ED overcrowding: the Ontario approach.
ABSTRACT Ontario is Canada's most populous province, with approximately 12 million people and 130 emergency departments (EDs). Canada has a national single-payer universal health care system, but provinces are responsible for administration. After years of problems and failed attempts to address chronic ED overcrowding, in April 2008 Ontario embarked on an ambitious program to improve system performance through targeted investments (initially CAN$500 million over 3 years) and realigned incentives. Supporting the program were requirements for hospitals to submit timely data and targets for length of stay (LOS) and annual improvements; results are publicly reported. The program has been continued this year. While not all our provincial level targets have been met as yet, major improvements have been made, especially in access to care and LOS in the ED for patients eventually discharged home. The greatest improvements were made among the cohort of mainly urban, high-volume EDs that had the worst performance at baseline. This presentation will highlight some of the controversies and challenges and key lessons learned. Overall, the Ontario experience suggests ED overcrowding is a soluble problem, but requires a system-level intervention.
- SourceAvailable from: Jesse Pines[Show abstract] [Hide abstract]
ABSTRACT: Emergency department (ED) crowding is a major public health problem in the United States, with increasing numbers of ED visits, longer lengths of stay in the ED, and the common practice of ED boarding. In the next several years, several measures of ED crowding will be assessed and reported on government websites. In addition, with the implementation of the Affordable Care Act (ACA), millions more Americans will have health care insurance, many of whom will choose the ED for their care. In June 2011, a consensus conference was conducted in Boston, Massachusetts, by the journal Academic Emergency Medicine entitled "Interventions to Assure Quality in the Crowded Emergency Department." The overall goal of the conference was to develop a series of research agendas to identify promising interventions to safeguard the quality of emergency care during crowded periods and to reduce ED crowding altogether through systemwide solutions. This was achieved through three objectives: 1) a review of interventions that have been implemented to reduce crowding and summarize the evidence of their effectiveness on the delivery of emergency care; 2) to identify strategies within or outside of the health care setting (i.e., policy, engineering, operations management, system design) that may help reduce crowding or improve the quality of emergency care provided during episodes of ED crowding; and 3) to identify the most appropriate design and analytic techniques for rigorously evaluating ED interventions designed to reduce crowding or improve the quality of emergency care provided during episodes of ED crowding. This article describes the background and rationale for the conference and highlights some of the discussions that occurred on the day of the conference. A series of manuscripts on the details of the conference is presented in this issue of Academic Emergency Medicine.Academic Emergency Medicine 12/2011; 18(12):1229-33. · 2.20 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: The emergency department (ED) is a “unique operation, optimized to exist at the edge of chaos”. It is the responsibility of the leaders and managers of the ED to ensure that their teams work in an environment where they can deliver the best care to their patients. This environment is defined by people, system and place. People are the most important asset of the ED. One of the most important responsibilities of the ED leaders and managers (senior management) is to foster teamwork. They will also have to ensure that communication between team members is optimal and that there is a structure in place for conflict resolution. ED senior management should be aware of their team dynamics and know the “movers and shakers” in their organization. ED systems should be kept simple. One of the core businesses of an ED is contingency planning. ED senior management must plan, prepare, practice, review, analyze, assess and strategize for unexpected events. The ED physical environment has an impact on the flow of care being delivered to her patients. ED senior management must manage change. Change works only if it takes root in the hearts and minds of the organization's people. The quality of the leaders and managers of the ED will determine whether or not, their teams work in an environment where they can deliver the best care to their patients.Journal of Acute Medicine. 09/2013; 3(3):61–66.
- [Show abstract] [Hide abstract]
ABSTRACT: As the United States seeks to improve the value of health care, there is an urgent need to develop quality measurement for emergency departments (EDs). EDs provide 130 million patient visits per year and are involved in half of all hospital admissions. Efforts to measure ED quality are in their infancy, focusing on a small set of conditions and timeliness measures, such as waiting times and length-of-stay. We review the history of ED quality measurement, identify policy levers for implementing performance measures, and propose a measurement agenda. Initial priorities include measures of effective care for serious conditions that are commonly seen in EDs, such as trauma; measures of efficient use of resources, such as high-cost imaging and hospital admission; and measures of diagnostic accuracy. More research is needed to support the development of measures of care coordination and regionalization and the episode cost of ED care. Policy makers can advance quality improvement in ED care by asking ED researchers and organizations to accelerate the development of quality measures of ED care and incorporating the measures into programs that publicly report on quality of care and incentive-based payment systems.Health Affairs 12/2013; 32(12):2129-38. · 4.64 Impact Factor
ED Overcrowding: The Ontario Approach
Howard Ovens, MD, FCFP(EM)
Ontario is Canada’s most populous province, with approximately 12 million people and 130 emergency
departments (EDs). Canada has a national single-payer universal health care system, but provinces are
responsible for administration. After years of problems and failed attempts to address chronic ED over-
crowding, in April 2008 Ontario embarked on an ambitious program to improve system performance
through targeted investments (initially CAN$500 million over 3 years) and realigned incentives. Support-
ing the program were requirements for hospitals to submit timely data and targets for length of stay
(LOS) and annual improvements; results are publicly reported. The program has been continued this
year. While not all our provincial level targets have been met as yet, major improvements have been
made, especially in access to care and LOS in the ED for patients eventually discharged home. The
greatest improvements were made among the cohort of mainly urban, high-volume EDs that had the
worst performance at baseline. This presentation will highlight some of the controversies and challenges
and key lessons learned. Overall, the Ontario experience suggests ED overcrowding is a soluble
problem, but requires a system-level intervention.
ACADEMIC EMERGENCY MEDICINE 2011; 18:1242–1245 ª 2011 by the Society for Academic
overcrowding: preemergency factors that drive demand
for emergency services, size⁄capacity of the ED and its
efficiency of processing, and flow out from the ED to the
hospital wards.3My own jurisdiction, Ontario, Canada,
is currently in the fourth year of a multiyear ambitious
approach to ED overcrowding across the province.
Ontario is the most populous province in Canada
with over 12 million people (one-third of Canada’s
population). Health care is publicly funded throughout
Canada, but service delivery is the jurisdiction of the
province. In Ontario there are approximately 75 hos-
pitals with EDs whose censuses are over 30,000 vis-
its⁄year, spread over a huge geographic area, and
there are approximately another 60 smaller units in
mergency department (ED) overcrowding is a
widespread problem with many negative poten-
tial effects.1,2Many factors can contribute to
rural centers. ED overcrowding has been a problem
in Ontario for many years4and had been blamed for
some tragic cases involving delays in provision of
care to newly arriving patients. Overcrowding had
also led to high rates of ambulance diversion, and
problems with staffing of units with physicians and
nurses due to high stress and low morale, and was
generally becoming a political problem. In response
to these pressures, the government commissioned a
report on the subject in 2006.5The report reviewed
the problem of overcrowding in general and made
many recommendations, but the key findings of the
• ED crowding is generally due primarily to sick
patients who need care and usually inpatient beds,
not inappropriate ED use by patients with low-acuity
PII ISSN 1069-6563583
ª 2011 by the Society for Academic Emergency Medicine
From the Schwartz⁄Reisman Emergency Centre, Mount Sinai Hospital, and the Department of Family and Community Medicine,
University of Toronto, Toronto, Ontario, Canada.
Received June 17, 2011; revision received July 15, 2011; accepted July 20, 2011.
This article represents a component of the 2011 Academic Emergency Medicine Consensus Conference entitled ‘‘Interventions to
Assure Quality in the Crowded Emergency Department (ED)’’ held in Boston, MA.
Funding for this conference was made possible (in part) by 1R13HS020139-01 from the Agency for Healthcare Research and Quality
(AHRQ). The views expressed in written conference materials or publications and by speakers and moderators do not necessarily
reflect the official policies of the Department of Health and Human Services, nor does mention of trade names, commercial prac-
tices, or organizations imply endorsement by the U.S. Government. This issue of Academic Emergency Medicine is funded by the
Robert Wood Johnson Foundation.
Dr. Ovens acts as an advisor on health policy to the Government of Ontario. He has no other conflicts of interest or disclosures to
Supervising Editor: James Miner, MD.
Address for correspondence and reprints: Howard Ovens MD, FCFP(EM); e-mail: email@example.com.
problems (they require few resources). Thus reducing
ED demand is a small part of the solution.
• ED crowding is most commonly due to the boarding
of inpatients lackingbeds
ods—reducing or eliminating this should greatly
improve ED efficiency.
• The problem is system-based, and related to lack of
incentives, or even perverse incentives for hospital
administrators, as well as problems in the wider
health care system. It is beyond the capacity of indi-
vidual hospitals to solve alone—it requires a system
The government responded with a major investment
of effort and funds to try and solve the problem defini-
tively. They appointed an expert panel to provide advice
on their strategy (I have been a member of the expert
panel since inception and am currently the co-chair).
Initial investment was roughly CAN$500 million over
3 years. The program began officially April 1, 2008. The
approach has been summarized by one of its architects,
Dr. Alan Hudson, as ‘‘data, money, and shame’’ and
built on experience reducing waiting lists for scheduled
surgical and imaging procedures in the province. The
key elements were:
• Ordering hospitals to report a common data set to
the government monthly (we now have province-
wide data on a host of indicators within 3 weeks of
month end). These are ‘‘the data.’’
• Setting targets for length of stay (LOS) of ED patients
based on triage acuity and disposition—the target for
patients being admitted or complex patients (based
on arrival acuity) being discharged home is 8 hours
from arrival to departure to unit or home and for
noncomplex (low-acuity) patients is 4 hours from
arrival to discharge. The overall goal for the program
initially was to have 90% of patients seen within their
target by end of March 2011.
• Hospitals receive additional funds each year contin-
gent on meeting hospital-specific improvements in
achieving targets. This is called pay for performance:
• Hospital performanceis
Other features include an expert panel to advise gov-
ernment on program planning, an intensive coaching
program for hospitals to provide staff with information
on best practices and to introduce them to ‘‘Lean’’ man-
agement techniques, and a major effort to improve hos-
pital outflow by reducing the number of patients in
hospital wards waiting for care in nonacute facilities
such as nursing homes, rehabilitation centers, etc.
(‘‘ALC’’ or alternate level of care patients).
After 3 years the results are mixed: the ED report-
ing system is a great success and provides a wealth of
timely data for local and provincial use. Ambulance
offload delays and diversions have largely been solved
(see Figure 1). Overall, 85% of all patients and over
90% of discharged patients meet their LOS targets
(see Figure 2). Some hospitals have achieved dramatic
improvements in flow; however, a few hospitals have
not made significant improvements yet. There has
been only marginal sustained improvement in flow of
admitted patients at the provincial level (see Figure 3),
and the effort to create capacity by reducing inpa-
tients waiting for alternate levels of care has had
some local success stories but only marginal success
overall. However, if we look at trends prior to 2008
and changes in population and hospital volumes since,
Mount Sinai St. Joseph’s St. Michael’s Sunnybrook Toronto East
90% TOC Time (pre)90% TOC Time (post)
Figure 1. Ambulance offload times for central Toronto. TOC = transfer of care; pre = before ambulance offload nurse program
April 2008; post = March 2011; UHN = University Health Network (a multi-site hospital corporation operating ERs on two sites,
Toronto General [General] and Toronto Western [Western]). All times are 90th percentiles. Note decreased variability as well as
improved performance. Result is 63.3 mean unit hours saved⁄day. Data courtesy of Toronto EMS.
ACADEMIC EMERGENCY MEDICINE•December 2011, Vol. 18, No. 12•www.aemj.org
we would be in a much worse position on admitted
flow and ALC levels in Ontario today without the
At the unit level, I believe the changes have been sig-
nificant and worthwhile and have positively affected the
patient experience. At my own facility, Mount Sinai
Hospital, an urban academic center in Toronto, flow is
dramatically improved, morale is better, patient satis-
faction is better, and conflict between triage and ambu-
lance staff has disappeared. Our 90th percentile LOS
for all complex patients combined (all those with 8-hour
targets including admitted patients) has gone from
18.5 hours at program inception to 11 hours currently,
while noncomplex discharged patients with a 4-hour
FY0809 FY0910 FY1011
Combined: Percent completed within 8/4 hours by Cohort
Year 1 sites (N=23) Year 2 sites (N=23) Year 3 sites (N=25)Provincial
Figure 2. Three-year trend by program year: percentage of all patients within target LOS. Total number of hospital sites = 128;
only the 71 sites with annual volume of > 30,000 visits were eligible for pay for results program, sites added to program in three
cohorts from worst performing in Year 1 to best in Year 3. Data courtesy of Access to Care at Cancer Care Ontario.
Admi?ed: Percent completed within 8 hours by Cohort
Year 1 sites (N=23)Year 2 sites (N=23)Year 3 sites (N=25)Provincial
Figure 3. Admitted: percentage completed within 8 hours by cohort. Total number of hospital sites = 128; only the 71 sites with
annual volume of > 30,000 visits were eligible for pay for results program, sites added to program in three cohorts from worst per-
forming in Year 1 to best in Year 3. Data courtesy of Access to Care at Cancer Care Ontario.
Ovens•ED OVERCROWDING: THE ONTARIO APPROACH
target have had their 90th percentile LOS in the same
period go from 6.6 to 4.3 hours. In October 2009, due
to H1N1 influenza, Ontario had a record volume of ED
400,000), but flow performance improvement was main-
tained, demonstrating the sustainability of the improve-
ments in the face of a significant volume surge.
Provincial performance also held steady during a signif-
icant province-wide bed crunch related to the higher
acuity flu season of this past winter.
The surprising thing so far is that the improvements
have been largely due to coordinated efforts to improve
processing within EDs, as flow out of the ED is only
modestly improved. Thus, most of the improvement we
have seen has been due to culture change, some tar-
geted staffing increases, and process improvement
within the ED: ‘‘RAZ’’ units (see below), patient flow
coordinators (coordinate bed supply and demand daily
hospital-wide), ambulance offload nurses (dedicated
staff to assume care of patients arriving by ambulance
in the waiting room if necessary—which has almost
eliminated the ambulance offload delay problem in
urban areas), and better staff scheduling (match peaks
in patient arrivals better).
One of the most successful and widely adopted strat-
egies within EDs has been what we have called ‘‘RAZ’’
for Rapid Assessment Zones. To prevent stretcher grid-
lock, an area in the ED is set aside for an internal wait-
ing room and patients who are able get undressed and
into hospital gowns and wait in a chair. They only use a
stretcher in one of several nearby exam rooms when
the doctor examines them, for nursing procedures, etc.,
and at all other times they wait in the chair. Patient
acceptance has been surprisingly good.
The program has not been without controversy.
Some health care workers have felt they were being
criticized or were being asked to work harder, faster,
or longer and were already doing the best they could.
We have tried to stress that individuals are being asked
to work smarter, not harder, within a better, more effi-
cient system—and that they should never compromise
any individual’s care to meet performance targets. To
support this position, we allow hospitals to elect to
observe up to 5% of their patients ‘‘off the clock’’ by
admitting them to a conforming observation area
(‘‘CDU’’ or clinical decision unit) of their ED under
strict performance criteria. While some have felt this is
a cynicalattemptto game
changing patient experience, we monitor compliance
closely and feel it is a worthwhile effort to ensure no
one uses the program and its targets as an excuse for
providing substandard care.
Perhaps the greatest barrier to solving ED over-
crowding is an attitude of nihilism, that nothing can be
done. Efforts at the individual unit and hospital level to
improve flow are to be supported, reported, and cele-
brated. However, ultimately the experience in Ontario
and other jurisdictions4,7,8proves that ED overcrowd-
ing is a system problem requiring a system solution.
2. Richardson DB, Mountain D. Myths versus facts in
emergency department overcrowding and hospital
access block. Med J Aust. 2009; 191:369–74.
3. Juan A, Enjamio E, Moya C, et al. Impact of hospi-
tal management measures to increase efficiency in
the management of beds and reduce emergency
department congestion. Emergencias. 2010; 22:249–
4. Schull MJ, Szalai JP, Schwartz B, Redelmeier DA.
systematic hospital restructuring: trends at twenty
hospitals over ten years. Acad Emerg Med. 2001;
Access to Emergency Care: Addressing System
Issues. Available at: http://www.health.gov.on.ca/
access/improving_access.pdf. Accessed Sep 2, 2011.
6. Ontario Ministry of Health and Long-Term Care.
Ontario Wait Times. Emergency Room Search Sec-
search/er/. Accessed Sep 2, 2011.
7. Olshaker JS, Rathlev NK. Emergency department
overcrowding and ambulance diversion: the impact
and potential solutions of extended boarding of
admitted patients in the emergency department.
J Emerg Med. 2006; 30:351–6.
8. Trzeciak S, Rivers EP. Emergency department over-
crowding in the United States: an emerging threat
to patient safety and public health. Emerg Med J.
ACADEMIC EMERGENCY MEDICINE•December 2011, Vol. 18, No. 12•www.aemj.org