ICES | Emergency Department Services in Ontario 1993 - 2000 - page 8

In the early 1990’s, planners believed that EDs could be consolidated if non-
urgent cases were diverted to care settings outside the ED. On this basis, a
Toronto study concluded that the city had an oversupply of ED capacity
a Windsor report recommended the closure of two of four EDs.
In the latter part of the 1990’s, the responsibility for hospital restructuring was
given to the Health Services Restructuring Commission (HSRC). Unlike earlier
restructuring efforts, which were voluntary, the HSRC’s recommendations
were made mandatory through provincial legislation. The HSRC closed or
merged numerous institutions in order to consolidate hospital services into
fewer sites, make better use of existing capacity and reduce duplication of
administrative staff. Many EDs either closed or reduced their services as
hospitals were closed or converted to other uses. ED renovation and
expansion was also undertaken at a number of the remaining hospitals.
Utilization of Emergency Departments
Longer Term Trends
Ontario residents made 314 ED visits per 1,000 persons in 2000, which was
lower than rates reported in the U.S. (378 visits/1000)
or Edmonton (426
Part of this difference may be due to the exclusion of twelve
EDs on AFPs from this study, which resulted in an approximate undercount
of ten per cent of visits. Comparisons with other jurisdictions should be made
with caution, as different definitions of EDs and visits may have been used.
Over the study period, ED use declined significantly in Ontario. This trend is
opposite to that in the US, where ED use rose 14 per cent over 7 years (357
visits/1000 population in 1992 to 378 in 1999).
Reasons for the increase in
the US are not entirely clear, but possibilities include:
Population growth and aging;
The easing of restrictions on emergency care utilization by health maintenance
Stricter enforcement of legislation guaranteeing access to emergency care;
Increasing numbers of uninsured Americans who use the ED as the
provider of last resort.
The decline in ED use in Ontario was more noticeable among visits for colds,
ear infections and other infectious diseases. Such conditions represent
relatively low acuity cases, although the reader should be cautioned that
such inferences are imprecise when based on an after-the-fact diagnosis.
Nonetheless, this finding helps explain why ED use has declined in the
pediatric population, among whom these minor conditions are most common.
There are several possible reasons for the decline in ED use:
There may have been a proliferation of walk-in clinics to handle low acuity cases;
The closure of EDs may have reduced access to care;
The shift from fee-for-service to remuneration by the hour may have
encouraged the diversion of non-urgent patients to other care settings.
It must be emphasized that these theories are speculative and further
research is needed to determine their validity.
Some observers may find a decline in ED use unusual given the attention paid
to ED overcrowding in the past few years. However, several studies have
failed to identify a strong relationship between ED overcrowding and overall
This study suggests two reasons why overcrowding may be
worsening despite reduced overall utilization. First, ED closures have led to
a 10 per cent increase in visits at the remaining centres. Second, ED patients
are older and have fewer minor conditions than before. This may have resulted
in higher patient acuity and increased ED workload. A third possibility is that
admitted patients may remain in the ED longer because hospital restructuring
has led to reductions in acute care beds and planned increases to community-
based long-term care services have not been fully implemented.
Predictable Variations in Demand Over Time
This study shows that there are clearly identifiable peak periods in ED volume
which occur at a system-wide level. Frequent headlines about ED congestion
in the media suggest that management of these peaks is a significant concern
among the public. These peaks are predictable and occur during public
holidays, weekends, and the summer months when hospitals typically
reduce staff.
Similarly, family physician offices may be closed or have
reduced hours during these periods. When patient load is heavy in the ED, it
may not be possible to shift patient volumes to other EDs in the system
because these facilities are also likely facing similar burdens.
Given the fact that ED volume can, on certain predictable days, be one-third
above average, this study raises questions about how to best manage these
peaks. In theory, managers may want to ensure that additional staffed hospital
beds, physicians and other personnel are present or on standby to clear the
overload on predictably busy days. Ensuring flexibility in the system, such as
by having a pool of staff available for short-term peaks or being able to vary
the number of hospital beds from day to day, may mitigate the impact of
these peaks. This assumes, however, that hospitals have the resources and
staff available to do so. Furthermore, the peak periods—public holidays and
weekends—occur when physicians and hospital personnel themselves want
Institute for Clinical Evaluative Sciences
Emergency Department Services in Ontario
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