1. Why are so many Canadians accessing ED care?

Prior to the 2019–20 coronavirus (COVID-19) pandemic, almost every province and region in Canada were experiencing increased ED patient volumes, with predictable bursts during seasonal epidemics; compared with other countries, our ED use is high.⁵ When asked, most patients have actually attempted other alternatives, such as calling their family physician, seeking an alternative provider (either physician or other health professional), calling a provincial health line, and/or waiting for their symptoms to resolve.^{Reference Krebs, Kirkland and Chetram1} In the end, when surveyed, once again, most patients feel that the ED is the appropriate location for care, and they are willing to wait to obtain the expertise of trained emergency providers. In fact, tech savvy millennials have often searched their symptoms online (“there's an app for that”), consulted with others, and made a conscious decision to use the ED when necessary.

You may ask: why not visit another provider? For a variety of reasons, access to other providers may not be possible. Firstly, for the most recent period for which statistics were available (2015–2016), Statistics Canada reported approximately 15% of the population age 12 years and older had no regular healthcare provider. In EDs where research on this topic has been conducted, that percentage approximately doubles to 30%.^{Reference Krebs, Kirkland and Chetram1} There are many reasons for these observations. Canada appears to have slightly fewer physicians per 1,000 population (2.5 v. 3.5 for other countries) in the Commonwealth Fund Survey; however, the maldistribution of family physicians limits access for many patients, especially inner city, remote and rural, and many disadvantaged populations.

Even when patients have a family physician, timely access is a major issue. This is further borne out by the Commonwealth Fund Survey, a comparison of 11 high-income countries, which suggested that patients age 18 years and older in Canada receive poor healthcare on the basis of metrics associated with wait times for family physicians, specialists, and emergency physicians.⁵ Importantly, Canada ranks last with more than 57% of citizens not being able to obtain a same day or next day appointment at their regular place of care.

2. What is the rationale for diversions?

One healthcare zombie idea (i.e., ideas that refuse to die, despite being refuted) is the myth long popularized by politicians, administrators, and the media that ED overcrowding results from large numbers of patients seeking “unnecessary” or “inappropriate” care. The diversion of such patients away from the ED has gained widespread popularity with bureaucrats, health consultants, and even with some physician groups.^{Reference Berthelot, Lang and Messier4} The term diversion was first used to describe patients transported by emergency medical services (EMS) with serious conditions where this approach was shown to be detrimental to patients and some unfortunately died. While some patients with simple presentations are treated and released by EMS staff, there is consensus on what constitutes safe practice. For example, patients with treated and resolving hypoglycemia and those with minor trauma who are ambulatory are routinely and appropriately treated and released. The application of this approach to all comers seems both unnecessarily complex and risky.

3. Why can't we agree on low-acuity presentations?

In a systematic review on the topic, the definitions of low-acuity care or avoidable ED visits varied widely.^{Reference Kirkland, Soleimamn, Rowe and Newton6} Three approaches have been taken: patient triage, provider triage, and outcomes (discharge); however, these provide incomplete pictures of ED encounters. Firstly, there is good evidence that patients both underestimate and overestimate the severity of their illnesses; these decisions can be deadly in conditions like acute strokes, myocardial infarction, and sepsis. Secondly, the five-level Canadian Triage and Acuity Scale (CTAS) used in Canadian EDs is not a scale for appropriateness; it simply sorts patients to determine priority of assessment based on a brief assessment. Patient complexity and comorbidities, which contribute to resource use, are not measured by CTAS. Indeed, it has been demonstrated that patients in all CTAS levels may require imaging, consultation, and hospitalization for their conditions.^{Reference Dong, Bullard and Meurer7} New algorithms for diverting patients are being deployed in some Canadian EDs; however, until they are carefully tested, everything is an unproven proxy for proper clinical assessment by a trained provider. Thirdly, the outcomes in administrative data (e.g., discharge status) are provided after the ED assessment and treatment, and cannot be used to determine who can safely be diverted elsewhere for care.

4. What is the evidence supporting these diversions strategies?

The most important reason for not diverting patients is the complete lack of high-quality evidence to support the practice. A recent systematic review of both EMS and ED diversions found poor methods/biased evidence, disparate outcome reporting, and heterogeneity. Importantly, many patients who arrived in the ED refused the alternative option.^{Reference Kirkland, Soleimamn, Rowe and Newton6} Clearly, we can learn from patients! Secondly, diversion failed to reduce ED presentations and admissions. With the known risks associated with diversion after a brief encounter, it's hard to understand why so much effort is directed at this issue. Wouldn't it be more appropriate to see this same level of effort directed at strategies that have evidence to support their implementation?^{Reference Rowe, Guo and Villa-Roel8} Finally, patient satisfaction scores suggest that, despite waits, the quality of ED care is rated highly. This is even more impressive since prolonged wait times often decrease satisfaction scores.

5. What are the alternatives?

Given that there is no acceptable definition, the intervention may be unsafe, and it's not what patients want, what alternatives are there? At a health system level, a focus on strategies that pull patients towards appropriate care alternatives may be more successful than those that push them away from the ED. Increasing same-day access to family physicians, improving urgent care models so they integrate with primary care and ensure continuity post-visit, and creating information systems that share real-time patient data among providers may help. Moreover, planned seasonal pop-up “fever clinics” that can be set during anticipated annual influenza/cough/cold outbreaks could all provide patients with alternatives that they could choose to use, while still enabling those patients to choose the ED when that is their best option.

Within the ED, there are also strategies proven to help, some with quite strong evidence to support them. For example, nurse-directed orders, especially for musculoskeletal conditions, can expedite care and have been found to be safe.^{Reference Rowe, Villa-Roel and Guo9} In addition, most EDs now have a fast-track area for more minor problems. The use of triage liaison physicians have been shown in systematic reviews^{Reference Rowe, Guo and Villa-Roel8} to be effective. Finally, intake areas or clinical decision units have been used successfully by many Canadian EDs. These are but a few of the options available to Canadian decision-makers; however, it's important to recognize that every ED has its own signature, and adopting interventions or strategies needs to be tailored to the specific ED.

During the current COVID-19 pandemic, some Canadian EDs are experimenting with virtual care where physicians provide advice to patients or their referring physicians based on a telephone or a video/phone assessment, resulting in a suggestion to proceed to the ED in person or the provision of an alternative. This happened during times when ED volumes were low, when physicians on duty had time, and avoidance of in-person assessments, where possible, was encouraged to conserve personal protective equipment and limit viral spread. If the logistics, including payment models, are resolved, this approach has the potential to safely triage patients to alternative care based on a true, albeit virtual, emergency assessment.