3 patients are urgent but relatively stable, such as a person with influenza or a dislocated shoulder. Level 4 and 5 patients have less severe conditions such as minor fractures or lacerations.
Patients are seen based on the acuity of their conditions, not arrival time. Level 4 and 5 patients are usually directed to the after hours clinic/fast track of the ED where they can be treated reasonably quickly. Level 1 and 2 patients are treated in the acute section of the ED and naturally have priority because of their conditions. This means it is the Level 3 patients who usually end up waiting the longest.
In 2004, the ED at Osler’s Etobicoke Hospital implemented a new process to address this issue. During the day and evening shifts, part of the ED is designated as an assessment area with dedicated stretchers and chairs. A nurse is assigned solely to this area. When patients enter the ED, they are evaluated by the triage nurse. The Level 3 patients are then sent to the assessment area with their charts. Once there, the assessment nurse places them in one of the beds. If all the beds are in use, patients wait in chairs until a bed is free. After being examined by the physician, any necessary tests are ordered and the patients go back to their chairs to wait for the results. The system bucks tradition in that patients move between chairs and beds rather than occupying beds while waiting for test results or other procedures. This allows patients to move through the physician examination stage quicker.
Dr. Naveed Mohammad, Site Chief of Emergency Services at Etobicoke Hospital, said the process has definitely reduced the time it takes for patients to be seen by the physician. “Patients measure waiting time by how long it takes to see a doctor, not how long it takes to get a bed,” he said. “For Level 3 patients, it used to take between 130 and 158 minutes ‘from door to doctor’. Now it’s between 85 and 95 minutes.”
Another benefit is that patients in the assessment area are always within sight of the nurse and can communicate with her if necessary. Patients whose conditions may change for any reason can be monitored more effectively.
During the night shift, the assessment centre is used as part of the acute care area since patients presenting on that shift tend to be sicker and there are fewer Level 3 patients.
The assessment concept worked so well on the day and evening shifts that in May 2005 it was expanded to Osler’s Peel Memorial (Brampton) Hospital. This campus has extremely high patient volumes and so far the ‘Emergency Process Unit’ appears to be just as successful as the Etobicoke assessment area.
Deborah Hill, Patient Care Manager for Emergency Services, said, “The model is fantastic. When you reduce wait times, patient satisfaction improves.”