Ontario Invests $109 Million for ER Wait Times & EMS Delays

As previously reported EMS has been in a no win situation in Ontario (and many other jurisdictions) when arriving at the emergency room. The ER refuses to accept the patient and EMS cannot abandon them. The Ontario government has announced $4.5 million targeted for dedicated nurses to accept patients who arrive by ambulance to ease the EMS pain.

To minimize ER overcrowding money is also being targeted at alternate level care (ALC) to allow chronic care patients in the emergency room to be transferred out and minor injury patients to seek primary care elsewhere.

Ontario's $109 million investment includes:

• $39.5 Million for a Performance Fund targeting Ontario's 23 poorest performing emergency rooms, IT enhancements and coaching teams to enhance hospital efficiency
• $38.5 million for increased home care personal support and homemaking services and enhanced integration between hospitals and Community Care Access Centres
• $22 million in new priority funding for Ontario's 14 Local Health Integration Networks (LHINs) to invest in local solutions to further address ALC pressures
• $4.5 million for dedicated nurses to care for patients who arrive at ERs by ambulance to ease ambulance offload delays
• $4.5 million for new nurse-led outreach teams to provide more care to patients in long-term care homes to avoid transfers to the ER

According to survey studies by ICES scientist Dr. Michael Schull , chronic patients occupying ER beds waiting for ALC are a major cause of ER overcrowding. Interestingly, emergency room physician and nursing staffing had been previously identified as potential causes of overcrowding but this does not seem to feature predominantly in current research or funding.

I was left wondering whether overcrowding correlates strongly to ER wait times, since most ED patients are never admitted. As we found in our own office, more space does not necessarily equate to lower wait times but it is a good first step. Regardless, rather than penalizing hospitals that perform poorly the government is targeting additional funding towards them and offering expert assistance in streamlining patient flow.

Ambulance Delays Continue

If you live in London, Ontario your 911 call may go unattended by ambulance because they've been drafted by the local emergency department. In a follow-up to my previous post about 911 wait times here's an article where the head of EMS reports 19/19 ambulances have been waiting in the ED to transfer patients. As I said before, there's no winner in this situation. The patient, the ED and the ambulance service are all in a bad place. Legislation needs to be passed to protect the hospital and let them accept patients without fear of litigation or persecution from their regulatory colleges. In the mean time, London needs to staff the ED with ambulance attendents.

EMS in No Win Situation

In a classic no win situation EMS in Edmonton have been forced to station personal at local emergency rooms to care for patients during times of high call volume. In case, you the reader, have not heard of this problem before, EMS will bring patients into the ER during times of high call volume only to find that the emergency will not accept them because it's not safe to do so. In other words, there is not enough beds, space or nurses to accept the patient so the EMS crew can be left waiting for minutes to hours with the patient on the gurney.

With EMS crews tied up in the ER the result is delays to 911 calls and longer response times. In the case of Edmonton they spent only 92 minutes per day with high response times a year ago which ballooned to 4.5 hours this year. Rather than try and change the ER departments, they put crews in the ER to allow the ambulances to get back on the road.

Between 1997-2001 I helped organize the medical teams for the Caribana Parade in Toronto (a retrospective review of the event can be found here). Because of the crowds, EMS response times would quickly become horrific because it took so long for ambulances to get too and from hospitals. To rectify the problem we put a medical tent on site (with excellent effect). It improved service for the patients, relieved the load on the EMS system (because each ambulance could respond to many more calls) and was a blast to work at.

In Edmonton, it's a similar problem except that the slow turn-around for ambulances is because of the delay at the ER. My opinion on this? Congratulations to the EMS chief that had the guts to put crews at the hospital. I suspect passing the patient from one EMS crew to another (especially in an ER) is not without it's legal liability but they're looking at the greater good and doing the best they can with the system. As for the emerg departments, I cannot find fault. To accept a patient that you know you can't monitor carries great risk. On the one hand, they've now transferred the burden of slow response times to the EMS service but on the other hand EMS usually has a greater pool to call on in dire situations (such as neighbouring ambulances and other first responders).

The government could act decisively in this situation with staffing for this specific situation or legislation to protect the ER personnel that accept the patient in a bad situation. Having the staffing, physical space and legal protection to create a non-ambulatory triage area would go a long way to allow ER departments to accept these patients during busy times. The long term answer, unfortunately, is greater long-term beds to get chronic care patients out of the emergency. And that will not be a quick fix. In the mean time, someone from the government needs to look to a better solution other than creating a virtual ambulance in the emergency department.