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In November 2009, the Journal published our manuscript entitled “Shortening the wait: A strategy to reduce waiting times in the emergency department.”¹ Shortly after publication, we received the response above, and we wish to offer the following comments. The interested reader acknowledged that many emergency departments are working toward improving patient access to care. This work requires team commitment and a willingness to do things differently and challenge the status quo. We would like to acknowledge the hard work of the many stakeholders who made the Burnaby Hospital (BH) ED initiative successful. We would also like to provide an update on our progress with the BH ED access and flow project.

BH ED visits fall within the following acuity groupings: Canadian Triage Acuity Scale (CTAS) 1, approximately 2%; CTAS 2, 10%; CTAS 3, 45%; CTAS 4, 40%; and CTAS 5, 3%.² Acknowledging the early success of the satellite follow-up clinic, we reviewed the data and determined that despite ED overcrowding, the vast majority of ED users were not subsequently admitted to the hospital and did not need to be cared for on a stretcher. The primary users were noted to be hemodynamically stable, able-bodied patients, of whom 75% were aged under 65 years. Of note, BH ED visits for the fiscal year had increased substantially and are currently projected to surpass 60,000. However, the mean admission rate remains approximately 10.5%. Given this information, we concluded that increasing the number of inpatient beds was not a solution for ED overcrowding.²

One year ago, the fiscal resources were secured to expand the trial project, with the scope of the initiative being the creation of 3 distinct “streams of care” according to the CTAS acuity scale. The acute care stream includes all patients with a CTAS rating of 1 and 2 or complex CTAS 3. The rapid assessment stream is for patients who have a CTAS rating of 3 or complex CTAS 4. Finally, the super-track stream includes patients with a CTAS rating of 4 or 5. Services were subsequently tailored to meet the needs of the 3 distinct streams of patients treated at BH Emergency Department.

Since operationalizing this plan 1 year ago, we have sustained a left-without-being-seen rate of approximately 2% and maintained a mean admission rate of approximately 10.5%. We have been able to meet the Ministry of Health (MOH) targets for CTAS 1, 2, and 3 (arrival-to-disposition time within 4 hours) an average of 75% of the time. Prior to this initiative, we were only able to meet the MOH targets for CTAS 3 patients less than 20% of the time. In addition, we have been able to meet the MOH targets of CTAS 4 or 5 (arrival-to-disposition time within 2 hours) 71% of the time. Previously, our performance meeting this target was 40%.², ³

In summary, this initiative has made a tremendous impact on patients' access to care and in turn has improved the quality of our work environment. We have been incredibly successful in streamlining our processes and increasing ED throughput. Now that we have reviewed and improved ED flow, we are ready to engage the “rest of the house” in this process. Moving forward, we seek to improve our performance in relation to MOH targets for admitted patients, specifically focusing on placing admitted patients in inpatient beds within 10 hours of their initial presentation to the emergency department.³ Currently, we meet this target on average 58% of the time.² We have collected data with regard to discharge and admission practices within the various programs in the hospital and hope to engage the stakeholders of these units to optimize existing capacity within the hospital and improve access to in-hospital beds ultimately decongesting the emergency department.—

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1. Finamore SR, Turris SA. Shortening the wait: a strategy to reduce waiting times in the emergency department. J Emerg Nurs. 2009;35(6):509–514
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2. Fraser Health Authority . ED Visits, ED Admits to Burnaby Hospital. Burnaby: Fraser Health Authority; 2009;
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3. British Columbia Ministry of Health . Profiles of British Columbia's Six Health Authorities. British Columbia Ministry of Health; 2008;http://www.bcbudget.gov.bc.ca/2007/sp/hlth/default.aspx=10Accessed June 16, 2008
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