Hospital Emergency Departments: Section

Chapter 3 Ministry of Health and Long-Term Care
Section
3.05 Hospital Emergency
Departments
nurses assess and classify patients based on the

Background Canadian Triage and Acuity Scale (CTAS). CTAS
is a five-point scale, with level 1 being the most
acute and level 5 the least acute. Figure 2 provides
Hospital emergency departments provide medical
descriptions and examples of patient symptoms
treatment for a broad spectrum of illnesses and
and distribution of emergency-department visits,
Chapter 3 VFM Section 3.05
injuries to patients who arrive either in person or by

at each CTAS level, showing that less urgent and
ambulance. In the 2008/09 fiscal year, there were
non-urgent visits to emergency departments
about 5.4million visits to the provinces 160 hospital
constituted nearly half of all visits in the 2008/09
emergency departments, at a cost of approximately
fiscal year.
$960million. The number of emergency-department
Each hospital in Ontario reports to one of 14
visits increased about 6% from 2004/05 through
Local Health Integration Networks (LHINs), which,
2008/09, while costs increased 28%.
under the Local Health System Integration Act, 2006,
The quality and efficient delivery of patient care
are responsible for prioritizing, planning, and
in emergency departments depend on a variety of
funding certain health-care services. The LHINs, in
interrelated elements, such as prompt offloading of
turn, are accountable to the Ministry of Health and
ambulance patients, quick and accurate triage (that
Long-Term Care.
is, the process of prioritizing patients according to
the urgency of their illness or injury), nurse and/or
physician assessment, diagnostic and laboratory ser-
vices, consultations with specialists, and treatment. Audit Objective and Scope
As Figure 1 shows, a patients length of stay in the
emergency department depends on the timeliness
The objective of our audit was to assess whether
of each part of the process, as well as on the ready
selected emergency departments had adequate
availability of further care, such as an in-patient
systems and procedures in place to ensure that:
hospital bed if the patient needs to be admitted.
Timely and accurate triage in emergency depart- services were managed and co-ordinated effi-
ciently to meet patients needs;
ments is critical to ensure that patients with urgent,
life-threatening conditions are treated as quickly as services were delivered in compliance with
applicable legislation and policies in a cost-
possible. In Ontario emergency departments, triage
effective manner; and
132
Figure 1: Patient Flow through an Emergency Department
Prepared by the Office of the Auditor General of Ontario
ARRIVAL EMERGENCY DEPARTMENT DEPARTURE
diagnostic and
laboratory services
(e.g., blood work,
ultrasound, CT scan)
patient
discharged
home
patient arrives
by ambulance
triage and nurse physician disposition patient
treatment admitted to
registration assessment assessment decision
hospital
patient
walks in
patient
transferred
to another
hospital
consultation
services
(e.g., urology, cardiology)
usually occurs
sometimes occurs
Hospital Emergency Departments
133

134 2010 Annual Report of the Office of the Auditor General of Ontario
performance was reliably measured and Figure 2: Canadian Triage and Acuity Scale (CTAS)
reported.
Levels and Emergency-department Visits, by Level,
We conducted our audit work at three hospitals
2008/09
of different sizes that provide services to a variety Source of data: CTAS Implementation Guidelines and Ministry of Health and
of communities: Hamilton General Hospital, Scar- Long-Term Care
borough General Hospital, and Southlake Regional % of
Health Centre, located in Newmarket. To obtain
Examples of Emergency
additional information from a representative sam- Level Acuity Patient Symptoms Dept. Visits
ple of emergency departments across all 14 of the 1 resuscitation cardiac and/or 0.6
provinces LHINs, we sent a survey to 40 hospitals pulmonary arrest
of varying sizes. About two-thirds of these hospitals major trauma
responded. We also surveyed all 14 ambulance (severe injury and
burns)
Emergency Medical Services (EMS) providers that
unconscious
had received funding from the Ministry of Health
2 emergent chest pain with 12.9
and Long-Term Care (Ministry) specifically targeted cardiac features
to help reduce emergency-department wait times. stroke
Ten of these EMS providers responded. serious infections
In conducting our audit, we reviewed relevant 3 urgent moderate abdominal 39.0
files and administrative policies and procedures; pain
moderate trauma
interviewed appropriate hospital and ministry staff;
(fractures,
reviewed relevant research, literature, and best dislocations)
practices in other jurisdictions; and met with rep- moderate asthma
resentatives from the EMS providers that serve the 4 less urgent constipation with 39.0
catchment areas of the three hospitals we visited. mild pain
ear ache
We also reviewed information from the Ministrys chronic back pain
Wait Time Strategy and interviewed staff from Can- 5 non-urgent medication request 8.5
cer Care Ontario, which is responsible for managing or dressing change
data on emergency-department wait times. In addi- sore throat
minor trauma
tion, we engaged on an advisory basis the services
(sprains, minor
of independent consultants with expert knowledge lacerations)
in emergency-department operations.
We did not rely on the Ministrys internal audit
Our work at the three hospitals we visited,
service team to reduce the extent of our audit work
as well as the responses from the hospitals we
because it had not recently conducted any audit
surveyed, indicated that addressing emergency
work on hospital emergency departments.
wait times has become a major focus at many
Ontario hospitals. The public suspects that the
main underlying causes are the inappropriate use
Summary of emergency departments by walk-in patients with
minor medical ailments, and poor management by
hospitals, including understaffing. Although these
Overcrowding and long waits in hospital emer-
are contributing factors, our research indicated
gency departments have been common complaints
that the lack of available in-patient beds at the
for a number of years. Both impact the quality of
hospitals, requiring admitted patients to be housed
patient care.
Hospital Emergency Departments 135
in the emergency departments, may well have an States, and New Zealand and almost five times
even greater impact on overcrowding and long more than in Germany or the Netherlands.
wait times. This lack of available in-patient beds is
The Canadian Triage and Acuity Scale (CTAS)
influenced by two main factors: hospital beds being guidelines recommend that patients be tri-
occupied by patients who are awaiting alternative aged within 10 to 15 minutes of arrival at the
care in a community-based setting, and less-than- emergency department, yet in all three hos-
optimal practices by hospitals in managing and pitals we visited, some patients waited more
freeing up in-patient beds. than an hour to be triaged. We also noted
The Ministry of Health and Long-Term Care is that in about one-half of the files that were
also well aware of the problem of long wait times in reassessed by the hospital nurse educators,
emergency departments and has sponsored expert the CTAS levels originally assigned by triage
panels and other initiatives to address this. As nurses were incorrect. Of these, the majority
well, additional funding of $200million has been was under-triaged: in other words, triage
provided over the last two fiscal years ($109million nurses underestimated the severity of the
in 2008/09 and $82million in 2009/10) to address patients injury or illness.
the wait-time issue. However, significant province-
There were inconsistencies between the way
wide progress has not yet been made in reducing EMS paramedics and emergency depart-
emergency-department wait times. ments applied the CTAS guidelines, due in
Our visits to the three selected hospitals, survey part to outdated training for paramedics.
of other hospitals, and review of literature and best The discrepancies in applying the guidelines

practices also indicated that although hospitals are could impact which hospitals the ambulances
clearly seized with addressing the wait-time issue, should transport their patients to. Paramedics
there are steps that hospitals can take to better told us that they have been raising this issue
assess patient needs and improve patient flow. with the Ministry for some time.
Some of our most significant observations were
The higher the triage acuity level, the sooner
as follows: nurses and physicians should assess the
Since April 2008, the Ministry has been pub- patient and the sooner treatment should
lishing emergency-department length-of-stay commence. Our review of files at the three
data. At the time of our audit, emergency- hospitals indicated that high-acuity patients
department wait times had not yet shown a sometimes waited for over six hours after tri-
significant improvement and did not yet meet age before being seen by nurses or physicians.
provincial targets. Although the length of The CTAS guidelines recommend maximum
time patients with minor conditions waiting wait times before physician assessment. Prov-
in emergency departments almost met the incially, actual times to physician assessment
four-hour target, emergency-department did not meet the CTAS-recommended times
length of stay for patients with more serious by a wide margin, especially for high-acuity
conditions could be up to 12 hours, which patients in CTAS levels 2 and 3: only 10%
was still significantly over the eight-hour to 15% of the patients in these levels were
target. According to a survey published by seen by physicians within the recommended
the Ontario Health Quality Council, in 2007, timelines. The CTAS guidelines also prescribe
47% of the people surveyed in Ontario waited when nurses should reassess a patients
more than two hours for treatment, about the condition, to confirm that there has been no
same as the rest of Canada but far more than deterioration. We noted that these timelines
Australia, the United Kingdom, the United were often not recorded or adhered to.
The effectiveness of emergency departments Our review found that paramedics often had to
is heavily dependent on other hospital depart- stay in emergency departments for extended
ments and specialists. At the three hospitals periods of time and care for their patients while
we visited, the timeliness of accessing special- they waited for an emergency-department bed
ist consultations and diagnostic services was or until emergency-department nurses could
having an impact on emergency patient flow. accept the patients. We noted cases where
Also, over three-quarters of the hospitals that ambulance crews waited up to three hours
responded to our survey indicated that limited for their patients to be attended to, resulting
hours and types of specialists and diagnostic in fewer or on occasion no ambulances being
services available on-site were key barriers to available to respond to new emergency calls in
efficient patient flow. the community.
Not being able to move patients requiring The opinion of the 2006 expert panel on
admission into beds in an in-patient unit is Improving Access to Emergency Care was
one of the key causes of delays in treating that diverting low-acuity patients would only
emergency-department patients. Across the minimally reduce the demand for emergency
province, from April 2008 to February 2010, departments and only minimally impact wait
time to in-patient bed did not improve signifi- times. However, we noted that, province-
cantly. At the time of our audit, emergency- wide, about half of emergency-department
department patients admitted to in-patient visits were made by patients with less urgent
units spent on average about 10 hours waiting and non-urgent needs, who could have been
in emergency departments for in-patient beds, supported by other alternatives such as walk-
but some waited as long as 26 hours or more. in clinics, family doctors, and urgent care
We noted that delays in transferring patients centres. We estimated that such patients took
from emergency departments to hospital beds up 30% of emergency-department physician
frequently occurred because empty beds had time, which could have been spent on patients
not been identified or hospital rooms cleaned with more urgent conditions.
on a timely basis.
Two of the three hospitals we visited had dif- summary of hospitals Overall
ficulty finding staff to fill nursing schedules, Response
especially at nights and during weekends and
Overall, hospitals generally agreed with our
holidays. They often incurred extra costs to
recommendations and felt that they reflected
pay nurses overtime. We found that a number
opportunities for improvement while recogniz-
of emergency-department nurses consistently
ing the pressures and issues faced across the
worked significant amounts of overtime or
system.
took extra shifts, not only leading to addi-
tional costs but also increasing the risk of staff
Overall Ministry Response
burnout. In one hospital, one nurses annual
overtime pay accounted for over half of her The Ministry is committed to working with the
total earnings for nine consecutive years. For LHINs, hospitals, and others on ways to improve
instance, in 2009/10, she earned $157,000, the performance of emergency departments
of which $90,000 was overtime pay. At (EDs) across Ontario. Progress has been made,
another hospital, one nurse earned $193,000 but more work is obviously needed.
in 2009/10, due to extra shifts and overtime The latest available information, from June
payments. 2010, indicated that 84% of patients with
complex conditions were treated within eight

hours, compared to 79% in 2008; length of stay
Detailed Audit Observations
(LOS) dropped by 21.5%, from 14 hours to 11
hours. During the same period, 88% of minor Ontarios Wait Time Strategy for
and uncomplicated patients were treated within Emergency Departments
the four-hour target, compared to 84% in 2008,
In April 2008, the Ministry of Health and Long-
and LOS dropped by 10.7%, from 4.8 hours to
Term Care (Ministry) announced that reducing
4.3 hours.
emergency-department wait times would be
The Ministry has engaged the field,
an important priority over the next four years.
established the targets, and incentivized and
The Ministry introduced several initiatives and
monitored performance. It continues to drive
incentives as part of its Wait Time Strategy by
improvement through Pay-for-Results (P4R) and
investing $109million in 2008/09 and $82million
the Emergency Department Process Improve-
in 2009/10 to reduce the amount of time people
ment Program (ED PIP). The decision to fund in
spend in emergency departments. Two key initia-
Year 2 those hospitals that underperformed in
tives were Public Reporting of Emergency Depart-
Year 1 recognizes that it takes time to improve
ment Wait Times and the Pay-for-Results program.
emergency-department performance; however,
the Ministry did recover some funding for
underperformance in Year 1. Both P4R and Public Reporting of Wait Times in

EDPIP have been expanded in the 2010/11 Emergency Departments
fiscal year, with $100million in performance
Our research indicated that outside Ontario, there
funding for 71 emergency departments focused
has not been much public reporting of emergency-
on reducing LOS, improving patient satisfaction,
department data in Canada. However, the Ontario
and reducing time to initial assessments.
Health Quality Council published the results of the
The Ministry has undertaken numerous
Commonwealth Fund International Health Policy
activities to strengthen the LHIN model, includ-
Surveys in its annual reports in 2008 and 2009.
ing conducting quarterly meetings with each
These results provide for some comparison between
LHINs CEO to review emergency-department
jurisdictions:
performance (reports are posted on the Min-
istrys website); convening a two-day session in The 2009 report indicated that about 48%
of Ontarians who spent time in emergency
May 2010 with all LHINs and Community Care
departments in 2008 waited for more than
Access Centres to review Aging at Home invest-
two hours, while in the rest of Canada, 39% of
ments aimed at relieving pressures on hospitals
people who spent time in emergency depart-
and long-term-care homes by placing patients
ments waited this long.
in the most appropriate settings (this session
resulted in three LHINs undergoing peer reviews The 2008 report showed that Ontarians,
like other Canadians, were far more likely
and in the issuance of commitment letters that
to wait more than two hours in emergency
confirmed expectations and targetsfailure to
departments than people surveyed in other
meet targets will result in a performance audit);
comparable countries. In 2007, almost half
and elevating province-wide performance by
of the people surveyed in Ontario waited
mobilizing all LHINs to operate as a cohesive
more than two hours for treatment, about the
system.
same as the rest of Canada but far more than
Australia, New Zealand, the United Kingdom,
and the United Statesand almost five times

Figure 4: Ontarios Targets for Emergency-department
more than in Germany or the Netherlands
Length of Stay (EDLOS) by Acuity Level
(Figure3). Source of data: Ministry of Health and Long-Term Care
In April 2008, the Ministry introduced the
Emergency Department Reporting System (System) Acuity Target
Level Description (hours)
to collect monthly emergency-department data
high1 patients with complex conditions
from 128 hospitals. The System is administered for that require more time for treatment, 8
the Ministry by Cancer Care Ontario. In February diagnosis, or admission to a hospital bed
2009, the Ministry began publishing emergency- low2 patients with minor or uncomplicated
department data, from April 2008 onward, on a conditions that require less time for 4
public website. As of the time of our audit, the Min- treatment, diagnosis, or observation
istry was releasing the results of what is known as 1. High-acuity patients are specifically defined as those at all CTAS levels
who have been admitted to an inpatient bed, and patients at CTAS 1, 2,
emergency-department length of stay (EDLOS), and 3 who have not been admitted to an inpatient bed.
which measures the length of time a patient spends 2. Low-acuity patients are specifically defined as patients at CTAS 4 and 5
who have not been admitted to an inpatient bed.
in the emergency department, beginning at the
point when the patient sees a triage nurse and
ending when the patient leaves the emergency decision to gather length-of-stay data and report it
department. publicly is a good initiative.
The Ministry has set two targets for the max- We obtained data from the System and exam-
imum length of time 90% of patients should spend ined EDLOS trends. As Figure 5 indicates, from
in the emergency department (Figure 4). These April 2008 to February 2010, there was no signifi-
targets were developed with the help of clinical cant reduction in the EDLOS. Specifically:
experts and provide a goal for emergency depart- Ninety percent of patients with complex con-
ments to achieve. Given the adage that you cant ditions could spend up to 12.2 hours in emer-
manage what you cant measure, the Ministrys gency departments in February 2010 versus
14 hours in emergency departments in April
2008, well above the target of eight hours.
Figure 3: Percentage of Emergency-department
Patients in Selected Jurisdictions Who Waited Two Ninety percent of patients with minor condi-
tions could spend up to 4.7 hours in emer-
Hours or More for Treatment, 2007
Source of data: Annual Report of the Ontario Health Quality Council, 2008
gency departments in February 2010 versus
4.8 hours in April 2008, which, while showing
50
no real improvement, is relatively close to the
target of four hours.
40
We also noted that the EDLOS varied across
30
the province, especially for patients with complex
conditions. None of the LHINs met the eight-hour
20 EDLOS target for high-acuity patients (Figure 6).
We noted a fundamental problem affecting
10 emergency-department wait times for patients
with complex conditions who needed to be
0 admitted to hospital: many of these patients were
boarded in emergency departments because in-
om
rio
es
ny
ds
da
d
ali
lan
at
n
a
ta
na
gd
str
rla
rm
St
On
a
Ca
Kin
Ze
patient beds were not available on a timely basis.

Au
e
Ge
d
th
ite
w
d
Ne
Ne
ite
Un
The problem was partly due to the fact that about

Un
Figure 5: Maximum Emergency-department Length of Stay (EDLOS) in Hours for 90% of High-acuity and
Low-acuity Patients, April 2008February 2010
Source of data: Emergency Department Reporting System, Cancer Care Ontario
16 high-acuity patients: patients with complex conditions

low-acuity patients: patients with minor conditions
8-hour target
14 4-hour target
12
10

2
0
8
9
08
09
8
9
8
9
8
9
09
10
08
09
09
8
10
8
9
y0
y0
c0
c0
v0
r0
v0
g0
g0
r0
t0
r0
t0
l0
l0
p
p
b
b
n
n
Ma
Ma
Ma
No
No
De
De
Ap
Oc
Ap
Oc
Au
Se
Au
Se
Fe
Fe
Ju
Ju
Ja
Ju
Ju
Ja
17% of in-patient beds were occupied by alternate- However, the alternate-level-of-care issue is but
level-of-care patients, who no longer required one factor affecting emergency-department waits;
hospital care but could not be discharged because there are multiple factors throughout the hospital
of the lack of services and supports available in system. The solution to lengthy emergency-
the community (see Section 3.02, Discharge of department wait times is not always the allocation
Hospital Patients, in this Annual Report). In recent of more resources: the removal of impediments
years, the Ministry has implemented a number of to patient flow, which later sections of this report
initiatives to deal with the alternate-level-of-care address, could also help to reduce the EDLOS.
issue by increasing community resources, although
the impact has yet to be felt. All three emergency
Pay-for-Results Program
departments we visited and over three-quarters of
the emergency departments we surveyed agreed Pay-for-Results is an incentive program that
that the alternate-level-of-care issue contributed provides funding to selected hospitals with high
to lengthy emergency-department waits because emergency-department volumes and significant
patients had to be boarded in the emergency emergency-department wait-time pressures. The
department until an in-patient bed became hospitals were to be rewarded for meeting specific
available. emergency-department wait-time-reduction
targets set by the Ministry. The program provided
Figure 6: Maximum Emergency Department Length of Stay (EDLOS) in Hours for 90% of High-acuity Patients by
LHIN, February 2010
18
16 8-hour target
14
12
10
0
Ontario
Waterloo Wellington
Mississauga Halton
Toronto Central
Central
Champlain
North Simcoe Muskoka

South West
Central West
Central East
South East
North East
North West
Erie St. Clair
Hamilton Niagara
Haldimand Brant
$30million to 23 hospitals in 2008/09 (Year 1) and tions. The Ministrys evaluation of the hospitals
$55million to 48 hospitals in 2009/10 (Year 2). performance in Year 1 showed that the expected
Of the three hospitals we visited, one received results had not been achieved. Specifically, of the
funding in both years; the other two received fund- 23 hospitals that received Year 1 funding, only
ing only in Year 2. Although the hospitals were three were able to meet the Ministrys targets; 15
pleased that program funding did help relieve their showed some improvement but did not meet the
emergency-department wait-time pressure, two targets; and five declined in performance. We noted
of the hospitals we visited indicated that they did that all Year 1 hospitals continued to receive fund-
not receive the funding until the end of September, ing in Year 2 regardless of their performance in
which was six months into the fiscal year. Such Year1. In fact, certain hospitals that did not meet
delays made it difficult for them to use the fund- the targets in Year 1 received even more funding
ing to implement their proposed initiatives in a in Year 2 than they did in Year 1. The worst-
cost-effective manner by the end of the fiscal year. performing hospital in Year 1 received the greatest
To illustrate, one of the emergency departments amount in Year 2. Of the three hospitals that met
received about $1.4million in Year 1 funding, the targets in Year 1, two received less funding in
but $800,000 remained unspent as of March31, Year 2 than in Year 1. This funding methodology
2009the end of Year 1. seems somewhat inconsistent with the concept of
This delay in funding affected the effectiveness paying for results. The Ministry informed us that,
of the program and the rationale for funding alloca- although the hospitals performance in Year 1 was
a criterion for determining Year 2 funding alloca-

Ministry Response
tions, there were other factors that were taken into
account, including hospitals projected growth in The Ministry is continuously reviewing and
emergency-department utilization and wait times learning from health system experiences in
for admitted patients. other jurisdictions and across Ontario. A com-
prehensive environmental scan of best practices,
Recommendation 1 lessons learned, and progress made within and
outside Ontario supported the Ministry in creat-
To ensure that emergency departments are
ing opportunities for LHINs and health-care
operating in the most effective way to provide
providers to share knowledge and disseminate
high-quality emergency care as quickly as pos-
best practices. The Ministry facilitates regular
sible to all patients:
peer exchange forums with the LHINs to share
hospitals should identify causes of delays in
their experiences in achieving successful results.
patient flow and examine ways of reducing
As well, through the ED Process Improvement
wait times in emergency departments
Program, the Ministry provides:
accordingly;
the Ministry of Health and Long-Term Care training of front-line staff (more than 1,000
since March 2008) and LHIN representatives
should work with the LHINs and with hospi-
on process improvement;
tals to identify and disseminate best practices
from Ontario and other jurisdictions; and bi-monthly centralized training events at
which knowledge and best practices are

the Ministry should provide funding to hospi-
shared among hospitals; and
tals in a timely manner to enable hospitals to
have adequate time to implement the funded a website, accessible to all hospitals, onto
which the Ministry uploads ideas, tools, and
initiatives cost-effectively.
best practices.
In Year 2 of the Pay-for-Results program,
Response from Hospitals
seven hospitals that exceeded ministry expecta-
The hospitals concurred with this recommendations by achieving emergency-department
tion and expressed support for Pay-for-Results improvements greater than 10% were asked
funding and performance improvement to lead and engage in activities facilitating
strategies. One hospital commented that knowledge transfer and dissemination of best
both efficiency and quality of care are equally practices.
important indicators of emergency-department Regarding the provision of funding in a
performance. timely manner, the Ministry will review internal
This hospital also suggested that milestone processes to explore possibilities for expediting
achievements for Pay-for-Results funding the flow of funds.
should be based on the hospitals improvement-
proposal submission rather than on a fiscal-year
basis. They indicated that this would allow
Triage Process
hospitals time to fully plan, implement, and
demonstrate improvement according to the Triage is the process of prioritizing patients accord-
improvement-proposal time frames. ing to the urgency of their illness or injury. Triage
is critical to effective emergency-department man-
agement because it identifies patients with urgent,
life-threatening conditions so that resources can
be allocated to them as quickly as possible. Upon the time from arrival until triage and acceptance of
arrival at emergency departments, patients are the patient by the hospital was often longer than
seen by a triage nurse, who assesses and classifies desirable.
them based on the five-point Canadian Triage and It was difficult to accurately capture the time
Acuity Scale (CTAS), with level 1 being the most walk-in patients spent between arrival and triage
acute and level 5 the least acute. The intention of because their arrival times were unknown and
CTAS (which was developed and endorsed by the the time they spent determining where to go, or
Canadian Association of Emergency Physicians, the waiting to be triaged, went unrecorded. In its Emer-
National Emergency Nurses Affiliation of Canada, gency Department Process Improvement Project in
and lAssociation des mdecins durgence du Qu- 2009, one hospital we visited identified the average
bec) is to establish a national standard for triage, time from the walk-in patients arrival until triage
improve patient safety, and increase triage reli- as more than 20 minutes. This delay presented a
ability, consistency, and validity. Figure 2 provides patient safety issue and caused staff and patient
descriptions and examples of patient symptoms at frustration.
each CTAS level. To reduce the risk of triage delays, we noted a
good practice at two of the hospitals we visited:
they performed pre-triage on patients who
Timeliness of Triage Assessment
could not be triaged immediately upon arrival.
According to CTAS guidelines, patients should be Pre-triage was the rapid assessment of patients
triaged within 10 to 15 minutes of arrival at the to determine whether they needed to be seen more
emergency department. However, at the three hos- quickly. An operational review of one hospital we
pitals we visited, we noted that triage could often visited also noted that quick assessments will
not be undertaken within this time frame. For this facilitate the identification of very ill patients in line
reason, patients length of stay in the emergency awaiting their triage assessment.
department (EDLOS) that is publicly reported
has often been understated because it measures
Quality or Accuracy of Triage Assessment
only from the time the patient is triaged until he
or she leaves the emergency department: it does Triage nurses assess the urgency of a patients con-
not include any wait time from arrival to triage. dition on the basis of a combination of subjective
We found that the time from arrivalwhether by and objective information, including the patients
ambulance or walk-inuntil triage occurred could presenting symptoms and general appearance.
be lengthy. Accurate and complete documentation of these
For ambulance patients, the databases main- details is critical to facilitate triage audits, which
tained separately by the paramedics and the are retrospective reviews of triage records to valid-
emergency departments were not integrated to ate the decisions made by triage nurses. All three
assist analysis of patient data. For instance, they hospitals we visited informed us that they per-
did record the same time that ambulances arrived formed triage audits to monitor whether patients
at the emergency departments so that this could be were triaged accurately based on CTAS guidelines.
compared to the time the patient was accepted by Each of the hospitals had a nurse educator, who
the hospital. Our review of a sample of patient files was responsible for keeping up to date on nursing
at the three hospitals we visited indicated that the practices, supporting nursing-staff competency, and
average time from ambulance arrival to triage was conducting triage audits. However, we noted that
about 30 minutes, ranging from a few minutes to triage audits were not performed on a consistent
over an hour. The paramedics also informed us that basis. One hospital had not completed any since
December 2006. Another hospital had stopped Of the cases where the file documentation was
conducting them in June 2009 but reinstated sufficient to enable a triage audit, the nurse
them during our audit in February 2010. The third educators in all three emergency departments
hospital told us that it performed them on a regular would have assigned different CTAS levels
basis but was unable to provide any supporting about half the time. As Figure 7 shows, in these
documentation of any triage audits actually done. cases, the majority were under-triaged (that
To examine the quality of triage at the three is, the severity of a patients illness had been
hospitals we visited, we selected a sample of triage underestimated). In some cases, patients were
records at each hospital and asked each hospitals under-triaged by two levels: rather than being
nurse educator to perform triage audits of the sam- triaged at CTAS 4 (less urgent), they should
ple files. The results of these triage audits indicated have been triaged at CTAS 2 (emergent).
that the original CTAS levels assigned by the triage Patients suspected of having a heart attack are
nurses were often different, sometimes significantly supposed to be assigned as CTAS 1 or 2. How-
so, from the CTAS levels assigned by the nurse edu- ever, we noted cases where such patients were
cators. Specifically: triaged as CTAS 3 or 4. Our observation was
Documentation of patient assessment infor- consistent with a study published by the Insti-
mation, such as vital signs, allergy status, tute for Clinical Evaluative Sciences in June
and visual presentation, was lacking for 2009 that found that heart-attack patients
about 20% of the cases (see Figure 7). The were not prioritized properly in Ontario emer-
nurse educators informed us that visual gency departments. The report stated that

patient presentation is an essential element of 50% of patients who were ultimately found to
assigning a CTAS level. Documentation of this be having heart attacks were under-triaged,
element is necessary for nurse educators to leading to delays in initiating appropriate
be able to monitor the quality of triage assess- treatment.
ment through triage audits.
Figure 7: Results of Triage Audits Conducted at Three Emergency Departments

undetermined due mis-triaged (44%)

to incomplete
documentation (19%)
under-triaged1 (38%)
appropriately
triaged (37%)
over-triaged2 (6%)
1. under-triaged underestimating the severity of a patients illness or injury

2. over-triaged overestimating the severity of a patients illness or injury
Consistency of Triage Assessment by

Paramedics and Hospitals the Ministry should work with the Emer-
gency Medical Services (EMS) to provide
Based on discussions with EMS paramedics and updated training for paramedics to ensure
the three hospitals we visited, we noted that there that hospitals and paramedics are using con-
were inconsistencies between how the paramed- sistent triage practices.
ics and the emergency departments applied the
CTAS. In October 2001, the Ministry introduced a Response from Hospitals
program called the Patient Priority System (PPS),
The hospitals agreed with this recommendation
under which both paramedics and hospital staff
and supported standardization of triage tools.
assess patients and communicate with each other
One hospital also suggested using the National
using the five-level CTAS. Under PPS, ambulances
Emergency Nurses Affiliation (NENA) to teach
are required to transport all high-acuity patients
triage and optimize the use of the Canadian Tri-
(CTAS1 and 2) to the closest emergency depart-
age and Acuity Scale (CTAS). Another hospital
ment, with the exception of special services such
commented that the Ministry should reconvene
as for stroke and trauma. However, paramedics
an expert panel to evaluate CTAS in terms of its
informed us that the Canadian Association of
reliability and effectiveness and to review other
Emergency Physicians revised the CTAS guidelines
possible tools to predict patient acuity.
in 2004 and 2008. Hospitals have been using these
updated guidelines, but the Ministry has only
Ministry Response
provided training for the paramedics based on the

2001 version of the guidelines, without the updates, The Ministry agrees that the quality of triage is
resulting in discrepancies in the application of the very important. It is the hospitals responsibility
CTAS. The paramedics told us that they raised this to triage accurately and to monitor triage quality.
issue with the Ministry on numerous occasions but As part of the Emergency Department Process
have not yet received updated training. Improvement and Pay-for-Results programs, hos-
pitals have developed strategies for facilitating
Recommendation 2 pre-triage to expedite assessment and start the
patients care plan as soon as possible.
To ensure that triaging is done appropriately
The Ministry supports exploring the feasibil-
and consistently within the recommended time
ity and reliability of capturing data starting from
frame:
the time of arrival of walk-in patients, and will
hospitals should conduct periodic audits to
develop an appropriate business case to enable
monitor the quality and accuracy of triage
a solution.
and identify areas for improvements;
The Ministry is working with the Medical
hospitals should consider performing a quick
Advisory Committee, Regional Base Hospital
pre-triage on patients who cannot be tri-
Programs, and municipal EMS agencies to better
aged immediately upon arrival at emergency
align the definitions used in verbal and written
departments;
communications between pre-hospital and in-
the Ministry of Health and Long-Term Care
hospital staff when describing a patients med-
should work with the LHINs and with hos-
ical condition. The Ministry will explore avenues
pitals to assess whether the reported length
for providing updated training for paramedics.
of stay at emergency departments should
include the time that patients wait for triage;
and
Assessment and Treatment assessment, we reviewed a sample of patient files

at the hospitals we visited. Our samples focused on
The higher the acuity level, the sooner the patient
CTAS2, 3, and 4 patients because they accounted
should be assessed by nurses and physicians and
for the largest percentage (90%) of all emergency-
the sooner treatment should commence. CTAS
department visits. As Figure 9 indicates, average
guidelines recommend specific wait times for
times from triage to nurse assessment varied
nurse assessment, physician assessment, and
between hospitals but were well in excess of the rec-
nurse reassessment for each CTAS level (Figure 8).
ommended time frames. Only one hospital was able
Although these recommended times are operating
to meet the recommended time frame for patients
objectives rather than standards, they are patient-
in the CTAS 4 category. There were cases where
focused and are based on the need for timely inter-
high-acuity patients (CTAS 2 or 3) had to wait up to
vention to improve patient outcomes. In recognition
six hours for their initial nurse assessment.
of the fact that these objectives cannot always be
achieved without unlimited resources, each CTAS
level is given a target percentage, which describes Timeliness of Physician Assessment
how often the recommended time frame ought to
According to CTAS guidelines, The primary
be achieved. For example, the guidelines indicate
operational objective of the triage scale is related
that a CTAS 3 (urgent) patient should be seen by
to the time to see a physician. This is because most
a physician within 30 minutes 90% of the time.
decisions about investigation and initiation of treat-
Thus, under the guidelines, it would be reasonable
ment do not occur until the physician either sees

that 10% of CTAS 3 patients are seen by a physician
the patient, or has the preliminary results of other
after more than 30 minutes.
tests needed to recommend a course of action.
Although data on times from triage to physician
Timeliness of Nurse Assessment assessment were collected in the System, this infor-
mation was not released on the public website. To
None of the three hospitals we visited tracked or
assess the timeliness of physician assessment, we
monitored the average time from triage to nurse
obtained and analyzed province-wide data from the
assessment against the time frames recommended
System. The length of time that patients waited for
in the CTAS guidelines, nor was such data col-
physician assessment did not show any improve-
lected in the Emergency Department Reporting
ment from April 2008, when the System was first
System (System). To assess the timeliness of nurse
Figure 8: Recommended Times from Triage to Nurse Assessment, Physician Assessment, and Nurse
Reassessment by CTAS Level
Source of data: CTAS Implementation Guidelines
CTAS Time from Triage Time from Triage to Frequency of Nurse Response Time
Level Acuity to Nurse Assessment Physician Assessment Reassessment Target* (%)
1 resuscitation immediate immediate continuous care 98
2 emergent immediate < 15 minutes every 15 minutes 95
3 urgent < 30 minutes < 30 minutes every 30 minutes 90
4 less urgent < 60 minutes < 60 minutes every 60 minutes 85
5 non-urgent < 120 minutes < 120 minutes every 120 minutes 80
* The response time target rate is the percentage of times in which the standard can reasonably be expected to be met.
Figure 9: Average Time in Minutes from Triage to Nurse Assessment by CTAS Level on Sample of Patient Files at
Three Ontario Hospitals
CTAS Recommended Time from Hospital (minutes)

Level Acuity Triage to Nurse Assessment* 1 2 3
1 resuscitation immediate not tested not tested not tested
2 emergent immediate 79 16 60
3 urgent < 30 minutes 177 46 120
4 less urgent < 60 minutes 167 55 98
5 non-urgent < 120 minutes not tested not tested not tested
* according to CTAS Guidelines
implemented, to the time of our audit in February assessment for patients with non-urgent conditions
2010: were almost meeting CTAS guidelines, wait times to
High-acuity patients with complex condi- physician assessment for patients with more serious
tions spent on average about two hours in conditions requiring urgent attention were signifi-
emergency departments waiting for physician cantly longer than the recommended time frames.
assessment, and some spent as long as four
hours or more.
Use of Medical Directives to Improve

Somewhat surprisingly, low-acuity patients
Timeliness of Assessments
with minor conditions spent less time
1.6hours on average, although some spent as One way hospitals could increase efficiencies and
long as three hours or morein emergency decrease emergency-department wait times is to
departments waiting for physician assessment. put greater emphasis on the use of medical direc-
We also calculated to what extent the average tives, which enable nurses to initiate investigations
province-wide time to physician assessment met and treatments prior to physician assessment. Med-
the CTAS guidelines recommended timelines, ical directives are a set of instructions by physicians
according to acuity level, in April 2008 and Febru- to nurses that delegate the authority to carry out
ary 2010. As Figure 10 shows, in both April 2008 certain treatments, interventions, or procedures,
and February 2010, the recommended time frames such as requisitioning laboratory blood work and
were met at none of the CTAS levels. Only in CTAS4 applying oxygen. Medical directives are intended
was there slight improvement from April 2008 to to provide more timely, consistent, and appropriate
February 2010; in CTAS 1, 2, 3 and 5, there was treatment for patients, especially during periods
actually a decrease in performance against the CTAS when emergency departments are busy and phys-
guidelines. In February 2010, only 10% of CTAS 2 icians are not available for immediate assessment
(emergent) and 15% of CTAS 3 (urgent) patients and treatment. They are not meant to replace phys-
were seen by physicians within 15 minutes and 30 ician attention when it is required immediately. The
minutes, respectively, as compared to 95% and 90% Ontario Hospital Association strongly advocates
recommended by the CTAS guidelines. In contrast, the use of medical directives and provides hospitals
76% of CTAS 5 (non-urgent) patients were seen with implementation kits that include samples and
by physicians within 120 minutes, which was very suggestions.
close to the 80% recommended by the CTAS guide- In our audit, we noted that there was no consist-
lines. In summary, although wait times to physician ent list of medical directives used throughout the
Figure 10: Percentage of Emergency-department Visits with Time-to-Physician Assessment Meeting CTAS
Operating Objectives, April 2008 and February 2010
% recommended by CTAS Guidelines

100 actual % in the province (April 2008)
actual % in the province (February 2010)
90
80
70
60
50
40
30

20
10
0
CTAS 1 (Resuscitation): CTAS 2 (Emergent): CTAS 3 (Urgent): CTAS 4 (Less Urgent): CTAS 5 (Non-urgent):
% of ED Visits with Time % of ED Visits with Time % of ED Visits with Time % of ED Visits with Time % of ED Visits with Time
to Physician Assessment to Physician Assessment to Physician Assessment to Physician Assessment to Physician Assessment
within 5 Minutes within 15 Minutes within 30 Minutes within 60 Minutes within 120 Minutes
province. Of the three hospitals we visited and the might be possible, mainly owing to physicians
hospitals we surveyed, some developed and used concerns about delegating treatment decisions to
more directives than others. Many factors influence nurses.
the implementation and use of medical directives,
including physician support of nurses use of the
Timeliness of Nurse Reassessment
directives, nurse confidence and willingness to
assume responsibility, the amount of education and CTAS guidelines specify not only the recommended
monitoring needed, and the additional paperwork time from triage to nurse and physician assessment,
required. but also how frequently a nursing reassessment
Two of the three hospitals we visited did not should occur to confirm that the patients status has
have information on how frequently they used med- not deteriorated. The guidelines state that there
ical directives. The third hospital had established should be a nursing reassessment on all patients
three medical directives, which physicians used to at the time intervals recommended for physician
delegate certain decisions to nurses about 30% of assessment. Thus, CTAS 1 patients should have
the time. Our discussions with hospitals indicated continuous nursing care, CTAS 2 patients should
that medical directives were not used as often as be reassessed every 15 minutes, CTAS 3 every 30
minutes, CTAS 4 every 60 minutes, and CTAS 5 A number of patients were not followed up
every 120 minutes. The CTAS guidelines also state on for as long as seven hours following triage.
that reassessment results should be documented. When reassessment attempts were made, the
The importance of reassessment was also recog- nurses found that many of these patients had
nized by the CTAS National Working Group, which already left. Some of them were high-acuity
indicated that the focus on time-to-nurse and patients at CTAS 2 and 3.
time-to-physician assessment should shift to the
timely reassessment of patients waiting to be seen,
Timeliness of Treatment for Time-sensitive
to ensure that unavoidable delays do not jeopardize
Illnesses
patient care.
The medical director of one hospital we visited Our discussions with hospital staff and our research
indicated on his response to a patient complaint indicate that the most common types of time-
that it is difficult to assess the quality of care sensitive life-threatening illnesses being treated at
patients are receiving during their waiting period if emergency departments are heart attack, stroke,
the reassessments are not recorded. In our review and sepsis (that is, a severe infection spreading
of patient files at the three hospitals we visited, through the bloodstream). We reviewed these three
we noted a number of cases where the CTAS- areas including patient files at the hospitals we
recommended reassessment timelines were not visited, and noted the following:
adhered to or there were no records to indicate that An electrocardiogram (ECG) is the most
patients were reassessed at the recommended time important diagnostic test for heart-attack
intervals. For example: patients when they arrive at emergency

A patient with chest pain was triaged at departments. ECG results affect the timeli-
CTAS2 and spent three hours waiting for an ness of initiating other cardiac procedures,
emergency-department bed, but the patient such as angioplasty, which is the technique
file did not include any reassessment record of widening a narrowed or obstructed blood
during this three-hour wait. Thirty minutes vessel with a balloon. The Ministry has not
after obtaining an emergency-department established benchmarks for door-to-ECG
bed, the patient experienced cardiac arrest and door-to-balloon times, but the three
and a doctor was called in to perform cardio- hospitals we visited indicated that the gener-
pulmonary resuscitation. ally accepted benchmarks are 10 minutes and
A patient with syncope (loss of consciousness) 90 minutes, respectively. Two of the hospitals
waited for six hours to be seen by a doctor, but we visited have cardiac labs that are capable
was reassessed only once during this time of performing angioplasty. We noted that, in
about 40 minutes prior to the doctors arrival. 2009, one of these hospitals met these bench-
A patient with a history of cardiac problems marks about half of the time; the second,
had an electrocardiogram done within 11 about two-thirds of the time.
minutes of his arrival at the emergency An important factor that contributes to timely
department. He then waited for three hours and quality stroke care is the rapid assess-
without being reassessed. Consequently, he ment of stroke patients in emergency depart-
decided to leave the hospital, but while he ments. This includes access to a CT scan,
was walking to his car, his condition deterior- which is often the first test scheduled before
ated. He immediately walked back to the further treatment can be given. A CT scan of
emergency department and was eventually the head must be done before giving medi-
diagnosed with acute coronary syndrome. cine to any patient who is having a stroke
caused by a blood clot. One of the hospitals

we visited had a dedicated stroke centre. hospitals should work with the respective
LHINs to develop, document, and implement
It had an emergency-department stroke
procedures for monitoring and reassessing
protocol that set benchmarks, including
the status of patients in the time interval
door-to-doctor time within 10 minutes and
between triage and treatment in accordance
door-to-CT-scan time within 25 minutes.
with their assigned triage level; and
These benchmarks apply to those patients
with stroke symptoms who are eligible to the Ministry of Health and Long-Term Care
should encourage hospitals to track critical
receive medicine to dissolve blood clots. The
quality-of-care measures with respect to the
data provided by this hospital showed that it
most serious time-sensitive illnesses com-
was able to meet the door-to-CT-scan bench-
monly seen in emergency departments and
mark about half the time.
consider the applicability of protocols or
With regard to sepsis, according to a report
best-practice guidelines for those illnesses on
published by the Canadian Institute for Health
a system-wide basis.
Information in 2009, a study of 12 Canadian
hospital critical-care units found that the mor-
tality rate for patients with severe sepsis was
just over 38%. Recognizing and treating sepsis The hospitals agreed with this recommendation.
is a time-critical process. According to an arti- One hospital is currently developing a process-
cle published by the Society of Critical Care flow map and tool to ensure that patients are

Medicine in 2008, a group of international reassessed and that their status is monitored
experts recommended beginning intravenous from the time of triage to the time of treatment.
antibiotics as early as possible and always This hospital has also worked with its LHIN to
within the first hour of recognizing sepsis. develop quality-of-care measures, including
Lengthy wait times at emergency departments those for the most serious and time-sensitive
could result in delays in recognizing sepsis illnesses.
and applying antibiotics on a timely basis. All
three hospitals we visited agreed that door- Ministry Response
to-antibiotics time is an important quality
Hospitals that receive funding as part of the
measure, but none of them have tracked it.
Pay-for-Results program are already required
Based on our review of patient files, we noted
to ensure that information on quality of care in
that door-to-antibiotics time could be very
the emergency department of each designated
lengthy and varied significantly, ranging from
hospital is reviewed regularly by its Board Qual-
27 minutes to 10 hours. As well, only one of
ity Committee.
the three hospitals we visited has developed
The Ministry also has an established process
emergency-department protocols and stan-
called Stocktake for continuously adding
dardized orders to ensure early identification
relevant key performance indicators through
and treatment of sepsis.
regular quarterly meetings between the LHINs
and the Ministry. Examples of indicators include
Recommendation 3
time to decision to admit or discharge the
To ensure that patients receive timely assess- patient; time to initial assessment by physician,
ment and treatment and an appropriate level of nurse, or other appropriate professional; time
care at emergency departments: to in-patient bed; and percentage of hospital in-
patient discharges before 11:00 a.m.
Co-ordination with Other Hospital Access to Diagnostic Services

Departments
Emergency departments rely on diagnostic services
The smooth functioning of any emergency depart- to assist physicians in performing comprehensive
ment is highly dependent on good working relation- assessments of patients. Prompt requests for and
ships with other hospital departments. At the three reporting of diagnostic results are important to
emergency departments we visited, we noted that speed up decision-making, which is crucial for
access to specialists, diagnostic services, and equip- emergency-department patients. The key indica-
ment has a direct impact on patient flow within the tor of the timeliness of diagnostic services is
emergency departments. diagnostic-turnaround time, which measures
the time from the emergency department ordering
diagnostic tests to the results becoming available.
Access to Specialist Services
The three hospitals we visited and the hospitals we
Emergency cases often demand prompt access to surveyed indicated the following:
specialists in various specialties such as urology One hospital we visited identified improving
and cardiology, who interact with the emergency diagnostic-turnaround time as an opportun-
departments to confirm diagnoses. The key indica- ity to improve patient flow. A time-study this
tor of the timeliness of consultation services is hospital conducted on 30 patients found the
consult-response time, which measures the time average diagnostic-turnaround time was 139
from when the emergency department requests minutes. A closer analysis of this time noted
consultation services to the consultants arrival. that the actual diagnostic test took, on aver-
The three hospitals we visited and the hospitals we age, only about 20 minutes; the additional
surveyed indicated that long consult-response time time was due to other factors, including
can be a significant impediment to efficient patient limited hours of service for ultrasound, com-
flow. Specifically: peting demands for diagnostic services from
Two of the three hospitals were able to pro- hospital in-patients and out-patients, delays
vide us with their consult-response times. in transferring patients from the emergency
One emergency department has been tracking department to the diagnostic-test room, and
this time component since April 2007; the delays in alerting the emergency department
other collected this data in 2009 as part of its when the test results became available.
Emergency Department Process Improvement The most common types of diagnostic services
Project. We noted that their consult-response ordered by emergency departments are x-rays,
times were lengthy, ranging from two hours to ultrasounds, and CT scans. All three hospitals
almost four hours. At the third hospital, which we visited co-ordinated with their diagnostic
did not routinely track consult-response imaging departments to ensure timely access
times, we reviewed patient files and found to emergency-department patients and
that, of those files with consult-response times arranged on-call services for emergency after-
recorded, the average was about three hours. hours access. However, access to ultrasounds
Over three-quarters of the hospitals that and CT scans was limited at night and during
responded to our survey indicated that limited weekends and holidays. Turnaround times for
hours and types of consultation available on- ultrasounds and CT scans at the three hospi-
site were key barriers to patient flow, but most tals we visited ranged from 1.5 hours to 2.5
of them did not collect and monitor data on hours. Two hospitals we visited had specific
consult-response times. concerns about their access to CT scanners.
One indicated that the CT scanner was not

for high-acuity patients, hospitals should track
located in close proximity to the emergency
targeted and actual wait times for specialist con-
department, which affected the timeliness
sultation and diagnostic services for emergency
and safe transport of acutely ill patients need-
patients, so that the impact of these wait times
ing diagnostic tests.
on providing timely and appropriate patient
Over three-quarters of the hospitals that
care can be periodically assessed.
responded to our survey also confirmed that
limited hours and types of diagnostic testing
available on-site were key barriers to efficient
patient flow. The hospitals agreed with this recommendation.
One hospital commented that, although timely
access to consultation and diagnostic services
Emergency-department Equipment
was important, the development of new and
Management
innovative diagnostic supports would also sup-
The three hospitals we visited all acknowledged port overall efficiency and timely access to qual-
concerns about the amount of time emergency- ity care for emergency-department patients.
department staff spent searching for equipment.
We noted the following: Ministry Response
Emergency-department equipment was often
The Ministry is continuously reviewing best
misplaced for various reasons, such as equip-

practices and learning new ways to improve
ment not being returned to its assigned loca-
data collection and reporting. The Ministry
tion, emergency-department layout or space
anticipates that by next year it will have a stan-
constraints, and patients taking portable
dardized process for capturing and reporting
equipment with them when going to different
the time to specialist consultations and the time
parts of the hospital.
to diagnostic services.
Emergency-department equipment for which
staff spent the most time searching included
ECG machines, ultrasound machines, vital-
sign monitors, blood pressure cuffs, and Patient Departure from the
thermometers. Emergency Department
The hospitals we visited had not quantified the
Access to In-patient Beds for Admitted
actual time spent in searching for equipment and
Emergency-department Patients
the impact such time away from the bedside had
upon patient care. However, a study published Time-to-in-patient-bed measures the time from
by the Ontario Health Quality Council in 2008 an emergency-department physician deciding to
confirmed that emergency-department nurses and admit the patient to the hospitals in-patient area to
doctors often spent a significant amount of time the patients actual departure from the emergency
searching for equipment. department. Although the System has collected
data since April 2008 on the time it takes for an
Recommendation 4 emergency patient to be admitted to an in-patient
bed, as of the time of our audit, this information
To better allow hospitals to assess the impact
had not been publicly released on the Ministrys
that timely specialist consultation and diag-
website and no provincial target had been estab-
nostic services have on patient care, especially
lished. The Physician Hospital Care Committeea
tripartite committee of the Ministry, the Ontario waiting for in-patient beds in this hospital,
Medical Association, and the Ontario Hospital and the majority of them were waiting in the
Associationrecommended in 2006 that emer- emergency department.
gency department time to admission be a perform- Another hospital noted that there were too
ance target established at one hour. many admits to no bedsadmissions
To assess the timeliness of access to in-patient made when, in fact, in-patient beds were
beds for admitted patients, we obtained data unavailableleading to increased length of
from the System. The most recent data available stay and interruption of patient flow through
during our audit showed that, in February 2010, the emergency department. This situation was
emergency-department patients admitted to in- caused by delays in portering, delays in bed
patient units spent on average about 10 hours wait- cleaning, and unclear communication from
ing in emergency departments for in-patient beds, the in-patient units that beds were ready.
and some waited as long as 26 hours or more. The We noted that such delays were often caused
average times from admission to in-patient bed did by lengthy periods of time during which in-patient
not improve significantly from April 2008 to Febru- beds were emptycommonly referred to as bed-
ary 2010, fluctuating from eight hours to 11 hours empty time:
on a monthly basis. The Canadian Association of One hospital recognized the importance of
Emergency Physicians and the National Emergency this issue and specifically used three systems
Nurses Affiliation have both stated that patients to track bed-empty time: the housekeeping
requiring hospital admission should not be held departments system monitored bed-cleaning
in emergency departments, hallways, or waiting times; the emergency-department system

rooms for more than six hours because, for longer tracked patient movement in the emergency
durations, these are not safe or humane conditions department; and the in-patient units bed-
for sick people. tracking board monitored bed availability.
A monthly survey conducted by the Ontario Hos- Although this approach provided useful
pital Association also indicated that, from November information, better integration was required
2008 to October 2009, at any point in time there to ensure that bed cleaning was initiated soon
were about 700 patients across the province waiting after a bed became available and that, once
in emergency departments, hallways, or other hos- the cleaned bed was ready, the next patient
pital public space for in-patient beds. The three hos- was admitted in a timely manner. We found
pitals we visited indicated that getting emergency the average bed-empty time in this hospital to
patients into in-patient beds on a timely basis could be about 5.5 hours.
have a significant impact on the smooth operation of The other two hospitals did not monitor the
their emergency departments. For example: extent of their bed-empty times. One did not
One hospital received a complaint in 2009 have the necessary systems to analyze the
that a cancer patient had waited for three entire process; the other had the required sys-
days in the emergency department for an in- tems but had not integrated them. As a result,
patient bed. After investigation, the hospital while they acknowledged this was an issue,
found that the emergency department had they could not identify the specific sources of
been holding 24 admitted patients during that any delays.
period, but there were actually 18 empty beds About two-thirds of the hospitals we surveyed
available in various in-patient units. We also indicated that they did not have the capacity
noted that on about 60% of all days in 2008 or infrastructure in place to measure the
and 2009, there were more than 16 patients extent of their bed-empty times.
Recommendation 5 department to discharge from an in-patient

unit. Improved bed-empty times and admission
To ensure that vacant in-patient beds are identi-
processes have been identified by more than
fied, cleaned, and made available on a timely
80% of ED PIP sites.
basis to admitted patients waiting in emergency
The accountability agreement between the
departments:
Ministry and LHINs includes LHIN-specific tar-
hospitals should have an effective process in
gets for three emergency-department wait-time
place to identify vacant beds and communi-
indicators. The Ministry and the LHINs meet
cate their availability between in-patient
quarterly to discuss the performance reports
units and emergency departments; and
submitted by LHINs, including progress made
the Ministry of Health and Long-Term
and challenges encountered in meeting targets.
Care should work with the LHINs and with
hospitals to identify and disseminate best
practices that enable hospitals to reduce
unnecessarily long stays of admitted patients Staffing
in emergency departments.
Appropriate staffing levels are essential to the effi-
cient and effective operation of emergency depart-
ments; inadequate staffing can clearly contribute
The hospitals concurred with this recommenda- to emergency-department wait times. There are no

tion. One hospital has begun exploring the use provincial standards for determining emergency-
of technology to identify and track the current department staffing requirements. Each emergency
status for patients and beds, and to allow real- department makes staffing decisions based on its
time direct communication across hospital patient numbers and average levels of patient acuity.
departments. Another hospital commented that
using best practices to address the complex issue
Emergency-department Nurse Scheduling
of ensuring timely access to in-patient beds for
emergency-department patients is a top priority Two of the three hospitals we visited had difficulty
of its senior management team. scheduling staff to fill emergency-department
nursing schedules. We reviewed these schedules
Ministry Response on a sample of days in the 2008/09 fiscal year and
found that one hospital was unable to schedule
The Ministry has undertaken numerous activ-
enough staff each day to fill about 15% of its emer-
ities to facilitate knowledge transfer and timely
gency departments nursing hours. As a result, the
dissemination of best practices across the
emergency-department manager had to call upon
system. It is also working closely with the LHINs
other nurses to work extra shifts in order to meet
and hospitals on a range of initiatives to reduce
the workload requirement. Management at two
unnecessarily long stays in emergency depart-
of the hospitals we visited told us that scheduling
ments and to ensure that vacant in-patient beds
nurses was difficult for emergency departments for
are made available on a timely basis.
a variety of reasons. Nurses tended to stick to their
The Ministrys Emergency Department
preferred schedules; some were able to negotiate
Process Improvement Program (ED PIP) trains
a favourable schedule and only worked certain
staff on best practices related to in-patient bed
shifts when they were specifically recruited. All
turnover, and supports hospitals in improving
three hospitals had to follow the terms of collective
patient flow from admission to the emergency
agreements, especially in scheduling staff during over several years, but the issue still had not
holiday seasons. been resolved.
The three hospitals we visited often incurred
At another hospital, one nurses total earnings
extra costs by having emergency-department nurses in 2009/10 were $193,000, which included
work extra shifts for which they received premium payments for extra shifts and overtime. This
and overtime pay. According to the hospitals col- was almost three times the average salary of
lective agreements with the nurses, such extra pay nursing staff at that hospital.
is to be offered only after all opportunities to pay at The emergency department is a busy, demand-
regular-time rates have been exhausted. We identi- ing environment in which staff work under con-
fied a number of emergency-department nurses siderable pressure. Nurses consistently working
whose overtime payments accounted for a signifi- overtime and/or handling extra shifts can lead not
cant portion of their total earnings. For example: only to additional costs for the hospital but also to
At one hospital we visited, one nurses annual staff burnout and errors, with an attendant nega-
overtime pay accounted for over half of her tive impact on the quality of patient care. Although
total earnings for nine consecutive years. In overtime costs cannot be eliminated, hospitals need
the 2009/10 fiscal year, her total earnings to adequately oversee this area through regular
were $157,000, of which 57% or $90,000 was report-backs on overtime levels and through use of
overtime pay. The hospitals finance depart- alternative staffing approaches, such as hiring addi-
ment told us that it had informed emergency- tional staff and using contract nursing staff where
department management about this situation permitted under the collective agreements.
Figure 11: Number of People per Emergency-department Physician, by LHIN, 2008

Source of data: Ontario Physician Human Resources Data Centre
30,000
25,000
20,000
15,000
10,000
5,000
0
Ontario
Waterloo Wellington
Mississauga Halton
Toronto Central
Central
Champlain
North Simcoe Muskoka

South West
Central West
Central East
South East
North East
North West
Erie St. Clair
Hamilton Niagara
Haldimand Brant
Emergency-department Physician Capacity The quality of agency physicians varied, and

and Distribution the emergency department had no control
over their level of skill and commitment.
The Ontario Physician Human Resources Data
An independent study commissioned by the
Centre (Centre) maintains a registry of all phys-
Ministry in 2006 recommended that hospitals
icians practising in Ontario. The most recent data
should work as aggressively as possible to eliminate
show that, in 2008, the province had about 1,000
the use of agency physicians in staffing their emer-
emergency-department physicians. However,
gency departments. At the time of our audit, based
there have been no comprehensive studies to
on information provided by the staffing agency,
determine the provinces current and projected
there were about 20 hospitals still using agency
needs for emergency-department physicians.
physicians to staff their emergency departments.
HealthForceOntariothe provincial strategy to
ensure that Ontarians have access to the right num-
Recommendation 6
ber and mix of qualified health-care providers
published a report in November 2009, which stated To ensure that emergency departments are
that to understand what the right capacity is in operating cost-effectively with adequate nurses
delivering access and quality of care to residents, a and physicians:
provincial study should be conducted to understand hospitals should deal with chronic overtime
emergency department resourcing and distribution by setting targets for reducing overtime costs
needs across the province. to acceptable levels and implementing effect-

Data provided by the Centre show that the ratio ive measures for achieving these targets; and
of emergency-department physicians to population the Ministry of Health and Long-Term Care
varied among the provinces 14 LHINs from 1:8,000 should work with the LHINs and with hospi-
people to 1:27,000 people, indicating the uneven tals to conduct studies to assess the require-
distribution of emergency-department physicians ments, availability, and regional distribution
across the province and possible shortages in cer- of emergency physicians across the province
tain regions (Figure 11). in order to develop a sustainable human
The uneven distribution of emergency- resources strategy that will ultimately elim-
department physicians has resulted in shortages in inate the use of agency physicians.
certain regions of the province, which has resulted
in some emergency departments engaging the Response from Hospitals
services of emergency-department physicians from
For the most part, the hospitals agreed with
a staffing agency. Two of the hospitals we visited
this recommendation. One hospital commented
and about 40% of the emergency departments we
that the use of contract nursing staff to solve
surveyed had used agency physicians. The informa-
the nurse-scheduling problem was not a feas-
tion they provided indicated that:
ible and cost-effective long-term solution.
Using agency that physicians was expensive.
Another hospital suggested that a sustainable
In addition to paying agency physicians for
human resources strategy should include ways
the shifts worked, the emergency departments
to support unexpected increased emergency-
had to pay various non-clinical fees such as
department physician coverage needs caused by
out-of-town travel and accommodation costs,
seasonal closures of other, alternative urgent-
a one-time implementation fee ($5,000 to
health-care facilities.
$7,500), and an administration fee (about
$300 per shift).
Impact of Emergency-department
Ministry Response
Wait Times on ambulance
The Ministry is working with various delivery Emergency Medical Services (EMS)
partners to ensure that emergency departments
In the 2008/09 fiscal year, ambulances delivered
are operating cost-effectively by applying best
about 700,000 patients to emergency departments,
practices and lessons learned from others who
accounting for about 13% of all emergency-
have experience and demonstrated improve-
department visits. Over 80% of them were high-
ments. These initiatives include:
acuity patients in CTAS 1, 2, and 3. Ambulances
the Emergency Department Coverage Dem-
carrying patients often queued at emergency
onstration Project, which provides urgent
departments, and could not immediately offload
coverage as an interim measure to desig-
patients due to emergency-department overcrowd-
nated hospitals that are facing significant
ing or lack of beds. Such delays have significant
challenges covering emergency-department
implications for the Emergency Medical Service
shifts;
(EMS) providers across Ontario. Responsibility for
the ED Staffing Reference Guide, which helps
providing land ambulance services rests with the
hospital leaders and LHINs understand and
40 upper-tier municipalities (regions, counties, and
access government programs and incentives
cities) and 10 designated delivery agents in remote
that may assist emergency departments;
areas. The Ministry is responsible for setting stan-
a two-day Emergency Medicine Primer for
dards and funding 50% of approved eligible costs
Family Physicians, offered by the Ontario
of municipal land ambulance services. The balance

College of Family Physicians in collaboration
of funding and actual delivery of service is the
with the Ministry; and
responsibility of the municipalities and designated
a Ministry-funded proposal for a Supple-
delivery agents.
mental Emergency Medicine Experience, a
pilot project that would create an intensive
program in emergency medicine for family Offload Delays
physicians (the Ministry received the pro-
Paramedics stay with and continue to care for their
posal in March 2010 and it is under review).
patients who have been delivered to the emergency
The Auditors report recognizes that hiring
department by ambulance until emergency-
additional nursing staff in emergency depart-
department nurses can accept the patient and there
ments can reduce overtime costs. The 9000
is an emergency-department bed available. A delay
Nurses Commitment supports the implementa-
in transferring a patients care from the paramedics
tion of newly committed, full-time, permanent
to the emergency department is known as an off-
nursing positions. Movement toward 70% full-
load delay. Our review of patient files at the three
time employment may also reduce the burden of
hospitals we visited and information we received
overtime costs and promote better continuity of
from EMS providers indicated that ambulance
care, leading to improved patient outcomes and
crews often had to wait for over an hourand in
a more sustainable workforce.
some cases up to three hoursfor their patients to
be attended to by the emergency department.
We sent a survey to all 14 EMS providers that
received ministry funding for the Offload Nurse
Program (discussed in a following section), which
was specifically targeted to reduce emergency- reached. Although the Emergency Department
department wait times; 10 of them responded. All Reporting System (System) has collected ambu-
of them expressed frustration with long offload lance offload times since October 2008, they were
delays, which diminished available ambulance not published on the public website or measured
resources, resulting in fewer or even no ambulances against the 30-minute benchmark.
being available to respond to new emergency calls. To assess the extent of offload delays, we
Most of the respondents complained that offload obtained ambulance offload times from the System
delays increased EMS providers operating costs to review the trends and regional variations in
and adversely affected staff morale because the the province. Ambulance offload times decreased
paramedics frequently incurred overtime and were in the first few months after the introduction of
unable to finish their shifts on time. In addition, the Offload Nurse Program (see next section) in
they commented that offload delays could have late 2008, but by February 2010 were higher than
implications for quality of patient care because they had been in October 2008. On average, every
paramedics were being requested to perform month about 20% of patients arriving by ambu-
procedures outside their skill sets and to render lance at emergency departments still exceeded the
ongoing nursing care until the patient was accepted 30-minute benchmark, compared to the 10% target
by the emergency department, during which time noted earlier.
there was the increased risk of the patients condi- Our review indicated that ambulance offload
tion deteriorating. times could be understated at some hospitals. The
data one of the hospitals we visited had provided

to the System indicated that its average ambulance
Ambulance Offload Time
offload time from October 2008 to August 2009
Delay in offloading ambulance patients is an was very shortonly eight minutesyet the data
important indicator of the accessibility and maintained by the EMS provider serving this hos-
effectiveness of emergency departments. The key pital indicated it to be 82 minutes. We requested
performance indicator is ambulance offload time, raw data from the hospital and recalculated the
which is defined as the time from the arrival of ambulance offload time, determining that it was
the ambulance until the patient has been removed actually 33 minutes. The discrepancy between the
from the EMS stretcher and care transferred from hospitals ambulance offload time and that of the
the paramedic to hospital staff. Ambulance offload EMS provider came from two sources. First, the
times vary throughout the province and are notably EMS provider informed us that paramedics often
longer in urban areas. In 2005, the province estab- did not record ambulance offload times for all
lished the Hospital Emergency Department and ambulance patients, with the compliance rate for
Ambulance Effectiveness Working Group to study this provider being about 60%. Second, hospital
emergency services. The group issued a report, staff confirmed that an error had been made in the
which advised that ambulance offload time must original data submitted to the System, resulting
be improved immediately and recommended the in the ambulance offload time being understated.
implementation of a benchmark ambulance offload Although the offload time of only eight minutes
time of 30 minutes, 90% of the time. (In other seems significantly low, Cancer Care Ontario,
words, it would be acceptable for the ambulance which is responsible for managing the System, did
offload time to exceed 30 minutes 10% of the time). not question these data. It informed us that it has
The report also recommended that hospitals been working closely with EMS providers across the
improve their ambulance offload time by 10% province to improve the quality of data submitted
per month from baseline until the benchmark is by emergency departments.
Offload Nurse Program freed up ambulances, and brought emergency

departments and EMS providers together to
To alleviate offload delays, in May 2008, the Min-
improve offload delays. However, additional
istry began funding the Offload Nurse Program
longer-term data would be required to
(Program), intended to improve teamwork and
confirm the sustainability of these initial posi-
co-ordination between emergency medical services
tive results. Although the Program was not
and hospitals. The Ministry provided $4.5million
intended to solve the overall systemic issue
in 2008/09 and $5million in 2009/10 to 14 EMS
of emergency-department wait times, it did
providers in Ontario to reimburse hospitals for the
provide a short-term relief. For this Program
cost of providing offload nurses, who are dedicated
to have long-term success, the hospitals
solely to assuming care of EMS patients. By taking
would concurrently have to make other long-
care of patients when they arrive, the offload nurses
term process improvements to emergency-
are intended to free up ambulances and paramed-
department flow. Therefore, it would be
ics to respond to other calls. The 14 selected EMS
important for the Ministry, hospitals, and EMS
providers entered into agreements with specific
providers to continue to monitor the impact of
hospitals to purchase the services of offload nurses.
the Program and other initiatives intended to
Although the offload nurses were employed by the
alleviate emergency-department wait times.
hospitals, the Ministry provided funding directly
to the EMS providers rather than the hospitals to Some of the EMS providers told us that the
Program had limited focus and did not signifi-
ensure that the money was used specifically for
cantly improve ambulance offload times. In
offload nurses and not merely to increase overall

certain regions, offload delays continued to
staffing in emergency departments.
increase because of two main problems. First,
All three hospitals we visited welcomed the
staffing shortages precluded the offload nurse
additional resources given. However, they indicated
position being staffed at all times to optimize
that offload nurses provided only short-term relief.
the Programs benefits. Second, funding and
In fact, one hospital questioned the effectiveness of
offload nurse coverage hours were far below
having offload nurses. It commented that the Pro-
the levels needed to have any significant
gram was not a good use of resources because dedi-
impact.
cated offload nurses were not integrated well into
the whole system of operating emergency depart-
Recommendation 7
ments. At times when other areas of emergency-
department operations had more urgent needs, the To ensure the efficient use of the ambulance
hospitals were not allowed to assign offload nurses Emergency Medical Services (EMS) and to
to those areas: offload nurses could only take care enhance co-ordination between EMS providers
of ambulance patients. and emergency departments, the Ministry of
Because the Ministry had not formally evaluated Health and Long-Term Care should:
the Program, we contacted all 14 EMS providers determine whether the recommendation in
that received funding to obtain their feedback; the 2005 expert panels report on ambulance
10 of them responded. In general, they told us effectiveness of a benchmark ambulance
that although the additional funding had helped offload time of 30 minutes 90% of the time
improve offload time, more work will be required to should be accepted as a province-wide target;
sustain these short-term results. Specifically: work with hospitals, EMS providers, and
Most EMS providers acknowledged that the Cancer Care Ontario to improve the validity
Program reduced ambulance offload times, and reliability of ambulance offload data and
Performance Monitoring
to ensure that such data are standardized,
consistent, and comparable; and Complaint Process and Incident Reporting
work with hospitals and EMS providers
Each of the three hospitals we visited had different
to evaluate on a province-wide basis the
processes in place to resolve complaints and review
effectiveness of the Offload Nurse Program
serious incidents that occur in their emergency
in reducing offload delays and improving
departments. Our audit indicated that:
patient flow within emergency departments.
All three hospitals have complaint policies or
processes that set out the ways of handling
complaints and indicate that complaints need
The hospitals supported initiatives to improve to be resolved within two to three weeks. At
the quality of ambulance offload data across the time of our audit, one hospital had com-
Ontario. They appreciated receiving the sup- plaints related to its emergency department
port of the Offload Nurse Program to improve that had been outstanding for two months.
ambulance offload time. One hospital indicated Another hospital had closed complaint files
that, ideally, the time of the patients transfer of without issuing a response or taking action;
care needed by the hospital and that of the EMS at the time of our audit in March 2010, we
should be identical. noted that there were a number of complaints
received as far back as July 2009 that were
Ministry Response still open.

The Ministry has been providing tools and All three hospitals we visited had an incident
reporting system or process in place to record
programs to reduce ambulance offload times
events that caused harm to a patient. Our
since 2008, and continues to do so. Hospitals
analysis indicated that two of the hospitals
that receive Pay-for-Results funding are required
had under-reported adverse events that had
to submit valid ambulance offload data reports
occurred in their emergency departments.
that allow their progress toward the 30-minute
We also noted that critical incidents were
ambulance offload standard to be tracked.
often captured not by the incident-reporting
The Ministry, Cancer Care Ontario, and EMS
systems but through other channels, such
providers will also continue to work together to
as patient complaints and word of mouth.
improve the validity and reliability of the ambu-
We also noted that, when incidents were
lance offload data.
reported, there was generally a lack of docu-
Although the hospitals audited have not yet
mentation of the investigation results and any
seen improvements in ambulance offload times,
corrective actions taken.
other hospitals, particularly in the Toronto
area, have shown significant improvement.
The Ministry continues to work with municipal Unscheduled Return Visits to Emergency
stakeholders and receives in-year performance Departments within 72 hours
reports to ensure that the Offload Nurse Pro-
Our research indicated that the rate of unscheduled
gram is effective in reducing ambulance offload
return visits to emergency departments provides
delays.
a measure of the quality of emergency care.
Returning within 72 hours could indicate that the
reason for the patients initial visit was not handled
adequately and appropriately. Patients could have
received wrong diagnoses during their first visit, documentation was a major concern and needed
or diagnosis was delayed, resulting in their return. to be improved; it indicated that it was difficult to
The medical directors at all three hospitals we align the review results with recommendations and
visited informed us that, although they were able to follow up on the recommendations it had made.
to provide data related to return visits, the only The third hospital required quarterly reviews of all
return-visit cases they usually reviewed were those deaths that occurred in its emergency department
where deaths had occurred. and that the results be reported to its Quality and
We reviewed patient files related to return- Patient Safety Committee. However, we noted that
visit cases in the three hospitals we visited and no such reviews had been done since July 2008.
found instances where patients were discharged
inappropriately from emergency departments with
Patients Who Left without Being Seen or
no proper tests, such as ECGs or blood work, done
Left against Medical Advice
during their initial visits to emergency depart-
ments. Some of those patients who had revisited The rate at which patients leave the emergency
the emergency departments shortly after being department without being seen by physicians
discharged were admitted for emergency surgery or without having completed treatment is a
or, in a few cases, had even died subsequently. recognized indicator of emergency-department
Clearly, medical decisions involve a high degree performance and quality. Although there is cur-
of judgment, and medical staff will not make the rently no provincial standard, our research shows
right decision 100% of the time. From the perspec- that the industry standard rate of patients who
tive of accountability, oversight, and learning, it is leave without being seen or treated is 2% to 3%.
important that return visits, particularly those that At each of the three hospitals we visited, the rate
result in death, be investigated. However, in virtu- was about 6%, reaching as much as 8% during
ally all the return-visit cases we reviewed where the some months. Patients leave before being seen or
patient died and the initial decisions may not have completing treatment mainly due to prolonged
been appropriate, either no formal death review waiting. According to the Ontario Hospital Asso-
was completed or, if it was, no supporting evidence ciation, all hospitals should have a documented
was available documenting the review. In three process in place to follow up with those patients
of these cases, the emergency department agreed who leave without being seen or treated. Our
that the patients should not have been discharged review of patient files showed that one of the three
on their initial visits and that death reviews should emergency departments we visited generally did
have been conducted. In another case, we were attempt to follow up with these patients, especially
told that, because the discharge was determined to if they left against medical advice. However, at the
be the wrong decision, a formal review would not other two hospitals, there were instances where no
provide any additional value. follow-up occurred with patients who were triaged
Our review showed that death review processes as high as CTAS 2 and 3 but who had left the emer-
varied among hospitals. One hospital did not have gency department without being seen or against
a formal process to review all deaths occurring in medical advice.
its emergency department; the emergency depart-
ments medical director told us that review results Recommendation 8
or recommendations were not documented but
To ensure that emergency departments are
were shared with physicians verbally. Another
providing high-quality emergency care to all
hospital had a formal process involving a Death
patients, hospitals should:
Review Committee. The Committee noted that
Alternatives to Emergency-
promote a culture of patient safety by using a Department Services
non-punitive and lesson-learned approach
to ensure that adverse events are reported The opinion of the Physician Hospital Care Com-
and summarized for analysis and corrective mittee in its 2006 report on Improving Access to
actions; and Emergency Care was that diverting low-acuity
follow up with patients who have been tri- patients would only minimally reduce demand
aged as having serious medical conditions for emergency departments and only minimally
but who have left emergency departments impact wait times. However, we noted that in
without being seen by doctors or having 2008/09, 2.5million emergency-department
completed treatment. visitsabout half of all emergency-department
visits in Ontariowere made by patients with less
Response from Hospitals urgent (CTAS 4) and non-urgent needs (CTAS 5),
who could have been supported by other medical
The hospitals generally agreed with this recom-
alternatives, such as walk-in clinics, family doctors,
mendation and acknowledged the importance
and urgent care centres.
of incident reviews and reporting as a means of
monitoring the quality of patient care. One hos-
pital noted that it has a formal policy and pro- Low-acuity Patients
cedures in place to review unexpected deaths. It
Although low-acuity patients (CTAS 4 and 5) arriv-
has a multidisciplinary team that reviews cases

ing at emergency departments with minor condi-
and then makes recommendations and specific
tions can usually be treated and discharged quickly,
action plans. Another hospital has launched an
over three-quarters of the emergency departments
on-line incident-reporting tool to track incidents
we surveyed stated that low-acuity patients
throughout the hospital.
definitely had a detrimental impact on emergency-
department overcrowding and patient flow. We also
Ministry Response
noted that:
The Ministry supports this recommendation In July 2009, the Canadian Journal of Emer-
and agrees that reducing the left without gency Medicine published the Predictors of
being seen (LWBS) numbers will contribute to Workload in the Emergency Room (POWER)
patient safety. The Ministry also believes that study, which found that there was marked
research should be conducted to determine the variation in the amount of time required by
prevalence of adverse events among patients emergency-department physicians to assess
who have left emergency departments without and treat patients in each CTAS level. (The
being seen. average time was 73.6 minutes for CTAS1;
In the 2010/11 fiscal year, the Ministry 38.9 minutes for CTAS 2; 26.3 minutes
provided dedicated funding as part of the Pay- for CTAS 3; 15.0 minutes for CTAS 4; and
for-Results program to reduce the wait time 10.9 minutes for CTAS 5.) Using the results
to initial assessment by 10%. This indicator is from the POWER study and the volume of
closely correlated with the number of people emergency-department visits in 2008/09, we
who have left without being seen; thus, as we estimated that about 30% of all emergency-
reduce the time to initial assessment, we will see department physician time was spent on
a reduction in LWBS numbers. CTAS4 and 5 patients in Ontario.
Patients without family doctors or patients the evening, and on weekends to provide diagnosis
who are unable to get in to see their family and such treatments as casts, eye care, stitches, and
doctors often end up in emergency depart- x-rays. (They do not provide surgery.) Emergency
ments. We noted that, in 2008/09, of those departments and paramedics informed us that
low-acuity patients (CTAS 4 and 5) who urgent care centres have the potential to relieve
visited emergency departments, about 14% pressure at emergency departments by reducing the
(349,000) had no family doctor. All three hos- number of low-acuity patients visiting emergency
pitals we visited and over 80% of the hospitals departments. However, the following factors have
we surveyed expressed concern about people prevented urgent care centres from functioning as
with untimely access to or no family doctors effectively as possible:
frequently visiting emergency departments. The public has not been educated sufficiently
There were many frequent visitors to emer- to be able to make the decision whether their
gency departments who made at least one condition requires treatment in an emergency
visit per month. In 2008/09, about 100 department or can be handled appropriately
patients made 1,600 visits in total to the three by an urgent care centre. One emergency
emergency departments we visited. Many of department informed us that, although there
these visits were related to minor symptoms. has been a Ministry-sponsored TV advertise-
For example, one patient made 43 visits in 22 ment aimed at educating the public on where
months with such non-emergent conditions to seek medical care, much more needs to be
as back pain, headache, dizziness, or flu-like done. Another emergency department told us
symptoms. The patient was instructed on that it is important to provide ongoing educa-
several occasions to follow up with the family tion and send clear messages to the public on
doctor. appropriate use of urgent care centres and
At one emergency department we visited, we emergency departments, because it is often
were told that emergency departments are no mistakenly believed that urgent care centres
longer a place for emergencies because they are staffed and equipped like emergency
are inundated with patients who believe that departments to provide resuscitation, when,
they can obtain faster access to specialists and in fact, high-acuity patients need to go to a
lab tests at emergency departments instead of full-service emergency department.
waiting for referrals from family doctors. The EMS paramedics told us that they had
manager of the diagnostic imaging depart- transferred a number of patients from urgent
ment at another hospital also informed us that care centres to emergency departments
many patients visit emergency departments when the patients conditions were such
simply because they are unable to have their that they should have gone directly to an
diagnostic tests completed quickly through emergency department. On the other hand,
other channels. one urgent care centre told us that only about
4% of its patients were transferred to emer-
gency departments for treatment. As well,
Urgent Care Centres
emergency-department management at one
At the time of our audit, there were 15 urgent care hospital also told us that the transfer rate to
centres in Ontario, established to serve patients emergency departments was less than 5% for
who need treatment for illnesses or injuries that most urgent care centres.
cannot wait but that are not life-threatening.
Urgent care centres remain open during the day, in
Recommendation 9 includes opportunities to support seasonal and

unexpected physician coverage needs.
To ensure that the needs of patients are met
appropriately, the Ministry of Health and Long-
Ministry Response
Term Care should:
work with hospitals to conduct further In February 2009, the Ministry introduced a
research on the impact of low-acuity patients website called Your Health Care Options, which
on emergency services and on what province- lists alternative access points, including walk-in
wide initiatives can be undertaken to encour- clinics and urgent care centres. The Ministry has
age people to seek the right treatment from implemented extensive TV and media advertis-
the right medical provider; and ing over the past two years aimed at promoting
assess and promote the availability and the website and raising public awareness of
public awareness of health-care alternatives alternatives to hospital emergency depart-
to emergency departments on a regional ments. As well, pamphlets have been mailed to
basis, including walk-in clinics, urgent primary-care offices for public dissemination.
care centres, family physicians, and other Additionally, since 2008, the Ministry has
community-based supports, to optimize the funded 14 Nurse-led Outreach Teams, which
right care in the right environment. travel to long-term-care facilities to proactively
assess the health-care needs of residents and
Response from Hospitals deliver services in order to reduce emergency-

department visits by providing the required care
The hospitals supported this recommenda-
at the long-term-care facility.
tion. One hospital reiterated that seasonal
The Ministry is also working closely with
closures of alternatives to emergency depart-
the LHINs to assess changes in volumes of
ments often put extra pressure on emergency
emergency-department visits by low-acuity
departments. As a result, it was important to
patients as well as potential local initiatives to
have a sustainable human resources strategy
continue to divert these visits to other appropri-
for emergency-department physicians that
ate care settings, including Family Health Teams.

Hospital Emergency Departments: Section

Enviado por

Dados do documento

Descrição original:

Título original

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

Hospital Emergency Departments: Section

Enviado por

Direitos autorais:

Formatos disponíveis

Chapter 3 Ministry of Health and Long-Term Care

nurses assess and classify patients based on the

injuries to patients who arrive either in person or by

ARRIVAL EMERGENCY DEPARTMENT DEPARTURE

Chapter 3 VFM Section 3.05

Chapter 3 VFM Section 3.05

complex conditions were treated within eight

Chapter 3 VFM Section 3.05

and the United Statesand almost five times

patient beds were not available on a timely basis.

The problem was partly due to the fact that about

16 high-acuity patients: patients with complex conditions

Chapter 3 VFM Section 3.05

North Simcoe Muskoka

a criterion for determining Year 2 funding alloca-

Chapter 3 VFM Section 3.05

Chapter 3 VFM Section 3.05

Figure 7: Results of Triage Audits Conducted at Three Emergency Departments

undetermined due mis-triaged (44%)

1. under-triaged underestimating the severity of a patients illness or injury

Consistency of Triage Assessment by

provided training for the paramedics based on the

Assessment and Treatment assessment, we reviewed a sample of patient files

Chapter 3 VFM Section 3.05

CTAS Recommended Time from Hospital (minutes)

Use of Medical Directives to Improve

% recommended by CTAS Guidelines

Chapter 3 VFM Section 3.05

intervals. For example: patients when they arrive at emergency

caused by a blood clot. One of the hospitals

Chapter 3 VFM Section 3.05

Co-ordination with Other Hospital Access to Diagnostic Services

One indicated that the CT scanner was not

Chapter 3 VFM Section 3.05

in emergency departments, hallways, or waiting times; the emergency-department system

Recommendation 5 department to discharge from an in-patient

Chapter 3 VFM Section 3.05

Figure 11: Number of People per Emergency-department Physician, by LHIN, 2008

North Simcoe Muskoka

Emergency-department Physician Capacity The quality of agency physicians varied, and

Chapter 3 VFM Section 3.05

of municipal land ambulance services. The balance

Chapter 3 VFM Section 3.05

Offload Nurse Program freed up ambulances, and brought emergency

offload nurses and not merely to increase overall

Chapter 3 VFM Section 3.05

Chapter 3 VFM Section 3.05

Recommendation 9 includes opportunities to support seasonal and

Chapter 3 VFM Section 3.05

Você também pode gostar