Chapter 3: ED Categorization, Quality, and Standards
Introduction
Reliable, accountable, and coordinated Emergency Departments (EDs) are essential nodes in a high-performance network of emergency care. More importantly, emergency care systems (ECSs) are an essential part of Quintuple Aim (value-based) healthcare systems. This is the future Canadians deserve and expect, and proper system design contributes towards that goal.
Across the world, this has not always been the case. In 1966, the American College of Surgeons Committee on Trauma published an important document titled Regional Trauma Systems: Optimal Elements, Integration and Assessment Guide. (1) In it, the authors wrote: “the human suffering and loss from preventable accidental death constitute a public health problem second only to the ravages of plagues and world wars” and that the public was “largely insensitive to the magnitude of the problem.”
They went on to say that the development of a mechanism for categorization, inspection, and accreditation of emergency departments on a continuing basis must become a minimum standard in modern healthcare systems. Similar recommendations followed in the service of better cardiac, medical/critical, and pediatric care. These reports helped drive the emergence of a new specialty—emergency medicine.
The Case for Categorization (2)
Why should EDs be categorized? The staffing, training, and services available in small rural EDs are clearly very different from those in a downtown urban emergency department, but from the public’s point of view, they both have the same name. The potential benefits of a national ED categorization scheme include:
Informing public knowledge, expectations, and use of the system
Standardizing a health authority or ministry’s responsibility to support the required equipment, medication, and personnel readiness
Benchmarking quality and performance targets across similar EDs in Canada, and
Informing a more intentional approach to emergency physician resource planning (covered in more detail in Chapter 6).
A call for categorization was also issued by the US Institutes of Medicine Future of Emergency Care 2006 series, (3,4) and the Society of Academic Emergency Medicine’s 2010 Consensus Conference, Beyond Regionalization: Integrated Networks of Emergency Care. (5) Initial approaches to regionalization improved care in some disease-specific areas, such as trauma. (6) However, regionalization isn’t the same as integration, (7,8) and doesn’t always mean one-way movement of patients to centralized resources. (9) Geographically-organized governance and financial structures in Canada should not be conflated with coordinated, accountable, and responsive care at a population-based, system level.
How far have we come with categorization? And are we starting to slip backwards? Despite the calls for a categorization and designation scheme, or a Regionalism 2.0 approach, (9) little has been done in this country around a common national framework for emergency departments. Different provinces have used different classification schemes, and some provinces have used none. Emergency care systems have evolved organically, and mostly follow population-weighted distances as a guide when building and resourcing EDs, although political expediency has played a role. Do we have too many EDs? Do we have too few? Are they optimally distributed? Can the public be sure that what’s called an ED can fulfill its mission? (10)
To be fair, when categorization has been attempted, most provincial approaches have been broadly similar. While there will always be some variation due to local and/or province-specific contexts, a plain-language and common-sense national framework to guide ED categorization is a critical step in moving towards integrated networks of emergency care in the future. (9)
Canadians expect to understand and trust what they are getting when terms like emergency department are used. Moving forward—if they don’t already exist—emergency care clinical networks (ECCN) (11) or the equivalent should be established in every province/region to lead and coordinate clinical services and HHR planning, as well as to oversee operational decision-making, and quality improvement/patient safety (QIPS) initiatives.
ED Categorization
The International Federation of Emergency Medicine (IFEM) terminology project defines an ED as: “The area of a medical facility devoted to provision of an organized system of emergency medical care that’s staffed by emergency medicine specialist physicians and/or emergency physicians, and has the basic resources to resuscitate, diagnose and treat patients with medical emergencies.” (12)
It is not feasible—nor is it fiscally reasonable—to maintain a tertiary care hospital in every community in Canada. As the medical ethicist Norman Daniels has said, “The social goods we often must provide including… healthcare…aren’t sufficiently divisible to avoid unequal or lumpy distributions—allocation decisions are necessarily messy.” (13) That said, optimizing the number, distribution, and capability of EDs must be made as non-lumpy as possible. A layered, balanced, and integrated approach is important in the clinical services planning of any region or province.
Categorizing EDs is an essential part of that strategy. One model that should be used as a starting point is a simple four-level approach to EDs: Comprehensive, Advanced, Full, and Basic (14) (see Figure 11). Reasonable subdivisions of categories may also be useful, such as a Level 1 Pediatric ED, or a Level 3 Freestanding ED. (14)
Figure 11. Recommended Levels of Emergency Department (ED) Service Categorization
Clinical Services Planning and integrated Health Human resource planning, as well as the EMS system status plan (SSP) and broader system integration issues, requires a rational and intentional approach to ED categorization and standards, as recommended here. To be clear, in this context a Basic level 4 ED still must meet the baseline standards of in-person teams/physician-led resuscitation and stabilization of the acutely ill and injured, they must stay on the EMS SSP, and they must be capable of the initial assessment and treatment of the broad spectrum of unexpected illness and injury in all age groups. If these standards are not met, they should no longer be referred to as an Emergency Department.
A plain language four-level categorization taxonomy should be used (see Figure 11 and specific recommendations below) to help guide clinical services planning. These levels should be Figure 10 determined/assigned by population-weighted distance calculations and be guided by the function they are expected to fulfill in the system. Specific details about the standards expected at each level could vary slightly by province, but general principles need to be set at the national level. Once assigned, the Ministry of Health (MoH) and Health Authority (HA) must adequately fund and support the ED site to meet this function.
EDs must meet the standards consistent with their level of designation. If a hospital posts signage using the term “Emergency Department,” the public expectation, at a minimum, is that the ED—no matter its level—is capable of the assessment and treatment of unexpected, undifferentiated, and time-sensitive illness and injury. The additional assumption is that its staff have the competencies for the resuscitation, stabilization, and transfer out, if necessary, of any patient that arrives, either by ambulance or as a direct walk-in.
Network-Integrated Urgent Care Centres
The role of Urgent Care Centres (UCCs) is expanding rapidly across Canada. (15) Like EDs, the capabilities of UCCs span a wide spectrum, and their clinical services may potentially overlap. Over the last 20 years, these centres have become integral to several urban acute care systems. In metropolitan Calgary, for example, five urban and suburban UCCs annually service approximately 180,000 patient visits, in addition to the approximately 440,000 visits seen by the five adult and children’s hospitals. Similar high-volume UCCs operate in Vancouver, Hamilton, Kingston, and London, and more are developing in many other locations, including Saskatoon, Halifax, Toronto, Montreal, and Ottawa.
While there are currently no nationally-established standards, UCCs typically have the following characteristics: in urban areas they are located outside of hospitals, provide unscheduled care, do not necessarily operate 24/7, and offer a spectrum of services focusing on acute/unscheduled illness and injury of urgent but not emergent need. In most cases UCCs come off the EMS system status plan, and do not receive ambulances. They do provide on-site labs and imaging, medications, and multidisciplinary care. (16,17)
Urgent Care Centres can also be established in rural areas, physically located within hospitals. Again, they are geared towards unexpected/time-dependent illness and injury in the CTAS (Canadian Triage and Acuity Scale) 3-5 range, but not for the more severe CTAS 1,2 patients.
To be clear, the recommendations for UCCs in this categorization framework include:
They must be operated by hospital corporations or regional health authorities, and therefore have some formal relationship to a nearby hospital and ED.
They must also be integrated with regional clinical services plans and Continuous Quality Improvement (CQI) programs.
This integration is to differentiate them from privately-owned and operated transactional retail clinics that exist on the spectrum which range from walk-in clinics to direct-to-patient virtual ERs.
While “Urgent Care” from a public perception allows it to remain distinct from EDs, the Canadian experience demonstrates that their utility and impact on the delivery of acute care here is complementary. Because of this, we believe that clear standards must exist for the structure, processes, equipment, and provider competencies for Network-integrated Urgent Care Centres, just as they must when we categorize emergency departments.
Peer-To-Peer Virtual Care
Peer-to-peer virtual care will play an increasingly important role in the evolving design of emergency care systems. In the context of categorization definitions, peer-to-peer programs, like RUDi (Rural Urgent Doctors in-aid) (18) in BC and TRON (19) (the critical care rural support program in Ontario), can fulfill a crucial function for a site to maintain its designation as an ED. They could also strategically become a Network-integrated Urgent Care Centre, local out-patients department, or nursing station.
Designation and categorization of EDs in an integrated network of Emergency Care is only the first step. Concurrently, ED standards must be associated with each level. Chapter 5 addresses the even more important issue of integration, examining how the various network nodes and access points to the Emergency Care system interface, connect, and transition patients through their journey across the broader healthcare system.
Pediatric and Geriatric Considerations
The ethos of emergency medicine is its readiness to care for anybody from 0 to 100+ years of age. However, two cohorts that require special consideration are the care of children, and the care of elders within our system. Some of this readiness is embedded in the general system design and integration principles discussed further in this section, and some are specific to pediatrics and geriatrics (see Appendices 3 and 4 at the end of this report).
More children in Canada receive their emergency care in EDs associated with general hospitals than in urban tertiary care pediatric emergency departments. Pediatric emergency care systems have been early adopters in creating integrated networks of care through EMS transport connections, and peer-to-peer telemedicine supports. TREKK (20) is a freely-available collection of online resources for front line providers who are caring for ill and injured children. The network demonstrates the power of national projects to effectively support the real-time, clinical decision-making that takes place across the country. These approaches should be funded and strengthened in the future. Additionally, emphasis should be given to provide more and better pediatric emergency care training experiences for learners, as well as the maintenance of competence opportunities to improve the proficiencies of all types of emergency care providers (paramedics, nurses, physicians, etc.).
The evolving demographics of our Canadian population are well known. We are now on the leading edge of a significant rise in the number of elderly patients who will need medical and emergency care services. This increases the necessity to develop and support multi-disciplinary healthcare homes that are closely integrated with home and community care options and have mobile and virtual connections if needed (see System Integration, Chapter 5). Improved access to better quality long-term care is part of the equation, but only after all home and community care options have been exhausted. Emergency care systems will need to improve their approach to elder-friendly care spaces and options. In addition, geriatric competencies for all providers must be increased, with specific geriatrics clinical pathways and access to geriatricians when required.
ED Consolidation and Distribution: A Polarity Management Approach
Once categorized, where should EDs and Network-integrated Urgent Care Centres be placed to optimize care? Planning and implementing the number, distribution, capabilities, connections, and workforce in an integrated network of care will require an approach that balances issues viewed to conflict with each other. Polarity management is used to solve unsolvable problems when solutions on each end of the spectrum have trade-offs. Closing or relocating EDs are examples of this type of tension; potential trade-offs are ever-present, and there will always be some degree of tension around these network system decisions.
illustrates these pressures and the various trade-offs in access, quality, and costs when the optimal geographic distribution of emergency care access points is under consideration. Using this framework to evaluate an existing system can fuel the creative energy for change. It’s essential for provincial emergency care clinical networks (ECCNs) to monitor, evaluate, and modify these trade-off decisions over time to evaluate whether they’re ultimately improving patient outcomes in a cost-effective manner — i.e., are they consistent with a value-based healthcare system? (10,21)
ED Access And Quality: A Polarity Management Approach
Media coverage on delays in access to emergency care has dominated the news headlines for over a decade and highlights a major problem. Demand for care in Canadian emergency departments has far outpaced the growth in population, leading to stress in the system and societal expectations that cannot be met. The immense public and political interest are often singularly focused on wait times. This relentless focus on a single dimension of quality may force decision-makers, individual healthcare providers, and payers to ignore other important elements of safe care. Over time it additionally has the potential to degrade the quality of treatment provided in the ED.
In their updated position paper on quality and safety in emergency medicine, (12) IFEM wrote that on arriving in an ED, patients should expect that their care will be provided by the right personnel, making the right decisions, following the right processes and approaches, in the right environment, in the right place, in the right system, with the right support. They go on to say that in countries like Canada, where emergency medicine is established, patients should also expect early and reliable access, as well as support from specialist in-patient, out-patient services, and critical care expertise. Appropriate durations of stay in the ED should be expected, together with the development of related EM services, such as short stay/observation pathways, social and mental health services, and options for outpatient follow-up.
IFEM also describes five enablers and barriers to quality care in the ED:
ED staff: are they trained, qualified, and motivated to deliver effective and efficient care in keeping with national guidelines?
Physical structures: is there the appropriate size and numbers of treatment rooms/areas, and triage, and waiting space? Are there fail-proof equipment, well-stocked consumables, and IT systems (with back-up)?
ED processes; are there validated triage systems, access to clinical practice guidelines, and appropriate policies and procedures?
Systems approach; are there coordinated and accountable pathways prior to, during, and after their ED care, and are they seamlessly integrated and appropriately resourced?
Monitoring outcomes; is there an appropriate gathering of, synthesizing, and interpreting of data, especially patient-oriented outcome data? And how is that data feeding back into the iterative improvement of value in a Learning Health System? (12)
Six Dimensions of Quality in Healthcare
The Institute of Medicine states that the quality of care is the “degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” The Institute goes on to define the dimensions of quality as being safe, effective, patient-centred, timely, efficient, and equitable. Hansen et al (12) suggest several potential quality indicators for the ED system, mapped to each dimension in Table 2.
Table 2. From Hansen et al. (12) suggested indicators for EDs, grouped within structure, process, and outcome to address the six Institute of Medicine domains of high-quality care. Canadian citizens deserve and expect emergency care that’s successful in all the dimensions of quality.
Data and Quality Care Indicators
It is common to use data to determine improved outcomes, cost effectiveness, accountability, safety or even satisfaction in the care provided. Information is collected in a variety of ways throughout the system. This includes reviews of patient medical charts, use of large databases, findings from local quality or patient safety meetings, patient feedback files, safety event reporting, accreditation surveys and patient registries. (22) These metrics provide a window into the quality of healthcare delivery and must be chosen carefully.
Alarmingly, most provinces in Canada monitor only markers of timely care, with reports expressed as averages or percentiles. Metrics such as “Initial Time to Physician Assessment”, “Overall ED Length of Stay” and “Ambulance Offload Time” dominate reports. Although these time markers give some information about patient movement through the system, they do not provide any insight into other aspects of quality. There are some audits on outcomes or adherence to guidelines at the individual hospital or regional levels, but no national repository of data or benchmarks for much of it. This is a major problem in planning and evaluating emergency care in Canada.
Standards
Standards are essential to maintain public trust, and to guide future policy direction and resource allocation decisions. In business, standards can refer to goods, services, and systems; they ensure safety, quality, and consistency which are fundamental to trade. In healthcare they play the same role and are fundamental to quality care. Without standards and definitions, rules become fuzzy, health system redesign becomes sketchy, and public trust can be undermined. Innovation and creativity can push the resistance of a conservative or stuck system, but there must be an ongoing commitment to do no harm, and to improve value in the system where value = quality/cost.(23)
Standards establish minimum levels of performance and consistency across multiple individuals and/or organizations. Minimum standards for hospitals and health authorities are the jurisdiction of Accreditation Canada, but the specific standards around EDs—and more broadly emergency care systems—are not well defined.
Other countries, such as the UK, have invested in creating baseline standards in emergency and urgent care, though many are still narrowly focused on time-based measures. (24,25) The Australasian College of Emergency Medicine has defined national minimum standards on cultural safety, clinical care pathways, administration, professionalism, education/training, and quality improvement. (26) CAEP’s essential next step is to lead a uniform approach to EM standards for emergency departments and emergency care systems across Canada.
Availability of Curated Standards for Good Practice
The publication of evidence-based tools is commonplace across the country, which may be in the form of clinical practice guidelines (CPGs) or standardized order sets. In British Columbia and Alberta, this work is coordinated on a provincial basis through their ECCNs, (11) where clinical guidelines are available in an easily accessible website. (27) Many other Canadian provinces have created similar repositories or toolkits that are available on local IT infrastructure throughout their region. CAEP also has several guidelines to help direct care. The Translating Knowledge for Kids (TREKK) resource regularly publishes best practice guidelines in emergency care for children, and this is used from one end of the country to the other.
Conclusion
The discipline of emergency medicine is now seriously challenged by the stressors of a supply/demand mismatch in the rest of the healthcare system. The creation of national standards that define acceptable benchmarks for access to and quality of care is an essential next step in ensuring accountability for everyone, from front-line providers to executive-level decision-makers.
Optimizing the number, distribution, capabilities, connections, and workforce in an integrated network of care will require an intentional approach to categorizing EDs, as well as other potential access points to the emergency care system, such as Network-integrated Urgent Care Centres and virtual care.
Access is just one side of the coin; quality and standards are the other. The ethos of quality improvement is embedded in the core values of emergency medicine. (28) It is time to develop and implement a better systems approach (4,29) to emergency care in Canada that balances the best aspects of consolidation and distribution, with additional assurances that quality is not compromised in the quest for access.
Recommendations for ED Categorization, Quality, and Standards
Provincial health ministries should establish Emergency Care Clinical Networks (ECCNs) to coordinate clinical service and HR planning, operational guidance, and quality improvement-patient safety initiatives.
A National Emergency Clinical Care Council (NECCC) should be created; endorsed by CAEP, supported by the federal government (secretariate, administration, travel, integration with CIHR etc.), and given a mandate by the Council of Provincial Deputy Ministers of Health to support the EM:POWER recommendations at the provincial level through national collaborations, benchmarking, and sharing of successes, innovations, and lessons learned.
Provincial ministries of health and/or health authorities should fund and enable these provincial ECCNs and integrate them with the broader healthcare system governance structure.
Emergency physicians, ideally in a co-lead dyad, should provide leadership to these ECCNs and be given a seat at the appropriate decision-making tables.
ECCNs should oversee categorization, standardization (facilities, equipment, required competencies) and integration of EDs and other emergency care access points.
A plain-language four-level categorization taxonomy should be used to help guide clinical services planning:
Level 1 ED = comprehensive services associated with large tertiary care hospital
Level 2 ED = advanced services associated with other large urban or regional hospitals
Level 3 ED = full services associated with community general hospital
Level 4 ED = basic services associated with small rural hospital.
These levels should be determined/assigned by population weighted distance calculations, annual volumes, and be modified by the function the ED is expected to fulfill in the system. Once assigned, the MoH/HA must adequately fund and support each ED site to meet this required function. EDs must meet the standards consistent with their level of designation.
Network-integrated Urgent Care Centres and Network-integrated peer-to-peer Virtual Care (P2PVC) in this context means that these access points to the Emergency Care system must be designed, integrated, and held to the same quality improvement patient safety standards as EDs (one network, many access points).
CAEP/NECCC should create a national template and example standards for provinces to adopt in the domains of physical space, safety, equipment, DI/lab availability, medication availability, staffing numbers, competencies, professionalism, and transitions of care pathways.
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