The Solution to Relieve Congestion in the Emergency Room

Sep 10, 2019, 08:00 AM by Francis Cuerrier

For more than 20 years, emergency room overcrowding has been a major issue in Canada. We have seen an increase in awareness at the political and administrative levels as well as the public level. Despite all the efforts and changes that have been put in place, the difficult situation in emergency rooms continues to grow, especially since bottlenecks are more frequent, but also more significant[1]. In Quebec, emergency departments regularly make headlines about the issues created by overcrowding or long waiting times for consultations.

Family waiting in the emergency room to meet a doctor

There is some consensus among healthcare professionals, with 81% of them believing that there are too many patients with minor problems visiting the ER[2]. Indeed, it is common practice for patients with non-urgent problems to visit hospital emergency rooms to access treatment. In order to sort the priority level of patients’ medical conditions, patients are ranked according to the Canadian Triage Scale from Priorities 1 to 5. For example, a P1 patient must be seen immediately, while a P4 patient can, in principle, wait a maximum of 60 minutes before being seen by a physician[3].

 

How Can We Properly Identify Patients Eligible for Redirection?

According to the report of the Commissioner of Health and Welfare[4], almost half (44%) of ER patients had a condition that could be treated by a general practitioner.

Individuals who visit emergency rooms with non-emergency medical conditions contribute to their bottlenecks, which has direct effects on the delivery of care. Indeed, these situations lead to prolonged wait times, delays in treatment, quality assurance problems and patient dissatisfaction. In addition, several studies have shown that, at some stage, ER overcrowding has direct effects on patients’ health, which can even lead to mortality[5].

In general, the longer the delays in the ER, the higher the proportion of patients who leave without being seen by a physician. In Quebec, this proportion is 10% on average. In some cases, it can go as high as 17%[6]. However, leaving the hospital does not mean that these patients are less ill. Some are consulting for serious pathologies and leave against medical advice, which leads to their readmission in the following days[7].

While there is a need to improve access to front-line care in Quebec and the rest of Canada, it is impossible for us to know whether this will solve the problem. Indeed, in Germany, despite being among the countries with the highest rates of access to a family doctor according to the report Results of the 2015 Commonwealth Fund International Health Policy Survey, overcrowding is still considered a hot topic. Emergency room visits for minor reasons continue to increase. As a result, there are two main causes to the problem: the practical aspect of emergency rooms (no appointment, 24/7 opening hours, radiological examination, blood work and specialists on site) and the psychological aspect characterized by anxiety related to patients’ health[8].

 

Possible Solutions

Some suggest redirecting all P4 and P5 patients to front-line clinics. Theoretically, this would free up nearly 60% of emergency departments[9]. However, a major problem remains: subjectivity in triaging patients in the ER. For example, for the same patient with the same medical condition, just over one third of ER professionals (37%) triaged them as P3, although they could have sorted them as P4 or P5 as well[10]. Furthermore, just because a patient’s case is classified as non-urgent does not mean that their condition could not be a serious pathology and would not require available facility resources. A study conducted between March 2008 and March 2016, observing the number of deaths among patients classified as P4-P5 within 30 days following a visit to a hospital in Quebec, revealed that out of 187,224 visits there were 964 deaths[11]. On average, this is equivalent to one death every three days. If we were to extend this across the province, there would be more than 10 deaths per day.

We can therefore conclude that the Triage Scale is not an effective tool for determining which patient in the ER can or cannot be safely sent home.

 

Logibec Redirection

To meet all these challenges, Logibec offers a redirection tool for triage personnel. In addition to assisting in clinical decision-making, this tool helps to reduce the variability or subjectivity that may exist between users. The collaboration of emergency physicians and healthcare professionals resulted in the development of a unique medical algorithm that includes more than 50 common reasons for visits. In order to minimize the risk of a return to the ER, these specific reasons are associated with appropriate contraindications. In addition, a key element has been included for the first time in a medical algorithm and is essential to support the redirection system: technology.

The ER is known to be a place where stress is palpable and where medical decisions must be made properly and quickly. Regardless of the format, an algorithm alone—on paper, on a poster, in a binder or in Excel—could not be viable and effective. The use of this tool would require an unreasonable amount of assessment time for triage personnel. They should then make an appointment for each patient eligible for clinic referral by telephone or fax, which slows down the process once again. It should be noted that Logibec’s redirection tool removes these obstacles by giving triage personnel access to availability slots reserved specifically for redirected patients, in such a way that patients leave the emergency room with a quick appointment, at a specific time, in a clinic of their choice. If a patient has a family doctor, the tool facilitates appointment scheduling in the clinic where their doctor works.

The Hôpital du Sacré-Cœur de Montréal, which receives close to 60,000 ER visits each year, has adopted this solution and reduced pretreatment departures by 35% in the past year. Since then, the solution has been successfully deployed in two additional hospitals. In total, more than 12,000 patients per year were safely redirected, representing 15% of ambulatory visits. Finally, out of 1,112 patients who were questioned in a satisfaction survey, 95% of respondents indicated that they would like to see this project rolled out across the province[12].

Finally, the research done on our solution demonstrates the safety, feasibility, reproducibility and improvement of patient experience in the ER. However, we have strong reasons to believe that our redirection tool will lead to better results in other environments. It would be interesting to look at hospitals with a proportion of P4 and P5 patients or with a higher rate of pediatric visits than the Hôpital du Sacré-Cœur de Montréal, where the research was conducted.

 

Learn More About Logibec ER Redirection >

 

References:

[1] L’ENGORGEMENT DES DÉPARTEMENTS D’URGENCE ET LE BLOCAGE D’ACCÈS, 2013. Affleck, A., et al.

[2] [3] [6] [9] APPRENDRE DES MEILLEURS : ÉTUDE COMPARATIVE DES URGENCES DU QUÉBEC, 2016. Commissaire à la santé et au bien-être.

[4] PERCEPTIONS ET EXPÉRIENCES DE SOINS DE LA POPULATION : LE QUÉBEC COMPARÉ – RÉSULTATS DE L’ENQUÊTE INTERNATIONALE SUR LES POLITIQUES DE SANTÉ DU COMMONWEALTH FUND DE 2013. 2014a. Commissaire à la santé et au bien-être.

[5] BETTER PERFORMANCE ON LENGTH-OF-STAY BENCHMARKS ASSOCIATED WITH REDUCED RISK FOLLOWING EMERGENCY DEPARTMENT DISCHARGE: AN OBSERVATIONAL COHORT STUDY, 2015. Schull, M., et al.

[7] WHAT HAPPENS TO PATIENTS WHO LEAVE HOSPITAL AGAINST MEDICAL ADVICE? 2003. Hwang, S.W., et al.

[8] PATIENT MOTIVES BEHIND LOW-ACUITY VISITS TO THE EMERGENCY DEPARTMENT IN GERMANY: A QUALITATIVE STUDY COMPARING URBAN AND RURAL SITES, 2016. BMJ Open.

[10] THE RELIABILITY OF THE CANADIAN TRIAGE AND ACUITY SCALE: META-ANALYSIS, 2015. Mirhaghi, A., et al.

[11] MORTALITÉ À TRENTE JOURS DES PATIENTS TRIÉS P4 OU P5 AUX URGENCES, 2016. Chauny, J.M., et al.

[12] MESURE DE LA SATISFACTION DES PATIENTS FACE À UN PROGRAMME DE RÉORIENTATION DES PATIENTS DE L’URGENCE DANS LES CLINIQUES AVOISINANTES : UNE ÉTUDE PROSPECTIVE SUR 977 PATIENTS, 2017. Chauny, J.M., et al.