No “simple solutions” to emergency log-jam

The Canadian Association of Emergency Physicians (CAEP) calls it “counter-productive.” Several of its findings seem counter-intuitive. Yet, the authors of the first national, comprehensive study on emergency department (ED) overcrowding in Canada say there's no evidence that many institutional reforms and responses, such as senior physician flow shifts, have any impact on reducing the nation-wide log-jam.

Figure. There's no evidence that triaging patients has any impact on overcrowding or wait times. Photo by: Digital Stock

Other responses, like fast tracking patients with minor injuries or illnesses, have proven to reduce ED length of stay and wait times, according to the report, Emergency Department Overcrowding in Canada: What are the Issues and What Can Be Done, prepared for the Canadian Agency for Drugs and Technologies in Health. Other measures may yet prove to be beneficial, like “ambulance diversion strategies, short stay units, staffing changes and system-wide complex interventions.”

But there's no evidence that triaging patients has any impact on overcrowding or wait times, according to a scientific literature review led by Dr. Brian Rowe, a clinician and holder of a Canada Research Chair in Emergency Airway Diseases at the University of Alberta.

Nor is there any evidence of efficacy for “float nurse pools, senior ED physician flow shifts, home or community care workers assigned on-site to the ED, over-census on wards, establishment of orphan clinics, ‚coloured' codes to decongest ED, and ‚overload' units for in-patients.” Some of those procedures, however, may simply be too new to have been evaluated.

In a parallel element of the study, a survey of 243 ED directors in Canadian hospitals indicated that 85% believe a lack of beds is the cause of overcrowding. The majority also believed that other contributory causes include increased complexity and acuity of patient systems, the occupancy of stretchers and length of stay of admitted patients in EDs.

The directors generally agreed that overcrowding has a major impact on the stress levels of nurses, along with their recruitment. Stress caused by overcrowding is lower among physicians (65%) than nurses (82%).

In short, ED overcrowding is “system-wide. It's profoundly complex. It has multiple causes and there are no clear, simple solutions,” Rowe said.

In so saying, the report tempts policy-makers to ignore the fact that there's been a crippling 40% cut in hospital beds generally over the past decade, argues CAEP President Dr. Andrew Affleck. “When you cut 40%, you're going to have a lack of beds, particularly when you have an aging, elderly, complex patient population.”

National Emergency Nurses Affiliation president Janice Spivey says it's vital that bed capacity be restored if “we're ever going to tackle the ED backlog.”

Spivey also argued there's a need to ensure that medical equipment such as MRIs and CT scans are available beyond the typical 9-5 workday and that programs be put in place to ensure there'll be an adequate supply of properly-trained emergency nurses to handle the expected influx of patients as the population ages. The roster of available nurses is so limited that the system can't handle staff nurses' illness or injury without forcing people into lengthy, multiple work shifts.

But the survey of ED directors doesn't identify human resources as a problem. And while they did identify bed shortages as an obstacle, Rowe noted that clinical efficiencies could alleviate the problem. “We can be better and more efficient at throughput within hospitals, so busy hospitals with care plans and with clinical practice guidelines might be better at treating conditions and reducing the length of stay so that those beds transition much more quickly.”

In other recommendations, the report urged the development of a national emergency department database to promote additional studies and, ultimately, the adoption of best practices.