Here’s how we can do better and offer the right care in the right place
By Ashley Woytuik
October 23, 2023
You’re in the wrong place. It’s not your fault that you’re in the emergency department (ED). I’ve heard the story a million times: the clinics are closed, you can’t get an appointment with a primary care provider for three weeks, you did try to see the doctor and were told to come straight here instead, you called the provincial telehealth provider and were told to come here immediately.
You’re not the problem, and we will absolutely see you. It’s just that you’ll have to wait in the waiting room for several hours before we can see you. I hear how frustrated you are. I share your frustrations, and I have a few ideas on how we can make things better.
The moral distress that nurses face when putting patients in overcrowded waiting rooms is soul crushing. Reminders are everywhere in the news: in July 2022, a man died in a Fredericton ED; in August 2021, a man had a sudden cardiac arrest in a waiting room in Winnipeg; and in December 2022, a 37-year-old mother died in a Nova Scotia hospital after waiting in excruciating pain for more than six hours. EDs have become the supporter of health care, and this is not safe or sustainable.
In nursing school, nurses learn to apply the eight rights of medication administration: the right patient, right medication, right dose, right route, right time, right documentation, right reason and right to refuse. We diligently carry these out with each patient, no matter how busy or chaotic things are. We need politicians and policy makers to apply these same rights to EDs — and fast.
The right care in the right place at the right time, for all patients, will make a huge difference in patient outcomes, quality of care, nurses’ satisfaction with the care they provide, and patients’ satisfaction with the care they receive. We saw this start to happen during the height of the COVID-19 pandemic: patients were doing virtual visits with primary care physicians or nurse practitioners for non-emergent things (right care), and some EDs were allowing triage to divert patients to other care providers (right place). But EDs also dealt with patients who were refused care elsewhere: primary care providers who wouldn’t see a patient who had a sore throat or mental health clinics unable to see a patient due to a runny nose. Where did these patients go? Straight to the ED.
When beds are full in the hospital, the ED cares for them. When the wards are short-staffed, inpatients wait in the ED. When a patient needs a specialty service or care that a rural site cannot provide, they are transferred to an urban facility and become another ED inpatient. When a patient exceeds their current level of assisted living care or becomes difficult to manage in long-term care, off to the ED they go, and, you guessed it, they are admitted and wait in the ED. Chong, Haywood, Barker, and Lim (2013) noted that a longer stay in the ED resulted in a longer stay on the inpatient ward. The longer a patient is in an inpatient bed, the longer other patients have to wait in the ED. The problem feeds itself.
We need to redesign health-care systems with a true focus on patients. This means systems that look at patients and outcomes, not at what is only good for care providers.
Ensure THAT Patients feel valued by the health-care system
A patient’s time is not less important than the time of a nurse or doctor. We make patients come in hours early for surgery, consultations or appointments knowing that they will need to wait because a doctor cannot see six or eight people at once. System efficacy is focused on how quickly a physician can see a patient and move to the next, so it works well in that regard. However, the logistical problems a patient might have to overcome — work, childcare, travel — to be at that appointment can be enormous. Giving real arrival and appointment times and having patients arrive at the right time for the right treatment demonstrates respect for the patient.
Design a service delivery model whereBY primary care is valued above specialty care
Family medicine is largely undervalued in favour of the more idolized specialties, such as surgery, orthopaedics and pediatrics. The breadth and scope of knowledge of a family physician is indispensable. Government and educational institutions need to recognize and incentivize this type of practice so that it can be the most sought-after specialty. This could increase the number of people entering family practice and produce more primary care physicians.
Improve access to virtual health care
Huge strides were made when COVID-19 hit, which was promising. Internet infrastructure needs to keep pace, but with the right set-up, this is a game-changer for remote communities and rural populations, which can suddenly access primary care without travelling. Having patients leave their home community, drive or fly to a city, stay in a hotel or go to a clinic for a physician to spend 10 minutes with them (see the first recommendation) demonstrates that patients are not the priority in the system. Governments and administrators need to capitalize on the success of virtual services during the recent pandemic and make this the normal standard for delivering health care to people, not forcing people to deliver themselves to health care.
Improve public education
Provincial organizations need to do better at encouraging the public to avoid EDs for things that are not emergencies. Family doctors and primary care providers need to teach patients what to expect when they are sick instead of simply sending them to the ED for a “quick” blood test or swab. The public needs to know that in order to keep having access to high-quality and safe health care, they need to be responsible for using it wisely and judiciously. We can no longer afford for EDs to be the supporter of the failing health-care system.
So please, have a seat in the waiting room. All of our care spaces are currently occupied. Please be patient with us. I am juggling many priorities right now. I am terrified that something bad will happen to one of you and I will miss catching it in time. I share your frustrations. I promise I will get you seen as soon as I can.
Chong, C. P., Haywood, C., Barker, A., & Kwang Lim, W. (2013). Is emergency department length of stay associated with inpatient mortality? Australasian Journal on Ageing, 32(2), 122–124.
Ashley Woytuik, RN, BScN, is the clinical coordinator in the Grande Prairie Regional Hospital emergency department. She is an active community service member engaged in multiple professional leadership roles in various organizations.