Chapter 2: What Have Emergency Departments Become and What Should They Be?
Watch the news and you’ll see that emergency departments (EDs) are failing. They’re often closed because of physician or nursing shortages, and when open, they’re overwhelmed with packed waiting rooms, ambulances that can’t unload, interminable delays to care, and waiting room disasters.
Appropriate care means the right care in the right place, but the ED is the wrong place for most patients. EDs are designed for 1–6-hour encounters; emergency teams are trained and equipped for acute problems and life-limb threats. We don’t provide quality inpatient care, intensive care, mental health intervention, chronic disease management, rehabilitation services, or primary/preventive healthcare, but these roles consume substantial ED resources.
Even when emergency care is complete, unfortunate patients who need hospitalization will face many more hours—sometimes days—in the ED before an inpatient bed becomes available. It’s unacceptable and detrimental to patient outcomes to leave frail or acutely ill patients on hard narrow stretchers in noisy crowded rooms where the lights never go out, without privacy, sleep, or bathroom access while they wait hours or days for a hospital bed. Providing the wrong care in the wrong place increases system cost, decreases care quality, and creates chaotic work environments that burn out ED staff. [7] Worse, it compromises the ability of EDs to provide the care they were intended to provide. [4]
Emergency leaders will tell you that EDs have been getting worse for 25 years, and that none of the solutions have worked. Governments have spent hundreds of millions on urgent care centres for low acuity patients, primary care diversion strategies, telephone support lines, public campaigns to discourage ED visits, and even expanded emergency departments. But ED congestion just keeps getting worse.
Why? Because these solutions don’t address the actual causes.
Research shows that the unbridled demand facing EDs is not from too many non-urgent patients, but because of poor access to primary and specialty care, [5] a rising burden of unmanaged chronic disease and—most importantly–a lack of hospital beds for admitted patients. [6-8]
Canada’s Universal Contingency Plan
Canada performs poorly relative to other OECD countries in providing access to primary care, specialists, surgical procedures, and imaging. [6,7] When patients can not find a GP, see a specialist, or have an imaging study, they head for an ED. An Alberta Health Quality Council survey reported that 58% of patients attending the ED did so because it was the only place they could get care when they needed it. With poor access elsewhere, EDs are often the only option; consequently, Canada has the highest rate of ED use among wealthy countries with universal healthcare. [9] A Canadian Foundation for Healthcare Innovation report showed that ED visits are rising much faster than population growth, and without fundamental system change, they will grow an additional 40% in the next two decades. [10]
The emergency medicine credo is that every patient’s concern is important, and that patients cannot be turned away, regardless of their condition. The scope of practice in EDs has expanded well beyond emergent and urgent care. However, attempts to provide unconditional service to nearly everyone have left EDs failing to fulfill their core mission.
EDs are the first or only health access point for many people; [5] they are increasingly a destination for patients with complex and specialty health problems, [4,5] and a referral destination for difficult or marginalized patients who need integrated longitudinal care that should be available in the community. [5] They have become a primary staging area for acutely ill patients, for access to diagnostics, and for hospitalization decisions; all of these make ED practice increasingly complex. [5,11] With the shortage of hospital beds, diagnostic workups that used to require hospitalization are often conducted during an ED visit, and many EDs have developed observation units or long-stay pathways to prevent avoidable admissions.
Inpatient care has become the greatest challenge for emergency departments. Based on the number of admitted patients blocked in ED stretchers and the amount of inpatient care provided by ED nurses, the primary role of most urban EDs now isn’t to provide emergency care, but to serve as holding areas for inpatients awaiting a hospital bed. All these factors have aggravated the crowded conditions that compromise ED patient safety and outcomes. [11,12]
Public Health
ED expectations have expanded in many directions, which are all intuitively good. But they compete for care resources and provider time when emergency care capacity is already overwhelmed, and when EDs are often unable to provide timely emergent care for seriously ill patients. In addition to growing clinical care demands, many believe EDs should provide public health services. [13] The US Public Health Task Force has recommended that EDs conduct alcohol screening and intervention, HIV screening and referral, hypertension screening, pneumococcal vaccination, and smoking cessation counselling. [14]
EDs have a potentially important role as an early/sustained warning system for public health emergencies, including infectious disease outbreaks. Many or most EDs already screen for intimate partner violence, injury risk behaviour, influenza-like illnesses, safe drug use practices, and suicide risk. They frequently provide drug or alcohol counselling, initiate treatment for opioid addiction (opioid agonist therapy), disburse naloxone kits and clean needles, and connect patients to detox programs or targeted therapy. [15] They help patients who are struggling with homelessness and develop programs for frequent ED users. Emergency medicine advocates are now developing sub-specialty training in Social Emergency Medicine (SEM). These programs will develop better ED processes to systematically screen for health-related social needs, connect patients with external agencies, and initiate important community services. They will also develop strategies to reduce social inequity and provide resources that address the social determinants of health.
Figure 1. A Hierarchy of Emergency Care
Is Less More?
ED efforts to provide unlimited care have decreased the need for other programs to solve many of the access problems described above. This has enabled other providers to eschew care for unplanned illness and injury, limit off-hours work, avoid inconvenient disruptions in always busy days, and address countless patient needs with an almost magical directive: “Go to the emergency department.” [4] But can EDs fill the care gaps left by other programs and still provide timely, high-quality emergency care? The state of today’s EDs makes the answer a painfully obvious NO. [5]
The concept of the ED as healthcare’s universal contingency plan is flawed and dangerous. [4] Ever-increasing volumes, complexity, stress levels, and demands to deliver inpatient care, primary care, non-emergent care, and public health services have become unmanageable. In an ideal world, EDs would continue providing as much care as possible; but if they’re unable to accomplish their primary mission, it may be time to rethink “emergency,” [4] refocus on the core mission in keeping with the specialty’s original intent (Figure 1) and determine how to provide timely high-quality care for patients with acute unforeseen illness and injury.
However, if EDs must cut back, which populations and services should be downprioritized? Re-engineering ED services would require a rational approach that does not put patients at risk, moves care to the most appropriate location, and has some chance of success.
What is Emergency Medicine (EM)?
The Canadian Association of Emergency Physicians (CAEP) has defined EM as a unique set of competencies required for the timely evaluation, diagnosis, treatment, and disposition of patients with injury, illness and behavioural disorders that require expeditious care. [16] The International Federation for Emergency Medicine (IFEM) defines emergency medicine as a practice based on the knowledge and skills required for the prevention, diagnosis, and management of acute and urgent aspects of illness and injury with a full spectrum of undifferentiated physical and behavioural disorders. [17]
The American College of Emergency Physicians (ACEP) defines EM as a specialty dedicated to the diagnosis and treatment of unforeseen illness or injury that includes the initial evaluation, diagnosis, treatment, and disposition patients requiring expeditious medical, surgical, or psychiatric care. [18] These organizations also state that EM incorporates an understanding of hospital and pre-hospital emergency care systems, and provides readiness for large-scale health emergencies, ranging from local multiple casualty incidents to large-scale pandemics and disasters. All these definitions emphasize acute, unforeseen illness and injury, and this focus has determined the content of EM training programs (to be discussed later in this document).
What About Acute, Less Urgent Care?
Many policymakers believe emergency departments should deprioritize or eliminate less urgent patients who fall into Canadian Triage and Acuity Scale (CTAS) levels 4-5. This belief has led to diversion initiatives to offload EDs, like telephone advice lines and urgent care centres (UCCs). Both provide patients with an alternate care option, but neither have reduced ED volumes or improved emergency care access. [19] Instead, they’ve resulted in an unintended consequence and present a rarely-discussed potential downside: telephone advice lines have provided thousands of nurses the opportunity to move out of direct patient care during a time of profound staffing shortages. And while UCCs do not decompress EDs, they do draw patients and physicians away from primary care. This raises the possibility that these innovations may, in fact, reduce access to the most important and threatened type of care in the system.
The Theory of Constraints
In EDs, emergent care trumps less urgent care, but if the goal is to improve emergency access, low-acuity patients are the wrong population to eliminate. All EM organizational definitions specify that unforeseen low-acuity conditions—particularly injuries—are EM core competencies, and these less urgent patients often require hospital-based diagnostics and expertise. [20,21] Contrary to popular belief, less urgent patients aren’t a significant cause of emergency access block; [21] the reason for this is logical but rarely understood.
The ED’s functional unit and critical resource is the nurse-staffed-stretcher, which is also the primary emergency department constraint (bottleneck). Operations management theory tells us that to maintain flow and reduce care delays, we must increase bottleneck resources (e.g., nurse-staffed stretchers) or unload bottleneck servers (decrease the number of patients placed on stretchers). Diverting low acuity patients away from EDs accomplishes neither, because these patients do not occupy nurse-staffed stretchers. Sadly, ignoring the bottleneck and spending time and money fixing unrelated issues like low acuity patients has not succeeded, and will not succeed in the future. [22]
Less urgent patients also serve an essential function in most emergency departments. Truly emergent cases, our raison d’etre, comprise only a fraction of ED inflow; but EDs must be staffed 24×365 to assure care is available when critical patients do arrive. Less acute patients are a queueable source of work, revenue, and clinical experience for physicians. They fill the gaps between emergencies and make ED staffing economically feasible. In addition, less-urgent care provides return on investment for the high fixed-costs of the department and offers valuable service to the community. Because less urgent patients do not need nurse-staffed stretchers, they do not compete for bottleneck care.
Physicians are a secondary bottleneck, and if the crisis of stretcher availability is solved, they will become the primary bottleneck and main cause of care delays. However, at least in urban settings, physicians are a less constrained resource because it is easier to add physicians than nurse-staffed stretchers. In addition, available physicians can be diverted from treating less-urgent patients when necessary. If we agree that physicians are an important ED bottleneck, the theory of constraints tells us to increase the number of physicians or reduce their workload as much as possible. [22] Less urgent patients who can be processed quickly aren’t a major problem, but complex patients who consume substantial physician time will make the bottleneck worse, and therefore become a priority for diversion to more appropriate care destinations, as illustrated in Table 1.
A decision matrix to identify patients who should or should not be prioritized for ED care might incorporate several factors. First, is the emergency department the right (most appropriate) place for the care in question, and was the ED designed and staffed for this type of care?
Second, does the care in question substantially strain ED bottleneck resources (nurse-staffed stretchers and ED physician time)? Finally, are there unique circumstances that make the ED the only place that can deliver this care? If so, then additional funding, redesign and staff training are probably necessary.
Table 1. Decision Matrix: Impact of ED Case Mix Groups on Bottleneck Resources
*The most appropriate ED activities include diagnosis and treatment of acute unforeseen illness or injury, initial evaluation, diagnosis, treatment, and disposition of patients with medical, surgical injury, illness and/or behavioural disorders that require expeditious care.
What Should an Emergency Department Be?
EDs and the services they offer will differ by location, based on community resources and needs. Rural departments differ from urban departments, and inner-city departments differ from community departments. Deprioritizing a non-emergent service does not mean the service should no longer be provided, but rather that external resources, funding, and expertise might be necessary so that the core mission is not compromised. An inner-city ED might, for example, add an adjacent, independently funded mental health addictions (MHA) unit with appropriate expertise, while a community ED might add a similarly-resourced unit focused on the optimal management of elderly patients in their region who are failing.
Recommendations: What Have Emergency Departments Become and What Should They Be?
EDs should prioritize emergent and urgent care based on the definitions above.
To do so, they should review their usage and identify non-emergent populations that have the greatest impact on their bottleneck resources, then negotiate or develop more appropriate alternative care options and pathways for these patients. Based on Table 1, top priority populations will include admitted patients waiting for inpatient beds, frail elderly patients (especially those requiring housing, placement, or complex chronic disease management), and patients with chronic mental health and addiction concerns.
References
Grant K. Canadian nurses are leaving in droves, worn down by 16 merciless months on the front lines of COVID-19. In: The Globe and Mail. 2021. https://www.theglobeandmail.com/canada/article- canadian-nurses-are-leaving-in-droves-worn-down-by-16-merciless-months/ Accessed 10 Mar 2023
Sutherland M, Ibrahim H. Oromocto hospital ER to CLOSE 6 hours earlier each day due to staff SHORTAGE | CBC News 2021; https://www.cbc.ca/news/canada/new-brunswick/overnight-er-closure-doctor-shortage-1.6073531#:~:text=’Serious’%20shortage%20of%20staff%20is,doctors’%20mental%20health%2C%20doctors%20say&text=Horizon%20Health%20Network%20will%20be,Tuesday%20because%20of%20staffing%20shortages. Accessed Sep 11, 2023
Lam P. Staff raise alarm Over ‘exceptionally dangerous’ wait times at St. Boniface Hospital | CBC News. In: CBCnews 2021. https://www.cbc.ca/news/canada/manitoba/16-hour-wait-time-st-boniface-hospital-staff-shortage-1.6135667. Accessed Sep 11, 2023
Atkinson P, George, Innes GD. Is less more? Can J Emerg Med 2023; 24:9-11
Morganti KG, Bauhoff S, Blanchard JC, et al. The Evolving Role of Emergency Departments in the United States. Santa Monica, CA: RAND Corporation, 2013. https://www.rand.org/pubs/research_reports/RR280.html. Accessed Sep 11, 2023
Canadian Institute for Health Information (CIHI). How Canada Compares: Results from the Commonwealth Fund 2016 International Health Policy Survey. Ottawa, ON; 2016. https://www.cihi.ca/sites/default/files/document/text-alternative-version-2016-cmwf-en-web.pdf. Accessed Sep 11, 2023
Berchet C. The Directorate for Employment, Labour and Social Affairs Health Committee of the Organisation for Economic Cooperation and Development (OECD). Emergency care services: Trends, drivers and interventions to manage the demand. 2015. https://www.oecd-ilibrary.org/emergency-care-services_5jrts344crns.pdf. Accessed Sep 11, 2023
Rowe BH, Bond K, Ospina MB, et al. Emergency department overcrowding in Canada: what are the issues and what can be done. Canadian Agency for Drugs and Technologies in Health. Technology overview. 2006.
Canadian Institute for Health Information (CIHI). How Canada Compares: Results from the Commonwealth Fund 2016 International Health Policy Survey. Ottawa, ON; 2016. https://www.cihi.ca/sites/default/files/document/text-alternative-version-2016-cmwf-en-web.pdf. Accessed Sep 11, 2023
Barr S, Campbell S, Flemons W et al. The Impact on Emergency Department Utilization of the CFHI Healthcare Collaborations and Initiatives: Report to the Canadian Foundation for Healthcare Improvement. 2013; pp. 2–44. https://www.cfhi-fcass.ca/docs/default-source/about-us/corporate-reports/risk-analytica.pdf?sfvrsn=f2ef76ab_2. Accessed Sep 11, 2023
Pitts SR, Pines JM, Handrigan MT, Kellermann AL. National trends in emergency department occupancy, 2001 to 2008: effect of inpatient admissions versus emergency department practice intensity. Ann Emerg Med. 2012 Dec;60(6):679-686.e3
Bernstein SL, Aronsky D, Duseja R, et al. Society for Academic Emergency Medicine, Emergency Department Crowding Task Force. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med. 2009;16:1-10.
Gordon JA, Billings J, Asplin BR, et al. Safety net research in emergency medicine. Proceedings of the Academic Emergency Medicine Consensus Conference on The Unraveling of the Safety Net. Acad Emerg Med 2001;8:1024–9.
Rhodes KV, Gordon JA, Lowe RA, for the SAEM Public Health Task Force. Clinical preventive services: are they relevant to emergency medicine? Acad Emerg Med 2000;7:1036–41.
Selby S, Wang D, Murray E, et al. Emergency Departments as the Health Safety Nets of Society: A Descriptive and Multicenter Analysis of Social Worker Support in the Emergency Room. Cureus. 2018 Sep 4;10(9):e3247. doi: 10.7759/cureus.3247. Accessed Sep 11, 2023
McEwen J, Borreman S, Caudle J, et al. Position Statement on Emergency Medicine Definitions from the Canadian Association of Emergency Physicians. Can J Emerg Med. 2018;20:501-506.
International Federation of Emergency Medicine. IFEM Definition of emergency medicine. Online 2012. Accessed Sep 11, 2023
Definition of Emergency Medicine. Approved January 2021. https://www.acep.org/globalassets/new-pdfs/policy-statements/definition-of-emergency-medicine.pdf. Accessed Sep 11, 2023
Lake R, Georgiou A, Li J, et al. The quality, safety and governance of telephone triage and advice services – an overview of evidence from systematic reviews. BMC Health Serv Res. 2017 Aug 30;17:614.
The Royal College of Physicians and Surgeons. Emergency Medicine Competencies. 2018 pp,1-20. file:///Users/grantinnes/Downloads/emergency-medecine-competencies-e.pdf. Accessed Sep 11, 2023
Schull MJ, Kiss A, Szalai JP. The effect of low-complexity patients on emergency department waiting times. Ann Emerg Med. 2007 Mar;49(3):257-64
Goldratt, Eliyahu M. (1990). Theory of Constraints. [Great Barrington, Massachusetts]: North River Press. ISBN 0-88427-166-8.