Dr. Tahara Bhate and Dr. Kevin Wasko are both emergency physicians practising in the Greater Toronto Area, and alumni of the Action Canada Fellowship program.
The headlines have been fast and furious: Canadian emergency departments are in crisis. From front-line staff to advocacy bodies, the alarm has been sounded repeatedly, with minimal effect. As emergency physicians working in two of Canada’s largest hospital systems, we witnessed the situation continue to deteriorate this past weekend. The root causes are multifactorial and not easily packaged into media-friendly messaging; the complexity of the situation has hindered both widespread public concern and a focused government response.
We both bring policy backgrounds to our medical careers, and so it is impossible for us to ignore the systemic failures underpinning our daily reality. During our shifts, we regularly see long and unsafe wait times, patients treated in hallways and waiting rooms, the repurposing of space to increase capacity and inadequate nurse-to-patient ratios. We also know that the current state of our emergency departments is not just a result of the pandemic – it’s been years in the making. COVID-19 certainly stalled system reforms and stretched teams beyond their limits, but it also happened to collide with a broken health care structure that has been crumbling for years. The failure of our antiquated health system, centred around the hospital model, makes the case better than any white paper could as to why robust primary health care, with integrated multidisciplinary teams, should be the anchor of any high-functioning system.
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In the absence of that care, emergency-department patients are presenting as sicker, with more medical complexity. Sicker patients increase our admission rate, but the inpatient beds are too few and are already full, resulting in admitted patients waiting days in the ER and creating “bed block.” The inadequacy of long-term care beds and community supports for seniors means that elderly patients also languish in medical wards.
After 2½ years of hearing that our health system is under threat, both governments and the public have responded with indifference to the current crisis. But our new reality is beyond sobering – for the first time, we are facing the spectre of preventable deaths in our emergency rooms. The same focused crisis response seen early in the pandemic is now needed again. As terrible as that time was, there was a mobilization of system transformation on a scale we could have only imagined: We saw overnight adoption of virtual care, clinicians and nurses working to their fullest possible scope of practice, new types of clinics launched within days and a true, system-wide response to a singular problem. That urgency and unity of purpose is what is needed now, both in terms of funds and the political and administrative will to do things differently.
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We must start with supporting our nursing colleagues. With nurses already in short supply prepandemic, the loss of nearly 50 per cent of our nursing staff to retirements, other clinical roles or other careers entirely has been catastrophic. Our emergency departments can’t run without nurses, and working with them toward innovative solutions has to be the most important short-term priority.
We need to reverse the alarming trend toward the “uberfication” of nursing, as we lose skilled colleagues to private agencies and casual lines of work. Those who stay need to have their commitment and sacrifice rewarded financially. Emergency-department nurses are highly skilled. That must be recognized and properly remunerated.
Staffing models need to change. We need a mix of professionals in our departments to ensure that skillsets are matched to tasks, and to optimize our scarce human resources. Emergency-department registered nurses (RNs) should function as the expert leaders of teams. There is work that only RNs can do, but other tasks can be completed by registered practical nurses, phlebotomists, personal support workers and others, who are all quicker to train and in greater supply than registered nurses.
To address burnout and provide the flexibility that RNs desire, new staffing lines should be considered that are based part-time in the emergency department and part-time in another, less intense area of the hospital, allowing RNs to get a predictable break from the chaotic ER environment while also offering reliability and predictability to both the hospital and the nurse.
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There is no doubt that long-term reforms are needed. But while we debate the structure of those reforms (and the associated accountability and funding considerations), we still need to act now to stabilize our system. If we want to get through this summer and the anticipated fall wave of COVID-19, the one critical priority must be the support and stabilization of our acute-care work force. Our health system is in crisis – in response, we must focus our attention and get creative with our solutions.
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