Michael Schull ICES Report Benchmarking Patient Delays in Ontario’s Emergency Departments: What Are We Waiting For? T he problem of prolonged patient wait times in Ontario emergency departments (ED) has, once again, become front-page news. Renewed interest stems largely from two factors. The first concerns reports of lengthy delays occurring before the unloading of ambulance patients in crowded EDs (Gray 2005); the second is a high-profile coroner’s case of a young woman who died after leaving an ED when she was informed she would have to wait eight hours to see a physi- cian (Blatchford 2005; Ontario Emergency 2005). The most common reason for prolonged waits is fully occupied ED stretchers; thus there is a lack of places for medical staff to receive new patients. In general, the most acutely ill patients experience longer total wait times (regis- tration to discharge), a result of more intensive levels of assessment, investigation and treatment than that required by less urgent patients. Paradoxically, these patients may also wait longer for initial physician assessment than patients with minor illnesses or injuries. The reason is that the ED areas serving them are more likely to be filled with other patients undergoing assessments and treatments, or waiting for an inpatient bed. As shown in Table 1, 90% of ED patients in the “urgent” category receive physician assessments within 2.9 hours – 47 minutes longer than patients with non-urgent problems, and the longest wait duration of the five triage acuity categories. Total wait times in EDs vary substantially throughout Local Health Integration Networks (LHINs) in Ontario (see Figure 1). Compared to a provincial average of 6.6 hours (within which 90% of patients are seen), there is a 2.6-fold difference between the fastest-performing LHIN, at 4.2 hours (South West), to the slowest- performing LHIN, at 11.2 hours (Toronto Central). Such wide variation needs to be considered in the context of local differences among LHINs such as patient case-mix, availability of inpatient beds and existing alternatives to EDs for care of patients with minor complaints. Various solutions to the ED wait problem have been proposed, including increasing inpatient bed capacity, increasing ED physical space, speeding up test turnaround times and reducing patient inflow by diverting patients with minor illnesses or injuries elsewhere for care. In the right context, all of these initiatives might work to reduce wait- times for some patients. However, solutions must be tailored to resolve predominant local causes of wait times, as it is unlikely that a “one size fits all” remedy is the answer. So where do we go from here? One way forward is to examine the approaches of other jurisdictions that have successfully reduced ED wait times. The best-documented example is the National Health Service (NHS) in the UK, where dramatic reductions in ED wait times were achieved following the adoption, in 2001, of a country-wide target of four hours or less total wait-time for 98% of ED patients (Alberti 2005). In 2005, the NHS reported that less than 4% of ED patients spend more than four hours in an ED (Alberti 2005), compared to about 23% in Ontario and about 28% in the US (McCaig and Burt 2004). Table 1. Time to First Physician Assessment and Total Wait Time after Patient Registration in an ED, by Triage Acuity Level, in Ontario, 2003–2004 Triage acuity level* Time to first Total wait-time† physician assessment (90th percentile, hours) (90th percentile, hours) Resuscitation 0.6 8.7 Emergent 2.0 10.3 Urgent 2.9 8.4 Less urgent 2.6 4.7 Non-urgent 2.1 3.2 *Canadian Triage and Acuity Scale assigned when patient registers. †Time from patient registration to discharge from ED. Data source: Canadian Institute for Health Information – National Ambulatory Care Reporting System. Figure 1. Total Wait Time (Registration to Discharge) Within Which 90% of Patients are Treated in Ontario EDs, by Local Health Integration Network, 2003–2004 Data source: Canadian Institute for Health Information – National Ambulatory Care Reporting System. Provincial average Southwest Northeast Northwest Erie St. Clair North Simcoe Muskoka Waterloo Wellington Champlain Central East Southeast Hamilton Niagara Haldimand Brant Central West Mississauga Oakville Central Toronto Central 2.0 0.0 4.0 6.0 8.0 10.0 12.0 H EALTHCARE Q UARTERLY V OL . 8 N O. 3 • 2005 | 21