The Grand River Hospital ED team
By: Stuart Paavola, Program Director for the Emergency, Medicine and Stroke Programs at GRH
Grand River Hospital (GRH) is home to the largest emergency department (ED) in the Waterloo Wellington region, consisting of 51 stretcher bays which managed to flow 75,282 ED patients through in 2022/23. Despite its size, the ED still faces significant challenges with congestion and overcrowding, particularly in the late afternoon and early evening, leading to extended waits to see a physician or nurse practitioner and increasing the risk of an adverse event.
“It's stressful for everyone working in the ED, particularly our triage nurses, when the number of patients coming through the front door exceeds our ability to place them in a treatment space in a timely manner. It wasn't uncommon to run out of chairs in the waiting room during peak hours due to the sheer volume of patients coming in," said Stuart Paavola, Program Director for the Emergency, Medicine and Stroke Programs at GRH.
To manage these challenges, the ED partnered with the Surgical Program to gain access to one of their ambulatory clinics located near the ED. This space was utilized from the time the clinic finished seeing outpatients at 4:00 PM until 10:00 PM each weekday and holiday. The additional space was used to see and treat low acuity patients in the waiting room who couldn't access the main ED in a timely manner because of the number of admitted patients in the ED waiting in stretchers for inpatient beds to become available.
The goal of operating additional ambulatory space outside of the main ED was to reduce wait times, improve safety and the patient experience. An additional experienced ED registered nurse (RN) was scheduled to work in tandem with a designated ED physician. Inclusion and exclusion criteria were developed to flow patients from the waiting room through the clinic space and back home without ever entering the main ED.
“The additional clinic space is essential to keep patients moving during a time when the designated ED beds are typically filled to capacity," said Dr. Bill Kalirai, Chief of both GRH and St. Mary's General Hospital EDs.
The concept was launched as a pilot. During the 10-week pilot from November 2022 to January 2023, 680 patients were seen and treated in the clinic space. Amanda Lavender, Decision Support Analyst for GRH, completed an analysis of the pilot data and found that statistically significant improvements were made in three pay-for-results (P4R) metrics:
- Time to physician initial assessment
- Length of stay (LOS) for non-admitted CTAS I-II
- LOS for non-admitted CTAS III-IV
Each metric saw improvements by approximately one hour at the 90th percentile. The improvements noted in the pilot contributed to GRH's rise in the Provincial ED P4R funding rank from 16th at the start of the pilot, to 10th by the end of January 2023. In addition to reductions in wait times, 89% of the patients surveyed who went through the clinic said they spent less time in the ED than they expected and 100% of patients said they would recommend the GRH ED.
Feedback from the nursing staff was also overwhelmingly positive. Judy Goetz is the Clinical Manager of the ED at GRH and had this to say about the pilot, “ED staff enjoyed working in the pre-surg clinic as it provided them with an opportunity to work one-on-one with an ED physician and the change of pace from working in the main department has been great for staff morale as well as helping to decant volume out of the waiting room. The positive feedback received from patients has also been a great morale booster for nurses working in the area."
Due to its success, the pilot is now being implemented and funded on a permanent basis.