Can we truly claim to have a modern, humane health system when we leave frail, frightened, elderly people for hours, even days, on gurneys in hospital emergency departments?
It's an uncivilized, disrespectful and disgraceful practice. Yet, it's been going on, to varying degrees, since the 1970s and, as the population ages, it's getting worse, not better.
The most recent evidence we have comes from Quebec, where Robert Salois, the provincial health and welfare commissioner, has just released a new report in which he traces the "evolution" of emergency care in the province over the past 10 years.
It makes for chilling reading, especially if you have a loved one like a frail elderly parent or grandparent who routinely needs medical care.
There are two types of patients in hospital emergency departments : 1) The ambulatory who are able to move about and sit to wait for care, and; 2) the non-ambulatory, meaning they need a bed or stretcher, and usually come in by ambulance.
In Quebec last year there were 3.4 million ER visits, including 2.3 million ambulatory and 1.1 million non-ambulatory patients. (Canada-wide, it's 14 million visits, with roughly the same two-thirds, one-third split.)
According to Quebec's health and welfare commissioner, the ambulatory spend, on average, 4.6 hours in the ER. Almost all are discharged home, none the worse for wear (and waiting).
The non-ambulatory are a different story.
The true emergencies, the trauma cases that are a mainstay of prime-time TV, have an average wait time of fewer than 10 minutes from the time they hit the ambulance bay. Perhaps we should take some comfort in that, but these "code blue" cases make up fewer than one per cent of patients.
Most people who come to a hospital emergency department by ambulance will be triaged and treated relatively quickly, but then they will wait.
These non-ambulatory patients, most of them frail seniors with chronic conditions like COPD or heart disease, wait, on average, 18.4 hours in the ER.
Remember, that's an average; waits of 24 to 48 hours are not uncommon. We stick them in hallways, behind curtains or in transformed broom closets. These patients, in their 70s, 80s and 90s, are essentially living on a gurney for days with little or no access to meals, toilets or privacy, and they are often alone.
In fact, the seniors-on-stretchers meme is so commonplace that we take it for granted. The media coverage only tends to start once someone's grandmother has been in the ER for 72 hours or more.
Mr. Salois calls the situation "preoccupying" – an understatement if there ever was one – and says policy-makers should be compelled to act, for humanitarian as much as economic reasons.
The commissioner makes the point that waits in the ER are not the fault of the ER. The endless bottlenecks are due to problems upstream and downstream. In other words, it's an engineering issue, not a medical one.
The commissioner estimates that 60 per cent of patients who go to the emergency room should not be there at all.
They should be treated in primary care, by physicians or nurse practitioners. But lots of people don't have a regular doctor and very few of those who do can get same-day appointments for urgent (but not emergency) problems.
Healthy people wasting a few hours in the ER waiting room is not, in the grand scheme of things, a big deal, though it does not make for good continuity of care.
The real worrisome situation is that of the non-ambulatory patients stuck in ER purgatory.
Some of the gurney-bound are waiting for a hospital bed, but only about one-third are admitted to hospital. Beds are in short supply because there are many frail seniors already stuck living in hospital with nowhere to go for lack of home care or long-term care beds.
The majority of elderly ER patients have the same dilemma: They're not sick enough to be hospitalized, but too sick to go home alone, or back to a nursing home where there is no medical care.
It's a perverse scenario that plays out daily and with increasing frequency.
But we know the solution.
We don't need bigger ERs. We need to shift resources from hospitals into primary care for the ambulatory and home care and community care for the non-ambulatory.
Until we do, our parents and grandparents will continue to fill emergency departments and fester in hospital hallways, gasping for care.