mergency medicine is a relatively new kid on the
block; the first formal training programme started
about 25 years ago. Emergency Departments, as
such, are also fairly new entities having been born
out of Emergency Rooms, a name that was an
However, today, the specialty of emergency medicine is recognised
throughout the Anglophone world and continental Europe. There are
highly regarded specialty training programmes in most developed
countries. Newer systems in Africa and South America are adopting
the Anglophone model.
There is one visit for every three people in the US and the number is,
strikingly, identical in Canada and almost identical in Ireland, despite
the latter having both stronger primary care networks and universal
insurance. Why such demand?
Members of the public know that they can go and be seen, albeit
with a wait, without phone calls and appointments, and, additionally,
actually receive on-site, contemporaneous testing. More often than
not, when a member of the public leaves the Emergency Department,
he or she knows what the cause of his or her problem was and what
course to follow. This is a very attractive model to the individual. So
much so, virtually every Emergency Department in the developed
world is operating well over capacity.
However, waits are inherently bad. The patient feels that what is
wrong with them requires attention now, and, while 75-80 per cent of
patients will receive care and go home, 20 per cent will be admitted
and there is no reliable method of separating out the two ahead of
time. By default, there are individuals in the waiting room who have
substantive illness and we know that, for some of them, the wait is
depriving them of effective, time-dependent treatment (acute MI,
The result is that the number of `head of the line privileges' conditions
is now growing to the extent of undermining our traditional sorting
mechanism (triage). There is an entire body of evidence showing
that patients either waiting to be seen, or waiting for a hospital bed
after being evaluated in the Emergency Department, suffer harm.
Additionally, despite the growth of tested triage schemes (Emergency
Severity Index, the Canadian Triage tool, the Australian Triage
scheme etc), evidence finds most to be flawed because of elements of
subjectivity in each.
Waiting and crowding are the result of dysfunction in one or more
of three discrete areas: 1), Demand (input); 2), Throughput; and 3),
Disposition (output). When the National Health Service (NHS) in
England set limits on throughput time (The Four-Hour Rule), they
also attacked the other two elements. To decrease demand, they
opened acute care centres, instituted a telephone advice line (NHS
Direct) and gave both triage nurses (made nurse practitioners by fiat)
and medics in the ambulance service prescription authority (`first to
see, first to treat').
To provide more access for patients destined for hospital wards
the no wait
J. StEphEn Bohan, exeCutive viCe ChAir of the depArtment
of emergenCy mediCine At BrighAm And women's hospitAl,
Boston, provides An overview of the work Being done
there to develop the `no wAit emergenCy depArtment'