Canada’s emergency departments are in crisis: hospital occupancy rates exceed 90% for many days in a row, and many Canadian hospitals have been exceeding 100% occupancy for months on end. As a result, quality of care has decreased, staff retention has become problematic and overcrowding of emergency departments, a symptom of the problem, is assured.
On this episode, Drs. Omole and Bigham speak with Dr. Catherine Varner, an emergency physician in Toronto, deputy editor of CMAJ, and author of two editorials in the journal detailing the state of Canada’s emergency departments, the causes of the crisis and possible solutions. Joining the conversation is Dr. David Petrie, an emergency physician in Halifax and co-chair of the Canadian Association of Emergency Physicians’ EM:POWER Task Force on the Future of Emergency Care who explores what a whole system approach to resolving this pressing issue might look like.
Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.
You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole
X (in English): @CMAJ
X (en français): @JAMC
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Instagram: @CMAJ.ca
The CMAJ Podcast is produced by PodCraft Productions
Canada’s emergency departments are in crisis: hospital occupancy rates exceed 90% for many days in a row, and many Canadian hospitals have been exceeding 100% occupancy for months on end. As a result, quality of care has decreased, staff retention has become problematic and overcrowding of emergency departments, a symptom of the problem, is assured.
On this episode, Drs. Omole and Bigham speak with Dr. Catherine Varner, an emergency physician in Toronto, deputy editor of CMAJ, and author of two editorials in the journal detailing the state of Canada’s emergency departments, the causes of the crisis and possible solutions. Joining the conversation is Dr. David Petrie, an emergency physician in Halifax and co-chair of the Canadian Association of Emergency Physicians’ EM:POWER Task Force on the Future of Emergency Care who explores what a whole system approach to resolving this pressing issue might look like.
Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.
You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole
X (in English): @CMAJ
X (en français): @JAMC
Facebook
Instagram: @CMAJ.ca
The CMAJ Podcast is produced by PodCraft Productions
Dr. Blair Bigham:
I'm Blair Bigham.
Dr. Mojola Omole:
And I'm Mojola Omole. This is the CMAJ podcast. Blair, this topic that we're going to dive in today, about the crisis that's in emergency medicine, is something that we've talked about quite a bit, and it's something that you're quite passionate about.
Dr. Blair Bigham:
Yeah, I think we've taken the opportunity, based on some recent activity in both CMAJ and the popular press, to rush this episode to really address a worsening problem, although it sounds perennial, this idea that emergency departments are in crisis. And we're going to get into why that is and how we might actually start to address that in meaningful ways.
Dr. Mojola Omole:
And Catherine Varner, one of the deputy editors of the CMAJ, wrote a very eloquent and articulate editorial just outlining some maybe easy solutions or some areas that we should focus on that often have been left out when we're talking about the crisis in the emergency department.
Dr. Blair Bigham:
Yeah, there's a lot of evidence out there. There's 20, 30 years of literature about how hospitals and governments can address this in ways that make the burden a little bit lighter. And I guess that's the real emergent issue right now, is that the burden in the ER on patients and on workers is just through the roof. We've had so many physicians quit and nurses quit at the hospital where I work in the ER. I actually took myself off the schedule for the next couple of months because I can't deliver good care when I go to work. I literally go home feeling terrible and lose sleep over the state of what I'm able to accomplish with the resources at my fingertips in the emergency department. It's just soul-crushing right now. And so I'm really glad that we've decided to jump into it here.
Dr. Mojola Omole:
For sure. So we're going to have a great conversation with Catherine Varner and David Petrie.
Dr. Blair Bigham:
We have an all-star panel to discuss with us the crisis going on in Canada's emergency department. David Petrie is an emergency physician in Halifax and the co-chair of the Canadian Association of Emergency Physicians Task Force on the Future of Emergency Care. And Catherine Varner is a deputy editor of the CMAJ, and an emergency physician in Toronto, and the author of two summer editorials in CMAJ entitled, Without more acute care beds, hospitals are on their own to grapple with emergency department crises. Thank you both so much for being here today.
Dr. David Petrie:
Glad to be here.
Dr. Catherine Varner:
Thanks so much, Blair.
Dr. Blair Bigham:
So anyone who's walked into an emergency department in the last 10 years probably thinks that this is old news, but there's been quite a bit of media attention just in the last couple of weeks. Some big national stories have been released talking about the crisis in emergency rooms across the country. What do we actually mean when we're talking about a crisis? What's happening now that wasn't happening a year ago or even a few months ago that has brought this bubbling up to the surface again?
Dr. Catherine Varner:
I think what we're hearing from emergency providers across the country is that they're seeing levels of crowding in their emergency department waiting rooms in particular and in their care spaces that they have not experienced before. And at the beginning of the summer, we actually saw emergency physicians in large numbers write open letters to media outlets and their politicians about their inability to provide safe and timely care in Canadian emergency departments. And I've worked in this field for 10 years. I have not been a part of something like this before, and I think all of us on the ground in emergency medicine feel like the ability to see patients is harder than it's ever been before because we just don't have the space or the staff to look after the number of patients that are coming in and seeking emergency care.
Dr. David Petrie:
Yeah, I mean I would agree. My take on that, as you know, Blair, this problem goes back for decades probably. So it's not like it hasn't been a problem in the past, but I think increasingly the literature would suggest that waiting in the emergency department is not just an inconvenience. It does correlate with morbidity and mortality and more and more studies are coming out to show that. So I think that is part of it. But post COVID, things seemed to get worse with regards to the number one cause of this. I think that's boarding of admitted patients in the emergency departments went up. ED length of stays of admitted patients, which were in the 90 percentile, 20 to 30 hour range are now in the 40 to 50 hour range.
At the same time, there was a significant impact on staff. We started to lose especially emergency nurses who had been at the front line of all of this. And I think the third thing is this sense that given it's been a problem for so long, we're not really seeing change where we need to see change in order to impact and make things better for the patients that we serve. There's this moral injury thing and it's just hit a tipping point. It really has hit a tipping point.
Dr. Blair Bigham:
David, you talked about a couple of metrics there that we talk about, sort of ER lingo around people who are boarded in the emergency department and how many hours, or nowadays how many days it takes for them to leave the emergency department and be admitted to hospital. Catherine, in terms of patients who are admitted, often you or I on shift can't fix that. We can't make those people go up to the ward or get space. Tell our audience just a little bit more about how those admitted patients really bung up the way we're supposed to be functioning.
Dr. Catherine Varner:
So I completely agree with David that the primary problem for why we're seeing crowding in our emergency departments right now is that we are working with near a hundred percent occupancy of even the emergency departments of being fully filled with admitted patients. Which means that when a new patient arrives seeking emergency care, we don't have a bed or the staff to look after them. So they sit in the waiting room regardless of what their emergency is. The challenges we then are seeing and needing to care for our patients in these unconventional spaces like the waiting room or a bed that we use temporarily for our EMS personnel, we're now using and trying to use as a fully functioning bed in the waiting room. And that's really not where we are able to provide adequate care for patients or care that allows for privacy or the type of equipment that we need to care for patients, particularly if they're really sick.
Dr. Blair Bigham:
Go ahead.
Dr. David Petrie:
Blair, can I just add to that? There was an interesting editorial that came out this week in Annals of Emergency, which pairs well with Catherine's, I think, and they talk about occupancy as being an important factor but probably underestimates the real problem. The reason for that is that about 80% of admissions from the emergency department are admitted to about 20% of the services. So if we're looking at occupancy in the entire hospital, and that is measured as a single point in time occupancy at midnight usually, it underestimates what I would call or what they call in that editorial the bed hour utilization of the acute care services that the emergency department is so dependent upon. I would hazard most of the places I've looked at run those services at 110 to 120% most of the time.
Dr. Mojola Omole:
I'm just a bit lost from your point, David. So you're saying 80% of the patients are admitted to 20% of the beds?
Dr. David Petrie:
No, 80% of the admissions that come from emergency department flow through 20% of the services. In other words, if you want a bang for your buck and put some money and resources and capacity into where the main problem is, then that's an important number and ratio to understand.
Dr. Mojola Omole:
So, the main problem would therefore be having more of those beds unoccupied to be admitted to.
Dr. David Petrie:
Right. I mean, that's where the whole issue of queuing theory comes in. It really is. That's the physics of flow. It's mathematic, right? If there is no surge capacity, in other words, we run our system on average at a hundred percent capacity, then 15% of the time we're going to be busier than that and they will wait in the emergency department.
Dr. Catherine Varner:
Now I'm going to just chime in here because I think what David is pointing to is I think the internal medicine services could as easily write an editorial saying that they're in crisis too. That's what I've heard from our internal medicine colleagues who have been functioning at 120% capacity now for two years. That occupancy affects the flow considerably of the emergency department because that is the admitting service that we rely on almost the most. So any measures that we can do to increase surge capacity to those services, the downstream effect will improve the flow of what happens in the ED.
Dr. David Petrie:
And I think that's super important to point out because this is a whole-of-system problem. So internal medicine, if you look at their outflow into long-term care or continuing care or home care transition type places, they aren't available either, right? But one of the fundamental problems I think is that we have one of the lowest number of hospital beds in the OECD, right? We are on that bottom.
Dr. Blair Bigham:
Second to last at 38, I think.
Dr. David Petrie:
That's right. We can turn up efficiency probably in some places a little more than we have already, but at some point it is a capacity issue.
Dr. Blair Bigham:
Let's talk about some of those solutions that don't actually give us much bang for our buck. What are some of the myths out there about the problem in the emergency department and how to fix it? What doesn't work or what is just rearranging deck chairs?
Dr. David Petrie:
Well, I think it's an interesting question, because in my mind, has evolved over the last 20 years. Early on there were great studies to suggest that low acuity patients are not the problem in the emergency department. The variance of one more low acuity patient in terms of wait times is seconds to minutes. But over time, and I think especially post pandemic, there's a growing group of what we would call avoidable ED visits. So I think we have to be careful not to confuse those with low acuity emergency patients. An emergency patient, I would define and is defined by others internationally, as a patient with a problem that is unexpected or unscheduled and has some time dependency to it. A laceration, which may be a CTAS 4 or a 5, is reasonable to come to the emergency department. It does not block ED beds and does not block ambulance offloads.
But there's a growing number of patients that are sent to emerg or come to the emerg because there is no other option for them that are continuing care issues. There are the frail elderly that feels a little different today, a workup of weight loss for two months. A lot of schedulable and predictable transfusions come to the emerg and need to be... The emergency department has turned into this outpatient clinic and it becomes they just need a CT or an ultrasound and they're sent to the emerg. So none of that is good for patients. Patients don't like waiting 6, 8, 10, 12 hours for that and it really is a problem. I think that, back to your original question, things that have focused on low acuity patients like big education, expensive sometimes education programs, putting in a walk-in clinic across the street, even this transactional retail medicine virtual care stuff, sometimes referred to as fast food medicine where they're not integrated with a primary care home, there is no continuity of care, those things don't solve the problem, A, and in the long run probably make the problem worse.
Dr. Blair Bigham:
Let's jump into the problem. What are the system level changes other than just swiping a credit card and building new hospitals? What can we do in the near to moderate term to start to alleviate some of the stresses that we're all facing day to day?
Dr. Catherine Varner:
What I outlined in the editorial is that I think hospitals are really in a precarious place because they haven't been sent a lifeline at all over the last two years. So they're really on their own to institute some hospital level changes that may be able to mitigate some of the challenges happening in the emergency department. I think that starts with communication. In emergency medicine, we think of one of our most valuable skills as being good communicators in crises. And I think this is time to really foster that, and from a hospital administration standpoint is that we need to see what's happening in the emergency department as a hospital-wide problem and not just for the emergency department providers to shoulder.
I think recognizing and stating that there's a problem. I think visible hospital leadership coming to the emergency department, talking to emergency department providers about what they're experiencing on a day-to-day basis cannot be underestimated. I think these are really important things for hospital leaders to do.
Then with the addressing the challenge of patients who are boarding in the emergency department, first recognizing that patients who are boarding have worse outcomes than those who are cared for on the services where they are slotted to go. The intensive care unit, for instance. So making concerted efforts to move patients to the intensive care unit or to the floor such that they can receive the specialist care that they need is really important. And emphasizing that at a hospital level, I think at this point in time is of particular importance for the care of patients.
Dr. David Petrie:
I'll just follow up with maybe a couple comments. There was a great study that looked at high performing hospitals comparing them to medium and low performing hospitals, and it wasn't what everybody did. In fact, most all three categories did similar things, but there were four hows, how they did things that made a difference. One was executive leadership involvement, not just lip service but direct involvement. And I know that Catherine mentioned how important that is in her editorial. Two is performance accountability, three is system-wide whole-of-system solutions, and four is decision-making and iterative decision-making. So those are the things that actually work.
That other editorial I was talking about, they make a big deal about talking about the fact that in today's hospital systems, 100% of the services are squeezed into 25% of the hours. So if you look at the eight to five on weekdays, that's only 25% of the hours that a hospital is open. So that speaks to some of the issues around consultant availability as well as the diagnostic imaging accountability and that sort of thing. There are ways and other hospitals have shown that they can do it and do it without burning out their consultants in a way that is more patient-centered and does actually improve care across the board, including reducing mortality. Those things have been done and can be utilized. We haven't done a lot of that in Canada.
One of the ways that they've done it in the UK, let's say, and in Australia and New Zealand is create either, you might call them observation units, short stay units or assessment bays. So if a consultant can't make a decision within a certain amount of time and they need more time, they leave the emergency department so the next ambulance can be unloaded, and they go to an area that's staffed with nurse practitioners, house staff and consultants in order to make decisions. And that's been done at an entire system or country level. Ireland has some really great examples of how that could work. So I think all of those things are out there, but we just haven't had the accountability around some of our performance metrics. And that's a big issue.
Dr. Blair Bigham:
Talk to me more about the accountability piece and how you can build that into a healthcare system or ramp that up so that we have more accountability from everyone in the system who at any point could help alleviate the crisis that we're in now?
Dr. David Petrie:
Well, I think again, accountability is tricky because sometimes it gets interpreted as compliance and compliance in an era where healthcare morale is down and the number of doctors and nurses that are available to work becomes really tricky. I think that's where we have to come together across silos and across programs and work towards common goals such as the Quintuple Aim or what's sometimes referred to as value-based medicine and work back from there. We have to understand what patients need and what patients want and design our system around that. There's a great JAMA article about health system redesign talking about form following function. Let's decide and see what patients need and then organize and redesign our system around that rather than it's been the exact opposite. We've often designed our systems around what's good for providers. So there hasn't been that level of accountability either.
Dr. Blair Bigham:
At the end of the day, everyone's on the same side of the table in the hospital trying to deal with... Well, I think everyone in the hospital is on the same side of the table because this is 30 years of funding neglect, right? It's because the government has not adequately funded health services. There's just too many sick people.
Dr. Mojola Omole:
I think that part of that is just listen, if we are dialyzing people that weren't dialyzed 50 years ago, if we are keeping people alive by stenting them and bypassing 97 year olds, well, what do you expect? We are keeping people alive longer, which I don't think is a bad thing. But the downside of that is that you have people who have complex medical problems who are going to keep coming back into the emergency department. Then on top of that, we have no social safety net for patients. In this country, there's zero social safety nets. Why are people on ALC? Because I get those patients because, well, we can't take them home.
I feel for the family because it is difficult to care for people, but for people who are like, "Well, I'm working two jobs. How am I going to take care of this 90-year-old patient who can't move?" There's no social safety net for people to actually go home. So oftentimes I think, honestly, people are fed up and this is an easier place for their parent or their loved one to be because they can't do it themselves.
Dr. David Petrie:
I think that's an excellent point. And I was going to try and get to that when you suggested that the whole system's overcrowded and that you go from ED to inpatient to nursing home, but it doesn't have to track like that, right? There's a lot of excellent work and literature out there about improving the care of the elderly and how important integrated home care and well-resourced home care, continuing care options are, hospital at home options. There's a great article in today's CMAJ I think in recent work in the area of COPD and recent work in congestive heart failure. Not everybody with that diagnosis needs to be admitted, but they need to have early outpatient clinic follow-ups and they need to have a primary care at home who can quarterback care outside. They need the same day, next day access to their primary care team, which should be multidisciplinary, of course, and regionally rostered.
All of those things make a huge difference. They may seem small and you may say that's not going to solve the boarding problem, but altogether we may have... I'm not sure this is a funding issue, Blair, right? If funding was allocated a little more appropriately to system-based solutions like that, we wouldn't be feeling that stress and then starting to have tension between and among various services and programs.
Dr. Blair Bigham:
But David, nothing you said seems any different than when I started being a paramedic in 2005. If we need more home care, people shouldn't be in hospitals, they shouldn't be in nursing homes, they should be in the community. We need families to take care of people. We need to have better palliative care so that people aren't getting cathed when they're 97. All these ideas seem to have been around for the 20 years that I've been playing in the healthcare field. What is the next move? Because no one has seemed capable of spearheading that in a way that has helped the system. Here we are in the worst crisis we've ever been in, it seems. What is the systemic change that is actually feasible to happen in the next year or so? Like something somewhat near term that can lead to a sustained safety pop-up valve so that people can start to enjoy being an emergency medicine practitioner again? Sorry. It seems like we just cycle around the same idea. We all have this speak of solutions, but no one's been able to implement them.
Dr. David Petrie:
Well, I mean it comes back to the very first question you asked, why the tipping point and why is it crises now? And I think it's this sense that the answers are out there. They have been shown to work in other jurisdictions. They've been shown to work in some smaller regions in Canada, but there hasn't been the will to scale and spread them.
One of the things that I've seen called for a lot by some commentators, Andre Picard and others, is that we need to actually separate healthcare system decision-making from the short political cycle that sometimes drives government decisions and certainly significant resource allocations. That's easier said than done perhaps. But I think if we truly commit to this thing called the learning health system and what that means and we bring in and scale up the good ideas, try them out, evaluate them, get rid of the ones that don't work, scale the ones that do, we can get there. It might be slowly and surely, but there will be a tipping point.
Dr. Catherine Varner:
I'm going to jump in there. I completely agree. The political decision-making that goes into healthcare funding is not necessarily what's in the best interest of patients. We see that in these very short-term, quickly rolled out programs that are advertised to the public as fixing the healthcare crisis. And these short-term solutions are expensive, they're rarely evaluated, and for those of us working on the ground, seem to do absolutely nothing. I'll give you a few examples where patients describe, "Oh, I thought things were going to be better in the emergency department because pharmacists are now allowed to prescribe medications for pink eye," or urinary tract infections or a list of other low acuity conditions. That has not measurably changed who or how we see patients in the emergency department.
And the same is true, and this was rolled out years ago to end hallway medicine, was the availability of nurse operated telephone lines that patients could call. And if anything, patients are told at a higher rate to go to the emergency department than if they just made the decision on their own. So I can't tell you how often patients come in the middle of the night and say, "I wouldn't have come, but a telephone operator that I spoke to said I had to come in." And I say, "I think everything's okay," and then they're discharged home. So I think the evaluation piece and thinking about what is going to have an impact on patient care and at a provincial level is really important.
Dr. Blair Bigham:
I want to bounce off of what you both said and bring it to a wrap here with a final question. David, as co-chair of the Task Force on the Future of Emergency Care, what type of response have you gotten in your engagement with governments across the country in terms of appreciating the severity of the problem and bringing forward some of the solutions that we've talked about?
Dr. David Petrie:
Well, I would say pretty good. In fact, perhaps as we speak, members of our group are meeting with the Council of Deputy Ministers of Health somewhere in Toronto to talk about some of the issues. There's a recognition. I mean, one of the things that drives political decision making is the media and what's in the media these days are ED closures and ED crowding, both of which are not really ED problems, they are whole-of-system problems manifesting there. And that has been one of the main messages of our task force. But I think for the most part, it does feel just a little bit different this time that finally we're getting through with some of those messages and certainly this sense that post pandemic, something has to be done and some media voices like Andre Picard and others that suggest we can't just nibble around the edges anymore. We need structural change. That's what we're suggesting in this Task Force Report.
Dr. Blair Bigham:
Thank you so much for joining us. That was a great conversation.
Dr. Catherine Varner:
Thanks so much, Blair. Thanks, Mojola, for having us.
Dr. David Petrie:
Thanks. That was great.
Dr. Blair Bigham:
David Petrie is an emergency physician in Halifax and co-chair of the Canadian Association of Emergency Physicians Task Force on the Future of Emergency Care. And, Catherine Varner is a deputy editor of the CMAJ, an emergency physician in Toronto, and the author of the editorial in CMAJ titled, “Emergency departments are in crisis now and for the foreseeable future.”
Dr. Mojola Omole:
So Blair, leaving this conversation with your colleagues, what are your initial thoughts of what possible solutions there can be, or maybe where we need to refocus our energy when we're talking about the crisis in the emergency departments?
Dr. Blair Bigham:
Well, I think what strikes me is that you really have to separate all this anger and this emotional turmoil that you go through on an emergency medicine shift from your efforts to find solutions. Because at the end of the day, the solutions are obviously not easy to actually get any yield from. So I do think that most people in the emergency department have been trying for a long, long time to fix this. Most people in the hospital seem to now have a better understanding that the root cause isn't something the emergency department can fix, that this has to be at a whole hospital level.
Dr. Mojola Omole:
But I also think that part of it is that as people are living longer, we don't have social safety nets that used to be there for people. And part of that is that, and this is the kumbaya part of me, is that we live in a capitalist society that really prioritizes your ability to make money over anything else. And so when the way we look at our elderly population, our geriatric population, is that we don't necessarily invest in proper social safety nets that could help them, right? Because that's part of the issue of why people are staying longer in hospital is they don't have a social safety net. They have nowhere to go, and they're not being able to be taken care of at home.
Dr. Blair Bigham:
Well, they always the emergency department to go to, because we are traditionally the social safety net. But now, literally the other day in my emergency department, there were more patients admitted to hospital in the ER than we had ER beds. We had people in wheelchairs who had already been admitted. They'd been seen by the consultant. So when we lose that social safety net, yeah, you're right, that is-
Dr. Mojola Omole:
That's a bigger conversation-
Dr. Blair Bigham:
... a huge problem.
Dr. Mojola Omole:
... that I think is beyond us as physicians, besides being advocates for health equity, is that it's great to build a new tower, it's great to get a new robot, but really and truly, maybe the best way to spend our dollars is to provide services like home care and being able to have that so patients can vacate the hospital bed. Not necessarily go to nursing home, but to be able to be taken care of at home. So I am a big advocate for things. I do think we have to view it as bigger than just what's happening in the hospital, and David mentioned some great things that were happening in Ireland in terms of the assessment lounge.
I think having, like for specialties, because the emergency folks talks about us all never coming downstairs, but having units where the next day there's a clinic that you can send the patient to, because you might be like, "I'm not 100 percent comfortable with this patient." But you know what? If they can be seen in five hours or six hours, the next day, I'm comfortable with that. But having those type of mechanisms actually is helpful, and people will appreciate it, that you know what, I don't have to wait here any longer. Someone will see me tomorrow morning. Great. That's wonderful.
Dr. Blair Bigham:
Totally. And there's great evidence for both stroke care, for TIAs for example, and for low-risk chest pain, that being seen within 24, 48, 72 hours is perfectly fine. You don't need to be admitted to hospital. Maybe that type of next-day clinic model could be expanded with other services as well. That's it for this episode of the CMAJ podcast. If you like what you heard, please give us a five-star rating wherever you download your audio, and share it with your networks, leave a comment, and help us get the word out. The CMAJ podcast is produced for CMAJ by Podcraft Productions. Thanks so much for listening. I'm Blair Bigham.
Dr. Mojola Omole:
I'm Mojola Omole. Until next time, be well.