(Illustration via iStock)
As Canada’s emergency rooms grapple with persistent staffing and bed shortages, hospital admission wait times are getting longer. This past December in Ontario, patients waited in ERs for an average of nearly 22 hours before getting admitted to the hospital—almost three times longer than the provincial target time of eight hours.
According to Michael Howlett, president of the Canadian Association of Emergency Physicians, or CAEP, decades of underfunding fuelled systemic problems, which are now hitting a breaking point. Ontario wait times will likely only get worse, he says, particularly during respiratory virus seasons.
Howlett—who works as an emergency physician in Durham region, just east of Toronto—is concerned that these extended wait times are causing preventable deaths: in November, a patient died in a Winnipeg ER hallway after waiting for a bed for 33 hours. The following month, two patients died over two days while waiting for treatment in a Quebec ER that was operating at nearly 200 per cent capacity for weeks. This is the worst year Howlett has seen in his three-decade career as an emergency physician. Here, he explains how we ended up in such a dire situation and what needs to change to save patients’ lives.
You started off as an emergency physician in Nova Scotia back in 1987. How does what’s going on now compare to back then?
In 1987, there was no such thing as a person waiting in an ER to be admitted. It just didn’t happen. If a physician or nurse called in sick, we had enough replacements—full-timers and part-timers—to cover for them.
Things started to change around 1990, when provincial governments cut back on staffing in the name of improving efficiency, which has long been used as an excuse for fiscal restraint in health care. Now, all the redundancies and fail-safes we had in place have been removed. I started to notice the impact of those losses in the early 2000s. And now, 20 years later, we have overburdened physicians and nurses in ERs that routinely operate far above capacity.
How did these cutbacks ripple out beyond the ER?
The efficiency-focused reforms have also led to inadequate investments in acute care, long-term care and primary care. In Ontario, there were more than 35,000 acute-care hospital beds in 1990. Despite the province’s growing and aging population, Ontario’s government had cut that number down to 20,000 beds by the start of the pandemic.
As early as 1992, emergency physicians like myself worried that cutting back on clinical care beds would result in more people being housed in ERs. And that’s exactly what’s happened. An ER has become the collection point for patients who can’t get treatment elsewhere in the health-care system.
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For example, some seniors face mobility difficulties, as well as functionality challenges caused by conditions like dementia. These individuals require specialized long-term care from geriatric nurses and other professionals in a hospital setting. But because we don’t have enough long-term care beds to keep up with our aging population, many of these seniors find themselves at home without adequate assistance for their complex needs. Inevitably, they develop serious problems and seek help in ERs. And since we don’t have enough acute-care beds, hospitals will try to find a way to discharge patients and send them home. This cycle then repeats, resulting in progressively worse health outcomes for the patients each time.
How else are these cutbacks and extended wait times affecting ER patients?
I’ve heard stories from emergency physicians around the country about patients who don’t get to a bed before they have a crisis. Patients have had heart attacks while sitting in the waiting room. Others, brought in by ambulance, are being resuscitated on the floor or on the ambulance offload stretcher. Elderly people are developing bed sores and ulcers because they’ve been lying on a stretcher for two or three days, and they aren’t moved because staff are too overwhelmed with all their other tasks.
There have been some shifts where every single patient I treated was on a stretcher in the hallway or in a chair somewhere in the ER, simply because there were no beds to put them in. Some of my patients have waited 100 hours to get admitted.
What about preventable deaths? There are reports across the country of patients dying in ERs while waiting to get adequate treatment.
It’s important to note that the wait times aren’t equally bad for everyone. Emergency professionals are pretty good at identifying the worst cases and treating them as quickly as possible. For example, my last heart attack patient was triaged, examined and tested within 10 minutes of entering the ER.
The real problem is patients with less immediately serious issues, who face long wait times that can potentially kill them. Patients might first enter the ER with mild chest pains that are precursors to a heart attack, or they could have internal bleeding that isn’t detectable when we initially assess them. They’re waiting 20, 40, 60 hours or more for a bed to open up. As those wait times go up, death rates also inevitably go up.
Are people with potentially serious issues getting discouraged from going to an ER because of long wait times?
Definitely. Often someone dies or has a major problem because they stayed away when they shouldn’t have. Even though I may send some of my patients home because they aren’t really sick, I never tell them it was wrong to come to the ER. I’ve seen many people who looked exactly like them and they ended up having a serious issue. So people shouldn’t stay away, because they don’t have the expertise to know how serious their issues are.
How are emergency staffers coping with this crisis?
It’s impossible for emergency staff to keep up with the current care load. Five years ago—right before the pandemic—one of the hospitals I work at had 70 beds and about 25 nurses seeing 250 people in the ER in a given day, with 15 admitted patients waiting for an acute-care bed. Today, that same ER is dealing with upward of 70 admissions.
When emergency staff can’t perform in the ways they’ve been taught, they feel like they’re failing. Sometimes, a sick patient might need to be on a monitor, and the emergency staff know that, but there aren’t any available monitors. And then the patient’s condition might suddenly worsen without staff catching the issue as fast as they should. That’s not their fault, they’re doing the best they can, and yet it’s still upsetting because their hands are tied. It’s demoralizing to know what you should be doing and not have the time or resources to do it. It causes tremendous moral angst and moral injury, and that’s driving them away.
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Some of them are transitioning to walk-in clinic and family medicine work, while others take on administrative or leadership roles and only do emergency work part-time. The same phenomenon is happening with nurses: they often move from the emergency room to operating rooms, long-term care or public health, where the work is more predictable and less demanding.
To make things worse, we don’t have adequate numbers of medical professionals graduating to fill in those gaps, especially at the specialist level in emergency and critical care. So, when we find ourselves with a shortage, we’re forced to hire people with less specialized experience. This risks lowering the quality of care, because there’s a steep learning curve for non-specialized staffers.
If this status quo holds, how bad will things get over the next decade as our population ages?
Without alternative options, patients who don’t know what to do about their health issues will continue going to ERs. This will increase stress on the acute-care system. Wait times will get longer, especially for those middle-of-the-road sick people, more of whom might get sicker and die right there in the waiting area.
We will also have more makeshift care: improvised treatment locations, like hospital corridors, will become the norm. We might also resort to alternatives like virtual care online, particularly in smaller communities that struggle to find medical staff. There’s only so much a doctor can do virtually without physically examining a patient.
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What tangible steps can we take to solve these problems?
We need a new system-wide, top-down approach that prioritizes a culture of patient care and safety. For example, we must see seniors as people with problems that need addressing, rather than thinking of them as the problem. That new approach means targeted investments from all levels of government to tackle critical pinch points in the system where we’ve neglected seniors’ needs: acute care and long-term community care have significant capacity problems, so we must boost investments in beds and staff in those areas.
We also need targeted investment in emergency care professionals: more trained emergency physicians, emergency nurses, critical care nurses and support staff. CAEP predicts that we’re going to have a shortfall of 1,500 emergency physicians in Canada by 2025. That number is going to keep growing. We’ll also need to devote resources to increasing the number of family doctors and social supports, like community health workers.
By employing a proactive approach with all these investments, we’ll address patients’ needs and pull them out of the cycle of inadequate care and worsening health outcomes that they’re trapped in right now. This will reduce the pressure on our ERs and could very well pull us out of this crisis.
What about privatization? Could that help improve things for Canadian health care?
Spending money on the private system takes the focus off the essential improvements we need in the public system. Privatization is an option for those seeking quicker and more efficient treatment than what the public system provides. However, it’s crucial to maintain emergency medicine as an accessible option for everyone. With an already insufficient number of emergency physicians and nurses, we can’t afford to lose staff to nine-to-five private care positions.
How confident do you feel about your proposed solutions actually happening?
Well, CAEP called for a national forum with all the provincial health ministers back in October, but we didn’t hear a thing from them. All we can do is continue to advocate for what the system needs.
I keep at it because I like talking to people, and there’s a certain joy in using your abilities to help individuals. But the energy it takes to stay positive is hard to muster when it often feels like I’m losing the battle. There are always trade-offs when it comes to where we invest our resources, and we as a society have to decide whether or not letting people die for preventable reasons in hospital corridors is a price we’re willing to pay.
What does the future hold for you as an emergency physician?
I don’t like how difficult it’s become to work within the system. I hate seeing patients lying in the hallways. Even little things like finding supplies are now a struggle. Advocating to improve those things is an even bigger struggle. It’s just been so difficult to get any traction on bringing attention to these problems.
I’m 63 and close to retirement, but what really sustains me is the joy I still get from seeing patients and doing what I can for them, despite all the difficulties. Sometimes, my efforts pay off and a patient who could have died lives instead. And for me, making that positive difference is what it’s all about.
