|Implemented in this survey?|
Canadian hospitals are having trouble coping with increasing wait times in Emergency Departments (EDs). Recent reports of improvements in hospital operations indicate that quality of care in hospitals could be improved through greater attention to internal hospital processes, especially in the EDs as well as to divert patients from using the ED when other alternatives are equally or perhaps more appropriate
About 15% of Canadians or 3.5 million people over age 12 received care for their more recent injury or had their most recent care provided by staff in an Emergency Department (EDs). Of these, more than one million (1.1 M) were admitted for hospitalization. Over half of all hospital admissions (60%) were admitted from EDs. Patients admitted to hospital through the ED were more likely to be older and sicker than patients admitted through other means such as planned admissions (CIHI, 2007). Some provinces such as Ontario have identified reducing wait times in EDs as a new quality of care initiative. Among a number of causes of long ED wait times, one could be inefficient processes in the ED. The Province of Ontario has developed new performance management targets and financial incentives to encourage more efficient and effective use of EDs.
In May 2008, the Ministry of Health and Long-Term Care (MOHLTC) announced a new investment of $109 M (Cdn) to reduce wait times in EDs. Of the total new investment, $30M will be targeted to the 23 Hospital EDs with the greatest wait times. The Ministry also allocated $38.5 m to increase home care services and enhance integration between hospitals and the community, $4.5m for additional nurses in EDs to assist with reducing ambulance offload delays, $22M to Local Health Integration Networks to help provide community alternatives to hospital care, and lastly $4.5m for nurse-led outreach teams to provide residents of LTC facilities with timely and appropriate care in the LTC facility to avoid transfers to hospital EDs. All of these targeted initiatives are intended to help to reduce ED wait times inside and outside the hospital.
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
There need to be policy supports such as financial and performance incentives that are based in the regional system to influence successful uptake of improved hospital performance in other parts of the country. Barriers such as the quality of hospital leadership, lack of performance and financial incentives could prevent transferability to other areas within a province or other provinces/countries.
In a publicly financed health care system, problems in hospital services often receive media coverage. In recent years media coverage of temporary closure of EDs, long wait times, and deaths of patients in the ED received widespread publicity. Not only do these problems indicate poor access and quality of care, but they also increase pressure on government and politicans to respond to the issues.
|Implemented in this survey?|
Hospital restucturing in Canada began in the 1990s when every province took steps to restructure its hospitals because of perceived over capacity of inpatient beds. Since then hospital services, along with problems in the primary care system, and rising health care costs, have frequently been in the forefront of policy attention.
In 2001 a study of the effects of hospital restructuring (closing several short-term hospitals and increasing ambulatory care) in Montreal found that EDs experienced a marked increase in volume (overcrowding) after the restructuring. There were multiple reasons for this but the main ones were: the community sector was unable to adapt to the reduction in inpatient beds, access to hospital beds became more restricted for patients in EDs, the average length of stay of hospitalized patients began to rise. As well, some hospitals seemed to have too few beds to be able to safely respond to fluctuations in demand (Roberge, 2001). These reasons undoubtedly were also at play in other parts of the country as reports of ED problems began to be reported in various jurisdictions.
Today an additional issue has been the inablity to discharge patients who no longer require hospital care. In Ontario these patients occupy 20% of hospital beds and are a major barrier to improving the efficiency of the ED. Thus the new investment by the Ministry of Health and Long-Term Care represents a timely multi-focused attempt to improve ED and overall hospital performance.
The approach of the idea is described as:
There was little discussion about the new funding. Stakeholders, ranging from patients to physicians to hospitals, have a vested interest in effective and efficient hospital care. The announcement was greeted positively and has been widely promoted by the Liberal Party of Ontario and individual Liberal politicians. The opposing Conservative Party did not issue a news release in response to the announcement. The most influential supporters of the initiative to the government were hospital leaders.
|Ontario Government||very supportive||strongly opposed|
|Hospitals||very supportive||strongly opposed|
|Ontario Hospital Association||very supportive||strongly opposed|
|Hospital patients||very supportive||strongly opposed|
|Ontario Government||very strong||none|
|Ontario Hospital Association||very strong||none|
|Hospital patients||very strong||none|
The new funding is flowing to health providers. In February of 2009, the Ministry followed up the 2008 announcement with news that Ontario is setting targets for ED wait times. For patients with minor conditions the target is that 90% of patients will spend a maximum of 4 hours. Current performance for these patients is 4.6 hours. For patients with complex conditions, the target is that 90% will spend a maximum of 8 hours but the current performance is13.5 hours. Ontario is the first province in Canada to establish ED wait times and is perhaps the first jurisdiction in North America to do so.
It is too early to evaluate the success or the initiative.
Ontario is making investments in three types of interventions designed to improve ED performance:
Reports from some Ontario hospitals that have already tackled some of these issues indicate that improving ED performance can reduce wait times within six months for both lighter and heavier care patients by up to 60 percent (MacLeod, et al 2008). Providing alternatives to hospital EDs can also avoid ED visits among long-term care facilitity residents (The Globe and Mail 2009). The question will be whether these early gains in some parts of the Province can be achieved in other settings. As well, it would be useful for the government to undertake a cost effectiveness evaluation of the inititaives to ensure that the system is receiving value for money.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
It is difficult to evaluate the cost efficiency of the new investments because there have been no cost-effectiveness studies.
Canadian Institute for Health Information (CIHI). Understanding Emergency Department Wait Times: Access to Inpatient Beds and Patient Flow. 2007. www.cihi.ca
Canadian Institute for Health Information (CIHI). Understanding Emergency Department Wait Times: How Long to People Spend in Emergency departments in Ontario. 2007. www.cihi.ca
Mac Leod, H, B. Bell, K. Deane and C. Baker. Creating Sustained Improvements in Patient Access and Flow: Experiences from Three Ontario Healthcare Institutions. Healthcare Quarterly 11:3. 2008.
Ministry of Health and Long-Term Care, Ontario. Ontario targets shorter ER times. 2009. www.moh.gov.on.ca
Ministry of Health and Long-Term Care, Ontario. Enhanced home care coverage and efforts trageted at poorest performing emergency rooms lead the way. 2008. www.ontario.ca/health
Ministry of Health and Long-Term Care, Ontario. Ontario's $109 Million investment to reduce wait times in the emergency room. May 30, 2008.
Roberge, D. The Effects of System Restructuring on Emeregency Room Overcrowding in Montreal Centre. Canadian Health Services Research Foundation. June 2001. www.chsf.ca
Senior Fellow, Canadian Policy Research Network