Emergency Department “Did Not Waits” – what’s the real story?

This appeared in yesterday’s West: “Urgent ED cases walk out before treatment”

More than three patients needing urgent attention leave the busy emergency departments of Perth’s major hospitals every day without being treated, new figures show. Documents obtained through Freedom of Information laws show that last year, 7215 patients across all levels of urgency attended the emergency departments at Royal Perth, Sir Charles Gairdner, Fremantle and Princess Margaret hospitals but left without being seen by a doctor.

They included 48 category 2 or “emergency” patients, typically including suspected heart attacks, and 1184 category 3 or “urgent” cases, which can include head injuries and major bleeding or fractures. Twenty of these patients were children.

This article looks at some important questions, but it fails to illuminate us on what the answers might be – and the information presented is a little misleading.

First, the author makes a point of saying that the information was “obtained under Freedom of Information” laws, which usually implies that the Government was making efforts to keep the information as quiet as possible. However, Emergency Department (ED) performance statistics are typically not particularly secret or obscure.

Western Australian public hospitals now have ED attendance, admission, waiting times, and ambulance diversion and ramping times publicly available in real time on the WA Public Hospital Activity website. Here’s a snapshot of what to expect at the time of writing – from no wait for category 4 patients at King Edward (OB/GYN hospital with only 2 people waiting), to 72 minutes for cat 4s at Rockingham. It is recommended by the Australasian College for Emergency Medicine (ACEM) that 70% of category 4 patients are seen within 60 minutes. Median waiting times in the 24 hours leading up to writing have been within target in all categories across the metro area.

table of ED waiting times Sunday 19 April

This real-time site probably picks out Triage Category 4 to show waiting time to the public because Cat 4s are likely to need some sort of help, but also to have a choice about what to do and where to go.

You can read about the Australian Triage Scale at Medeserv. This is a standardised way of categorising people presenting to emergency departments by the urgency of their problem. Triage Category 4 includes conditions like lacerations without major bleeding, migraine, earache, limb injuries that could be sprains of non-urgent fractures, vomiting or diarrhoea without dehydration, and mental health problems without immediate risk. So Category 4 patients accessing this waiting-times website have the opportunity make an informed decision about whether they’re better off attending a general practitioner for assessment and treatment of their problem, or perhaps travelling a little further than the nearest emergency department to a further one if their local is very backed up.

The West’s article about Did Not Waits (DNWs) focusses on Category 2 and 3 patients. As they identify, Category 3 includes head injuries with transient loss of consciousness (now alert), and moderately severe blood loss. However, it does not include “major fractures”, as implied by the “major bleeding or fractures” construction – major fractures would be Category 2.

But that’s not all that goes into Cat 3. It can also include chest pain that’s likely to be non-cardiac, dehydration, and abdominal pain without high-risk features. So your heartburn or costochondritis or even a bad case of mittelschmerz (ovulation pain) might be put in this category. Any “moderately severe pain” goes into category 3. Folks who have had a seizure but are now alert go into this category also – so the “Did Not Wait” (DNW) group can also include your friendly neighbourhood person with known epilepsy who was shipped to the ED by helpful bystanders after a straightforward fit, woke up on the way, and chose not to wait; or a person with a migraine who decided to deal with it at home rather than in a brightly-lit ED, or any of a variety of other people. People who have been assessed as “potentially aggressive” but not an immediate threat also are put into Category 3, which could include various stroppy drunk youths with minor injuries. Over 50% of patients originally triaged to category 3 require no followup after discharge from the emergency department. Not all Cat 3s are seriously ill or injured. State AMA president Gary Geelhoed identifies this as one possible cause of DNWs in the West’s article.

Or we could have people routinely walking out of EDs with moderately severe untreated asthma, acute psychosis, diabetic ketoacidosis, chemotherapy- or AIDS-related fever, and appendicitis. They could be abused women or children dragged home by their abusers. Unfortunately, raw figures tell us nothing about which types of people are in that “DNW”.

The 48 Category 2 walkouts are more worrying, but these are a tiny percentage of the total; again, we need a lot more research before being certain that these weren’t mis-triaged, or chose freely to walk out. And we need to know more about the specifics in order to figure out how to reduce the chances of a walkout by someone who desperately needs and wants help. The most obvious categories of possible Cat 2 walkouts that stand out to me are “drowsiness or decreased responsiveness of any cause”, “violent or aggressive”, and “fever with signs of lethargy”. Drunk or drug-affected people who are presented drowsy or violent regularly disappear from medical care, and not all lethargic people with fever have meningitis – it is entirely possible for someone to improve and decide that they’re rather keep having their nasty flu at home.

Waiting times are a problem. Western Australian EDs are not meeting ACEM targets consistently right now, and waiting times for category 3 patients have been outside of ACEM recommended times for a long time. Page 109 of Performance Indicators Certification Statement 2005 shows the 2000-2005 numbers for the proportion of ED patients seen within recommended times.

Over 99% of Category 1 patients were seen immediately, which is a key performance indicator. ACEM recommends that 75% of Category 3 patients be seen within 30 minutes, but the figures in WA hovered around the high fifties. More recent figures for the Metropolitan Health Service (MHS) are available in its 2008 report, and unfortunately they have dropped away recently, from a peak of 60.6% in 2005-6 to a low of 48.6% in 2007-2008. The only category in which targets are being fully met by MHS Emergency Departments are in category 5, the least urgent minor presentations. Country health services in WA have been performing at a similar level.

We need action on ED waiting times, but putting the burden of that action purely on emergency departments to “perform better” is useless. EDs have been telling us again, and again, and again what they need in order to improve performance: a solution to access block. EDs can’t keep bringing sick people into emergency departments when there’s no way to get the sick people who are already there out. And why are sick people piled up in ED corridors? Because they need admission, but have nowhere to go.

You can’t blame the bottle’s neck for being “inefficient” when the bottle is overflowing.

Read more about access block here at ACEM’s 2004 paper on the issue, “Access Block and Overcrowding in
Emergency Departments
“, and in these MJA articles:

Emergency department overcrowding: dying to get in?” [George Braitberg, MJA 2007; 187 (11/12): 624-625]

Access block: problems and progress [editorial, Peter A Cameron and Donald A Campbell, MJA 2003 178 (3): 99-100]

The access block section of the 3 February 2003 issue

The access block section of the 6 April 2009 issue
(unfortunately most full text articles are now paywalled)

I’ll leave you with the abstract from “Myths versus facts in emergency department overcrowding and hospital access block” [Drew B Richardson and David Mountain, MJA 2009; 190 (7): 369-374], published just two weeks ago. Richardson and Mountain are saying the same things that experts have been saying for over six years now. Is anybody listening?

* Overcrowding occurs when emergency department (ED) function is impeded, primarily by overwhelming of ED staff resources and physical capacity by excessive numbers of patients needing or receiving care. Access block occurs when there is excessive delay in access to appropriate inpatient beds (> 8 hours total time in the ED).

* Access block for admitted patients is the principal cause of overcrowding, and is mainly the result of a systemic lack of capacity throughout health systems, and not of inappropriate presentations by patients who should have attended a general practitioner. Overcrowding is most strongly associated with excessive numbers of admitted patients being kept in the ED.

* Excessive numbers of admitted patients in the ED are associated with diminished quality of care and poor patient outcomes. These include (but are not limited to) adverse events, errors, delayed time-critical care, increased morbidity and excess deaths (estimated as at least 1500 per annum in Australia).

* There is no evidence that telephone advice lines or collocated after-hours GP services assist in reducing ED workloads.

* Changes to ED structure and function do not address the underlying causes or major adverse effects of overcrowding. They are also rapidly overwhelmed by increasing access block.

* The causes of overcrowding, and hence the solutions, lie outside the ED. Solutions will mainly be found in managing hospital bedstock and systemic capacity (including the use of step-down and community resources) so that appropriate inpatient beds remain available for acutely sick patients.

Categories: health, medicine, Politics

Tags: , , , , , ,

17 replies

  1. Only 72 minutes for Rockingham District for a Cat 4… that’s quick!

  2. It’s flipped now – 54 mins at Rockingham, 72 at King Eddies, right up to 82 at Charlies. I think the longer waits burn themselves onto memory better than the shorter ones do.

  3. Thanks for the link to the triage categories. Fascinating and helpful. While category 1 determines that you don’t have to wait, I’d much, much rather be experiencing something of the category 4 level and putting up with the 84 minutes.

  4. Wow, WA has an amazing health system compared with ours. I waited 8 hours to be seen by anyone other than triage with acute appendicitis in a Sydney hospital (several years ago). It wasn’t even a Saturday night.
    I’ve seen some amazingly bad queuing policies cause people to be in EDs for much longer than is necessary, but they were irritation level, not life threatening level. A basic lack of resources in the whole hospital has always looked like the root cause of long delays for moderate to serious cases to me. That extract resonates exactly with my experience.
    Ariane’s last blog post..The toast tongs have landed

  5. Hospital. Arteries. Clogged.With.Preventable.Cesareans.

  6. Also relevant: Peter Garling’s report and recommendations about acute care in NSW hospitals (section II contains most of the discussion and recommendations about overcrowding and emergency departments). I’ve not read it in a huge amount of detail but I don’t think he picked caesarians as a major cause of emergency bottlenecks—it’s the ageing population and understaffing that are more important.
    One other recommendation was that emergency departments improve their communication to people presenting: patients are less likely to leave if they feel they have some idea about what is happening “behind the doors” of the hospital, what the pressures are at the time, and why they are being made to wait.

  7. Unnecessary obstetric intervention soaks up money – largely in the private system, not so much the public system, which is what this post is about. I don’t think it has much direct explanatory power in this case. For a start, I think only two of those hospitals have an appreciable number of C sections (Joondalup/King Edward), and King Edward has a tiny ED that contributes little to the stats. The very busy hospitals RPH, SCGH, FH, PMH don’t have maternity units at all.
    We’re talking largely of medical beds and aged care beds, when we’re talking about access block.

  8. “While category 1 determines that you don’t have to wait, I’d much, much rather be experiencing something of the category 4 level and putting up with the 84 minutes.”
    Yes, excellent point Pen – every time my partner has ended up in emergency he’s been seen immediately. I’d much rather it was something less serious and he’d had to wait 84 minutes.
    Is it a common thing for hosptials to have emergency short-stay units? Our local one does, it’s got around ten beds in a ward out the back of emergency, where they stick people while they find a bed for them in the appropriate ward. It seems to have reduced the number of people lying around on trollies in corridors to almost none.

  9. lauredhel you’ve really brought such insight to issues like this in your posts – love having your background knowledge at my blog-reading disposal.

  10. Unfortunately it’s not often mentioned that the ACEM itself has a particular barrow to push that isn’t necessarily agreed to by those not in the College. In general the ACEM runs the strong line that ED (or A&E depending where you live) that Emergency physicians are teh best people to oversee treatment of a wide range of peopel and that ED should:
    “Give me your tired, your poor,Your huddled masses yearning to breathe free, The wretched refuse of your teeming shore.Send these, the homeless, tempest-tost to me, I lift my lamp beside the golden door!”
    Other equally caring people might reasonably disagree with this and suggest that EDs should deal mainly with Emergencies – not second opinions about sore throats etc.
    I’m not suggesting that the Cat4 &5 are holding things up for 1 & 2, (I know they don’t) but its usually 4 & 5 that the public experiences as “long waiting times”. It’s also usually the 4 &5 that are the loud, aggressive and downright obnoxious to staff and other patients.
    It’s convieniently forgotten that people don’t just wander into ED, grab a number, and wait, and wait to be seen. Everybody who enters ED is seen by the Triage person and allocated a Category. This triage is in effect a preliminary, or tentative diagnosis, – in some places basic treatment can even be commenced at this stage with advice from triage.
    As to waiting on a trolley complaints. I know where I’d rather be if I was really ill – not up in some ward, in a hard bed, with two nurses and a young registrar wandering around but down in a corridor on a trolley with a team of hotshot Emergency Medicine people and consultants running around next door to what is basically an ICU setup.

  11. Those average waiting times could be a bit misleading depending what “average” is used? A garden variety average will smooth out the outliers. A Std Dev or something would be a better figure.
    Even so 72 minutes for Cat 4 isn’t all that bad considering that its a walk in no appointment and at any time of night or day and some times are just busier than others. Try just dropping into a lawyers or car service, or hairdressers and see how long you wait.

  12. Try just dropping into a lawyers or car service, or hairdressers and see how long you wait.
    Who will book you in for an appointment at a specific time or at least give you a numbered ticket so you know how close it is to your turn.
    Actually, if I were in the ED waiting room, I wouldn’t mind the numbered ticket system for non life-or-death cases. At least it would let me know where I am in the line instead of a vague ’60 mins or so’ estimate…

  13. Yes, communication’s essential. I can understand why medical and non-medical staff don’t like to take time and energy to explain to cranky people why they’re waiting, but really, setting up better communication’s something that could be done relatively easily by administrators.
    Last time I was sick in an emergency room (thankfully-touch-wood a long time ago, before mass computerisation) there was a big whiteboard with a brief summary of every patient’s diagnosis and medication, and the treatment they were getting, in odd shorthand. I was sick and bored out of my head and it was fascinating to watch the nurses’ and doctors’ patterns of work. I’d imagined but never realised just how busy a hospital is.
    One of the nurses saw me looking at The Big Board and asked me—please, and sorry, because of privacy legislation—if I could look away from the board, please. Look at someone else in the room vomiting or picking their wound, fine, but not the whiteboard. I was very disappointed.

    Try just dropping into a lawyers or car service, or hairdressers and see how long you wait.

    My mechanic (who I use because they’re very good) open for dropoff and pickup 7.30am to 3pm, weekdays only. Emergency failures without a booking go to the back of the queue. Complaints about waiting times receive sarcastic brushoffs.
    Compared to mechanical workshops, every emergency room in the country is a model of efficiency, transparency and solicitude.

  14. But that is unfortunately the nature of the ED. Someone may be initially a Cat 4 with vague symptoms that suddenly manifest and they become a Cat 2 or 1 which means they are going ahead of you regardless of whether you have a number or not. Or a Cat 1 is carried in through the door, and waiting times blow out again. I don’t know for sure, but I suspect there is unofficial triaging in each of the categories as well. A Cat 4 child will probably get priority over a Cat 4 adult for example.
    I once waited in the ED for a couple of hours with my daughter until the local Drs opened and then took her down there. We saw the exact same Dr, he just didn’t have to come up to the hospital to see us. I told him we’d been waiting at the hospital, so he bulk billed us.

  15. This happened to be infront of me right now: It’s all the young trendies like Liam causing the problems – research belwo shows!

    Primary care type (PCT) presentations constitute 45 per cent of presentations in Victorian metropolitan Emergency Departments (EDs) and 51 per cent of ED presentations in larger Victorian regional hospitals.
    The proportion of PCT presentations is higher in areas that correlate with decreased accessibility of GP services, particularly outer metropolitan, regional and rural areas.
    PCT presentations occur more frequently in the evenings and at
    weekends. Over the past fi ve years, the demand for after-hours PCT
    services in metropolitan hospitals has increased by a total of 18 per
    cent or 3.6 per cent per annum.
    In 2007, New South Wales collaborated with four states, including
    Victoria, purchasing a joint study from Booz Allen Hamilton Ltd to
    examine the key drivers of ED demand. The fi ndings confi rmed
    the link between demand and GP access and highlighted changed
    patient attitudes towards GPs. The under 25 years age cohort were
    found to be driving PCT service demand, using EDs as a primary care
    substitute, seeking convenience and wanting to access services all
    in one place (Booz Allen Hamilton Ltd, Key drivers of demand in the
    emergency department––A hypothesis driven approach to analyse
    demand and supply, Sydney, 2008).

  16. This happened to be infront of me right now: It’s all the young trendies like Liam causing the problems

    Causing which problems, FXH?
    Number of presentations is a very poor measure of who’s taking up time, space, and staff resources in the emergency department. Simple low-urgency presentations take up little time and resources in a properly-run fast-track system. They don’t take up beds, they don’t need to hang around after assessment/simple treatment, and they can be safely bumped down when higher-priority cases come in.

  17. I recommend having blood pouring out of your head! Works for us!

%d bloggers like this: