Emergency Room Waiting Time
In 2012, during a first year engineering design course, we worked on a two stage project. The first stage was to identify a problem within the city of Toronto, and write an RFP addressing this issue. The second stage was to choose an RFP written by another team in the class and find a solution in order to "Sustainably improve the quality of life of a community-in-need in the city". If you are interested in the second stage, please visit the Navigator project. Below I have described the first part of the project, which we spent roughly 4 weeks on.
In order to identify a problem affecting the quality of life of Torontonians, we sat down as a team and thought about different issues that we had dealt with in the past. Prior to that meeting, I went to a tennis court with 3 other friends, and as we were playing doubles, unfortunately, one of my friends broke her nose. We took her to the hospital around 9 PM, we waited in the emergency room for 6 hours for the doctor to see her. It took another 2 hours for them to take an X-Ray, and near sunrise, we were told that her nose was broken, but she just had to go home and rest. I talked to my team about my experience and since everyone could relate to the emergency room waiting time problem we decided to go with that. We also did some research to ensure that this was a known problem that many people deal with everyday. We also went to the hospitals and interviewed some stakeholders, which was a valuable experience for us as first year students.
There was an obvious solution for the problem: increasing the number of staff and beds. But the challenge in writing this RFP, was to frame the problem differently. So instead of complaining about lack of resources, we requested a system that allows communication between hospitals, local clinics, and patients, so that they can relocated patients or resources accordingly. You can read the full RFP here.
The purpose of this request for proposal is to investigate the existing gap between different parts of the current medical system, in order to reduce the emergency room waiting time in city of Toronto hospitals. The proposal will introduce major causes of long ER waiting times, and elaborate on the significant changes that could be accomplished by investing on minor causes. The first cause is the presence of patients with non- complex medical need in large hospitals, resulting in occupancy of resources for patients in need of immediate medical attention . The other cause is the public misunderstanding that large hospitals have lower waiting times, while in practice local clinics and other medical care providers do not experience patient overflow.
The significance of ER waiting time is internationally recognized as an important quality of life indicator . Failing to meet provincial target for ER waiting times (4 hours for uncomplicated conditions and 8 hours for complex conditions ) in Ontario has resulted in patients’ dissatisfaction. As a result, there have been extensive researches concerned with major causes including lack of beds and shortage of health care professionals . It is important to acknowledge the fact that these researches focus on the patient queuing process in Emergency Department . However, this proposal focuses on shifting part of the triage nurses’ work load to an intermediate health service (Telehealth) which allows the patients to be dispatched before arriving to the hospitals.
The present actions taken by the Ministry of Health and Long-Term Care, including Telehealth Ontario service and e-Health Ontario website, strive towards educating general public about other means of receiving immediate health care. However, none of these services provide patients with sufficient information about the current waiting times at each hospital. This proposal requests a system that would allow hospitals to frequently report information regarding their current waiting time status to Telehealth. This will assist Telehealth to dispatch patients to less crowded health care providers, while keeping that information confidential. In addition, a strategy is required to improve the publicity of Telehealth, so that it is well known among general public.
Waiting time in emergency rooms is internationally recognized as one of the top 20 quality of life indicators . On December 2011, Ontario Ministry of Health announced that current waiting times are approximately 4.2 to 27.8 hours depending on the complexity of the patients’ condition . Due to the significance of this problem, reducing emergency room waiting times has become one of the top two health care priorities in Ontario . Ontario government has invested more than $82 million to reduce the amount of time people spend in hospital emergency rooms, and $7,902,200 of this budget has been devoted to the city of Toronto’s “waiting time strategy” . As part of this strategy, Ontario Ministry of Health has introduced a service called Telehealth Ontario, which provides the patients with access to health advice from a professional before visiting the emergency rooms . However, this service does not provide the patients with any information about the current waiting time at a particular hospital. In addition, lack of publicity has decreased the effectiveness of this service since it is not very well known. This proposal examines the gap between the patients in the city of Toronto and Telehealth Ontario, as well as improving the communication between the hospitals and this system, for the purpose of reducing waiting time in emergency rooms.
Significance of the Problem:
Toronto has the longest emergency room waiting time in Ontario  and hospitals do not meet the provincial target , which is 8 hours for complex condition and 4 hours for minor or uncomplicated condition, for 9 out of 10 patients . Ontario Ministry of Health has defined waiting time as “The time you spend in the ER, from the moment you arrive and register to the point at which you are either discharged or admitted to hospital” . Having long waiting times has resulted in unacceptable consequences. For instance, December of 2010 Marlene Stephenes died due to respiratory problems, after waiting about 90 minutes in Emergency Room of William Osler Heath Center . Every year about 3% of patients decide to leave emergency rooms without visiting doctors due to long waiting times . The process of registering and getting immediate care varies in different hospitals but the first step is always visiting a triage nurse. In order to have a better understanding of the problem it is critical to understand the causes of the problem.
Causes of the problem:
According to Canadian Health Coalition, which is a public advocacy organization dedicated to improvement in medical care, the long waiting times in emergency rooms have multiple causes:
° Poor organization and lack of coordination between services
° Shortage of Health-Care workers: Patients in ER need to visit doctor to assess their condition and then move to other settings. The lack of doctors can result in longer wait time for patients.
° Lack of coordination among staff
° Cuts to hospital services: Between 1988- 2002 64,000 hospital beds were cut.
° The need for more long-term care and home care: Some patients in ER need long-term care. These patients can be sent to other settings, or even home with some significant support.
° Better Outcomes: In the case of emergency, people often choose to go to hospitals that have had better outcomes
This proposal will not focus on the above causes of the problem (See Engineering Problem Framing.2). The two main causes that will relate to the scope of this problem are:
- Public misunderstanding: People tend to think that large hospitals have lower waiting times, while in practice local clinics and other medical care providers do not experience patient overflow.
- Non urgent visitors: These patients occupy the resources for patients in need of immediate medical attention
1. Large Hospitals vs. Small Hospitals:
A common belief is that the waiting time in large hospitals’ emergency rooms is less than the one of smaller hospitals and thus in the case of emergency, people are more likely to choose to visit larger hospitals . According to Ontario Ministry of Health and Long-Term Care, people spend more time in emergency room of larger hospitals . Therefore, this misunderstanding will result in an increase in emergency room waiting time of large hospitals. Hospitals are divided into 4 groups according to number of patients they treat in emergency rooms every year by Ontario Ministry of Health and Long-Term Care. These 4 groups have been described in Table I .
In Large-Volume Community hospitals half of the emergency room visits take more than 2.8 hours, while this value is 1.5 for Medium-Volume Community hospitals and 1.1 for Low-volume community hospitals. Furthermore, statistics show that in teaching hospitals and large volume community hospitals patients wait longer (median wait time of 6 -70 minutes) than Low-Volume hospitals (median wait time of 1-25 minutes) to visit a physician .
2. Non-Urgent visitors:
While large hospitals have higher emergency room waiting time, they are also more likely to see more urgent patients that have more serious illnesses . According to Ontario Ministry of Health and Long- Term Care, patients with urgent need of treatment have different choices based on the seriousness of their issue. These places include:
° Urgent care centers
° Walk-in clinics
° Family health teams
° Emergency departments
° Family practice offices that have extended and weekend hours. 
According to Canadian Triage and Acuity Scale (CTAS) 57% emergency department visits were non- urgent cases such as sore throat, menses, or isolated diarrhea . Figure 1 , shows that 17% of patients with minor health problem have contacted emergency rooms. The decrease in number of non-urgent visits to emergency room will result in reducing wait time.
Figure1 - Settings most often contacted for immediate care for a minor health problem; household population ages 15 and over; in Canada
Moreover, 18% of Canadians claimed that they could have gotten the treatment they got in emergency department in non-emergency settings . Non-urgent patients with minor symptoms can be treated in Walk-in clinics, Urgent care centers or by family health teams. In the influenza season large hospitals get more crowded and thus their waiting time increases. Statistics shows that every 10 local cases of flu results in 1.5% increase in emergency department visitors , while these patients would be better treated in local clinics. Furthermore, patients are more likely to visit emergency rooms between 8:00 AM to 8:00 PM  in that time most Walk-in clinics are open. Figure 2  illustrates how most of the patients with minor health access immediate care during office hours.
Figure2 - Percentage of people accessing immediate care among those who require care for minor health problem; at anytime of day (regular office hours, evenings and weekends, and during the middle of the night); household population 15 and over; in Ontario
3. Telehealth Service:
Ontario Ministry of Health and Long-Term Care has provided patients with a free 24 hours,7 days a week phone service that helps them asses their symptoms and decide which step to take next. In Figure 3  rate of satisfaction of telephone Health service users is illustrated. This system can help people find out whether they need to go to hospitals emergency rooms, a clinic, or make an appointment with a doctor ; however they will not be directed to a specific location. The lack of communication between Telehealth service and emergency department of hospitals may result in sending patients to ER of a hospital that is already crowded. According to a Telehealth representative the only time hospitals contact this service is when a drastic accident happens in the area and the ER cannot accept more patients.
Figure3 - Patients’ satisfaction with telephone health line services in the past 12 months; household population 15 and over ; in Ontario
Points of intervention:
Distributing the patients with less complex conditions to more appropriate medical centers will decrease the waiting time (see Definitions.1) in large hospitals. Consequently, the quality of medical services provided for the patients with complex conditions will be improved.
This distribution is currently done by Telehealth Ontario based on patients’ symptoms; however the effectiveness of the service can be improved by:
1. Increasing public awareness:
The service is not well recognized by the general public
2. Filling the gap between the hospitals and Telehealth Ontario:
According to a Telehealth Ontario representative, hospitals do not provide any information about their ER waiting time to this system
Figure 5 - The solid arrows represent the connection that needs to be improved, and the dashed arrows represent the gap that needs to be filled.
The patients can be distributed according to three categories: seriousness, crowdedness, and location.
The most important factor in guiding the patients to a certain medical center is the complexity of their condition. A patient with an urgent medical need will be sent directly to a large hospital.
The Telehealth representatives should also consider the crowdedness of the hospital, when recommending a medical center to a patient. This recommendation is based on the information they receive form hospitals and local clinics. Note that the information sent from local clinics might need to be analyzed differently than the ones received from hospitals, due to the very different nature of the two.
Location of the hospital is also an important factor in the direction of patient flow. However since by definition waiting time starts from the patients’ arrival to the hospital and according to the geographical scope of the proposal, this factor is irrelevant.
Figure 6 - The new role of Telehealth needs to provide the desired patient flow in the system based on these three categories. The ultimate goal is that patients who do not experience a serious medical condition could be distributed to secondary medical care services, while the patients with more complex cases could be directed to large hospitals according to the reported waiting time.
This dispatching process will indirectly affect patients with complex medical condition, by reducing the volume of non-urgent patients in the large hospitals, which allows them to get more medical attention. In figure 6, the patients with complex condition are considered to fall outside of the scope, since according to Telehealth Ontario they should immediately contact 9-1-1. Also note that this flow might be disrupted by patients who choose not to follow the recommendation of the Telehealth representative.
The stakeholders are listed below in the order of importance. The first 5 are primary stakeholders which define the problem and will be directly affected by the implementation of the solution, starting from the community-in-need (5.1). The last six are secondary stakeholders which could potentially provide useful insights and support implementations.
1. Patients with complex conditions:
The community in need is considered to be a stakeholder, since the solution to the proposed problem will indirectly affect the quality of the medical services they receive. By distributing the non-urgent patients to more appropriate medical centers, urgent patients will receive the medical attention they need.
2. Patients with non-complex situations:
This stakeholder will be directly affected by the outcome of this proposal, since the goal is to guide this group of people to other medical health centers, allowing the crowd of patients to deviate from the large hospitals. According to a manager of Telehealth Ontario a patient with a non-urgent medical condition might save hours by calling Telehealth before visiting the ERs [page10image1160]
3. Downtown Toronto Hospitals:
Toronto General Hospital, Mount Sinai Hospital, the Hospital for Sick Children, and St Michael’s Hospital are the stakeholders within the geographical scope. Since one of the objectives of this proposal is improving the communication between Telehealth and Hospitals, they will be affected by the additional work on their part. According to the Manager of Emergency Department in Toronto General Hospital, they requirement is to minimize the extra work added to their daily routine, regarding sending frequent information to Telehealth Ontario.
Note that the funding to each hospital is determined in part by total Emergency Department volumes , and there exists the motivation that hospitals might over-report the numbers of patients (see Requirements.4).
4. Local clinics:
Local walk-in/after hour clinics and other medical care centers are considered stakeholders since the process of distributing patients with non-urgent condition relies on their capability of providing medical care in a shorter period of time. They will need to communicate better with the Telehealth in order to provide them with accurate information about their waiting time. According to the receptionist at the Patient Networks Family Medicine Walk-In Clinic there are usually more doctors available for emergency cases, and the waiting time is roughly half-an hour.
5. Telehealth Ontario:
Telehealth Ontario is a telephone service that provides patients with medical advice from professionals . Telehealth is an important stakeholder, since it is where the solution will ultimately be implemented. This will require Telehealth representatives to evaluate another set of information to better assist patients to the most appropriate medical center. According to a Telehealth manager, this service is willing to adapt to any improvements imposed on this services. In return, Telehealth representatives request that the information is reliable and as clear as possible.
6. Ontario Ministry of Health:
Government is another stakeholder since its reputation will be affected by the amount of waiting time in emergency rooms. Ontario Ministry of Health And Long-Term Care directly leads and coordinates all health care providers and related organizations to provide health service to Ontario citizens  (see Reference Designs.3).
7. Ontario Hospital Association:
The goal of Ontario Hospital Association is to achieve a high performing health system by supporting for-profit and not-for-profit organizations involved in Ontario health care delivery, including approximately 151 Ontario hospitals . Due to the fact that they support the organizations and hospitals by advancing and influencing health system policies in Ontario, OHA is a secondary stakeholder (see Requirements.3)
8. The Patients Association:
The Patients Association is devoted to “listening to patients, speaking up for change”. They advocated for better access to accurate and independent information for patients and the public . As an association that represents patients across Canada, it plays an important role as a feedback collector and provides feedback to the healthcare system to make it more efficient and effective. The patients’ satisfaction is a metric to evaluate the solution adopted, which can be represented by the Patients Association (see Requirements.4).
9. Toronto Central Local Health Integration Network:
Toronto Central Local Health Integration Network is a network designated by the Ministry of Health & Long- Term Care to plan, integrate and fund local health services to ensure that the health system makes the best use of available resources and meets the needs of the community . Since Toronto Central LHIN is devoted to solve the problem in a similar manner, it is considered to be a stakeholder.
10. Canadian Institute for Health Information:
Canadian Institute for Health Information is an independent and not-for-profit organization working to improve the health of Canadians and the health care system by providing quality health information. CIHI is devoted to coordinate the development and maintenance of a common approach to health information for Canada. To this end, CIHI is responsible for providing accurate and timely information that is needed to establish sound health policies, manage the Canadian health system effectively and create public awareness of factors affecting good health . Since this proposal requests a system dealing with health information, CIHI is a secondary stakeholder.
11. The Institute for Clinical Evaluative Sciences:
The Institute for Clinical Evaluative Sciences is an independent, non-profit organization that conducts research on a broad range of topical issues to enhance the effectiveness of health care for Ontarians . Since ICES provides number of research relevant to this proposal, might also be able to conduct more research on different aspects of the proposed solution, and is considered a stakeholder.
Higher Level Objectives:
° Reduce waiting time in emergency rooms.
° Improve the effectiveness of services provided to urgent patients.
° Increase the efficiency of services provided to non-urgent patients.
° Enhance the communication between patients and Telehealth.
° Effectively share information among hospitals, local clinics, Telehealth, and other health care providers.
° Effectively dispatch patients before their arrival to the hospitals, local clinics, and other health care
° Promote the usage of Telehealth Ontario’s consultation before visiting the ER for general public.
The solution must agree with all health care policies and obey all related laws. Within those, the area of focus is confidentiality:
° Patients perspective:
The information about the patients’ symptoms must remain confidential within Telehealth Ontario; maintaining a level of privacy for the patients.
° Hospitals perspective:
The reported information from hospitals to Telehealth Ontario regarding the waiting times must remain confidential within Telehealth. The reason is that according to the manager of Emergency Department in Mount Sinai Hospital, this information might affect the patients’ decision of visiting the ERs. Considering the fact that patients are not qualified to evaluate their medical condition, this is considered to be bad practice.
° Implement a strategy to improve Telehealth’s publicity; making it better known by the general public.
° Design a system that allows hospitals to report their waiting times and other relevant information frequently.
° Total estimated decrease in Emergency Room waiting time (metric: %decrease in wait time hours)
° The publicity of Telehealth among general public (metric: % increase in the number of people using Telehealth)
° Cost: The solution should be as cost effective as possible (metric: $ - increase in the budget devoted to this problem) (see DFx. sustainability)
° Convenience: The system should be easy to use
- The patients should be able to contact Telehealth with minimum effort within a short period of time (metric: minutes - average hold time)
- The Telehealth representatives should be able to receive the information with minimum difficulty (metric: seconds - average time spent for recognizing the least crowded health care provider)
- The health care providers should be able to report the information with minimum friction (metric: seconds per patient – time taken to report information) (see DFx. Minimal Friction)
° Accuracy of Information: The design should verify the reliability of the shared information
- The questions asked by Telehealth should result in thorough explanation of symptoms from the patients (metric: # of questions asked on average resulting in a certain diagnosis
- The Telehealth representatives should have reliable evaluations in terms of patient diagnosis according to the reported symptoms (metric: poor to excellent – result of patient satisfaction surveys)
- Health care providers should report an honest information to Telehealth about their waiting times (metric: hours - deviation of the reported information from a known sample) (see DFx. Reliability)
Visit Navigator project to see another project that we worked on together as a team.
This seems like a very interesting problem that exists not only in Toronto, but in many other big cities. I would like to come back to this issue and work on it during my spare time.