Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada

I was interested to read Guttman et al's paper concerning the
association between prolonged lengths of stay (LOS) and poor outcomes in
the emergency department but feel that applying these findings to current
NHS working practices may be difficult. Emergency Department LOS greater
than six hours has tended to become less common in England following the
implementation of the previous 98% Government Standard and is likely to
reflect clinical acuity and access to specialist beds. Our experience does
not correlate with Goodman et al's relatively low number of attendances of
elderly patients and those with mental health problems or chest pain or
with the apparent inverse relationship between patients, who left without
being seen and the numbers of their previous attendances. Emergency
Departments caring for high numbers of patients in heavily populated urban
areas in England may not see a significant reduction in weekend
attendances.

Our local experience suggests that prolonged LOS reflects hourly
attendances, patients presenting with high acuity illness and adequate
medical and nursing staffing and skill mix. Efficient coordination of the
clinical workload and access to senior decision-making promotes prompt
assessment and improved outcomes and our efficiency has improved
significantly with electronic access to pathology and radiology results
with a concomitant reduction in length of stay. Effective care pathways
facilitate timely and efficient transfer of patients to tertiary centres
or referral to on-site specialist teams. Finally, Emergency Departments
need to ensure efficient and effective use of Clinical Decision Unit beds
to facilitate expedient but safe discharge of patients requiring short-
term observation.