Long Wait Times at Hospitals in Jamaica: A Potential Risk to Patient Safety

4.1 Ensuring patient safety

The WHO defined patient safety as ‘the absence of preventable harm to a patient during the process of health care’ [9, 10]. According to Ackroyd-Stolarz et al., there is a distinctive association between the length of wait time in the emergency room and the risk of hospital admission or death in the elderly patients [11, 12]. Thus, the importance of ensuring patient safety in hospitals in Jamaica since overcrowding in the A & E departments remains a major challenge. More so, patients have always been complaining about long wait time in hospitals across Jamaica and still such complaints have not resulted in any significant improvements in the health care system [12]. In fact, the MOHW in Jamaica has recently informed all Jamaicans to brace themselves for longer waiting time for the end of the year and going forward into 2024 [13]. Such news are not welcoming nor encouraging and so promoting the implementation of key strategies to decrease the waiting time in Jamaican public hospitals must be pursued and encouraged.

4.2 Effects of long wait time in A & E

A disorganized triage system is a major contributing factor to the long wait time of an average of over 4 hours in the emergency rooms on a global scale. Patients are often dissatisfied with the triage process and the medical teams are often disheartened by the outcome themselves [13, 14]. Also, Nyce et al., postulates that prolonged wait times are associated with worse patient experience with discharged patients from emergency departments [12, 15].

4.3 Risk management strategies

Risk management strategies in the Jamaican public hospital emergency rooms are essential in ensuring patient safety, since it requires implementing key guidelines to safeguard and alert health care providers in making needed changes, to provide the highest quality medical and nursing care in preventing patient injuries. Similarly, such strategies are crucial when caring for patients in an emergency care setting. Important to the risk management process are five common strategies for managing risk which are avoidance, retention, transferring, sharing, and loss reduction. Each technique aims to address and reduce risk while understanding that risk is impossible to eliminate completely [16]. Hence, the investigation of the long wait time in hospitals in Jamaica, should assist in identifying these key risk management strategies that should be used to improve the quality of care and patient safety on a global scale.

5.1 Utilization of the conceptual framework

5.1.2 Identification and reporting of risk factors

It is highly recommended that an established system for identifying risk factors be established in the A & E departments. A variety of formats do exist that may involve the use of technology, or a charting system using a whiteboard and other forms of documentation. Also, there must be an established protocol for reporting these identified risk factors so that the required solutions can be provided, allowing for enhanced problem-solving to occur from all levels of the health care system. This means that there must be open and efficient communication throughout the health sector. Below is a diagram that illustrates the open communication and collaboration that should exist among the various levels of the health care sector, to address the challenge for example of shortage of beds in A & E department, using Falmouth hospital in WRHA for the illustration in Figure 2.

It is important that this form of health care organized communication and collaboration include the entire health care sector, thereby, allowing the A & E departments to receive the necessary assistance in advance such as equipment, beds, and labour force to prevent major challenges in providing efficient patient care and decreasing long wait time. Also, there must be effective communication from the point of the A & E departments in Jamaica internally at public hospitals and with the wider health care sector. Effective communication means the relaying of information in regards to the need of the A & E department for example as shown in Figure 2 with the ministry of health and the private health sector. Thereby allowing the A& E departments to be linked with the required staff and equipment to ensure that health care staff, medical procedures and equipment are available to decrease the wait time for patients. Patients can also be referred to other health care facilities for further management of their health conditions.

6.1 Comparative waiting times in other countries including emergency care

It is essential to note that the long waiting time for patients to receive treatment in the accident and emergency department is not unique to Jamaica but is of growing concern for health care delivery on a global scale. It is important to reveal that there are three countries mentioned by the Organization for Economic Cooperation and Development (OECD) as having the shortest wait times for patients receiving health care and they are notably Switzerland, Netherlands, and Germany, with 88%, 87%, and 87% of patients, respectively, generally being seen in 1 day or less, as shown in Figure 3.

7.1 The psychological effects of long wait time

An essential study was conducted by Lee & Yoon in November, 2023 suggests patients do experience high levels of anxiety while waiting for medical care in emergency rooms. The study purports that using nature to enhance the environment while patients wait assists in significantly decreasing the level of anxiety using plants, nature images and a combination of both interventions [34].

Studies have shown that patients with mental health illness experience longer waiting times (16.5–21.5 hours) than those without a mental health disease which shows the disparity of care for this particularly vulnerable group [35].

7.2 Recommended risk management strategies

It is a fact that health care services can also benefit from shorter wait times at hospitals, since patient turnover improves on the use of resources and is more cost effective [36]. More so, the patients generally leave the health care facility more satisfied and are, therefore, more likely to return. Patients will also be more willing to encourage others to use the health care service, thereby improving their quality of life and that of others [37]. In addition, the WHO reported that many OECD countries have taken measures to reduce waiting times in hospitals through additional funding but with mixed success [38].

Therefore, to improve the wait time, every country should make an effort to develop a national health policy that includes a platform for better management of their health care issues impacting emergency care and waiting time. A risk management approach is recommended to ensure the interventions are preventive rather than corrective in nature.

Next, the use of technology in creating a reporting and alert system for A & E departments within all countries is necessary. Thus, ensuring that the needs of these emergency departments can be addressed in a timely manner.

7.3 Decreasing the psychological impact of long wait time

During COVID-19 it was evident that mentally ill patients were in need of more psychological support while waiting for completion of specific procedures such as Magnetic Resonance Imaging (MRI). The main reasons presented were the high level of anxiety and the increased risk of injury to the patient. A research study conducted in 2021 revealed that patients felt that their psychological needs could have been addressed more through the following implementations: acknowledgement of their concerns, peer support, and periodic communication about wait-list position, prioritization criteria and anticipated procedure date [39]. Similarly, long wait times in emergency rooms that do negatively impact the psychological state of patients requires interventions to ease the adverse effects that include anxiety, depression, increased stress levels, morbidity and even death. According to Shen & Lee 2018 a team-based approach that involves closer communication and coordination between patients and the care provider will result in more positive patient outcomes [40].

7.4 Improving triage systems

Separating critical and non-critical patients in the waiting room can help, as low-acuity patients may be able to be treated in another area [41]. Triage is a process that is critical to the effective management of modern emergency departments. Triage systems aim not only to ensure that the patient receive the required emergency care, but also to provide an effective tool for departmental organization, monitoring, and evaluation [39]. Globally, over the last 20 years, triage systems have been standardized in a number of countries and efforts made to ensure consistency of application. It is also noted that the ongoing crowding of emergency departments resulting from access block and increased demand has led to calls for a review of systems of triage. In addition, international variance in triage systems limits the capacity for bench marking [42]. The basic premise of Triage is primarily the sorting of patients for treatment in situations of least modest resource scarcity, according to an assessment of the patient’s medical condition and the application of an established sorting system or plan [43]. Defined in this way, the most common types of triage include emergency department triage, inpatient (ICU) triage, incident (multicausality) triage, military (battlefield) triage, and disaster (mass casualty) triage [44]. All the listed types of triage have distinctive elements such as: (1) modest scarcity of health care resources exists, (2) assesses each patient’s medical needs, usually based on a brief examination and (3) the use of an established system or plan, usually based on an algorithm or a set of criteria, to determine a specific treatment or treatment priority for each patient by the health care provider [44, 45]. In 2016, the Ministry of Health and Wellness in Jamaica selected the Emergency Severity Index as the triage tool to be used nationally. The Emergency Severity Index (ESI) is a 5-level triage tool validated and used in more than 70% of emergency departments in the United States [46, 47]. In Jamaica, there is variability across sites, and triage may be performed by physicians and/or nurses. Not all doctors and nurses engaged in triage are trained in emergency medicine. Triage training is quite variable across the island [48, 49].

7.5 Use of technology to decrease wait time

The utilization of digital technology and simulation techniques seem to be promising strategies to decreasing waiting times. Studies have shown that applying agent-based model (ABM), queuing model (QM) and simulation techniques related to patient access and patient flow in the emergency room coupled with hospital information systems may be the answer for optimizing hospital processes and reducing bottlenecks in the ED [50, 51]. This is an area that is still evolving, but we believe it has enormous potential in reducing waiting times in the ED. Advance customer technologies empower individuals to manage their own time and optimize the queuing process with queue management software called Q-Flow that delivers next-generation customer experience and simple, effective queue management solutions [42, 52]. In countries such as the United Kingdom the use of patient safety tools that are provided by the NHS such as National Patient Safety Alerting System (NPSAS), which enables the dissemination of patient safety alerts to healthcare providers via a central alert system and a National Reporting and Learning System (NRLS) for reporting serious incidents, helped improve both patient safety and waiting time at the ED [42].

7.6 Health information exchange system, telemedicine and data protection management in Jamaica

Over the period of July 2012 to March 2013 Jamaica developed an integrated National Health Information System (NHISS) that supports timely and efficient data management. This system have helped to produce quality health information for evidence based decision making at all levels of the National Health System. The main aim of this NHISS is to improve the management of the healthcare system [43].

Jamaica is listed among 125 countries in the WHO Atlas of e-Health states in which e-Health strategies, such as policies, funding, capacity-building, and necessary legislative framework to protect patients’ data, inter alia, are in place. In addition, it is mentioned the existence of telemedicine, mHealth, engagement of the population with social media, use of electronic records, use of e-learning in health sciences, and having a system in place to manage large amount of data [41]. The Electronic Management System in use in Jamaica is the first technology-driven element of its kind in Jamaica and the Caribbean region. It provides an electronic version of a patient’s medical history, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The intention is to provide a complete and accurate summary of an individual’s medical history that can be shared to improve the delivery of care and also provide quality data for decision-makers (health professionals, directors, researchers, citizens) across the health facilities of Jamaica [47].

7.7 Upgrading health policy for emergency care management

The main goal of safety and health programs is to prevent workplace injuries, illnesses, and deaths, as well as the suffering and financial hardship these events can cause for workers, their families, and employer especially for the emergency departments. The creation and recommended practices and policies, use a proactive approach to managing workplace safety and health, and upgrading is necessary. In Jamaica hospitals are some of the most frequented facilities based on the nature of the services they provide, and they are often overwhelmed with caring for and managing emergencies to reduce preventable mortality. Against this background, the Ministry of Health and Wellness normally request support from the Pan American Health Organization (PAHO), which facilitated an assessment through a survey and a two-day consensus meeting as part of an Emergency and Critical Care Assessment System. The PAHO governs the Caribbean Region and a similar approach in other Caribbean countries [42]. The Emergency and Critical Care Systems form an integral part of the broader implementation plan for the “Safe Systems Approach for Safer Roads in Jamaica,” which sets the island on a path to achieve the goals proposed for the second Decade of Action for Road Safety 2021–2030. It also comprises all other types of injuries and critical illnesses requiring urgent medical attention and establishes the care all seriously ill patients should receive in every hospital [53]. Similarly, in their upgrade of health policies The NHS and UK Government have published a new two-year delivery plan today to help recover urgent and emergency care services, reduce waiting times, and improve patient experience. The plan focuses predominantly on the need to improve hospital discharge and join-up with adult social care, reflecting the challenges of an aging population and frailty. However, we know that children’s urgent and emergency care has also faced unprecedented levels of demand and that some of the drivers of this are different than for adults. As part of the plan there are several welcome solutions to improve pediatric urgent and emergency care. These include: (1) expanding advice offered through NHS.UK and NHS111 online to support decision making for young people and families, including self-care and management, (2) roll out of acute pediatric respiratory hubs for children ahead of time for the winter, (3) expansion of virtual wards, with priority pathways for pediatrics, (4) expansion of virtual wards, with priority pathways for pediatrics, and (5) embedding family support workers in A & E settings to provide additional support to children and families presenting with non-urgent medical issues but overlapping needs [54].

7.8 Adequate evaluation process of risk management strategies

In Jamaica there is no documented established national plan for managing and evaluating emergency care risks. Therefore, the implementation of risk management strategies in emergency care at the public hospitals would be beneficial in maintaining patient safety in Jamaica [55]. However, there is a general national risk management policy that exists for the country governing all businesses [56]. Hence the importance of this study to aid in identifying the need for a national risk management policy specific for health care management. According to Gadding, to understand risk in the Emergency Department (ED), it is important to examine the workflow of the patient journey in an ED. The Emergency Department is a dynamic and often unpredictable place, which makes it a high-risk inducing environment. The staff of an ED may see anything during a shift, ranging from a common cold or upset stomach that are treated with a simple medication to a trauma or cardiac arrest that requires full resuscitation efforts. Speed, efficiency, and accuracy of assessing, diagnosing, and treating patients are essential, due to the unpredictable and often heavy flow of patients through an ED. A visit to an ED involves a complex series of decisions, interactions, and activities, which will make it vital for risk planning and assessment to be accurate. A systematic approach that facilitates fast, efficient, and accurate patient documentation and treatment within defined processes is required to minimize unexpected failures or human errors [32]. The main objective of carrying out the process of management of risk is appropriately controlling the health variables which affect the overall health condition of patients for enhancing the potential of achieving the most appropriate outcomes. Since the main reasons for accidents happening are a set of known or unknown failures in the health care system, in this regard conducting standardized approaches for the management of risks in a hierarchical framework could be very effective [57]. Moreover, preparing more accurate and standardized plans which sufficiently are investigated and prepared with continuous monitoring could be very effective in ensuring the proper management of the potential risks and damages to the patients and the emergency staff. The precise implementation of these kinds of strategies is strongly associated with the involvement of patients and the emergency staff and the overall support of administrative and Insurance organizations [58].

7.9 Decreasing overcrowding in A & Es

Empirical studies have demonstrated that overcrowding is a major risk factor to patient safety and mortality in emergency rooms worldwide. Addressing this problem has been a major challenge in emergency care for many years [58, 59]. Despite the existence of multiple interventions to address this problem, it continues to spiral out of control in many countries including Jamaica. Therefore, it is important that each healthcare system has consistent ongoing review of existing management of the influx of patients into emergency rooms. This influx may be seasonal or situational and so plans should be put in place to address the unavoidable increase in patient load. Where patients can be seen at clinics, private hospitals or medical offices they should be encouraged to do so [60, 61].

However, preventing the influx of patients in emergency rooms does not alter how patients receive emergency care. Therefore, it is essential that the emergency care provided to patients is efficient in decreasing long wait time as well. Interventions that can be employed to improve wait time in the Jamaican public emergency setting include improving hospital capacity, decreasing overcrowding by using observation units as a component of the triage process [62, 63].