Revamp Triage to Decrease Waits

Blue YetiSome people do not have time to read books. But they listen to podcasts.

So, I plan to give away as much of the content in No More Lethal Waits: 10 Steps to Transform Canada’s Emergency Departments as I can squeeze into podcasts and short blogs.

The first podcast covers the Introduction and first chapter: Step 1 – Revamp Triage. This blog gives a snapshot and overlaps the podcast. I hope it gets people talking about the ideas, even if they do not have time to read the book.

Here’s the first podcast (I had fun making it!):


Doctors, nurses, allied health providers, administrators make patients wait. We blame problems outside our department or clinic. But if we wait for outside help, nothing will improve.

We need to change how we work, first. We have to tackle misaligned incentives, arcane policies, and draconian legislation to do what is right for our patients. We need relentless devotion to improving patient service and care. Even if we only make small improvements, we will have much more credibility when we ask for bigger, system-level, changes.

NMLW uses old ideas. It does not describe a new fad or secret recipe to reform healthcare. We need a new perspective, not another wunder-plan that promises to fix everything.

The ideas in NMLW work together. You cannot close your waiting room without changing nursing ratios, doctors’ schedules, and furniture inside the ED.

If you give these ideas an honest try, you can expect that patients will:

  • Not wait in the waiting room
  • Be seen by an MD in < 1 hour
  • Have the shortest possible length of stay
  • Receive the highest quality care and service

Be careful, political responsibility, or system guilt, will ruin your best efforts to improve patient service. We need to put aside our angst about costs, the broader system, and spending for a moment. Only a relentless devotion to patient service will improve ED function.

Devotion to patient service drives down costs per case, length of stay, adverse events, and, in fact, everything in an ED functions better when we focus on patients first, and the broader system benefits for it. But do not start with system guilt; start with patients first.

Revamp Triage

Patient go the ED to get a diagnosis and treatment in the shortest time possible. They have no chance of getting what they need, while sitting in a waiting room.

Triage has become such a part of emergency medicine that we believe every patient deserves a good thorough triaging. Even with doctors and nurses standing ready to see patients, we still force patients through a fulsome triage.

Napoleon’s surgeon invented triage as the army ran out of soldiers. He needed a way to pick out wounded infantry that could be patched up and sent back into battle as quickly as possible.

We invented modern triage as our system started running out of money. Cash-strapped hospitals use EDs as an extra ward, and waiting rooms as overflow. Triage is designed to manage the crowds.

The Canadian Association of Emergency Physicians states that triage, in its simplest terms, is sorting or prioritizing. There has always been some kind of triage, long before modern triage existed. ED registration clerks working alone, out front, on overnight shifts, used to bring in patients who looked too sick to register.

Today, formal triage includes collecting a chief complaint, acuity score, and deciding on the best location for a patient to go. But it also includes a history, screening for influenza-like-illness, a focussed physical, past medical history, medication reconciliation, and a whole bunch of other duties. Large hospitals often employ 4 triage nurses to manage packed departments.

Patients just want a diagnosis and treatment as efficiently as possible. They do not go to the ED to endure processes of questionable benefit. Triage needs to change.

Patient Flow

Most of the time, providers inhibit patient flow. We batch tasks, work inefficiently, or we just get overwhelmed and slow down. Decreased patient flow causes increased length of stay which results in increased workload. There is no excuse for people doing “a really good job” by spending 45 minutes educating one patient, while everyone else waits for care.

At the same time, we cannot confuse great flow with cutting corners, going really fast, and providing inadequate, low quality service and care. We need to do fast things fast and slow things slow.

The Institute for Clinical Evaluative Sciences outlined quality indicators for emergency care. They found evidence for 48 indicators: 23 are related to time, and 16 are entirely time-based, e.g., time to antibiotics, time to ECG, or time to thrombolysis.

For emergency care, time equals quality. In other settings, “quality” balances effective, safe, patient-centred, timely, efficient, and equitable care. But the ED is different.

No matter how ‘great’ care you provide when patients finally receive it, if you make patients wait for hours, by definition, you deliver low quality care.

Historic Triage

We need to triage patients IN to the department and not back OUT to the waiting room. A skilled nurse can collect a chief complaint, assign an acuity score, and decide on the best location for a patient in 1-2 minutes. The rest of of the triage nurses can work inside the department providing care.

That leads us to the next chapter: Step 2 – Close the Waiting Room.

I hope you get a chance to discuss these ideas with your colleagues. If you have comments, comments and suggestions, leave them below or email me, so we can discuss them in the next blog / podcast. Thank you!

photo credit: Blue Microphones Yeti USB Microphone, Blackout on

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Politics and Wait Times (podcast)

Shawn and Jason 2016Dr. Jason Profetto made me squirm with tough questions on his podcast. Please let me know if I said anything crazy.

We discussed politics and wait times…even rectal exams.

This interview offers a great introduction to the content of No More Lethal Waits.

Episode 14: A Chat with Shawn Whatley

Jason asked what one thing needs to change to fix wait times. He tried to pin me down. Who makes a bigger impact: Concerned Ontario Doctors or the Ontario Medical Association?

He did a great job. I hope you enjoy the exchange!


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Book Launch – No More Lethal Waits (Book Review)

Bestsell Healthcare No 1 2016-02-15 at 5.47.09 AMNo More Lethal Waits officially launches today!

I will share the key content in the book over the next 2-3 weeks, answer questions, and respond to feedback so far. I also plan to include podcasts along with each post, if everything goes as planned.

Thanks so much to everyone who has shown interest and support so far! Please let me know how I can return the favour and help spread your ideas.

I did not expect so many people, who work outside of emergency medicine, to enjoy the content.  As Owen says in his book review below, NMLW applies to “…any health service where waiting is an issue.

Book Review

Owen Adams, PhD, is chief policy advisor at the Canadian Medical Association, Ottawa.

Owen writes well and has worked and taught in health policy since the late 1970s. I hope you enjoy his review.


No More Lethal Waits: 10 Steps to Transform Canada’s Emergency Departments

Shawn Whatley, MD, BPS Books, 2016

Review by Owen Adams, PhD

Emergency Department (ED) wait times continue to be a pressing health issue in Canada. A search of the Canadian Business & Current Affairs database using four combinations of ED/ER and wait, both spelled out and abbreviated, yielded 321 articles in 2015. To put that into perspective, a search for pharmacare and related terms, a re-emerging hot topic in 2015, yielded only 107 articles.

No More Lethal Waits is a highly readable and compelling book about the experience and lessons learned from the transformation of the ED at Southlake Regional Health Centre during author Shawn Whatley’s tenure as interim medical director of emergency services and physician leader of the Emergency Services Program in 2008–2014. Southlake is a full-service hospital located in Newmarket, Ontario; it has almost 400 beds, handles more than 100 000 ED visits annually, and serves more than a million people.

Unlike many studies of wait-time journeys, this one does not require postgraduate training in operations research or queueing theory to appreciate it, and Dr. Whatley uses several vivid analogies to draw key lessons. The book chronicles Southlake’s 10-step journey that resulted in a fundamental revamping of its ED.

The 10 steps borrow heavily from and build on the experience of Toronto’s St. Joseph’s Health Centre, which transformed its ED under the direction of Dr. Marko Duic, who was recruited subsequently to Southlake as chair of Emergency Medicine. Some of the steps, such as 2, “Close the waiting room,” and 4, “Use chairs and exam tables, not stretchers,” will no doubt seem heretical to some!

Aside from a methodical and thorough exposition of the 10 steps, Dr. Whatley pays great attention to the motivations, thought processes, and attitudes of the physicians and nurses in the ED, and the same elements are probably applicable in some measure to many other health care settings. Moreover, the treatment of nurses, physicians, other professionals, and staff seems even-handed. The book is as much a case study of change management in general as it is a guide to transforming the ED specifically. Throughout the book there was also emphasis on the importance of the patient.

By the time I had finished reading this book, my curiosity was piqued as to how Southlake is doing now, so I went to the Canadian Institute for Health Information’s to see the most recently posted results (time reference is not specified). They are impressive. The 90th percentile for ED wait time to initial physician assessment at Southlake is posted as 1.4 hours, compared with 3.2 hours at comparator large community hospitals, 2.5 hours for the Central Local Health Integration Network, 3.0 hours for Ontario, and 3.1 hours for Canada; in other words, about half the wait at these benchmark comparators.

In summary, No More Lethal Waits deserves to be widely read — not just in the ED community, but also by any health service where waiting is an issue. No More Lethal Waits is available at as well as


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