It was a Monday afternoon in early September, and a very bad day was about to unfold for Dr. Anil Chopra and the rest of the staff of the emergency department at Toronto Western Hospital.
Seven ambulances waited to unload their charges. The department's resuscitation room – where the severely ill and injured can be pulled back from the brink of death – was occupied by a patient with a breathing tube waiting for a bed in the intensive-care unit. But the ICU was full, just like the rest of the hospital.
With no room on the wards, the emergency department became a holding tank for 24 patients who were sick enough to be admitted, but who would have to languish on stretchers and in chairs until beds opened upstairs. At least 19 patients sat in the waiting room, three or four with chest pain, one who had vomited blood, another who may have had a stroke.
"We called the on-call physician that day," Dr. Chopra recalls. "We asked the physicians leaving to stay longer, just to maximize our resources. We pulled some of the team members from the rapid-assessment zone to help us in the sub-acute and acute areas. That was a very bad day."
Dr. Chopra, who is the chief and director of emergency medicine at the University Health Network, which includes Toronto Western, said dreadfully busy days are becoming more common in his emergency department, and all the emergency departments in the bustling heart of Canada's largest city.
Dr. Anil Chopra is photographed in the emergency room at Toronto General Hospital on October 21, 2016.
Jennifer Roberts for The Globe and Mail
As downtown Toronto's population has skyrocketed in the past decade, tens of thousands of patients have streamed out of their new condos and into the hospitals on their collective doorstep. At the same time, patients who live outside condoland or even outside the city limits – mainly commuters and people who choose the prestigious downtown facilities over their community hospitals – are also pouring in to core hospitals in record numbers.
The flood of new patients is putting added pressure on Toronto's downtown hospitals, which, like most big-city hospitals across the province, are already struggling to care for older, sicker patients during a prolonged funding squeeze by the provincial government.
But Toronto's marquee hospitals face some unique challenges. As teaching hospitals and referral centres for the Greater Toronto Area and the rest of Ontario, they provide some of the most complex surgeries and treatments in medicine while also absorbing emergency patients. They are also disadvantaged by a Byzantine hospital-funding formula that is not nimble enough to respond to such an extraordinary spike in traffic at one cluster of hospitals, according to a June, 2016, report commissioned by the local health authority that oversees Toronto.
"EDs can't survive in this way," Dr. Chopra said. "You'll have staff dissatisfaction, patient dissatisfaction, poor patient outcomes. We have been extremely lucky that somebody hasn't died."
For a glimpse of what the downtown emergency departments are up against, just look to the tower-filled skylines to their south and west.
In Toronto's core and the nearby neighbourhoods of King and Queen West and Liberty Village, the population increased by 48 per cent from 2006 to 2015. In the rest of the old city of Toronto, growth was 4 per cent.
More people are working downtown too. Nearly half a million were employed in the area in 2015, up 32 per cent from 2005.
The population boom is reverberating especially loudly down University Avenue's hospital row, where, from 2006-07 to 2014-15, annual emergency department visits increased by 43 per cent at the Hospital for Sick Children, 45 per cent at Mount Sinai Hospital and 59 per cent at Toronto General Hospital, which is also part of the University Health Network. Nearby, emergency visits to Toronto Western and St. Michael's Hospital grew by 43 per cent and 31 per cent, respectively, in the same period. (Sunnybrook Health Sciences Centre was the only acute-care Toronto hospital outside downtown to see a similar spike.)
The number of patients admitted to these hospitals through the emergency department is up dramatically too. At Toronto Western and Toronto General, admissions are up 60 per cent and 68 per cent, respectively, from 2006 to 2014. That matters because it is usually patients who have been admitted but are waiting for beds, not hypochondriacs with the sniffles, who cause backlogs in the emergency department.
Over all, emergency visits to the eight acute-care hospitals in the old city of Toronto are up 34 per cent from 2006-07 to 2014-15, an increase that would likely be even steeper if so many downtown dwellers were not healthy young professionals.
The emergency-department crunch is affecting Toronto's hospitals in different ways.
For instance, St. Michael's Hospital is a level-one trauma centre. If someone is shot at a nightclub or crushed in a car accident on the Gardiner Expressway, the ambulance will rush to the St. Mike's emergency department at Victoria and Shuter streets.
St. Mike's is also a magnet for the homeless, the addicted and the mentally ill. There's a needle exchange program right in the waiting room. The doctors and nurses care for these complex patients in an emergency department that was built for 45,000 visits per year. It now handles about 75,000 visits annually.
Dr. Douglas Sinclair, the executive vice-president and chief medical officer at St. Michael's Hospital, said staff are making the best of the space they have.
As he walked through the department in his scrubs after a shift last week, Dr. Sinclair showed off the comfy chairs that have replaced stretchers in some of the curtained patient bays in the area beyond the waiting room. Those bays can now accommodate three patients sitting up instead of one lying down.
He also pointed out the rapid-assessment zone, where patients who do not need to check in to the hospital are examined and sent on their way as swiftly as possible.
Dr. Douglas Sinclair is photographed in the trauma room at St. Michael’s Hospital on Oct. 20, 2016.
Fred Lum/The Globe and Mail
The old-school emergency room philosophy used to dictate that the least sick patients would be seen last. Now, it is common in Toronto for emergency departments to separate the easy cases from the hard and treat them in different areas, which has helped to control wait times for patients healthy enough to go home right away.
The most recently published wait times for Ontario show that for patients with minor or uncomplicated conditions, most of Toronto's downtown emergency departments are missing the provincial targets, but not by much. They are much wider of the mark for complex cases.
Still, ingenuity cannot overcome all the physical limitations of a cramped emergency department.
At St. Mike's, there are only three enclosed rooms in the department for people suffering mental-health breakdowns. If more people in crisis turn up, they have to wait for help in the open department, accosted by beeping equipment and fluorescent lights.
"If you're suicidal, upset, psychotic, if you're hearing voices, this would be the worst place," Dr. Sinclair said. "If you think about it, although you're in safe hands, theoretically, you could get worse. So that's the problem."
He expects such problems to be solved, at least partly, when the hospital completes a massive renovation that includes a new 17-storey patient tower.
The new emergency department, twice the size of its predecessor, will feature a designated quiet area for mental-health patients, staffed around the clock by specially trained health-care professionals. There will be a new trauma unit with three bays, up from two, and a new imaging suite with a CT scanner so that patients can undergo more testing right in the department.
But one thing won't change: the number of inpatient beds.
In a bid to control health-care spending, the Ontario Ministry of Health and Long-Term Care has made it clear that it wants as many patients as possible diverted from hospitals, where care can cost more than $1,000 a day. It wants inpatients discharged faster than ever.
It also wants – desperately – to reduce the number of mostly frail elderly patients in hospital who no longer need an acute-care bed, but have nowhere else to go. The percentage of downtown Toronto hospital beds blocked by alternate levels of care patients, as they are known, has begun to rise again recently, despite the ministry's fixation on reducing the ALC rate.
The fear is that handing hospitals money to open new beds would undercut these efforts. Like adding new lanes to a highway, opening more beds might simply induce more demand.
The Liberals have shifted their focus and funding to care at home, which is where the government says patients would prefer to heal and age. The government froze the base budgets of Ontario hospitals for four years before increasing them by 1 per cent in the past budget, which has left hospitals across the province scrambling to find efficiencies.
The University Health Network, for example, is currently hunting for savings with a third-party operational review. "But being in the fifth year now of fairly constrained funding, you can imagine that much of the low-hanging fruit has already been harvested," said Peter Pisters, the president of the UHN.
Meanwhile, the patients just keep coming, especially in downtown Toronto.
So far this fiscal year, Toronto Western and Toronto General have logged 105,743 inpatient days on the surgical, medical and combined medical-surgical floors. They budgeted for 95,573 days.
Not all of those patients came in through the front door of the hospital. But unscheduled admissions through the emergency room contribute to gridlock across the hospital.
At the UHN hospitals, a "bed alert" e-mail is sent to all staff whenever there are more than 15 admitted patients waiting in the emergency room, no available beds in the hospital and each inpatient unit has already accepted two additional patients in its hallways.
Toronto Western and Toronto General briefly came off bed-alert status at the end of July; they have been on perpetual bed alert ever since.
In the face of this kind of pressure, the Toronto Central Local Health Integration Network (LHIN,) which oversees health-care planning for an area roughly equivalent to the old city of Toronto, asked the consulting firm Hay Group to study how explosive growth in downtown Toronto was affecting the hospitals.
The report, submitted June 30, concluded that the government's funding formula hurt the high-growth hospitals downtown. The formula looks at population growth LHIN-wide and assigns funding accordingly, which masks much faster population growth in one part of the LHIN – downtown, King and Queen West and Liberty Village.
There is also a two-year lag between the formula's projections and the number of actual patients a hospital treats.
"It takes a long time to balance the books, if you will," said Howard Ovens, the chief of emergency medicine at Sinai Health System, which includes the Mount Sinai site. "The faster your volume is growing, the more disadvantaged you are because you're being funded at a rate lower, at least initially, than the actual number of patients you have to look after."
Susan Fitzpatrick, the chief executive officer of the Toronto Central LHIN, said the government seems receptive to the concerns raised in the report, but it has not promised any action.
Health Minister Eric Hoskins, who was not available for an interview, said in an e-mailed statement that the ministry regularly tweaks the funding formula, and did so recently to help children's hospitals, including the Hospital for Sick Children in Toronto.
"My ministry works closely with our hospitals and our LHINs to identify areas that may need to be adjusted and to provide support to hospitals when they're facing pressures," Dr. Hoskins wrote.
In the meantime, emergency physicians like Dr. Sinclair at St. Mike's worry that if nothing changes, the continued rise in emergency volumes will threaten the ability of the downtown hospitals to provide advanced care.
"The consequences, for us, [are that] we can't do our tertiary-care role. That's what we worry about," he said. "It's the same problem for the other downtown hospitals. We have this dual role. If we can't do that, then it's a problem for the province."