By: Catherine Varner
While Ontario’s COVID-19 Science Advisory Table has warned of critical care bed shortages in the coming months, emergency departments, especially those in non-urban regions, are experiencing unprecedented crowding and providing emergency care in precarious places.
On a recent shift, an emergency physician in southwestern Ontario said he did something he had never done in his decade-long career. In the face of relentless crowding in the department and waiting room, he started seeing patients in ambulances parked in the hospital’s driveway.
“I got in the rig to see a patient because the EMS stretchers could not fit in our department,” said the physician, who asked not to be named. “If this person had needed immediate resuscitation, it would have been in our triage bay, but there was already someone on that stretcher. There were no spots to see people anywhere.”
The situation is dire. According to Health Quality Ontario, many hospitals have reached unprecedented levels of emergency department crowding. In September 2021, the average length of stay for an admitted patient in the emergency department was 16.5 hours – a whopping eight times longer than what is defined as “prolonged boarding,” a health-care system quality indicator that, as it increases, puts patients at risk.
As described in the New England Journal of Medicine, patients boarding in emergency departments are at higher risk of clinical deterioration, have longer in-patient stays and have higher costs of care. Prolonged boarding also increases crowding, increasing the likelihood of human error, violence toward staff and high clinical staff turnover.
Andrea Unger, a 20-year veteran emergency physician in southwestern Ontario, says the causes of crowding in her department are no different than in other regions across the province: Shortage of nursing staff and large numbers of admitted patients waiting for long-term care beds or home-care services mean she cannot move patients from the emergency department to hospital floors.
“Our ER has been reduced from 30 acute care stretchers to see 100 patients per day down to 10 because the other stretchers are filled with 20 people waiting to be admitted,” she says. “We have seen a 100-per-cent increase in length of time people are waiting in the waiting room (since before the pandemic), and patients frequently exceed the number of chairs in the waiting room.”
Unger loses sleep thinking about the one in 20 patients who now leave her emergency department without seeing a doctor – a number that has skyrocketed in the past year. “These are the people who leave in frustration and come back with heart attacks or come back with a ruptured appendix.”
When asked about the emergency physician in her department seeing patients in ambulances, she says, “That afternoon there were eight ambulances parked outside without even room for one more stretcher to come through the sliding doors. This was a new low.”
Nearby, Norfolk General Hospital responded to nursing shortages by shutting down hospital services. This fall, it was the labour and delivery unit, meaning pregnant women have had to travel to other communities to deliver. Norfolk now also routinely receives ambulances that are diverted from larger area hospitals due to overcapacity, an occurrence that was relatively unheard of before the pandemic.
Rejean Duwyn, chief of the emergency department at Norfolk General Hospital who has worked in a variety of rural and remote settings in Ontario, says the current staffing crisis in the region is the worst he has ever seen.
In September 2021, the average length of stay for an admitted patient in the emergency department was 16.5 hours.
Norfolk General has a 15-bed emergency department, and in overnight hours only three nurses and one physician. A shift with one nurse short is now a more regular occurrence, says Duwyn, and creates a precarious situation if a patient arrives needing definitive treatment at a larger hospital.
Describing a patient who would face delays in care for a heart attack or a brain bleed, for example, Duwyn says, “These situations are a worst nightmare. At times, there are not enough staff to physically transfer someone and keep the emergency department open. It is one thing when it is beyond your control (like dangerous weather conditions in a remote location), but it is another when it is because of staffing levels.”
According to Anthony Dale, president and CEO of the Ontario Hospital Association, system overcapacity has been years in the making, especially in non-urban regions.
“We are looking at a 20-year period where the needs of rural and northern communities, with respect to hospital services, have been more or less overlooked,” says Dale. “Now the pandemic has revealed to all, not just rural and northern communities, the system is extremely fragile everywhere.”
With a hospital system running at or over capacity at all times, the highest proportion of acute care beds ever occupied by alternate level of care patients, higher vacancy rates in the health-care workforce, difficulty recruiting and retaining staff and workforce burnout, Dale predicts the situation in acute care hospitals over the coming months is precarious at best.
But it is not just in hospitals where the dangers of crowding are evident. Russell King, chief of the Brant/Brantford Paramedic Services, says because of emergency department crowding, his paramedic crews are unable to offload patients in a timely manner, causing what are called “offload delays.” These delays can result in worst-case scenarios called Code Zero, or when there are no ambulances available to respond to a 911 emergency in the community.
King says these delays have skyrocketed this year. With the average team waiting nearly an hour and a half to get back on the road, “each month we equivalently lose five full days on the road.”
With a fleet of only nine ambulances in the daytime and six at night, the region has had 500 instances this year when they have had to rely on neighbouring municipalities to respond to calls when no ambulances were available.
“Everywhere from Paris to Brantford is not covered,” he says. “If we start using vehicles from other jurisdictions, we take from them, and then they have to rely on other areas’ services too. It is a domino effect.”
Similar situations are occurring across the country. Quebec’s coroner is investigating after a man died after waiting two hours for an ambulance.
Unger, King and the emergency physician treating patients in the back of ambulances all agree: the solutions must come with input from the front lines.
“I have done every procedure you can think of, save a genital exam, in the hallway,” says the physician. “It is to the point that we are so gridlocked, if there is a spot to lay down, we are using it. Get the boarded patients out so that I can take care of my patients, talk to them, and do procedures in a place that I don’t have to pause to allow a stretcher to go by.”
King says he believes it is only the dedication, hard work and integrity of individuals that keep the whole system from collapsing – from the nurse working extra shifts in long-term care homes to the paramedic and emergency department teams that get ambulances out when there’s a three-car pileup or child without vital signs.
“People on the ground think (the system) is breaking. But the will of the people who are out there right now, the hard-working front-line individuals no matter where they are, will do their best not to let it.”
Catherine Varner is a Toronto emergency physician, clinical epidemiologist and freelance journalist. She is on the deputy editorial team at Healthy Debate.