Treatment in ER may take over 24 hours

The Hawkesbury and District General Hospital has some of the worst emergency room wait times in Eastern Ontario.
In March 2009 - the most recent month for which data is available - 10 per cent of patients in serious condition requiring admittance to a longer-term bed in the hospital waited more than 24 hours.
This is three times the provincial target.
The hospital recently got $400,000 for a study and is looking to improve.
"We are experiencing some difficulties in the emergency room," hospital chief executive officer Marc LeBoutillier admitted in a panel interview with The Review and key hospital staff earlier this month. "But we're not the only hospital."
When compared to hospitals elsewhere in the province, particularly in the north, Hawkesbury fares quite well. However, in the Champlain Local Health Integration Network, which stretches as far west as Deep River, Hawkesbury had the second worst wait times in March. Only Pembroke surpassed it, with wait times three hours longer for patients with the same requirements.
Data compiled by the province pegs Hawkesbury's wait times for serious conditions far above the provincial eight-hour target, and even above the higher provincial average.
The times include treatment and waiting to be discharged, transferred to another facility or moved to a longer-term bed elsewhere in the hospital.
All statistics depict the maximum time 90 per cent of patients spend in the emergency room. The remaining 10 per cent of patients experience longer times.

A sign of the times

Hawkesbury's wait times for complex conditions requiring admission to an inpatient bed have surpassed 23 hours for 10 per cent of patients since April 2008.
From January to March 2009, times for these patients have increased to 24.8 hours.
Wait times for 10 per cent of patients with minor conditions not requiring admittance to a bed have been about seven hours since April 2008. The wait times for these patients in March 2009 were over 7.4 hours. The provincial target is four hours.

"Our staff is very conscious of the gap between community expectations and current capacity to deliver," LeBoutillier said. "We understand that wait times have an impact on patients."

Flow

According to Hawkesbury General Hospital's VP of Nursing Marielle Heuvelmans, who was also part of the panel, the movement of patients through the hospital from check in through treatment to discharge or transfer is a major contributing factor to long wait times.
"The wait times are, from a patient flow perspective, dependent on needs like diagnostic imaging, lab work or waiting for an inpatient bed," Heuvelmans explained.
Heuvelmans used the example of a patient occupying a bed in the hospital without actually needing further medical treatment to identify where logjams can occur.
"That bed may be occupied by an elderly person or a person that no longer medically needs to be there, but can't get a bed right away in a long-term care facility," she said.
That person won't simply be discharged, however. They would need to stay in the hospital bed until they are transferred.
"If you're a patient in the emergency department and you need to be admitted to the hospital, you need to wait in the emergency department for that bed," Heuvelmans said.
Meanwhile, flow in the emergency room itself is a contributing factor.

Turn up the volume

Dr. Remi Chehade, head of the emergency room, said the high volume of patients being admitted to the emergency room - often due to a shortage of family doctors and a lack of medical clinics - contributes to longer wait times.
"Over the past few years, we've tried to address that by having an overlap physician... so we have a backup," he said.
In March 2009 the Hawkesbury hospital had 2,161 emergency room visits.
The Glengarry Memorial Hospital, meanwhile, had 2,125 emergency room visits - a one per cent difference.
Where Hawkesbury's 90th percentile wait times were 24.8 hours (complex) and 8.2 hours (minor), Glengarry's were 11.6 hours and 2.8 hours.

First contact

"When somebody asks you, ‘How long is my wait time?' it is very difficult to say because you may have two or three ambulances coming in at that time," Heuvelmans said. "That changes everybody's wait times because it's not first-come-first-served."
Upon arriving at the hospital, whether by ambulance or not, a patient's first point of contact is not a medical professional.
A clerk first takes pertinent details and documents like a health card and a hospital card.
The patient then waits in the emergency room until a triage nurse can identify their CTAS level. CTAS is a standardized government code used to rank patients based on their needs - with CTAS 1 being the most urgent and CTAS 5 being the least urgent.
Heuvelmans said it rarely takes longer than 15 to 20 minutes between the time a patient checks in and the time they are assessed by a triage nurse.
While the hospital is looking at making nurses the first point of contact, triage appears to have very little impact on emergency room wait times.
CTAS, however, does.
Chehade said a hospital isn't like a supermarket or bank where when it is busy "they have more tellers working."
"Medicine doesn't work that way," he said. "If you have a robber a few people ahead of you at the bank, you're going to wait longer. It's the same thing at a hospital. If there's a patient who is very sick, he's indirectly robbing the resources so you're going to wait longer."
However, according to some patients have recently complained of long wait times in Hawkesbury, the triage system doesn't always work as intended.
In one case, a family contacted The Review and explained of a young boy with a broken arm who waited a number of hours before finally being transferred to the Children's Hospital of Eastern Ontario.
"In this case," explained Chehade, "what needs to be looked at is the time to triage - the time between when the patient registers and the time when the nurse at triage sees the patient."

Emergency room review

"Volumes and wait times are fluctuating in the emergency department so there is a level of unpredictability," LeBoutillier said. "Our goal here ... is to make sure everything we have control over gets improved."
The Hawkesbury hospital has received $400,000 in one-time funding to undertake a fundamental review of its emergency room.
"We have access to one-time funding ... to help us identify all the steps and all the delays, and how we might improve," LeBoutillier said.
This review could take up to nine months.
"It's not for tomorrow morning," he said. "We're working with the Champlain Local Health Integration Network and they're requiring a 10 per cent reduction over the next six months."
The hospital is studying stopgap measures to reach that goal.

Remedies for maladies

Per current hospital policy, patients first see a clerk before seeing a triage nurse.
However, that is likely to change as the hospital undertakes its review.
"We are looking at triage as a first step," Heuvelmans said.
And with flow playing a major part in speeding up wait times, Heuvelmans said the hospital is "looking at making sure that flow happens in a way that is as expedient as possible."
This, she said, involves what hospitals call medical directives.
Directives are official permissions given to nurses.
"The triage nurse will have more responsibilities and scope of practice," Chehade said. "More authority to start the diagnostic process for the patient."
Currently, only a physician can send a patient for an x-ray, however nurses could be given that responsibility to expedite the process.
Meanwhile, the hospital is looking at transferring patients who no longer require medical care to their homes under the supervision of Community Care Access Centre (CCAC) staff until a bed in a long-term care or nursing home facility opens up.
This would free up beds at the Hawkesbury hospital when they're needed.
Heuvelmans said that at a very basic level, the hospital is simply trying to improve patient flow and having the "right person doing the right thing at the right time."
She said the review would also look at unnecessary practices and procedures patients might not require.
"Sometimes we do things we think are the right step, but when we really start analyzing it, we realize it might not be the best approach to take," she said. "We're going to look at it from ‘a' to ‘z'."

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Provincial target CTAS 1, CTAS 2: 8 hours

Provincial target CTAS 3 to 5: 4 hours

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ADMITTED PATIENTS

CTAS 1: no patients

CTAS 2: 63 patients, 11.4-hour median wait time, 90 per cent within 49.3 hours, 27 per cent of cases within provincial target

CTAS 3: 209 patients, 23.3-hour median wait time, 90 per cent within 58.5 hours, six per cent of cases within provincial target

CTAS 4: 70 patients, 25-hour median wait time, 90 per cent within 53.2 hours, one per cent of cases within provincial target

CTAS 5: no patients

NON-ADMITTED PATIENTS

CTAS 1: no patients

CTAS 2: 196 patients, 4.5-hour median wait time, 90 per cent within 20.5 hours, 70 per cent completed within provincial target

CTAS 3: 1,724 patients, 4-hour median wait time, 90 per cent within 14.5 hours, 72 per cent completed within provincial target

CTAS 4: 3,069 patients, 3.4-hour median wait time, 90 per cent within 7.8 hours, 59 per cent completed within provincial target

CTAS 5: 377 patients, 2.6-hour median wait time, 90 per cent within 6.2 hours, 72 per cent completed within provincial target

Legend:

CTAS 1 = Major cases, ie: cardiac arrest, shock, major trauma

CTAS 2 = Life threatening conditions, ie: head injury, chest pain, gastrointestinal bleeding

CTAS 3 = Urgent care, ie: moderate trauma, asthma and cases that could progress to serious problem

CTAS 4 = Less urgent care, ie: age-related problems, distress, earaches, urinary symptoms

CTAS 5 = Minor cases, ie: sore throat, conditions related to chronic problems, cases that can be transferred elsewhere with no riskMEDIAN = 50 per cent of cases below value, 50 per cent of cases above value

Hawkesbury hospital staffing figures

14 doctors in the emergency department (4 full-time, 10 part-time)
30 active physicians in the hospital
30 more physicians with consulting/visiting privileges
An unstated number of nurses
470 staff members, including administrative staff but excluding physicians