Canada’s foremost emergency room doctor calls it a “quiet crisis” – overcrowding in the country’s emergency departments, brought on largely by a shortage of long-term care beds, is putting patients at risk.
The issue has been thrust to prominence this fall in Alberta, where last month Premier Ed Stelmach received a letter from an emergency physician warning that overcrowding “is worse than it has ever been” in a provincial system on the verge of “catastrophic collapse.”
Since then, the issue has been given a human face with published accounts of extreme cases of system failure, such as that of Shayne Hay, 34, who earlier this fall checked himself into an Edmonton emergency room saying he was suicidal. After waiting in vain for a counsellor for more than 12 hours, he hung himself by his backpack strap.
This week, Raj Sherman, an emergency room physician and MLA, said in an e-mail to caucus colleagues he “can no longer support” his own government’s health policy. Scrambling to respond to the issue, the Stelmach government turned down his offer to resign.
ER overcrowding is a Canada-wide issue, and Alberta is following Ontario, British Columbia and Quebec in trying to find solutions.
“This is a national problem, really,” said Peter Toth, president of the Canadian Association of Emergency Physicians, adding that overall hospital overcrowding has turned ERs into “warehouses” for complex cases. “It has been a quiet crisis for many, many, many years.”
The model for success is unclear. Many provinces haven’t even begun tracking ER wait times. There are some glimmers of hope, but after more than two years of attempts to reduce the waits, it still takes 32 hours for an average patient in Ontario with a complex case to be formally admitted to hospital, well above the eight-hour target.
It’s worse in Alberta. Only 34 per cent of Alberta’s complex ER patients are admitted to hospital within eight hours (compared to 41 per cent in Ontario), largely because the long-term-care beds to which they’d typically be moved are already in use. (The Canadian Medical Association defines long-term care as a broad-ranging term meant to include many types of ongoing care.) Doctors say the root of overcrowding is, almost invariably, in long-term care, not overuse of ERs, which is nonetheless a problem, too.
In an emergency meeting held on Friday in response to the crisis, Alberta adopted a “push plan” modelled after systems in Ontario and B.C. meant to ease overcrowding in extreme situations by funnelling patients to other departments, which themselves are often at capacity. Alberta Health Services, the board overlooking delivery of care, says that for the first time, several factors (such as a shortage of ambulances, which have been known to line up six-deep in Calgary and Edmonton before being able to offload a patient) can trigger such an ER-clearing response. But it’s no easy fit.
“We’re trying to get a size 13 foot into a size 8 shoe. It’s going to be very uncomfortable for a while,” said Felix Soibelman, president of the Edmonton Emergency Physicians' Association, which first raised the alarm. “We were hoping for some kind of relief like this months, if not years, ago.”
There are two types of ER patients, and provinces adopt different targets for dealing with them. Alberta and Ontario seek to treat less complex, non-admission cases in no more than four hours. According to the most recent data, Alberta does so 58.3 per cent of the time, while Ontario does it 88 per cent of the time. Moving these cases through more quickly is relatively simple, and B.C. has had some success in doing so.
Complicated patients (those who arrive without vital signs or with life-threatening illness or injury) are much more difficult, and often stay for more than a day in ER.
It’s those complex cases that cause problems, say both Dr. Toth and Jeff Turnbull, president of the Canadian Medical Association, not an overabundance of cases such as ear infections that could otherwise be treated by a family physician.
“These are extremely minor contributors to the problem, and they serve to take focus away from the root cause, which is hospitals are currently running at capacity of 100 per cent,” Dr. Toth said. “Because of the overcapacity of the hospital, the backflow of its admitted [serious] patients happens in the emergency department, reducing our access to emergency patients.”
That backlog is costly. Dr. Turnbull is chief of staff at The Ottawa Hospital, where on Friday he had 160 patients in emergency beds (at $1,100 a day) waiting for spots in cheaper long-term care. As cash-strapped provinces look to cut costs, Dr. Turnbull says long-term care is an obvious move.
In Alberta, it was only after a revolt by Dr. Sherman that the government responded, although it has tried to play down the crisis by saying it is adding about 200 acute care beds and, eventually, 1,300 long-term care spots. (Alberta Health Minister Gene Zwozdesky said on Thursday that he hadn’t seen Dr. Sherman’s e-mail – even though it was sent directly to him a day earlier and appeared on the front page of a local newspaper that morning).
Alberta Health Services president Stephen Duckett has also tried to avoid the spotlight – on Friday, he darted from the emergency meeting, telling TV camera crews chasing him that he couldn’t comment because he was eating a cookie.
AHS executive vice-president Chris Eagle said the new steps weren’t taken earlier because the extra capacity, including new acute and long-term care beds, was expected to make a difference more quickly.
For Dr. Soibelman and other front line staff, the change is long overdue.
“We don’t like to use the word crisis, but when you're a front line doc trying to look after people in the waiting room that you can't provide care to because there's no space, for me that's a crisis,” he said.
With a report from André Picard in Montreal