1. Proposed Actions To Improve Waiting
Times At The Emergency Room
In Nova Scotia Hospitals
HESA 4003 & HESA 4020
Quality Management and Quality Improvement
Dalhousie University .N.S.
winter 2009
Xiomara Arias-Fernandez.

2. Emergency Room Wait Time Issue. A Need For a Change.
According to the Canadian Association of Emergency physicians (CAEP, 2005 )
reducing waiting times is a clear priority at national level established in the document
“A Ten Year Plan to Strength the Healthcare". In effect, from 2004 to 2010, Federal
and Provincial governments have assigned more than 4.5 billion dollars to implement
strategies that aim to accomplish this goal in priority areas. Prolonged waiting times
are also concerning for lack of effectiveness in Canada’s Emergency Departments
(CED). An excess of patients overusing the emergency service impedes their ability to
provide them of effective and timely services. The shortage of beds in hospitals and in
the Intensive Care Unit are the causes of the overload of patients requiring services at
the emergency room. Also, government funding cuts have lead to reduced hospital bed
capacity, generating an overload crisis in emergency departments and this is worsened
by the increasing number of aging users.

3. Emergency Room Wait Time Issue. A Need For A Change
Additionally, patients who require alternate services (alternate level care, or ALC) such
as palliative care, contribute to the overcrowding crisis, because approximately
20% of these patients have to use beds that should be assigned for acute care. Bed
waiting times and patient flow are affected by in-patients who no longer require
acute care (Canadian Institute for Health Information , 2007) “Most hospitals in
Canada currently operate on 95% bed occupancy rates” (CAEP, 2005 p.3) which
means that overcrowding is occurring consistently, deteriorating the service and
having harmful repercussions in health’s patients, ranging from worsening medical
conditions to loss of life. The aim of this presentation is to expose different
approaches based on the research of authors . These approaches could reduce the
wait times in ED. Also is presented an hypothetical design based on a previous
successful model put in operation in 2007 at Mary Washington Hospital in VA
USA . The intent of this hypothetical project is to help in making the necessary
improvements that lead in reducing wait times in ED.

4. Emergency Department Wait Time Issue In
The Healthcare System Across Canada
(Canadian Association of Emergency physicians, 2005)
Delays in treatment/Reduction in flow of patients to others wards
Worsened medical condition- Life-threatening
Owercrowding –crisis + overuse of ED service
Ineffective and untimely service
Government funding cut + High # of ALC patients
Beds shortage

5. Emergency Department (ED) Overuse By ALC Patients
A Brief Look To Part Of The Issue
The Toronto District Health Council defines an ALC patient as one that is “considered a non
acute treatment patient but occupies an acute care bed. This patient is awaiting placement in a chronic
care unit, home for the aged, nursing home, rehabilitation facility, other extend care institution or home
programs etc. The patient is classified as an ALC when the patient’s physician gives an order to change
the level of care from acute care and requests at transfer to another facility.” (GTA Rehab, 2004 , p.3)
In 2007-2008 ALC patients accounted for 14% of hospital days in acute facilities across Canadian
provinces “This means that, on any given day, almost 5,200 beds in acute care hospitals were occupied by
ALC patients.” (Canada Institute for Health Information, 2009 p.3). One of the major clinical
hospitalization categories was mental diseases and disorders -17% of the hospitalizations- (Discharge
Abstract Database, 2007–2008, Canadian Institute for Health Information, 2009 p8).

6. Discerning The Dynamic of Waiting Times In The E D
Outpatient status Inpatient status
Total ED length of stay
Time to disposition
Initial physician assessment wait time bed-wait time
ED registration triage Initial physician assessment decision to admit leave Ed (move to acute care ward)
The bed wait time is calculated as the time a patient spends waiting in the ED
from the physician(s) decision to admit them to an inpatient bed to the time that the patient leaves
the ED. (source: Canadian Institute for Health Information ,2007. Access to inpatient beds ,p8 )

7. Plan Action To Reduce Waiting Times In Emergency Room
Actions To Reduce Owercrowding –Crisis
(strategy based on Karpiel, 2004)
At Inflow process level: To Implement a triage-driven bed placement method (Patients are
taken immediately to a treatment area after triage and quickly registered).
Enforce the use of bedside registration.
At Throughput process level: create a separate "fast-Track” area staffed with mid-level care
providers such as nurse practitioners to care for low-acuity patients. In this way, less critical
patients would be seen quickly and leave ED physicians to focus on critically ill or injured
patients. Create a reasonable not limited access to lab services and diagnostic imaging by having
dedicated radiology and lab technicians assigned to the ED during the busiest hours of operation.
By implementing a point of care satellite laboratory ( Lee-Lewandrowski et al, 2003) the
patient length of stay and turnaround time can be reduced .
At Outflow process level: Use of :Pre-emptive bed requests to allow ED physicians to request a
hospital bed previous authorization patient admission. Perform faxed admission reports, to
eliminate consumed time for ED nurse give call to inpatient nurse .Carry out a capacity
Management System, to replace the floor nurse's role in alerting housekeeping of empty rooms.
(This action improves housekeeping productivity and expedite bed availability).

8. Plan Action To Reduce Wait Times In Emergency Room
Actions To Decrease Overuse Of ED Service By ALC Patients.
In the case of mental health patients and based on information provided by The
Ontario Partnerships Report, 2008 three alternatives can be used:
• Develop a 24/7 Crisis Response System. A comprehensive and coordinated crisis
response system should include the following components: crisis response line,
safe beds, mobile teams, direct links to emergency departments, and direct links to
community-based case management .
• Support peer support workers involvement in discharge planning to offer
support and facilitate transitions from institutional to community care, i.e. social
workers.
• Invest in community mental health and addiction services that connect directly
with hospitals, to facilitate appropriate diversion from emergency rooms; and
support access to the most appropriate community based services and supports

9. Plan Action To Reduce Wait Times In Emergency Room
Actions To Improve Patient Flow
(strategy based on Jensen and Crane, 2008)
1- To organize a measure of patient demand by hour, and outline a system to manage it. To
conform staffing to patient ingress and capacity. To break down ingress by main complaint,
triage, emergency medical services arrivals, emergency severity index (ESI) level, and
ancillary utilization. (all are calculable). To design a response plan for times when demand
unusually spikes (It is critical to match hours of operation to patient demand.)
2- To Justly empower triage processes and systems. Triage is a support, a function to help in the
process of reducing waiting times, and is not useful for properly staffing an ED or decide who
can wait or who not.
3- To consider using team triage to promptly discharge patients at CTAS level III .This process
involves quickly assessing, registering, and processing through team triage, and then
allocating or sorting patients CTAS levels I,II,IV and V to either a treatment area or results-
waiting area.
4- To appraise ongoing triage protocol By switching to a "see-and-treat“ model, EDs will have
one in-process queue, where patients wait just one time for a one-stage assess, treat, and
discharge process
5- To use a technician or secretary to follow patients who don't need a bed and their results
6- To prepare and handle a vigorous staff with an eager platform.

10. Time frames developed in 1998 by
CAEP and defined as reasonable times to
physician-directed care in person or
telephone advice or as care provided by
nursing staff in accordance with medical
directives agreed to in advance by the
physician (Beveridge R. 1998)
Objective: "more accurately define
patients' needs for timely care and to allow
emergency departments to evaluate their
acuity level, resource needs and performance
against certain operating 'objectives.'
“(Beveridge et al ,1998 p.2). The primary
objective of the triage scale is to define the
optimal time to see a physician
The Canadian Emergency Department Triage
and Acuity Scale (CTAS)

11. CTAS I: requires resuscitation and includes
conditions that are threats to life or imminent
risk of deterioration, requiring immediate
aggressive interventions (for example, cardiac
arrest, major trauma, or shock states).
CTAS II: requires emergent care and includes
conditions that are a potential threat to life or
limb function requiring rapid medical intervention
or delegated acts (for example, head injury, chest pain,
gastrointestinal bleeding, abdominal pain with visceral
symptoms, or neonates with hyperbilirubinemia).
CTAS III: requires urgent care and includes conditions
that could potentially progress to a serious problem
requiring emergency intervention, such as mild moderate
asthma or dyspnea, moderate trauma, or
vomiting and diarrhoea in patients younger than 2 years.
CTAS IV: requires less-urgent care and includes
conditions related to patient age, distress, or
potential for deterioration or complications that
would benefit from intervention or reassurance
within one to two hours, such as urinary symptoms,
mild abdominal pain, or ear ache.
CTAS V: requires non-urgent care and includes
conditions in which investigations or interventions
could be delayed or referred to other areas of the
hospital or health care system, such as a sore
throat, menses, conditions related to chronic problems,
or psychiatric complaints with no suicidal
ideation or attempts.
The Canadian
Emergency
Department
Triage and
Acuity Scale
(CTAS
Source: Canadian Institute for
Health Information ( p.7) 2005
Time to assessment
nurse: 0 min
Physician: 0 min
Time to assessment
Nurse:0 min
Physician 15 min.
Time to
assessment
Nurse:30 min.
Physician: 30 min.
Time of
assessment.
Nurse:60 min
Physician:60 min
Time of
assessment
Nurse: 120
min.
Physician: 120
min

12. The Maximum Efficiency Care Project
Hypothetical design based on RATED.ER project ( Crane J, 2007 )
Project developed to improve waiting times and
enhance Emergency department service
Xiomara Arias Fernandez

13. The Maximum Efficiency Care Project
Xiomara Arias Fernandez
( Based on Crane J, 2007 RATED.ER project)
The Maximum Efficiency Care Project must be performed in a triage setting at the hospital ED.
This project will be based in the called RATED.ER ( Rapid assessment, Triage, and Efficient Disposition in the
Emergency Department) project performed by Crane Jody at the ED in Mary Washington V.A. USA in 2007.
Crane’s project focus on apply Lean tools to a value stream of Emergency Severity Index (ESI) level 3
patients, instead The Maximum Efficiency Care Project will focus on improve the efficiency through of patients
classified as level III in the CTAS. To set up this project also some Lean tools will be applied , such as Rapid
improvement Teams, (teams who analyzed processes to make quickly improvements) Takt Times, (the time
required to produce a component or set of components to meet a customer demand )and Visual Signals,(use of
indicators and signs to share critical information) among others. In order to provide a comprehensive evaluation,
early treatment and to determinate the bed needs of these type o patients The Maximum Efficiency Care Project
will include a staff comprised of physicians, nurses and medical assistants. It will also be necessary to
implement a waiting area where patients will wait for ancillary test results, and where will be set beds and
treatment/ discharge chairs. These resources will be compiled according the demand presented. To accomplis
TheMaximum Efficiency project when beds are required it will be created an Intake Team System integrated by
physicians, midlevel ,Register nurses , a paramedic and a Unit secretary with a group of beds behind triage. One
of the core purpose of this team will be appropriately identify CTAS levels I,II and IV,V patients, so that they
can be seen quickly in Main ED or in a fast track area in order to alleviate potential backlogs.

14. Goals to be achieved with the creation of “The Maximum
Efficiency Care project” in Emergency Department (ED)
• To reduce work in process (patients long waiting at ED ).
• To reduce wait times in Ed.
• Decreasing length of stay(LOS) for fast track patients .This action will
allow to see the patients who are sicker.
• To eliminate waste of human time and material resources by decreasing
the non -value -added patient processes.
• To accurately determine the quantity of beds needed in the area of
emergency.
• To maximized the value of patients by being seen in a primary care
setting.
• To improve revenue (funding for the next fiscal year) through
enhance throughput and flow of patients.

15. Strategy to perform The Maximum Efficiency care project
Action Purpose/Targets
1)To create a platform consisting of an expeditious
nursing assessment, a brief triage assessment and an
intermediate evaluation by the team of providers.
To provide efficient patient flow
2)To create a System Reception where the patient will
be received by a ED medical technician, a registration
clerk and an Ed nurse ( Pivot nurse).
Pivot nurse will complete a brief sign –in sheet (based on the
main patient complain and general appearance) to be delivered
to the medical technician and also will assign the patient to
Main ED if the patient is an ESI levels I ,II, or to The fast- Track
area if patient is IV ,V CTAS levels or to a mini-triage. Then to
the intake team if patient is a CTAS level III or some IV level .
The Pivot nurse also places patients in the waiting and results
waiting area. The registration clerk will perform a quick
registration
3) To calculate takt times (based on patient
demand)
To allow staffing the Intake team system and to
identify bed needs a s well as to complete initial nurse
and physician assessment
4) To Perform a limited initial assessment To meet criteria that satisfy the need to assign an ESI
triage level as well as not to delay further progress of
the patient through the system
5) To set up a treatment area with treatment
beds , nurses and techs.
To eliminate backlogs by providing
quickly and efficient service
6) To update physicians periodically as to the
patients' status and t he status of ancillary test
resulting
To advise physicians come to discharge or to admit
the patients (continue the flow). To provide quickly and
efficient service. To eliminate waste of resources

16. The Maximum Efficiency Care Project
Patient at
the Reception
team
(Quick
Pre-
assessment
by Pivot
nurse and
registration
by clerk )
10min
Main ED (levels I,II )
Mini-triage process .Vital
signs, main complain,
allergies, pain scales
13 min
To complete assessment ,
initiate treatment, testing
and bed decision needs
20 min
Fast Track (levels IV, V) Performed by
Intake team system
ESI level
assigned
Level
III

17. Intake Team System Flow
Patient
Sent to ancillary
services
Laboratory/ Radiology (No
bed needed. Levels 3,4,5)
Main ED.
(Bed needed-
Levels 1,2 )
Discharged at
home
Sent to a
treatment area
Iv Fluids
medications
Waiting
area
Virtual
bed

18. Conclusions
The shortage of beds in hospitals and in Intensive Care Unit, the
overcrowding originated by an increasing number of ALC patients using
E.D beds, and the consequent low flow produced, seem to be the main
causes of prolonged wait times at the emergency room . There does not
appear to be a single solution to address the issue of overcrowding and
shortage of beds in the E.D, causes that lead to inefficiency in the service.
Several factors should be taken in account when strategies are
implemented to help reduce the time patients spend in the E.D, for
example, type of hospital, day of the week etc. However, the success of
these strategies also will depend upon the cooperation of other hospital
departments as well as the involvement of top management. The strategic
areas to improve wait times must be focused mainly on E.D overcrowding
management, E.D ,ALC patients overusing management, and E.D patient
underflow management. Improving the access to primary health care and
community-based services also can be a measure used to reduce the
unnecessary visits to E.D by ACL patients. Recurrent visits to the E.D
could be curtailed if opportune community discharge plans are aligned the
first time.

19. Conclusions
A significant percentage of emergency visits by individuals could be more
appropriately served through alternative programs and services, i.e. visits to
family doctor, crisis counsellors, etc. Implementation of triage systems with
fast-track areas has been shown to improve throughput and reduce waiting
times (mainly for patients with CTAS IV and CTAS V levels ). This arise as an
answer to diminish overcrowding in E.D in these group of patients. Additional
staff in the areas of laboratory, radiology and others support diagnosis during
the busiest hours in E.D, is going to cover part of the needs of patients with
CTAS III level. By implementing a design that incorporate the use of Lean
Tools on CTAS III level patients, length of stay could be reduced in ED. The
expected reduction in time at the different stages of this model is going to
depend on the patient demand in each institution. To successfully set up the
project data should be analyzed and Takt Times should be calculated.

20. References
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Beveridge R.; Clarke B.; Janes, L.; Savage, N.; Thompson J.;Dodd, G. et al.(1998) Implementation guidelines for the Canadian emergency department triage & acuity scale (CTAS). Canadian e.d triage & acuity
scale version CTAS 16: 11/14/98
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http://secure.cihi.ca/cihiweb/products/ALC%20AIB_FINAL.pdf. Retrieved February 20, 2009.
Crane.(2007) The journey toward a Lean ED. Available at http://www.x-cd.com/shs07cd/pdfs/547paper.pdfRetrieved 1th March 2009
Greater Toronto Area Rehabilitation Network Analysis of Alternate Level of Care (ALC) Snapshots: Patients Awaiting Rehabilitation in ALC and Inpatient Rehabilitation Capacity GTA Rehab. May 2004
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