An Ontario NDP election promise to cut emergency room wait times in half by hiring 250 nurse practitioners and opening 50 new 24-hour care clinics if elected is a worthy plan in theory, say nursing leaders, although they question how the desired results would be achieved.
“I certainly do think the nurse practitioner role can be very significant in reducing wait times in [emergency rooms]. My question though, is why are we encouraging people to visit the emergency department when in fact they would be better served in a primary care location?” said Paula Carere, the director of the Waterloo Region Nurse Practitioner-Led Clinic.
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“Honestly I think if we look at emergency department utilization you’ll see that it’s pretty quiet after 11 o’clock at night and probably before 7 o' clock in the morning. Most people who are unwell, unless they are dying, want to stay in their beds,” said Carere, who also used to lead the Nurse Practitioners' Association of Ontario.
Nurse practitioners are registered nurses who have additional training, which allows them to diagnose illnesses, prescribe medication and order and read diagnostic tests. Currently, the province has 2,407 registered nurse practitioners, according to the College of Nurses Ontario.
Doris Grinspun, the CEO of the Registered Nurses Association of Ontario, a professional association for nurses, called the push to hire more nurse practitioners "an interesting proposition."
"It’s something we have proposed in the past, not as a primary solution to the system, but as an interim solution,” she said.
“The reality is that if you have primary care functioning 24/7, if you have long-term care with the right care providers, including nurse practitioners….then you will not have emergency rooms that are at this point overwhelmed.”
But the NDP say that hiring more nurse practitioners is only one plank of their plan to reduce wait times.
The party also proposes building 50 new family health care clinics at an annual cost of $75 million.
They would be open roughly from 7 a.m. to 9 p.m. for regular appointments, and then moving to either an on-call model between 9 p.m. and 7 a.m., or a clinic with minimal off-hour staffing, said France Gelinas, the NDP candidate for the riding of Nickel Belt and the party’s health and long-term care critic.
The clinics would be built in areas where people have significant barriers to access to primary care, she said. They would be staffed by physicians, nurse practitioners, registered nurses, dietitians, social workers and physiotherapists.
“People end up in the emergency department because their primary care provider is not accessible. So this is why we’re going with a two-pronged approach,” she said, referring to the plan to hire more nurse practitioners and to open more primary care clinics.
The party has also proposed creating 1,400 more long-term care beds.
The case of St. Michael’s Hospital
While the NDP haven't cited any specific studies that show that more practitioners in ERs would reduce wait times by half, the party's platform singles out St. Michael’s Hospital in Toronto. The NDP says the hospital has cut ER wait times in half by implementing a program that uses nurse practitioners.
Wait times for low-acuity patients (those with minor issues like a sprain or a nosebleed) have indeed been cut by 45 per cent since 2006 at St. Michael's, partly because the hospital maximized the use of nurse practitioners to evaluate “select groups of patients,” said Dr. Glen Bandiera, the chief of emergency medicine at St. Michael’s.
But it’s not solely the use of nurse practitioners that allowed the hospital to cut wait times.
“In addition, we changed the way patients flow through our department by creating new waiting areas and implementing what we call a rapid assessment zone approach, where patients only stay in rooms as long as they need to, to be assessed and treated,” said Bandiera.
“And then they move through our department for tests and investigations and then an eventual discharge discussion at the end. All of these things in combination have allowed us to significantly reduce our wait times.”
Hiring more nurse practitioners would help bring down low-acuity wait times, Gelinas said.
“We are bringing an average of two nurse practitioners – so you can think about 70 hours a week of nurse practitioners – to most emergency departments,” said Gelinas.
When asked what the NDP would do to cut wait times for high-acuity patients, Gelinas said, “We’re hoping with the resources that already exist in our emergency rooms, that you will have a bit of a domino effect.”
Incentives for training
The first domino, however, is training more nurse practitioners and getting them to work.
Carere said it may not be easy to hire more nurse practitioners because the incentives to get registered nurses to take an additional 1-2 years of training are lacking.
“There has not been a kind of consistent, consolidated approach to promoting enrolment in the program and to remunerating [nurse practitioners] in primary health care,” said Carere, who added that NPs currently make less than registered nurses who have been working for seven years in hospital settings.
Gelinas, however, is confident that an NDP government would be able to hire more nurse practitioners.
“If you know you have a job waiting for you, it becomes a very strong motivator to do the work necessary to get your license. If the jobs for nurse practitioners were there, they were respectful, they allow them to practice within their full scope, a lot of nurses would be interested in extra schooling.”
The parties' promises on health care in this campaign have ranged from the NDP's vow to cut emergency room wait times, to eliminating the Local Health Integration Networks (PCs) and focusing on access to primacy care providers (Liberals).
Liberal Leader Kathleen Wynne has promised Ontario residents would have access to a primary care provider by 2018 under a Liberal government.
Progressive Conservative Leader Tim Hudak vows to scrap Ontario's Local Health Integrated Networks and divert the savings to frontline employees, like nurses. The LHINs employ about 2,000 bureaucrats and administrators.