Emergency departments at a ‘tipping point’

Emergency departments are in the “last stage of system failure,” says the co-author of a Jan. 17 paper calling for Canada to rethink how we use the departments to fill growing gaps in non-emergency care.

“Omicron has nudged us closer to the tipping point,” says New Brunswick physician Paul Atkinson, noting that there is an existential threat to emergency department medicine in Canada, perhaps best described by American physician Graham Walker: “What do you want from your emergency department? … A drop-in centre for any societal, social or medical problem? (Or) a place for the critically ill? … It’s high time we get a clear answer.”

Emergency rooms act as a safety net for failures in the health-care system, says Toronto emergency physician George Mastoras. “Things that are best managed outside of the emergency department are sent in because there’s no other option.”

People with mental-health concerns might not always require acute-care measures, “but it takes a lot of nursing care to be able to settle them, to spend time with them,” says Metro Vancouver ER nurse Alannah Wright.

The increasing burden on emergency departments has created a concern about quality of care. Atkinson says “the expectations of the public cannot be met right now due to many shortcomings” that have been accumulating.

Emergency rooms act as a safety net for failures in the health-care system.

Every year, emergency department volume in Canada grows more quickly than the  population. A 2016 Ontario study showed visits to emergency departments increased 13.4 per cent over seven years compared with just a 6.2 per cent rise in the population.

While a key driver of growth in use is Canada’s aging population, according to a 2013 report, it is in part also driven by health inequities.

According to a 2015 report of developed countries, poor and marginalized patients are disproportionately treated in emergency departments and half of their visits are for non-urgent concerns.

Canadians also wait longer in emergency departments than our peers in other developed countries, with 29 per cent reporting a wait of at least four hours during their last visit. In September, one Winnipeg emergency room saw such high wait times that one in four patients left without seeing a doctor.

Long wait times aren’t just inconvenient: They can also be deadly.

A recent U.K. study showed that for every 82 emergency department patients who need an upstairs bed but are delayed by more than six to eight hours, there is one death that otherwise wouldn’t have happened. Atkinson says there are thousands in Canada who wait longer than that.

It’s called “boarding” – the practice of keeping patients who need to be admitted in the emergency department because the hospital is full, says Walker. By default, these patients are the responsibility of emergency department nurses.

Yet, the solution to boarding is not as simple as moving admitted patients from emergency department hallways to upstairs hallways – Walker says upstairs services have the right of refusal, whereas emergency rooms do not. “The ER can get as crowded as possible, but the ward can say, ‘That’s it for us.’ ”

Atkinson says long-term care facilities send elderly residents they can’t manage to ERs, “not because we have geriatric expertise but because we will see the patient today.”

Vancouver paramedic Annelie van der Heyden recalls one case of a woman in her 90s living in a long-term care home whom she transported to an emergency department twice in the same day: The care home and the emergency department were at odds over where she should recover from a fall. “What are we hoping to achieve by going to the emergency room?” van der Heyden asks. “We can’t care for her here; we can’t care for her there.”

Walker says still others don’t have an emergency diagnosis but can’t be discharged due to such problems as caregiver burnout, gradual loss of independence and lack of home support.

Such strenuous conditions have emergency staff, especially nurses, leaving the profession, says Mastoras. “People at their breaking point decide they want to turn to something less taxing.”

In recent months, nursing shortages have been responsible for the closing of emergency departments in Manitoba, Nova Scotia, B.C., Quebec and Alberta.

Wright, who recently left full-time emergency nursing, says the demand of simultaneously caring for both emergency and non-emergency patients left her feeling “numb.” She says she remembers trying to save a patient dying of septic shock while the waiting room was full of people, many of whom she knew could just recover at home.

Long wait times aren’t just inconvenient: They can also be deadly.

“We went into this profession because we care and want to help people, but when I’m impatient or dismissive of their concerns because I know their condition could be managed at home, it just feels so awful. It just feels like I’m not human anymore.”

To save emergency departments from collapse, Atkinson and others have been asking for more support from other medical specialties and alternative care providers such as nurse practitioners and pharmacists – and many of these requests predate COVID-19.

Doris Grinspun, CEO of the Registered Nurses’ Association of Ontario, says Canada’s emphasis on emergency departments and hospital-based care is a system bound to fail: “We have designed a system where if you want a quick response, you go to the ER … We have to strengthen all the pieces where it’s most appropriate for patients to be seen.”

New Brunswick Health Minister Dorothy Shephard recently offered a glimmer of hope, announcing an expansion of primary care delivery in the province with the goal of relieving emergency department overcrowding.

In the meantime, Edmonton emergency physician Shazma Mithani has advice for the public: “At the end of the day, we’re always there for patients if they need us – if there’s any doubt whether you should come, just come and we’ll see you. But please be patient with us.”