M<$c$>ore than 1,000 people go to the Emergency Department at King Edward VII Memorial Hospital (KEMH) every week for treatment. Director of Emergency Services, Dr. Edward Schultz said the figure currently stands at 99.4 patients a day. That puts Bermuda in line with hospitals of the same size in North America. One of the main issues becomes how to best handle the volume of cases coming in. Everyone wants to be seen right away — no one wants to wait. Ten minutes to someone with a throbbing toothache can feel like forever.

What is an acceptable wait time? The answer will vary from person to person. And who should be seen first — a five year old with a 100 degree fever, a pregnant woman with a broken foot, an 82-year old who cannot move his left arm, the teenager who struck a car head on?

The answer is now clear-cut for triage nurses as the American Severity Index procedure has been adopted at KEMH.

A whole gamut of injuries and conditions are seen by doctors in the emergency department — everything from the common cold to gun shot wounds, from a small rash to heart failure. The triage nurses take information on injuries from incoming patients. Of course there has always been a system where a heart attack patient would be seen before someone complaining of a skin rash, but a more stringent and formal system has now been implemented.

The Canadian Council on Health Services Accreditation (CCHSA), the accreditation body of KEMH, demanded the move.

In a site visit in February 2006, CCHSA called on the emergency department to institute a formal procedure for seeing patients as a condition of accreditation.

That demand led KEMH to implement a system that would best serve the local population. Emergency Department clinical coordinator Lynnette Raynor said she looked at many different systems but chose the American Severity Index. This system lists patients according to the severity of their condition. There is a thick handbook of rules that guide triage nurses in knowing exactly where to class each patient that comes in.

“Having the formal procedure makes it much easier for the triage nurses,” said Ms Raynor. “It removes any subjectivity and makes clear the order patients are to be seen in.”

Patients fit into one of five categories level one to level five, with level one being the most acute cases. Under this system, patients in level one must be seen by a doctor immediately. People in cardiac arrest and serious accident victims are among the type of cases that fall into this category.

Patients listed as level two have serious injury but can wait between five and ten minutes. In these cases the new system dictates that a doctor sees such patients within ten minutes of their coming into the Emergency room. Level three patients can wait up to half an hour, level four up to an hour and patients classified as level five can wait over an hour, before seeing a doctor.

This means if your doctor is away and you have a hacking cough that you feel requires medical attention, you could have a long wait if you go to KEMH’s emergency room. E<$c$>mergency department clinical coordinator, Lynnette Raynor, admitted the change has meant longer waiting times in many cases for non acute patients. “We have had some complaints from people who don’t understand why someone who came in after them, gets seen before them,” she said. “But this system has been proven effective and ensures the sickest patients get the best care in the best time.”The new system looks only at the severity of the condition and does not take into consideration a person’s age. In some countries there are policies that children will be seen first. This is not the case with the American Severity Index system. Ms Raynor said babies and infants will often fall in category one or two because the system does recognise for example, that a high fever in a three month old may be very serious while a high fever in a 21-year-old may not be dire.

“Children tend to be level two’s or three’s,” she said. “A child who has been ill for a week, is not toxic in appearance and has seen his doctor, is not likely to be seen before you simply because of his age,’ said Dr. Schultz. “Eighty-five percent of the patients we see, could be seen in the doctor’s office but because the doctor’s office is closed or overbooked they come here,” he said. “We are happy to treat minor injuries but they should anticipate a wait. If they went to their doctor they would have to wait.” And Dr. Schultz noted that unlike a doctor’s office, the very nature of the Emergency room is such that patients don’t come there on scheduled visits.

“We don’t know what cases we will see each day and we don’t have the luxury of booking appointments in advance,” he said.

Wait times in KEMH’s emergency room are rarely more than two hours to meet with the doctor. Ms Raynor said it is typical in the US for patients to wait more than four hours.D<$c$>r. Schultz worked in hospitals in North America before coming to Bermuda. “In the last hospital I worked in, I never saw minor injuries,’ he said. “Patients would leave before having a chance to be seen. A wait could be as long as eight hours and for someone who had come because it was the middle of the night and the doctor’s office was closed, well, that office would be open by the time they might be seen by us in the emergency room,” he said.The growing complexity of people’s medical complaints also lengthens the waiting times at KEMH’s emergency room. “We have an increasing percentage of elderly patients with complex medical conditions. It is most time consuming treating these patients,” he said. “An older person with chest pain may spend eight hours in the department, having examinations and tests before a decision is made on their treatment,”

Dr. Schultz anticipates that seeing patients in a timely fashion will become more challenging. “It’s going to get more difficult so we are trying to be proactive,” he said. Meanwhile the department recognise the anxiety and tension of patients coming in. “We try to keep communication flowing between us and the patients in the waiting room,” said Ms Raynor. She said triage nurses try to give patients an idea of how long a wait they have and inform them when those times change significantly.