Congestion in the ER: Why wait times are so long and why the problem is so difficult to fix

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In the past year, The Montreal Children’s Hospital’s (MCH) ER has been busier than ever.  The ER has enough doctors, nurses and space to ably treat 180 patients a day.  But on average some 240 patients pass through its doors every single day, seven days a week. This means the staff is working extra hard day-in and day-out to make sure all children receive the care they need and deserve.

Why are so many children coming to the ER?  Why can’t the hospital simply hire more doctors and nurses to cope with the extra patients?  Why on earth do patients and parents have to wait so long to see a doctor?  These all sound like easy questions with easy answers. Unfortunately when it comes to health care, there are never any easy answers or easy solutions. 

The following questions and answers paraphrase a two-part audio interview by Dr. Harley Eisman, Director of the MCH Emergency Department. He explains why our ERs are so congested and why health care workers are struggling to come up with solutions.

Question:  Why has there been a jump in the average number of patients seen each day in the MCH ER?

Answer:  The Montreal Children’s Hospital ER Department has enough space and staffing to handle a maximum of 180 patients a day.  However, since November 2006, we have consistently seen over 200 patients a day with the average hovering around 240 patients per day.

The reason for the jump in the number of patients being seen in the ER is due to two viruses. One virus known as RSV, part of the respiratory bronchialitis family has affected a lot of young children who require specialized medical care. We’ve also been coping with an outbreak of the gastroenteritis virus. A lot of young children have come to the ER needing to be rehydrated and needing further care.

Q:  When children arrive for treatment, how do you decide who is seen first?

A:  Parents arriving in the ER department are frustrated because patients who arrived after them are often treated sooner.  I want to explain why this happens. The ER is not a walk-in-clinic, we don’t treat people on a first come, first served basis. We use a triage system. The first person the patient meets is a nurse who categorizes the patient from one to five, one being severely ill and needing immediate care and five being a health problem which can wait for two or three or more hours. Examples of what we consider a category five are:  a sore throat, sore finger or a small little cut.  The patients who are placed in categories one, two or three are obviously seen ahead of the patients placed in categories four and five.  The whole premise of the ER is to get specialized care to the patients who need it most and those who need it most are obviously the sickest. So, if you come to the ER with a minor ailment, you should be prepared to wait.

Q:  If it is not an emergency, why are parents bringing their children to the ER for treatment?

A: In 2005, the MCH did a study with Ste-Justine. We found that after 5 p.m., on weekends and holidays very few health care services such as clinics, CLSCs or family doctors’ offices are open. So there are very few resources in the community parents can turn to when their child has a minor health problem. Yes, some parents are privileged to have a physician who will see patients after hours and some hospitals in the community will treat non-urgent pediatric cases. But these services are very few and far between.  We urge parents to use their common sense when deciding if their child’s health problem has to be treated right away.  A common example of a non-urgent medical problem that we often treat in the ER is ear infection.  The first thing to do when your child has an ear infection, even if it flares up at one in the morning, is to reduce the pain.  You can use a pain reducer such as ibuprofen and then perhaps you can get an appointment at a walk-in clinic, or CLSC the next day.  This is an option open to parents.   

All of us who work in the MCH ER know parents and patients are frustrated.  And we know there are few other health care options for patients after hours, weekends and on holidays, and that’s why they are all coming to us.

Q:  If the number of patients has increased, why can’t you simply hire more doctors and nurses?

A: The answers are quite complicated, but there are two fundamental reasons why we simply can’t hire more doctors, nurses and other ER staff.  First, trained pediatric health care professionals are hard to find. People who work in a children’s hospital need special training. And quite simply, there are very few people available to be hired. Second, even if we were able to find someone to work in our ER, government funding makes it impossible to hire that person. The government gives us a yearly budget to run the hospital. We have to stay within that budget. There is no money available to hire extra staff, such as nurses or respiratory specialists.

Now, if we look at the issue of hiring more doctors, the government has put a cap or a limit on the number of doctors who can work in an academic health care centre such as The Montreal Children’s Hospital. In fact, in the case of the pediatricians who work in our ER, the government has decreed that we are not allowed to hire any new doctors and even worse, if one of our doctors retires or leaves the MCH, we are not even allowed to replace that physician.

Q:  If you can’t hire more health professionals, despite the increased number of patients arriving at the ER, what are you doing to shorten the wait times for patients and parents and reduce the tremendous workload on the staff?

A:  Our priority is to provide care to the children who need it the most, the sickest patients. And believe me, children who are very sick are seen and are treated right away. This is not something parents should worry about. 

However, we have started to implement some novel strategies to see children who are less severely ill, for example, those who come seeking care for an ear infection or sore throat. On a trial basis we will be operate a fast track type system where we are able to dedicate a physician who will see these minor problems quickly in an area close to but outside of our ER. If this fast track system works, we will solve the issue of space, and reduce the number of non-urgent cases filling up the ER   where no urgent cases fill up the ER. However, the drawback to this system is the dedicated physician would have to be liberated from the ER to do this work.

We also have tried to explain many, many times to parents that they should learn how to deal with minor health problems themselves. To this end, we are in the process of developing and upgrading educational materials for parents.  We hope this will reduce ER wait times. We are also trying to re-establish connections with our McGill affiliated health care providers in the community and other institutions. If one of our patients doesn’t have a family doctor, we will refer them to one of our community partners for follow-up care and to have someone take charge of their child’s condition.

Q:  What could the government do to help reduce the wait times for patients and workload on staff?

A: Clearly, form our perspective as front line providers, there has to be an influx of resources such as money and human resources. We need to be allowed to hire new nurses, doctors, administrators and clerks to be able to meet the needs of the population.  What I’ve outlined are solutions for the MCH. Beyond that, the whole health care infrastructure has to be looked at. We need to re-establish community resources, have clinics staffed and have them remain open after hours.  It’s a question of resources and funding.

Q:  What could parents do to make sure their children receive the care they need and deserve without having to resort to spending four or more hours waiting in a crowded emergency room?

A: My recommendation to parents is that they have to take the time to identify some health resources they can trust within their community. It might be the local CLSC, a pediatrician’s office, or walk in clinic; keep their phone numbers handy and know their office hours.  The other issue is parents have to use some common sense when deciding what is a true emergency and what can wait or what can be dealt with by giving a fever or pain reducer. They can then go to their CLSC or walk in clinic or doctor the next morning.

Q:  The Montreal Children’s Hospital is planning to build a new hospital. Will the new hospital improve the situation in the MCH ER?

A:  Yes, the new hospital will make a big difference. The ER department in the current hospital is about a quarter of the size it should be for the number of children we are caring for and the number of people who work in it. In the new hospital, the square footage will be three times larger.  This will dramatically improve the care we will be able to provide patients and families.  The treatment rooms will be more private and the additional space will allow us to improve and maximize our efficiency.  But we have to hope that along with our additional space we will receive extra funding so we can increase staffing.