Original article
Are wait times and length of stay in Alberta emergency
departments for children’s mental health meeting
national benchmarks? Trends from 2002 to 2008
Maryam Soleimani BSc MD(student)1, Simran Grewal MD FRCPC2, Rhonda Rosychuk PhD3,4, Amanda Newton PhD RN3
M Soleimani, S Grewal, R Rosychuk, A Newton. Are wait
times and length of stay in Alberta emergency departments for
children’s mental health meeting national benchmarks? Trends
from 2002 to 2008. Paediatr Child Health 2013;18(6):e26-31.
ObjeCTive: To describe wait times, treatment times and length of
stay (LOS) for pediatric mental health visits to emergency departments (EDs).
MeTHOdS: The present study was a retrospective cohort analysis of
mental health visits (n=30,656) made by children <18 years of age
between April 2002 and March 2008 to EDs in Alberta using administrative data. Wait time (time from triage to physician assessment),
treatment time (time from physician assessment to end of visit) and
LOS (time from start to end of visit) were examined for each visit.
Wait time and treatment time data were available for 2006 to 2008,
and LOS data were available for all study years. Wait times and LOS
were compared with national benchmarks for the Canadian Triage and
Acuity Scale (CTAS; levels 1 [resuscitative] through 5 [nonurgent]).
All times are presented in h and min.
ReSulTS: Median wait times for visits triaged as CTAS 1, 2, 3 and 4
exceeded national recommendations. The longest wait times were for
visits triaged as urgent (CTAS 3; 1 h 46 min) and less urgent (CTAS 4;
1 h 45 min). Lower-acuity visits had wait times that exceeded treatment
times (CTAS 4: 1 h 45 min versus 1 h 8 min; CTAS 5: 1 h 5 min versus
52 min). Across all CTAS levels, the LOS in the ED increased during
the study period, but met national benchmarks.
CONCluSiONS: Most median ED wait times for pediatric mental
health visits exceeded national recommendations, while the median
LOS for all visits met recommendations. Lower-acuity visits had wait
times that exceeded treatment times. Future research should explore
whether longer wait times are associated with adverse outcomes, and
whether current wait/treatment times are warranted to ensure that ED
throughput is optimized.
Key Words: Crisis intervention; Emergencies; Health services
administration; Pediatrics
O
ver the past decade, increased emergency department (ED)
wait times across Canada have been the subject of considerable examination (1-3), and a number of studies involving adult
patients have drawn attention to adverse treatment and patient
outcomes due to prolonged wait times and length of stay (LOS;
encompassing both wait and treatment times) (4-7). A position
underpinning these studies is that ED wait time and LOS are
important measures of treatment timelines and patient safety.
Longer ED wait times for patients of all ages have been associated with triage level (which denotes a level of urgency for the
les temps d’attente et la durée de séjour des
enfants ayant des problèmes de santé mentale aux
départements d’urgence de l’Alberta respectent-ils
les normes nationales? Tendances de 2002 à 2008
ObjeCTiF : Décrire les temps d’attente, la durée du traitement et la
durée de séjour (DdS) lors de visites au département d’urgence (DU)
en raison de problèmes de santé mentale en pédiatrie.
MÉTHOdOlOGie : La présente étude était une analyse rétrospective
de cohorte des visites effectuées par des enfants de moins de 18 ans
pour des problèmes de santé mentale (n=30 656) entre avril 2002 et
mars 2008 aux DU de l’Alberta, extrapolées selon les données
administratives. Pour chaque visite, les chercheurs ont examiné le
temps d’attente (délai entre le triage et l’évaluation du médecin), la
durée du traitement (délai entre l’évaluation du médecin et la fin de la
visite) et la DdS (délai entre le début et la fin de la visite). Les données
sur le temps d’attente et la durée du traitement étaient disponibles de
2006 à 2008, tandis que celles sur la DdS l’étaient pour toutes les
années de l’étude. Les chercheurs ont comparé les temps d’attente et la
DdS avec les normes nationales d’après l’Échelle canadienne de triage
et de gravité (ÉCTG; niveaux 1 [réanimation] à 5 [non urgent]). Les
temps et les durées sont présentés en heures et en minutes.
RÉSulTATS : Le temps d’attente médian des visites dont le triage correspondait à une ÉCTG de 1, 2, 3 et 4 était supérieur aux recommandations nationales. Les temps d’attente les plus longs s’associaient aux
visites classées comme urgentes (ÉCGT 3; 1 h 46 min) et moins urgentes (ÉCGT 4; 1 h 45 min) lors du triage. Le temps d’attente des visites
moins aiguës était plus long que la durée de traitement (ÉCGT 4 :
1 h 45 min par rapport à 1 h 8 min; ÉCGT 5 : 1 h 5 min par rapport à
52 min). Dans tous les niveaux d’ÉCGT, la DdS au DU a augmenté
pendant la période de l’étude, mais respectait les normes nationales.
CONCluSiON : La plupart des temps d’attente médians des visites
au DU pour des problèmes de santé mentale en pédiatrie étaient plus
longs que les recommandations nationales, tandis que la DdS médiane
de toutes les visites respectait les recommandations. Les visites moins
aiguës s’associaient à des temps d’attente plus longs que la durée de
traitement. Les prochaines recherches devraient viser à déterminer si
les temps d’attente plus longs s’associent à des effets indésirables et si
le temps d’attente et la durée de traitement actuels se justifient pour
assurer l’optimisation du cheminement au DU.
presenting complaint) (1,8), ED type (based on patient volume
and teaching hospital status) (1,8), day of the week (8,9) and time
of ED arrival (8,9). A longer LOS for admitted children has been
associated with ethnicity, time of year and time of ED arrival (10),
while ethnicity (11,12), resource use (diagnostic imaging and
number of diagnostic/screening tests) (13) and critical illness (13)
have been associated with a longer LOS for adult patients.
EDs are important sites of service for child psychiatric and
psychosocial (both comprising ‘mental health’) crises (14,15).
Care provided in an ED can stabilize acute problems and facilitate
1Faculty
of Medicine & Dentistry; 2Division of Pediatric Emergency Medicine; 3Research Division, Department of Pediatrics, Faculty of Medicine &
Dentistry, University of Alberta; 4Women and Children’s Health Research Institute, Edmonton, Alberta
Correspondence: Dr Amanda Newton, Department of Pediatrics, Room 3-526, Edmonton Clinic Health Academy (ECHA),
11405-87 Avenue, Edmonton, Alberta T6G 1C9. Telephone 780-248-5581, fax 780-248-5625, e-mail [email protected]
e26
©2013 Pulsus Group Inc. All rights reserved
Paediatr Child Health Vol 18 No 6 June/July 2013
ED wait times and LOS for children’s mental health visits
TabLE 1
Characteristics of mental health visits to emergency
departments (n=30,656)
Feature
n (%)
Age group, years
0–4
337 (1.1)
5–9
1375 (4.5)
10–14
9835 (32.1)
15–17
19,109 (62.3)
Sex
Female
17,943 (58.5)
Sociodemographic group
No subsidies received
18,715 (61.0)
Government-sponsored program subsidy
5739 (18.7)
First Nations status
4230 (13.8)
Welfare
1972 (6.4)
Discharge diagnosis
Anxiety/stress-related disorder
7989 (26.1)
Mental/behavioural disorder secondary to substance
abuse
7475 (24.4)
Mood disorder
5093 (16.6)
Intentional self-harm
4676 (15.3)
Behavioural/emotional disorders
3703 (12.1)
Psychosis-related illness
759 (2.5)
Personality-related disorder
593 (1.9)
Behavioural syndrome
304 (1.0)
Unspecified
64 (0.2)
Canadian Triage and Acuity Scale level
1 (resuscitative)
2 (emergency)
3 (urgent)
166 (0.5)
3580 (11.7)
11,318 (36.9)
4 (less urgent)
7310 (23.8)
5 (nonurgent)
1621 (5.3)
Not available*
6661 (21.7)
Geographical location
Urban emergency department
18,493 (60.3)
Rural emergency department
12,163 (39.7)
Disposition
Discharge
24,916 (81.3)
Admission
4154 (13.6)
Left before completion of medical care
752 (2.5)
Transferred
817 (2.7)
Died
17 (0.1)
*Mandatory reporting for urban emergency departments as of April 1, 2006
urgent follow-up for symptom management and family support
(14,16). Children who present to EDs with mental health complaints are known to have a longer LOS compared with children
with nonpsychiatric visits (17), and several studies have documented a lack of ED resources for mental health visits vis-à-vis
lengths of stay >5 h (18,19). To date, no published studies have
examined wait and treatment times for pediatric mental health
visits to help clarify and quantify ED LOS.
The objective of the present study was to describe trends in key
ED time intervals, wait times and treatment times, using an
administrative dataset to clarify LOS during pediatric mental
health visits across the province of Alberta. Wait times and LOS
were compared with national benchmarks for the Canadian Triage
and Acuity Scale (CTAS) (3,20), an instrument used during ED
triage assessment to estimate the level of clinical urgency for care
(21,22). We hypothesized that longer wait times would be observed
for visits assessed as less urgent according to triage level, that
Paediatr Child Health Vol 18 No 6 June/July 2013
treatment times would be longer for visits triaged as more urgent,
and that wait times and LOS would exceed national benchmarks.
MeTHOdS
design and study population
Data analyzed in the present retrospective cohort study were
obtained from the Ambulatory Care Classification System (ACCS)
provincial database created by Alberta Health and included visits
between April 1, 2002 and March 31, 2008 to all EDs in Alberta.
All cases in the ACCS database that met inclusion criteria for the
present study were extracted: visits by pediatric patients (<18 years
of age) with a main discharge diagnosis of mental illness, mental/
behavioural disorder secondary to substance abuse or intentional
self-harm, which were grouped according to WHO clusters (23).
This diagnosis reflects the main reason for provision of ED services. Using a de-identified, unique number, ACCS data were linked
to an annual cumulative registry file to obtain sociodemographic
data, and to identify First Nation Treaty Status (only for children
with Treaty Status through registration with Health Canada) and
membership in three socioeconomic groups (regular plan participant [ie, children of families receiving no social assistance] welfare
recipient or recipient of other government subsidy due to low
income). The three groups reflect the level of government subsidy
provided during the study period for provincial health care premiums, which provided revenue for provincial coordination of
health care in Alberta.
Study variables
Wait time was defined as the time (in h and min) from ED triage
assessment to initial physician assessment. Treatment time was
defined as the time (in h and min) from initial physician assessment
to end of ED service. Mandatory reporting of triage time for urban
EDs to the ACCS began April 1, 2006; a report of the initial physician assessment time is not mandatory. Data for wait and treatment
times were available from 2006 to 2008. LOS was defined as the
time (in h and min) from the start to the end of the ED service
(registration to disposition time), and LOS data were available for
all study years because the report of registration and disposition time
to the ACCS is mandatory. Triage data were obtained and grouped
according to the five CTAS levels (21,22). Geographical classifications were also defined for each ED (rural-based versus urban-based),
with urban-based EDs meeting the Statistics Canada definition of
census metropolitan area or census agglomeration (24).
Statistical analysis
Frequencies and percentages were used to summarize categorical
data (eg, diagnosis, triage level); continuous time data were summarized using medians and interquartile ranges and represented
graphically using boxplots. SPSS IS version 17 (IBM Corporation
USA) was used for data analysis. Boxplots were generated using
S-PLUS version 8.0.4 (TIBCO Software Inc, USA) for Windows
(Microsoft Corporation, USA).
ReSulTS
A total of 30,656 ED mental health visits made by 20,956 children
met the criteria for inclusion in the present study. Females made
60% of the ED visits, and the largest age group presenting were
between 15 and 17 years of age (Table 1). The most common diagnoses for visits were anxiety/stress-related illness (26.1%) and
mental/behavioural disorders secondary to substance abuse (24.4%).
More than 60% of patients were categorized as urgent (CTAS 3) or
less urgent (CTAS 4) at triage.
ED wait and treatment times stratified according to CTAS level
are summarized in Table 2. With the exception of CTAS 5 visits,
e27
Soleimani et al
TabLE 2
Emergency department wait and treatment times for the 2006/2007 and 2007/2008 fiscal years according to CTaS level, n
and median (interquartile range)
CTaS
1
2
3
4
5
2006/2007
% change for
median time
between years Overall median time (2006 to 2008)
2007/2008
wait (n=5): 9 min (1 min, 16 min)
wait (n=8): 3 min (3 min, 5 min)
↓67
wait (n=13): 3 min (1 min, 10 min)
treatment (n=5): 5 h 26 min
(5 h 16 min, 9 h 7 min)
treatment (n=11): 4 h 1 min
(1 h 47 min, 5 h 25 min)
↓26
treatment (n=16): 4 h 41 min
(1 h 57 min, 6 h 51 min)
wait (n=200): 52 min
(26 min, 1 h 43 min)
wait (n=247): 1 h 1 min
(28 min, 1 h 58 min)
↑1
wait (n=447): 57 min
(27 min, 1 h 52 min)
treatment (n=200): 4 h 13 min
(2 h 23 min, 8 h 13 min)
treatment (n=254): 4 h 11 min
(2 h 24 min, 8 h 22 min)
↓1
treatment (n=454): 4 h 12 min
(2 h 23 min, 8 h 22 min)
wait (n=665): 1 h 40 min
(56 min, 2 h 41 min)
wait (n=735): 1 h 53 min
(1 h 3 min, 3 h 6 min)
treatment (n=677): 2 h 7 min
(56 min, 4 h 12 min)
treatment (n=756): 1 h 55 min
(44 min, 4 h 5 min)
↓9
treatment (n=1433): 2 h 1 min
(49 min, 4 h 10 min)
wait (n=265): 1 h 46 min
(1 h 4 min, 2 h 46 min)
wait (n=259): 1 h 41 min
(54 min, 2 h 57 min)
↓5
wait (n=524): 1 h 45 min
(57 min, 2 h 47 min)
treatment (n=275): 1 h 34 min
(35 min, 2 h 51 min)
treatment (n=299): 55 min
(23 min, 2 h 5 min)
↓41
treatment (n=574): 1 h 8 min
(28 min, 2 h 25 min)
wait (n=23): 56 min
(36 min, 1 h 39 min)
wait (n=37): 1 h 6 min
(42 min, 1 h 50 min)
↑18
wait (n=60): 1 h 5 min
(40 min, 1 h 51 min)
treatment (n=25): 36 min
(26 min, 1 h 18 min)
treatment (n=51): 55 min
(15 min, 2 h 6 min)
↑53
treatment (n=76): 52 min
(22 min, 2 h 0 min)
↑13
National wait time
benchmark
(fractile response)
0 min (98%)
≤15 min (95%)
≤30 min (90%)
wait (n=1400): 1 h 46 min
(59 min, 2 h 53 min)
≤60 min (85%)
≤120 min (80%)
↓ Decreased; ↑ Increased; CTAS Canadian Triage and Acuity Scale
12
20
8
Time in Hours
Time in Hours
10
6
4
15
10
5
2
0
0
1
2
3
4
5
9
Triage Level
1
2
3
4
5
9
Triage Level
Figure 1) Wait time according to triage level. Canadian Triage and
Acuity Scale (CTAS) level 1, resuscitative; 2, emergency; 3, urgent;
4, less urgent; 5, nonurgent; 9, CTAS data unavailable
Figure 2) Treatment time according to triage level. Canadian Triage
and Acuity Scale (CTAS) level 1, resuscitative; 2, emergency; 3,
urgent; 4, less urgent; 5, nonurgent; 9, CTAS data unavailable
median ED wait times for pediatric mental health visits exceeded
national benchmarks. Overall median wait times from 2006 to
2008 were longest for visits triaged as urgent (CTAS 3; median
[IQR] 1 h 46 min [59 min, 2 h 53 min]) and less urgent (CTAS 4;
1 h 45 min [57 min, 2 h 47 min]) (Table 2, Figure 1). The most
common mental health diagnoses for these visits were anxiety/
stress-related disorders (26.4%) and mental/behavioural disorders
secondary to substance abuse (22.9%). From 2006 to 2008, ED wait
times decreased the most (% change) for CTAS 1 visits (a 67%
reduction in wait time) and increased the most for CTAS 5 visits
(an 18% increase in wait time) and CTAS 2 visits (a 17% increase
in wait time). The longest median treatment times from 2006 to
2008 were for visits triaged with the highest level of acuity, CTAS
1 (4 h 41 min [1 h 57 min, 6 h 51 min]) and CTAS 2 (4 h 12 min
[2 h 23 min, 8 h 22 min]) (Table 2, Figure 2). The most common
diagnoses for this level of visit acuity were mental/behavioural disorders secondary to substance abuse (41.1%) and intentional self-
harm (32.1%) (Figure 3). From 2006 to 2008, ED treatment times
decreased for all CTAS levels with the exception of CTAS 5 visits,
which exhibited a 53% increase. Median wait times for lower-acuity
visits exceeded treatment times (CTAS 4: 1 h 45 min versus
1 h 8 min; CTAS 5: 1 h 5m versus 52 min).
A post-hoc comparison of wait time and institution location
revealed that wait and treatment times in urban-based EDs were
shorter than those in rural-based EDs. The wait time in urban EDs
was 59 min (33 min, 1 h 45 min) versus a wait of 1 h 45 min
(55 min, 2 h 51 min) in rural EDs. The treatment time in urban
EDs was 1 h 3 min (25 min, 2 h 23 min) versus a treatment time of
2 h 27 min (56 min, 4 h 38 min) in rural-based EDs.
As shown in Table 3, the overall median LOS for all ED visits
for pediatric mental health increased during the study period, but
met national benchmarks overall. ED LOS was longest for visits
triaged as emergencies (CTAS 2) (4 h 50 min [2 h 50 min, 8 h
6 min]) and shortest for visits triaged as nonurgent visits (CTAS 5)
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Paediatr Child Health Vol 18 No 6 June/July 2013
ED wait times and LOS for children’s mental health visits
TabLE 3
Emergency department length of stay (LOS) according to fiscal year and Canadian Triage and acuity Scale (CTaS) level
Fiscal year
% change for
median time
(2002–2008)
CTaS
level 2002–2003
2003–2004
2004–2005
2005–2006
2006–2007
2007–2008
1
n=19
n=27
n=21
n=34
n=25
n=40
2 h 2 min
3 h 8 min
2 h 33 min
4 h 14 min
5 h 21 min
4 h 51 min
(52 min,
3 h 45 min)
(1 h 15 min,
5 h 54 min)
(2 h 7 min,
4 h 32 min)
(1 h 46 min,
7 h 38 min)
(2 h, 9 h 21 min) (1 h 47 min,
7 h 30 min)
n=241
n=500
n=622
n=640
n=684
n=893
4 h 32 min
4 h 28 min
4 h 31 min
4 h 49 min
4 h 52 min
5 h 16 min
4 h 50 min
(2 h 27 min,
7 h 28 min)
(2 h 31 min,
7 h 55 min)
(2 h 45 min,
7 h 40 min)
(2 h 40 min,
7 h 59 min)
(3 h, 8 h 1 min)
(3 h 11 min,
8 h 48 min)
(2 h 50 min, 8 h 6 min)
n=1075
n=1605
n=2115
n=2066
n=2240
n=2217
3h
3 h 17 min
3 h 21 min
3 h 30 min
3 h 42 min
3 h 41 min
3 h 29 min
(1 h 42 min,
5 h 9 min)
(1 h 53 min,
5 h 45 min)
(2 h 3 min,
5 h 27 min)
(2 h 3 min,
5 h 49 min)
(2 h 9 min,
6 h 7 min)
(2 h 9 min,
6 h 13 min)
(2 h 1 min, 5 h 50 min)
n=1057
n=1154
n=1241
n=1320
n=1296
n=1242
2 h 14 min
2 h 12 min
2 h 28 min
2 h 22 min
2 h 21 min
2 h 16 min
2 h 19 min
(1 h 8 min,
4 h 11 min)
(1 h 7 min,
3 h 53 min)
(1 h 11 min,
4 h 23 min)
(1 h 16 min,
4 h 23 min)
(1 h 13 min,
4 h 16 min)
(1 h 6 min,
4 h 19 min)
(1 h 11 min, 4 h 14 min)
n=205
n=213
n=248
n=285
n=326
n=344
1 h 3 min
1 h 8 min
1 h 9 min
1 h 2 min
1 h 7 min
1 h 16 min
1 h 8 min
(38 min,
2 h 11 min)
(39 min,
2 h 25 min)
(38 min,
2 h 5 min)
(36 min,
1 h 50 min)
(41 min, 2 h )
(45 min,
2 h 43 min)
(40 min, 2 h 7 min)
2
3
4
5
↑139
Overall LOS
(all years)
n=166
National
LOS
benchmark
<6 h
3 h 53 min
(1 h 39 min, 7 h 22 min)
↑16
↑23
↑1
↑21
n=3580
n=11,318
n=7310
n=1621
<6 h
<6 h
4h
4h
Data presented as n, median (interquartile range) unless otherwise indicated. ↑ Increased
Figure 3) Discharge diagnosis according to triage level.The following
diagnostic groups are not visually represented due to low numbers:
behavioural syndrome, personality-related disorder and unspecified
(1 h 8 min [40 min, 2 h 7 min]). LOS increased from 2002 to 2008,
with the most significant increases observed for CTAS 1 visits (an
increase of 139%). The change in LOS from 2006/2007 to
2007/2008, however, represented a decrease of 9%. ED LOS
increased from 2006/2007 to 2007/2008 for CTAS 2 visits (an 8%
increase) and CTAS 5 visits (a 13% increase).
diSCuSSiON
While recent studies suggest that pediatric mental health ED visits
involve long LOS (17-19), there is a lack of clarity regarding how
Paediatr Child Health Vol 18 No 6 June/July 2013
much ED LOS are reflected in lower visit acuity (eg, potentially
longer wait times) (19,25), resource intensiveness due to acute
behaviours and clinical investigations (eg, potentially longer treatment times) (18,26-28), and/or limited clinical resources (eg, potentially shorter treatment times) (19). The present analysis was the
first Canadian study to clarify and quantify ED LOS for pediatric
mental health visits. We found that while the overall median wait
times for CTAS levels 1, 2, 3 and 4 exceeded national recommendations (3), the overall median ED LOS for pediatric mental health
visits in Alberta met national recommendations (20). By quantifying wait and treatment times, we were able to identify periods during the ED stay that would benefit from further investigation to
ensure ED throughput and patient experiences are optimized.
With the exception of pediatric mental health visits requiring
nonurgent care (CTAS 5), all other median wait times for each
CTAS level exceeded national benchmarks (3). Contrary to our
hypothesis that longer wait times would correspond to CTAS levels (eg, longer waits for lower-acuity CTAS visits), the longest
median wait times were for urgent (CTAS 3) and less urgent
(CTAS 4) visits while nonurgent (CTAS 5) visits exhibited
shorter wait times, similar to CTAS 2 visits. Typically, CTAS 5
patients can be seen in ‘clinical fast track’ areas of the ED, where
patients are treated and discharged more quickly, which may
explain a wait time comparable with more urgent visits. While
there was a notable 18% increase in wait time from 2006/2007 to
2007/2008 for CTAS 5 visits, times remained below national
benchmarks, and it may be that clinical fast tracking for nonurgent
care is one clinical model that has helped clinicians manage waits
and promote more timely ED throughput to care for more urgent
but clinically stable presenting complaints. Given that treatment
times actually increased by 53% during the same time that wait
times decreased for CTAS 5 visits, a detailed examination of more
recent data (2008 to 2012) as well as factors related to treatment
delay is warranted, but was outside of the scope of the present
study. Delays in the time to specialty assessments (eg, psychiatry,
social work) and discharge planning may be areas in which EDs
can develop benchmarks for tracking and monitoring to ensure
e29
Soleimani et al
that ED LOS for lower-acuity visits is as short as possible to maximize resources for higher-acuity visits.
Triage-associated initiatives shown to improve timelines to
care may help to address the long wait times observed for CTAS 3
and 4 visits, where the patient may not be as medically stable as
patients seen in clinical fast-track areas. These initiatives include
having a health care provider (ie, nurse practitioner, physician
assistant) in the triage area to perform initial assessments and initiate diagnostic tests or referrals to other mental health services
(29), general practice clinics adjacent to the ED to divert patients
(30), and bedside registration/triage, which involves the primary
care nurse working alongside registration staff at a mobile computer station to log the presenting complaints and initial assessment (31).
Parent dissatisfaction with care (32) and leaving the ED before
the child is seen by a physician for diagnosis and treatment (33)
are two outcomes documented as a result of longer wait times for
children. The frequency of premature ED departure for pediatric
mental health visits (range 1.9% to 4.3%) (19,25) is comparable
with findings for other pediatric ED visits (range 3% to 5.5%)
(33,34), which suggests that lengthy wait times (such as the case
for CTAS 3 visits) may not be a deterrent for individuals waiting
for mental health care. In a study by Goldman et al (33), children
who left the ED early were more likely to be taken elsewhere for
care. Whether differences exist in a parent’s/child’s reasons for
enduring ED waits for mental health concerns (eg, other health
care venues have already been pursued or families are desperate for
help and regard the ED as their only remaining option) is not
known, but may help to explain motivations for accessing acute
care services and quantify parent/child satisfaction with care following this wait period. Using the present descriptive study as
impetus, future research is also needed to explore whether longer
waits are associated with adverse outcomes and to ensure that ED
throughput is optimized.
ED use for less urgent conditions do not factor into long wait
times or delays in ED throughput (3), and most EDs can handle
these cases efficiently. Less urgent visits are suggested to involve
shorter treatment times because these visits often require minimal medical/nursing intervention and usually require only
assessment and reassurance. In the present study, and as hypothesized, we found that treatment times for pediatric mental health
visits decreased with level of urgency, with a marked difference
between CTAS 3 and 4 visits (median CTAS 3 time 2 h 1 min
versus median CTAS 4 time 1 h 8 min). Given that wait times
for these visits tend to be longer, it may be of value to investigate
parent and child satisfaction with the ED visit because expectations following a lengthy wait time may include less time interacting with ED care providers. The adequacy of information
provided during provider-patient interactions and the quality of
this interaction has been associated with satisfaction (32) and
also warrants exploration for pediatric mental health visits.
Interaction quality is of particular importance given the results of
a recent study showing that pediatric mental health visits often
involve inadequate mental health assessments, counselling and
discharge recommendations (19). As suggested previously, the
length of treatment time may also reflect the time it takes to
arrange multiple resources including specialty consultations, versus ‘active treatment’ time. ED administrators may want to
develop ‘time and outcome benchmarks’ for tracking and monitoring treatment times to ensure that bottlenecks in care are
flagged and addressed.
On a final note, in our post hoc analyses, we found that wait
and treatment times were longer for visits to rural EDs. These
e30
findings may be explained by a lack of mental health resources that
are more readily available at larger centres. A shortage of trained
emergency physicians able to manage patients with mental health
concerns, as well as an inability of rural physicians to transfer
patients requiring a higher level of care to urban receiving facilities due to these facilities being full, may also explain longer wait
and treatment times at rural EDs. Further investigation is required
to determine whether differences in wait and treatment times are
reflected in patient outcomes and whether there are important
disparities regarding where children receive emergency mental
health care.
limitations
There are several limitations to the present study. First, the availability of wait and treatment time data was limited to the final two
fiscal years of the present study, and is reflected in the mandatory
versus optional provincial reporting guidelines for the ACCS database we used. For example, the proportion of pediatric patients triaged to CTAS 1 with wait and treatment time data was low (only
8% of wait and 10% of treatment times available for 166 ED visits)
and, although reflective of the relatively small proportion of pediatric mental health triaged at this level (19,25), the generalizability
of our conclusions including trends over time for this CTAS level
and level 5 (only 4% of wait and 5% of treatment times were available for 1621 visits) remains limited. The sample sizes for wait and
treatment time data for visits at the other CTAS levels were larger
and provided us with more confidence in our findings, as did our
analyses of the LOS data, which were available for all visits in our
dataset. Second, the trends detailed in the present study provide a
starting point to further investigations of ED wait and treatment
times and LOS, and analysis of more recent data (2008 to 2012) is
desirable. The present study should be viewed as a catalyst for further study on the topic and a reference point to support ED strategies and metrics for managing ED mental health visits. Finally, we
did not collect reference data on all pediatric ED presentations.
While the use of a comparison group was not part of the objectives
of the present study, and its use varies in the published literature
(10,17,35-37), such data would help contextualize time trends relative to other pediatric presentations. Even without these comparison data, however, it is clear that ED wait and treatment times for
pediatric mental health visits warrant further discussion to ensure
that visits are safe and effective for children. Importantly, for ED
administrators, whether wait or treatment times for mental health
visits are longer or shorter compared with other visits may not matter administratively as much as establishing universal metrics to
ensure that ED throughputs for these patients and others are
optimized.
CONCluSiON
Our findings indicate that median wait times for pediatric mental
health patients triaged from CTAS 1 to 4 exceeded national recommendations, although the ED LOS for these patients did not
exceed national recommendations. Future research should explore
whether longer waits are associated with adverse outcomes, examine child and parent experiences in the ED and, most importantly,
determine which clinical management strategies can expedite wait
and treatment times to ensure safe and effective emergency mental
health care.
diSClAiMeR: This study was based, in part, on data provided by
Alberta Health. The interpretation and conclusions contained herein
are those of the researchers and do not necessarily represent the views
of the Government of Alberta. Neither the Government nor Alberta
Health express any opinion in relation to this study.
Paediatr Child Health Vol 18 No 6 June/July 2013
ED wait times and LOS for children’s mental health visits
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