Introduction: Wait time predictions have become more common in emergency departments in Canada. These estimate the wait times a patient faces to see providers and they are usually provided in an accessible way such as through an online interface. One purpose of these trackers is to improve ED system efficiency. Patients can self-triage to alternative care such as their primary care physician, defer care until a later time or could move from oversubscribed to undersubscribed EDs. However, these mechanisms could also be abused. If providers can artificially influence the wait time this may provide a possible lever to change patients flows to an ED. I investigate whether there is evidence suggestive of manipulation of online wait time trackers at an ED system in Ontario. Methods: Inputs into the wait time prediction algorithm, like patient volumes are taken from the ED EMR. This is the most likely place where staff can manipulate the wait time tracker by retaining patients in the EMR system even after they are discharged. I examine two sets of data to assess whether the online tracker displays differences in patient volumes from “true” data. The first is scraped data of patient volumes from the wait times website. The second are the accurate patient volumes from administrative data which includes when a physician discharged patients from the ED. I compare values of the true patient volumes to the online values and plot distributions of these differences. I also employ measures of accuracy such as mean square error and root mean square error to provide a value of how accurate the online data is compared to the true data. I examine these by ED and over time. Results: There are differences between the number of patients that are posted online and those in the administrative data. The distributions of these differences are skewed towards positive values suggesting that the online data more often overcounts rather than undercounts patients. Measures of accuracy increase during times when EDs are congested but do not decrease when EDs become less congested. This inaccuracy persists for a period after EDs cease to be busy. Conclusion: ED wait time trackers have the potential to be manipulated. When staff have incentive to reduce patient volumes, online data becomes more inaccurate relative to true data. This suggests that wait time trackers may have unintended consequences and that the information that they provide may not be entirely accurate.

Background: Cervical spondylotic myelopathy (CSM) is the leading cause of spinal cord impairment. In a public healthcare system, wait times to see spine specialists and eventually access surgical treatment for CSM can be substantial. The goals of this study were to determine consultation wait times (CWT) and surgical wait times (SWT), and identify predictors of wait time length. Methods: Consecutive patients enrolled in the Canadian Spine Outcomes and Research Network (CSORN) prospective and observational CSM study from March 2015 to July 2017 were included. A data-splitting technique was used to develop and internally validate multivariable models of potential predictors. Results: A CSORN query returned 264 CSM patients for CWT. The median was 46 days. There were 31% mild, 35% moderate, and 33% severe CSM. There was a statistically significant difference in median CWT between moderate and severe groups; 207 patients underwent surgical treatment. Median SWT was 42 days. There was a statistically significant difference in SWT between mild/moderate and severe groups. Short symptom duration, less pain, lower BMI, and lower physical component score of SF-12 were predictive of shorter CWT. Only baseline pain and medication duration were predictive of SWT. Both CWT and SWT were shorter compared to a concurrent cohort of lumbar stenosis patients (p <0.001). Conclusions: Patients with shorter duration (either symptoms or medication) and less neck pain waited less to see a spine specialist in Canada and to undergo surgical treatment. This study highlights some of the obstacles to overcome in expedited care for this patient population.

Introduction: Prior Canadian Emergency Department (ED) studies have demonstrated variable benefits of initial assessment physician (IAP) to rapidly assess and initiate care of ED patients after triage. These studies have been conducted primarily in academic teaching and large urban hospitals. It is not clear if such an IAP role could be beneficial in an small community hospital. Our pilot study hypothesized that instituting a supported IAP role can reduce physician intial assessment (PIA) time, total ED length of stay (LOS), and left-without-being-seen (LWBS) rates. Methods: This was a pre and post interrupted time series observational study at a community ED in Niagara Health Systems (Welland Ontario, 4 MD shifts, 36hrs total coverage, 30000 annual visits). In July 2017, an IAP ED shift (with separate assessment/treatment area) was re-purposed, with nursing support, to reduce initial time to MD assessment after triage. For lower acuity cases, the IAP MD generally completed full case management & disposition. Higher acuity complex cases were initiated by IAP, and transferred into the main ED care areas for “inside” MD management. Administrative data was accessed for 6 months prior to intervention, and 4 months available post-intervention. Descriptive statistics were calculated for collected data. Results: A modest improvement in different administrative ED performance metrics was observed. The following changes were noted pre and post IAP intervention: PIA time reduced from 3.6hrs to 3.2hrs, total ED LOS reduced from 19.2hrs to 13.8hrs, and daily LWBS rate reduced from 4.2% to 3.7%. This pilot study demonstrated improvement trends in ED performance metrics, although there is insufficient data to show statistical significance. Aggregate data was not subgrouped based on CTAS categories. This pilot was not intended to collect patient or staff satisfaction data, adverse events, nor designed to demonstrate cost-effectiveness Conclusion: Introducing an IAP shift in a small community ED has shown improvement trends for various ED throughput measures pertaining to outcomes such as PIA time, total LOS and LWBS rates. Further research is required to determine statistical significance of time reductions, satisfaction (patients, staff), resource utilization impact and CTAS subgroup performance. This improvement demonstrates potential impact system-wide across Niagara region.

Introduction: Physician access to presenting complaint information may lead to cherry picking if some patients are seen as more attractive than others. Our objective was to determine whether chief complaint CC descriptors are associated with differing wait time to MD, hence whether physicians preferentially see patients with selected presenting complaints. Methods: We collated administrative data on all Calgary ED patients from 2016. Those in CTAS categories 1 and 5 were excluded, as well as fast track patients (because of single coverage). We described most common chief complaint (CC) categories and their median wait time to MD, adjusted for ED arrival site, patient sex, triage acuity, and need for admission. Results: We studied 128,812 subjects (54% CTAS2, 46% CTAS34) with 56,243 males and 72,569 females. Mean age was 50.6 years (sd=20), and most common CC categories (%) were abdominal pain (22%), chest pain (14.6%), musculoskeletal problems (7.2%), flank pain (5.2%), URI/Fever (4.7%), dyspnea (4.6%), headache (4.6%), and back pain (4.0%). Median TTMD was 84 min and admission rate in the study cohort was 30.4%. Multiple linear regression modeling showed that, in addition to CC category and ED arrival site, CTAS level, female sex, and need for admission changed TTMD by 18.6 min (per CTAS level), 6.6 min, -19.2 min respectively. Based on adjusted TTMD, the least attractive CC categories (adjusted median TTMD) were constipation (104 min), back pain (103), Depression/anxiety (103), abdominal pain (102), and dizziness/sensory disturbance (98); while the most attractive were trauma (44 min), allergic reaction (46), stroke symptoms (49), palpitations (61), and overdoses (66). Conclusion: There is a larger than expected difference in waiting times associated with specific chief complaint categories. This has implications for the way that patients are assigned to physicians or perhaps the way that chief complaint data is transmitted.

Introduction: Improving emergency department productivity has been a priority across Canada. In the United States, medical scribes have been utilized to increase the number of patients seen per hour (PPH) per physician; however, it is not well known if these outcomes can be translated to Canada. The purpose of this pilot evaluation was to (a) establish proof-of-concept of medical scribes in Canada and (b) gain experience in scribe implementation so as to inform future directions for the use of scribes in Canada. It was hypothesized that use of medical scribes would result in a greater PPH per physician. Methods: We conducted a four-month pilot evaluation of medical scribes in the emergency department of the Queensway-Carleton Hospital in Ottawa, Ontario. Eleven scribes were utilized in the study ranging in age from 18 to 23 years old. Following scribe training and an initial two-month acclimation period for both scribes and physicians, data collection began January 2015. Twenty-two full or part time emergency physicians were followed in this study, who received shifts with and without a scribe over the next four months. Physician work hours as well as the number of patients seen by each physician on each shift was documented. From these metrics, PPH per physician was calculated for each shift. Across the four months, the average PPH was determined for each physician during shifts with a scribe and shifts without a scribe. Two-tailed paired-samples t-tests (α=0.05) were used to compare mean (SD) PPH within physicians based on presence or absence of a scribe. Results: A total of 463 physician hours were documented without use of a scribe and 693.75 physician hours were documented with use of a scribe. Across all 22 physicians in the study, 18 (81.8%) demonstrated a greater PPH with use of a scribe. Overall, PPH per physician was significantly greater (12.9%) during shifts with a scribe (mean 2.81, SD 0.78) compared to shifts without a scribe (mean 2.49, SD 0.60) (p=0.006). Sensitivity analyses revealed that PPH per physician during shifts without a scribe during the study period were similar to the year prior, before scribes were introduced to the hospital (p=0.315). Conclusion: Use of medical scribes resulted in an increased PPH per physician in our hospital. While these results were from an evaluation at a single centre, they support broader implementation and evaluation of scribes in more centres across Canada.

Introduction: Patient satisfaction in the emergency department (ED) has been shown to be associated with patient compliance, likelihood to return, and likelihood to recommend the ED. Understanding the factors that affect patient satisfaction in the ED is important but remains poorly understood. This scoping review consolidates the information from the available literature to offer insight into which key factors influence patient satisfaction. Methods: A literature search using initial criteria identified 683 articles. These titles were subjected to inclusion/exclusion criteria and their relevance was independently reviewed by two authors. Consensus was reached on 24 articles to be included, and these were then classified according to study design (class I=observational studies, class II=focus group/qualitative studies, class III=reviews), as well as multiple other factors (ED type, volume of patients, sample size, population, type of study, methodology, study measures, statistical analysis, reliability and conclusions). Using these factors, 25 different ED care attributes were examined in the primary literature, and then narrowed to the 6 most commonly studied factors with 3 categories (wait times, communication/information received in the ED, and interpersonal skills of staff). Results: The impact of wait times (WT) on patient satisfaction in the ED was addressed in 58% of the articles and various studies have found that longer perceived WTs (the length of WTs as reported by patients) are associated with poorer patient satisfaction. Information delivery demonstrated statistically significant associations to both patient satisfaction and the likelihood of a positive recommendation. Interpersonal skills of the staff also demonstrated a strong association with patient satisfaction. Conclusion: The most common factors affecting patient satisfaction in the ED can be categorized under wait times, communication, and the interpersonal skills of the staff. However, the literature in this area is weak, and well-designed comparative studies of the relative importance of each of these factors are necessary to support evidence-based policy making and ultimately improve patient satisfaction.