Emergency overcrowding and access block: A smaller problem than we think.

OBJECTIVES: Emergency department (ED) access block, the inability to provide timely care for high acuity patients, is the leading safety concern in First World EDs. The main cause of ED access block is hospital access block with prolonged boarding of inpatients in emergency stretchers. Cumulative emergency access gap, the product of the number of arriving high acuity patients and their average delay to reach a care space, is a novel access measure that provides a facility-level estimate of total emergency care delays. Many health leaders believe these delays are too large to be solved without substantial increases in hospital capacity. Our objective was to quantify cumulative emergency access blocks (the problem) as a fraction of inpatient capacity (the potential solution) at a large sample of Canadian hospitals. METHODS: In this cross-sectional study, we collated 2015 administrative data from 25 Canadian hospitals summarizing patient inflow and delays to ED care space. Cumulative access gap for high acuity patients was calculated by multiplying the number of Canadian Triage Acuity Scale (CTAS) 1-3 patients by their average delay to reach a care space. We compared cumulative ED access gap to available inpatient bed hours to estimate fractional access gap. RESULTS: Study sites included 16 tertiary and 9 community EDs in 12 cities, representing 1.79 million patient visits. Median ED census (interquartile range) was 66,300 visits per year (58,700-80,600). High acuity patients accounted for 70.7% of visits (60.9%-79.0%). The mean (SD) cumulative ED access gap was 46,000 stretcher hours per site per year (± 19,900), which was 1.14% (± 0.45%) of inpatient capacity. CONCLUSION: ED access gaps are large and jeopardize care for high acuity patients, but they are small relative to hospital operating capacity. If access block were viewed as a "whole hospital" problem, capacity or efficiency improvements in the range of 1% to 3% could profoundly mitigate emergency care delays.

Nursing duties and accreditation standards and their impacts: The nursing perspective.

BACKGROUND: Medical advances and increasingly complex patients presenting to the Emergency Department (ED) make nursing challenging. Gaining new knowledge and skills is a perpetual requirement. New quality initiatives to improve patient safety and care are being constantly introduced and create significant work and time pressures for healthcare providers involved. STUDY QUESTION: Do ED nurses support the introduction of new quality standards, in addition to their current heavy workload? STUDY DESIGN: A cross-sectional survey. METHODS: All ED nurses in the Edmonton zone were invited to complete a survey on nursing beliefs regarding various accreditation standards and their impacts. The survey was developed iteratively, involving study investigators, the Health Authority Management Team, and Nursing Managers. Response options included a 7-point Likert scale of agreement. Median ratings and interquartile ranges were determined for each survey statement. RESULTS: A total of 433/1241 (34.9%) surveys were completed. Respondents were RNs (91.4%), female (88.9%), with 0-5years ED experience (43.7%). Overall, respondents 'agreed' or 'strongly agreed' with the statements, indicating favourable attitudes towards Accreditation Canada standards and other quality initiatives. They were neutral towards universal domestic violence screening, and the differentiation between a Best Possible Medication History and medication reconciliation. CONCLUSIONS: Despite their heavy workload, nurses strongly agreed on the importance of medication reconciliation, falls risk, and skin care, but felt that improved documentation forms could support efficiency. This nursing perspective is valuable in informing attempts to standardize and simplify documentation, including the design and implementation of a provincial clinical information system.

The development of a national emergency medical services curriculum framework for physicians in Canada.

BACKGROUND: As the role of emergency medical services (EMS) continues to expand, EMS physicians and medical directors require special skills and training to keep pace with the rapidly evolving subspecialty of EMS. In Canada, subspecialty training in EMS is still relatively new, and a standard national curriculum for physician EMS training does not exist. OBJECTIVE: To develop a national EMS curriculum for emergency medicine (EM) residents and fellows and an abbreviated curriculum for non-EM trainees and community physicians. METHODS: The authors obtained EMS curricula and opportunities from Canadian EM and EMS training programs and a sample of U.S. programs to determine existing curricula, and developed a framework for a national EMS curriculum using an expert working group of EMS medical directors and EMS leaders in Canada. RESULTS: Canadian EM residency training programs included an EMS rotation, but their content and depth of training were not uniform. The expert working group proposed a comprehensive set of training objectives, grouped into 16 categories, stratified by level of training. CONCLUSION: The proposed framework and objectives are suitable for training medical students, family medicine trainees, community physicians, EM residents, and EMS fellows in Canada. The authors hope this article will serve as a guideline for residency and fellowship directors to develop their EMS training programs in a consistent manner, promote formal training for physicians involved in EMS, and help define the specific knowledge and expertise required of physicians who provide EMS medical direction in Canada.