How one of Canada's busiest ERs made progress against overcrowding

A patient waits along the wall of a hallway in a hospital emergency room in this 2011 photo. (AP / David Goldman)

Five times a day, senior managers at Toronto's North York General get alerts on the ever-rising tide of patients arriving at the hospital's emergency department.

The updates are colour-coded -- and too many "red status" alerts prompt immediate action, with managers huddling with nurses and doctors to find space on medical units.

It's just one tactic used to make inroads against overcrowding in one of Canada's busiest emergency rooms.

From a "bed traffic control room" to a special outpatient clinic that strives to keep patients out of hospital, chief executive Dr. Tim Rutledge, a veteran ER doctor himself, cautions there's no single way to drop wait times for the 107,000 patients arriving each year.

"It's hundred and hundreds of small projects getting to the root causes," he said during an interview.

Across Canada, stories of patients languishing in emergency departments peaked this winter -- including a case of woman with internal bleeding who spent five days in the hallways of the Brampton Civic Hospital and a Halifax man dying from pancreatic cancer who was left on a gurney for seven hours before being seen by a physician.

The stories about patient indignities are prompting rising interest in what's gone right at North York General, situated between the Don River and a busy Ikea near Highway 401.

Five years ago, statistics at the mid-sized community hospital showed 90 per cent of emergency patients admitted to hospital were moved to an inpatient bed within 25 hours -- meaning some waited all day and a night for a spot in a ward.

As of late last year, the key measurement has fallen by a third to at about 19 hours -- a drop that occurred despite a 22 per cent hike in the number of patients.

When adjusted for volume, North York General's rank is now first among the 74 hospitals in ER performance, says Rutledge.

Behind it all, there's been a decade-long shift in culture aimed at seeing ER crowding as a problem that needs a hospital-wide fix.

"The emergency department and the whole in-patient side were in different worlds. We actually brought those two worlds together," said Karyn Popovich, the vice president of clinical programs and chief of nursing.

Medical departments that once saw a patient languishing in ER as another doctor's problem began to volunteer to bring them upstairs to a bed, she said.

There was also training that built understanding among the ghettoized specialities in a facility with almost 3,000 health care workers attached to it.

"We had nurses from the inpatient unit come down to emergency and see what it was like there and we had nurses from emergency go into the in-patient units ... so that we all understood the others' work environments and pressures," said Popovich.

Meanwhile, the hospital became a poster child for the North America-wide Choosing Wisely medical movement, where medical staff make recommendations on ways to eliminate wasted time and money.

Last April, the non-profit group recognized North York for reducing the number of ER laboratory tests by a third, chopping lab tests in the pre-operative clinic by 38 per cent, and cutting the number of ICU mobile chest X-rays by 12 per cent.

Dr. Donna McRitchie, vice president of medicine at North York, says "physician champions" circulate through other departments looking for ways to smooth the flow of patients.

"We had to ... make sure that everyone changed their way of thinking to, 'This is our patient. We need to deal with them,"' she says.

However, while North York has one of the country's best improvement rates, the wait times for ER patients awaiting a hospital bed is still higher than the Canadian Association of Emergency Physicians' benchmark for most patients to be placed in a bed within 12 hours.

Also, like other hospitals, it's not unusual for North York patients to be shifted into hallway placements in the medical units, rather than their own rooms, due to a lack of space.

Vicki McKenna, first vice president of the Ontario Nurses Association, said she's heard from senior nurses at the hospital that while they feel leadership listens to them, they're concerned about the future without more resources and beds.

"There's no flex in the system, there's no capacity," she said.

Nurses at the hospital also tell her they are worried what happens as a lease runs out for the hospital's Branson ambulatory care centre later this year, as it handles some cases that could end up at the main ER.

Rutledge acknowledges that he's concerned about the ever rising figures of long-term care patients -- 60 to 70 daily occupying beds -- many of them older people who can't find appropriate nursing homes.

"Not only do we get anxious about planning for population growth, but aging is a huge factor," he said.

"We need our policy makers to make sure they're thinking ahead and building the appropriate capacity."