What an Emergency Doctor Wants you to Know about ED Waits

In this episode, Kyla sits down with Dr. Brittany Ellis — an emergency physician with specialized training in geriatric emergency medicine — for a wide-ranging conversation about why Canada's emergency departments are in crisis, and why older adults are bearing the brunt of it.

Dr. Ellis walks us through the full patient journey: from an older adult struggling
to get home care in a timely way, to ending up in an ED hallway for days,
developing pressure ulcers within the first hour, experiencing delirium, and
leaving the hospital in worse shape than they arrived. It's a cascade of
failures across a fragmented system — and she breaks it down with clarity,
urgency, and a healthy dose of "delusional optimism."

Resources

• CIHI: Emergency Department Wait Times in Canada — Insights from a Health System Perspective
• CAEP Position Statement: Care of Older People in Canadian Emergency Departments
• What’s behind Canada’s Doctor Shortage?

Transcript

SPEAKER_02 0:12

Hi everyone, welcome to Shift. Well, so much for my summer hiatus plan. There's just too many interesting things happening in healthcare to take a break. And healthcare doesn't take a break, so neither shall we. Last week, the Canadian Institute for Health Information released a massive report called Emergency Department Wait Times in Canada, Insights from a Health System Perspective. It offered important insights into the wait times across Canada, and as you can imagine, it was not good. But what the report clearly highlighted was that the problems in the emergency departments are not able to be solved inside the emergency departments. It's bigger than that. In addition, the Canadian Association of Emergency Physicians, or CAPE, released a statement on the hidden drivers of ED overcrowding, one that points directly at long-term care delays and community care gaps as the real culprits, and they have the most impact on older adults. Dr. Brittany Ellis helped write the CAPE statement. She's an emergency physician in Saskatoon and the lead author of CAPE's landmark position statement on the care of older adults in Canadian EDs. She also works as a physician in the department where consequences of these system failures show up every day. This is a conversation about what's actually happening inside the system and offers some ideas of how to fix it. This is my conversation with Dr. Ellis. Can you hear me? I can. Can you hear me okay? Perfect. Yeah, I can hear you. Great. Okay. Yeah.

SPEAKER_00 1:34

Have you been doing tons of press this week? Um, I've not been doing a ton, but like collectively as a group. So the CAPE, like we have a public affairs committee who fields all the media requests. Okay. Um, and I've long been kind of lingering in the background a little bit. Um, but I finally started doing a little bit this week, which has been good. It's good. Yeah.

SPEAKER_02 2:01

Yeah. No, that's great. Did you guys intentionally put out your statement with the Kai High Report or did was that just a coincidence?

SPEAKER_00 2:07

It was, we were hoping, honestly, to get it out a little bit ahead of Kaihai, I think, but like it was we were knowledgeable that Kai Hai's report was coming. Yeah. Um, we just had a national forum in early May in Toronto, um, where Kai High was present and with a lot of like leadership from across Canada. So, like, what we've kind of done this thing now twice where we invite decision makers and policy and political leaders from across the country and kind of have a day um with them. And so it's this is the second one. And Kai High was there. They had actually specifically reached out to us and it just the timing worked perfectly. So Kai High came and shared their data with us, and then you know, we formed some working groups and stuff with them to try to enhance the data collection and you know, metrics and things like that.

SPEAKER_02 2:58

Good. Yeah, it's always good when people that are working on similar things can work together instead of working in silos, eh?

SPEAKER_00 3:04

Oh, the Kai thing has been fantastic though. Like, you know, because it's it's always one thing when it comes from us, but it's so much more when it comes from other people, right? Like sometimes you feel like people are sick of hearing from physicians or sick about hearing about the ED, but like when you get completely other bodies saying, like, hey guys, this is a problem. Like, that's yeah.

SPEAKER_02 3:26

Yeah, that's good. That's good. Yeah. Okay, so let's go back a little bit. Yeah. Um, I just read your bio from the U of S webpage. Oh, I was like, How are you not 135 years old for all this education? So, how did you make the loop from being born and raised in Saskatoon and then like coming all the way back to Saskatoon with the specialty that you have?

SPEAKER_00 3:48

Yeah. So I was born here, as you said. I left after my undergraduate degree, as many people do, with a little bit of a lost soul. Um, I did microbiology and loved it, but then wasn't quite sure where I was going with it. So I ended up doing a master's in public health, which was a natural transition with epidemiology and kind of public health thoughts in microbiology and infectious disease. And in my public health realm is actually when I first got involved in care of older adults. And that specifically was about dementia care and dementia policy and design from a like kind of regional health authority level in Scotland. And so that was my first kind of delve into some of the challenges that older people specifically face. And then I, yeah, did med school in England and didn't realize till quite late in my medical school that I was planning on coming back to Canada. So I moved to Ottawa um and did my residency there and uh five-year program in emergency medicine, and then into Toronto where I stumbled. I shouldn't say stumbled, it was somewhat of an organic um transition into my geriatrics fellowship. Um I had when I entered emergency medicine, care of older adults was something I actually talked about in my interview. Um, and it honestly seemed a bit far-fetched at that point. Nobody was talking about it. It was, it was just something that I realized with my public health hat on that the society's aging and we're not ready. And none of what I learned in in medical school and the early parts of residency was specifically tailored to the care of this like very important and very large group of our population. And later on, I went to meet with Don Malady, who was my mentor in Toronto for my geriatrics fellowship. And I had planned to go with him for two months um to do some geriatrics work. And after one conversation with him, I signed up for a year and moved to Toronto.

SPEAKER_02 5:45

Oh wow.

SPEAKER_00 5:47

Yeah. Um, so yeah, I did the fellowship in geriatrics in Toronto and wanted to always head out west. Wasn't um specifically looking to return to Saskatoon or Saskatchewan at that point, but was very fortunate in that I had some um allies and supporters and sponsors here in Saskatchewan who really helped to drive a position and develop a position for me here.

SPEAKER_02 6:10

So do you spend most of your time then in the emergency department? Like is that where your work is?

SPEAKER_00 6:15

Yes. My clinical, my clinical work is is solely in the ED. Okay. Um, and then my um I have like administrative work as well. And I also um do some transport medicine um as well. Okay. But clinically, it's largely emergency department based. Okay.

SPEAKER_02 6:33

So as we've seen this week, the ED weights are back in the news, was sort of all over the media last week, talking about the long wait times nationally. Everybody's struggling with it. And I was wondering, could you sort of give people a glimpse of what that pathway looks like for an older patient that presents to emerge with like whatever you kind of see commonly and how they get, they talk a lot about alternate level of care, but I don't know if people really know what that means. How they tend to get like stuck in the system, and then how that affects full circle back to the emergency department. Because I'm not sure people have the whole pathway laid out. And often people just think, well, make a bigger emergency room or add an urgent care center or like tell people not to come to the emergency room because it's too busy. So, can you describe what that looks like so people kind of get the full understanding of it?

SPEAKER_00 7:33

Absolutely. I mean, I think this may come up as like a couple different scenarios. Sure. Um, I think one of the easy cases to kind of talk about is starting with an older adult in the community who resides in their own home. Um, so you know, most older people want to be at home. They want to maintain their independence, they want to be at home, and they want to be at home with the minimal amount of supports that they need, um, typically. And so when they do require supports, they usually are requiring supports on a fairly time-sensitive basis because they've kind of gotten to that point where things are needed. Um, so the first hurdle they come up against is the fact that well over 10% wait more than a month to get home care. You know, so if an older adult needs assistance with getting up and bathing, for example, um, and they can no longer achieve that, they can't wait a month to get out of bed and to get some personal care. Um and so that may end up with them coming to an emergency department because there's nowhere else for them to go. Um, and so at times older adults present, you know, with that sort of a story where they they lack social and community supports, um, or it may be that they have complex health needs and they've got an infection, for example, a pneumonia, an influenza, COVID. Um, and that just tips them over the scale to be no longer independent, but again, they can't manage at home. So they end up in their emergency departments. We medically assess them, we treat them, we assess their home environment the best we can, take a social history, et cetera. But ultimately, these patients often need to become admitted to the emergency department.

SPEAKER_02 9:07

Because there's no one in the community that could give them the support that they need in that timely way. Is that often the barrier? They need supports and then those supports aren't available. Correct. Okay.

SPEAKER_00 9:18

And so that is that is improving, I would say. Um but probably, you know, we've seen the demographic shift coming for, well, 60 to 80 years now. Yes, yes. And so we haven't grown and evolved their services to keep in line with that. Um, and so if an older adult requires admission and say, particularly if they have mild cognitive impairment or dementia, or maybe they've developed a delirium as a result of their medical issue, they um will require a bed upstairs. But there are no beds upstairs in the hospital. And I say upstairs, I mean in an inpatient admitted bed in our hospital. So if there's no admitted bed for them to go to, or no admission bed that they deem they, as in their care system, deems appropriate for them, they wait and they wait in our emergency departments and they wait in our emergency department hallways and they wait for days. Because often these older adults are are not ones that require observation units or cardiac monitoring, for example. They require a hospital bed and the supports that the hospital can provide. And so if there's no bed upstairs, they wait in our departments. Well, what would happen to any of us if we sat in a hallway for 48 hours with lights on, people walking by? You know, we can all imagine that we might become sleep deprived, we might not be getting up and moving. You're on a stretcher lots of the time. So, like those are so uncomfortable. Yeah. Well, it takes an older adult less than one hour to develop things like pressure ulcers or begin to develop skin breakdown because their skin, you know, is typically very different from the skin of a younger adult or younger person. And so we know that the longer they wait in the ED, the more complications, the higher risk of death within 30 days, the higher risk of developing delirium or an acute confusional state, which comes with a single episode, increases the risk of developing dementia in the long term, pressure ulcers, etc. They functionally decline. So they came to the emergency department with a state where they needed some support, and they're leaving departments with a state of needing even more support. Right. Um, and then they, you know, they get admitted to hospital. And if they sit there for even longer, that circle kind of continues. You know, they're not getting up and moving, they're continuing to functionally decline. Um, and they might not have a window to be able to see.

SPEAKER_02 11:36

They might not have a window.

SPEAKER_00 11:38

Yeah, hospitals are not safe places that we commonly think they are. You know, sometimes I hear people say, Well, we're going to be admitting them for safety. And I say, Okay, that's fantastic. Can we just talk about safety for a minute and what safety means? Because some people need to be admitted. I 100% agree with that. But I think there are is opportunity for admission avoidance with appropriate timely access to community services. Um, but the other problem we're seeing is you kind of alluded to is this alternate level of care. So we know that roughly 10% of hospital admissions end up in people being labeled as alternate level of care. And what that essentially means is that their medical care is complete. They have no medical need to stay in hospital, but they now have a care need that cannot be met in the community. And so they remain in hospital waiting for whatever need that is to be met. Um, typically, alternate level of care patients, about 80 to 90 percent of them are older adults. And many of those are waiting for long-term care. Now, I take that with a little bit of a caveat because I think they're waiting for long-term care because no better alternate exists. Right.

SPEAKER_02 12:55

Or did they decline so much that uh they actually need long-term care, whereas they might not have if they had even supported in their home.

SPEAKER_00 13:01

You know, absolutely. I think that is a real possibility. We don't have good evidence to drive that argument, but certainly anecdotally, um, we see it happening, right? We see people entering hospital in one state and leaving hospital in a very diminished declined state. And some of that is likely due to the acute illness, their multimorbidity and complexity that, you know, would have happened anyways. But certainly I think that in many ways we're lacking the support and care that we know that older adults need to prevent functional decline, to prevent loss of muscle mass, to get them up and moving, to ensure their caloric dietary needs are met, etc. And so I do think some of that decline is avoidable that happens in hospital. Um, and then they they they wait longer. And then the longer they wait, the worse they get. And then they'll never get back to that independent state that they may have come into hospital with. Yes.

SPEAKER_02 13:59

And they might have just come in with the UTI and then it just like progresses from it can be such a simple thing, right?

SPEAKER_00 14:05

It can be, it could be a virus, a common cold. You know, when when you're older and you're living with a lot of medical complexity, it doesn't take much to kind of drop your independence just enough to mean that you need more supports. And if we can't get those supports in place in a timely fashion, then often we're left with no other choice than admitting to hospital. Right. Okay.

SPEAKER_02 14:29

Okay, that is a great explanation. Are there any interventions or things that people can do in a merge to kind of uh get them out faster, get them assessed? Are there things that are helping?

SPEAKER_00 14:40

Absolutely. There's there's a whole host of models of care that are going on around the country that are really impacting the way older adults move through our care system, including in our emergency departments. So, for example, um having a geriatrics team based in the ED that will kind of screen for and proactively assess patients to try to determine from the moment they set foot in that door what it's going to take to get them home successfully. And I mean successfully because it's not just a matter of getting them home, right? They need to be home and to have the supports to remain home. Um, and so models like that, there's fantastic ones going on in Eastern Canada that have been shown to really reduce the chances of patients getting admitted and to increase the chances of them going home in a like durable fashion where they're not just bouncing back or having unplanned visits back into the emergency department. So having geriatric support within the ED that can be ideally like a multidisciplinary team where we have things like a physician, a nurse to guide care, as well as allied health, physiotherapy, occupational therapy, pharmacy. Um, so this is happening in, I'd say, largely bigger centers across Canada. Okay. Um, and then there's various models that also I think can be adapted. You know, for example, a pharmacist doesn't necessarily need to be based in the emergency department, but this is something that could potentially happen in a virtual care model. So for our smaller departments, um, there's opportunities that exist there, even to provide more of a wraparound multidisciplinary service. Ontario has a uh geriatrics emergency nurse program where most emergency departments in Ontario have a gem nurse, it's called, okay. Um, who, you know, come and they do various roles adapted to the specific needs of their departments. But typically they're nurses who've undergone extra training in care of older adults, and they're able to take that time to do a bit of a mini comprehensive assessment to really focus in on a lot of the things that it's really difficult to do in the ED as a physician. So, for example, I don't often have a lot of time to call family members to really get a comprehensive history, to really see what's going on in that home that might be impacting care or impacting the ability for us to get that patient successfully discharged. I won't have time necessarily to ensure the patient's family doctor can see them in the next few days upon discharge, for example. But having it as somebody who's specialized in that area that can provide that care is fantastic and really can be impactful for older adults who come into our departments.

SPEAKER_02 17:25

What would you like to see available like in a perfect world? What models would you need in the community that you would feel comfortable and happy releasing your patients back into?

SPEAKER_00 17:38

Um, I think a lot of things. So, first, like is just timely access to even basic care needs. So, timely access to ensuring that, you know, somebody can be assisted to get up in the morning and to get their morning medications, for example. Um, and the same sort of thing in the evening, assisting them getting back to bed and ensuring that they've had their medications. But it's so much more than that. It's so much more than just the very basic needs that we often think about. You know, it's things like physiotherapy, it's things like having a home falls assessment. You know, patients can wait multiple, multiple months. We're talking six plus months to have somebody come into their home to aid them, to make sure that there's no trip hazards, like little carpets, like lighting cords, like good lighting, to put up handrails, you know, to raise toilet seats, things that are really essential to allow older adults to maintain their independence and mobility and to prevent them from having further falls, for example. So timely access to services like that as well. Um I I think at times it's just a matter of making sure that the patient has access to a reassessment in a short period of time to know that somebody's checking in on them. Not all older adults are fortunate enough to have family members or friends who can check in on them. And that sounds like a simple thing, but it's, you know, when your care might depend on that, when you need to know if that patient is doing okay and is managing at home, then that can be the difference between coming into hospital or not. And and again, you know, I think services are improving at this, but I think it's pretty piecemeal.

SPEAKER_01 19:19

Yeah.

SPEAKER_00 19:19

Um, and I think one of the great challenges is actually knowing what is available and trusting that what services are available are going to do the task that is required. Our healthcare system still depends on faxing, you know, like we're faxing these requests that patients are dependent upon and just trusting that somebody on the other side of this is receiving it and acting on it in an appropriate fashion. Um, and that's not a good feeling as a provider when you're, you know, accepting risk in the interest of a patient to try to get them home. Yeah.

SPEAKER_02 19:56

Yeah. Um, I interviewed Dr. Ginger Ruddy uh a few weeks ago. We talked about the patient health home and you know how you would have a place where people knew you and had a history with you and would be flagged as soon as you went to the emergency department. So they could call, connect with the emergency department, be like, it's okay, we've we know them, we've got them. We can connect with home care and get them sorted out if you can do what you need to do and we'll take care of them.

SPEAKER_00 20:25

Oh wow. Oh, yes. Like you're almost talking about a universal record system, for example. Oh, where we can actually see what's going on with people across the entire spectrum of care. Right. Um, which would be a huge step. I think the other thing to remember from an emergency point of view is that we operate 24 hours a day, seven days a week, 365 days a year. And unfortunately, the rest of the healthcare and community care systems do not.

SPEAKER_02 20:49

Yes.

SPEAKER_00 20:50

And so that creates problems. Even our acute care hospitals typically don't run effectively outside the hours of say 8 a.m. to 4 p.m.

SPEAKER_01 20:59

Yeah.

SPEAKER_00 21:00

Yeah. Um, discharges don't happen, patients don't move, access to our allied health services, which are integral to everybody's care, particularly older adults, is limited. Weekends, you know, you walk into a hospital on the weekend, it's a very different place to a hospital during the week in terms of the hustle and bustle and work that's going on. And that just gives you that overall sense of what is happening, um, you know, and it's a very quiet space um oftentimes.

SPEAKER_02 21:27

And I remember even working on medicine, like everybody would just get discharged Friday afternoons. Like the doctors would come in and make their rounds, everybody would get discharged Friday afternoon, and then we were sending them on a weekend where there was nothing in place for them. Do you think home care is suffering from a shortage of people, a lack of investment, a lack of prioritization? Like, is acute care just sucking up all the resources? Is it hard to shift from acute care? Like, I just see you know, so many places investing in capital and building. Buildings and beds. And then I I just keep thinking, well, no one wants to be in those beds. People want to be at home. Like, is it a better use of our resources to be putting that into home care? Or is that just not on the radar?

SPEAKER_00 22:14

I mean, I've been in practice now for just over seven years. Um, and what I've typically seen is further and further restrictions in many ways on like what it is that home care actually does in various provinces and how much care they can actually provide. So, you know, a number of provinces have time restrictions. You know, you can receive 14 hours of home care a week. Or that may be temporarily increased to 21, but that's not a durable solution, for example. Um, and then things that home care can typically do is quite restricted. So, for example, um many home care services um don't provide any form of like light cleaning or housekeeping or anything like that. Well, that's a pretty important part of independence around the home, you know. And if it's really difficult for you from a mobility point of view to pick something up off the ground that you've dropped, whether that's a handkerchief or a piece of toast, you know, that can really evolve into an unsafe environment pretty quickly. Um, I do think that there's been a lack of investment in home care. Um care aid workers, however you want to call them, healthcare workers, support workers, care aids are an essential part of our health care system. But they're actually not. If you look on paper, they're not. They're part of our community care system. So home care and long-term care aren't even kind of invested in terms of health care, right? This is a separate portfolio with a separate budget, with a separate political leadership portfolio. Um, and so I think that creates a lot of challenges as well when we start to silo out these services that are so interdependent. Um, and in doing that, we're starting to reduce our understanding of the needs of our population and how those needs are and are not being met. Um, I would love to see care aides get better training, get more investment within them as individuals, not only in recognition of the importance of the work that they do, but to make it a safer environment for them to promote more longevity and to also financially remunerate them in a way that recognizes their work. Um, you know, you talk to some and you can make more money working in a fast food place than you can providing this essential service for so many vulnerable people in our communities. And that to me just doesn't sit right. But we see that even in our acute care hospitals and the emergency departments, if I talk to colleagues who are across the country, we know that we don't have the number of care aids to support our patients that we would like to have. And typically there's gaps in schedules. Um, you know, so for example, the impact of that might be in the emergency department is is if I have an older adult presenting to a department who's confused, who has a delirium or an acute confusional state as a result of their illness, um, that's something that that is typically temporary but very impactful. That that might be, that might look like for somebody who's not familiar with delirium, that might look like an older adult who's laying in a bed calling out frequently.

SPEAKER_02 25:37

Yeah.

SPEAKER_00 25:37

You know, saying, help, help, help. Um, and then somebody goes in and they're not sure what they're needing or what's going on. That might look like an older adult trying to climb out of a bed. They just want to go home, they don't know where they are. It might look like somebody, you know, trying to take off their leads and their monitors, take their IVs out, for example. And so a lot of these behaviors can be very challenging. Um, they're challenging for the older adult, they're challenging for family members, and they're challenging for the care team.

unknown 26:04

Yeah.

SPEAKER_00 26:05

The good news is typically with these sorts of behaviors, redirection is very effective. You know, so if somebody could be there just to redirect them, to engage them in other ways, then that would be it. That's all we need. So a care aid is somebody who would be trained specifically in that and able to provide that. When we don't have these care aids, it creates an unsafe environment, particularly for the older adult who may become increasingly agitated. But it also creates an unsafe environment because our our teams in our departments don't have the time always to provide that care. You know, if they get an acutely unwell patient that needs full assessment and nursing, then suddenly this older adult is left somewhat less attended.

SPEAKER_01 26:48

Right.

SPEAKER_00 26:48

And the solution can often be things like restraints, which we know are harmful. And that can be physical restraints or that can be chemical restraints or medications to sedate. And so what we're seeing is something so simple is a lack of care aides, for example, who are, as I said, essential care workers can have devastating consequences. You know, now you put an older adult in restraints, they try to get out of bed, but now they're tethered and they can't get out of bed and they fall and they hurt something.

SPEAKER_02 27:16

Yeah.

SPEAKER_00 27:17

Or they don't move and they develop a pressure ulcer because they're now laying in bed without the ability to move themselves safely. Um, you know, so so many of these um small things are not small at all and are so impactful.

SPEAKER_02 27:32

Yeah, absolutely. I also heard about a program called the Hospital Elder Life Program. Were you involved in developing that?

SPEAKER_00 27:39

Um, we developed no, so so the HELP program was developed by some a lady named Sharon Inu, um out of the US, and that is a service that would be amazing. So um, for those who aren't familiar, the help program is kind of a more comprehensive wraparound program that provides um assessment and kind of like acknowledgement of the needs of older adults, and then targeted interventions to try to reduce the risks of hospitalization, improve their function. So, not only not diminish function, but actually improve function when they're in hospital. Um, and to perform all of those other tasks that are typically missed in an acute hospital setting where we just focus on the medical component of patients. So frequent mobilization, socialization, interaction, cognitive exercises, etc. Games, yeah, reading the newspaper and all the things that like we as humans need and like. Um, and these programs have been shown to reduce the risk of developing things like delirium to help patients get home healthier and faster. Um, and so when I was working in Toronto, um there was a similar program in the hospital I worked in. And then what we did is we actually took that and developed um an ED-based volunteer program that focused on providing a lot of those same services. Um, so providing older adults with things that some might say are comfort items, but actually, if comfort means sleep and sleep means recovery, then these are essential components of healthcare. You know, so things like having a warm blanket because emergency departments are often cold, you know, providing them with high calorie snacks and treats, um, you know, crosswords, word searches, as well as social interaction, assisting them in eating, because oftentimes, as we said, there's not a lot of time and people who can assist in these really important things. Um, and so those are certainly like the help program or variations of that. And there are many, um, but the help is probably the best studied ones, are evidence-based and have actually been shown to be cost neutral, essentially. Right. Right. So, so you know, having an older adult not stay an extra four days in hospital is actually a really good use of resources.

SPEAKER_02 29:53

Yes. I remember when I was on ED weights and patient flow initiative, that was one of the programs that actually, when we modeled it, actually had an impact. Like that was one of the big like blaring, blinking red lights. Like we could do this, we could do this. Um, I've shared it with so many people in the system that I could think of because particularly in Saskatoon, the university is right beside R UA, like right, you know, very close to the hospitals, right? Yeah. So I'm like, what if we could take students and train them to and they all need volunteer for whatever education or health care or whatever? You know, and it was things that I thought were so interesting, like making sure people's glasses are clean and their hearing aids have batteries in them and that are working and they get in the morning, you know, to avoid the confusion, writing the date, taking them for a walk. Like I almost think of like when I was a teenager and I did candy striping. Yeah, that was kind of what we did as candy stripers, right? And I didn't think it was really an important role, but now that I see it actually is like the nurses don't have time.

SPEAKER_00 30:56

No, it's super important, absolutely. And all the things that you talked about, you know, we're developing things like these geriatric carts, we call them, you know, where they we have instead of having a suture cart or a resuscitation cart, we have a geriatrics cart and it has all of those super duper important things. It has essentially temporary hearing assistive devices, it has batteries for hearing aids, it has reading glasses, sleeping masks, earplugs, you know, all the things that um are not just specific for older adults, but in some ways, you know, older adults are the more vulnerable. Um, we started this talk on talking like a little bit about Kai Hyde, um, the Canadian Institute for Health Informatics, about some of the data that's coming out there. Um, and studies from around the world, and we know that essentially the longer you stay in the emergency department, not only like the greater risk of dying, the greater risk of developing delirium, but also the greater risk of staying for a longer duration in hospital. Right, you know, and I think a lot of that is due to things that are avoidable, um, like sleep, like sensory deprivation. Um, you know, and and I think the data will continue to come out now that holy medicine has unfortunately become a normalized part of our healthcare system. You know, it's actually interesting if you talk to people across the country, they're not called holys anymore, you know, they're called pods or or they're called treatment space X, or you know, you've taken the cubby and and assigned it a treatment space. And so that house somehow seems to make it more acceptable. Um, but we know that the harms and the risks are just the same. And in fact, in the hallways, they're so much probably worse. You know, if a if our healthcare system, one of my colleagues, um Dr. Catherine Varner, wrote a really interesting editorial on this recently. Um, but if you think of a healthcare system right now that in many ways is struggling to provide good care to our current population, yeah, and then you add in an event like a potential war, for example, where we're having hundreds, if not thousands, of soldiers being repatriated for medical care. And we don't, we currently can't function. So, how are we going to provide that care to these individuals?

SPEAKER_02 33:24

Well, it's like it's a national risk. It's a national risk. It is a national to have a system that's not functioning and not working.

SPEAKER_00 33:30

And I think the ED, the challenges that we face in the emergency department, you know, the term like the canary in the coal mind is often thrown around because we really are, I think, the temperature gauge for the rest of the system. Yeah. Um, because when everybody else says no, we say yes. Yeah. And we will always say yes. But I will say, as a provider, it's it's disheartening. You know, we talk about moral fatigue and burnout. Everybody I know that works in an emergency department is there because they they care, because they want to do the job that they were trained to do. But I think when you start to see harm um and you start to be unable to perform to the level that you would expect of yourself and your colleagues, that's pretty injurious for most of us. Um, and so we are seeing national shortages of physicians, of nurses across the country, of, you know, care aides, et cetera. And again, I think that's a symptom of an underlying critical condition of our healthcare system. Yeah.

SPEAKER_02 34:38

Yes. And as I said, you know, that canary is ashes now, right? Like the canary died a long time ago. And we're at a point now where it is really about like survival. Um, and I don't know if people have the sense of urgency that many people in the healthcare system do. Yeah. Um, uh because they don't see it or they only really, if they have an experience, maybe it kind of wakes them up. But like Stephen Lewis said, you know, people aren't sort of marching in the streets yet, but it'll start affecting the sure.

SPEAKER_00 35:13

Yeah. Oh, absolutely. I think what people need to think about when it comes to emergency department wait times and overcapacity is really that the emergency department is like a straw. What goes in one end of the straw must come out the other end. Yes. You know, and so if somebody comes into our department, the number of people that go out needs to equal the number of people who come in in order for our patients to flow and receive appropriate care. And so when we get these lower acuity injuries that people think, oh, well, it's all the people who aren't using DEDs appropriately that are driving overcapacity and access block. It's the people with the pneumonia, it's the people with the infections, etc. Well, that's not the problem. Because if you imagine they come in and they go out and they go home. That's simple, you know, that's not leading. What's happening is we're getting our our populations of everybody, whether that's, you know, social deprivation, whether that's mental health, whether that's older adults that come in and need to be admitted, but they're not, right? There's nowhere for them to go. And so the number of people coming in is not equating to the number of people leaving. And that's what causes our access block. That's what causes our overcapacity. That's what causes people in our waiting rooms to be waiting five plus hours. You know, our patients to suffer harm in departments across our country. Um, so it's it's not a symptom of the number of people coming into our departments. Sure, you might wait a little bit longer at times, but that's not the problem, right? Yes. That's why we triage and that's why we do things to, you know, select who gets seen first. But when I no longer have a bed to assess a patient in because they're all occupied by inpatients, that's a problem.

SPEAKER_02 37:04

Yes, yeah.

SPEAKER_00 37:05

You know.

SPEAKER_02 37:06

So if you had your way, if you were the boss of healthcare, what would you want to change or do? Would you want to do sort of the simpler things like get help in every hospital in Canada? Would you want to restructure something? Where would the biggest bang for our buck be if we wanted to do something?

SPEAKER_00 37:29

I think so. I that's I need a lot of bucks, but um the I think that no, I do like I think we have 8.5 billion that we just put in in Saskatchewan, right?

SPEAKER_02 37:42

Like that's a lot of bucks.

SPEAKER_00 37:44

It is a lot of bugs. Um, and and I do like, I think whatever happens, the first thing is it needs to be a system-wide conversation. Okay. It can't be siloed, you know, it can't be an investment in one area without an assessment of what that looks like downstream and what that's impacting. So I think the first thing I would do is I would get all my community acute care, long-term care, I'd get all my partners at the table.

SPEAKER_02 38:08

Yeah.

SPEAKER_00 38:08

Um, because I don't know if that happens frequently enough. And I don't know if we have a true integrated community and healthcare system.

SPEAKER_01 38:16

Yeah.

SPEAKER_00 38:17

Um, and I think until we understand the needs of one another, we're not going to improve anything. And so I think that'd be a big thing. The other thing I think I would do is is yeah, I'd focus on kind of um harm prevention when it comes to hospital and moving patients through. Um, we alluded to this before, but if you ask, you know, 80, 90% of older adults, they don't want to be in long-term care, right? So, so the 85% of ALC patients that are over the age of 55 in our hospitals, that are probably the vast majority awaiting long-term care placement, that's not where they want to be. They want to be at home in a really heavily supported environment. And systems that do that well have been shown to actually be more cost-effective than places like long-term care. Um, but we're talking about a system overhaul, right? We're talking about taking a system of acute care that was developed for acute medical, fairly simple. Transactional kind of transactional exchanges. Yeah. And we're talking about recognizing that the needs of our populations have changed. And along with the needs, there's not really been a change in service provision.

SPEAKER_02 39:33

Yes.

SPEAKER_00 39:34

And so I think that we that's a big thing to do. It's not simple. Are there small things we can do along the way? Absolutely. You know, for example, things like transitional care spaces. Let's not admit them to an acute care hospital where they don't really get physio and occupational therapy and all the things. Maybe there's a space in the community where we can provide a more resource-intensive support and we can get them up and moving and get them home faster. Or maybe that can happen in hospital and we just develop our services to wrap around, kind of like a help type service.

SPEAKER_02 40:04

Yeah.

SPEAKER_00 40:05

You know, um, but having services that are more specifically designed to meet the needs of the population rather than providing kind of a one size fits all approach to support older adults or any of our complex needs patients.

SPEAKER_01 40:21

Yeah.

SPEAKER_00 40:22

Um, I like going back, I think I would, you know, we we do need, don't get me wrong, we probably need more long-term care beds. Some, right? But that is not the only part of this problem. We probably do need more acute care beds. In fact, we know we do, right? We're running per capita less acute care beds now than we were previously. And same similar thing to long-term care. So we probably do need more of these, but we also need much more in terms of community supports, home care, you know, keeping people in or in their own homes for longer.

SPEAKER_02 40:59

Yeah. Yeah. It's like seeing the problem together, right? Like, yes, acute care beds, but also building in that home support. And sometimes where I see the disconnect is that everybody's focused on that as being the solution, where it's part of a solution, but the solution is really in the restructuring of the whole way we've designed the system. Yeah, which I don't know. Well, I'm optimistic. I don't Well, you can't work in you can't work in healthcare and not have some level of optimism.

SPEAKER_00 41:31

Illusional optimism. Illusional optimism. That's okay. I do like I I think the more and more tension these issues get, the better it is.

SPEAKER_02 41:43

Yeah. Yeah. And you have been a real leader in this space. And I think the the things that CAPE is doing and you guys are putting out and all the interviews that you can do, the more that we all understand the system, the better it is. And, you know, when solutions come to the table, we can really think about if that if that's what we want as a as a community, as a province, as a country.

SPEAKER_00 42:09

Yeah. No, I couldn't agree more. I think I think people are smarter than a lot of leaders sometimes give them credit for.

unknown 42:19

Yes.

SPEAKER_00 42:19

Um, and should have more autonomy in decision making regarding their health and healthcare.

SPEAKER_01 42:24

Yes.

SPEAKER_00 42:25

Um, and and it's, you know, even things like um a bit controversial, but like ED closures, for example, and like how we how we share um with our communities across Canada if their emergency department is closed or if in fact it's being covered by a virtual physician as opposed to an in-person physician. Um, to try to allow them to make decisions that they feel is best for their care. Now that comes with like a little bit of a double-edged sword, and sometimes, you know, everybody gets it wrong. But I think that um people need to be a little bit more uh vocal about uh the challenges that they see, the things that they disagree with and and what it might look like moving forward for them. It shouldn't take somebody dying in a waiting room for stories to make headlines. It shouldn't take an older adult sitting in a hallway for 72 hours for stories to make headlines for change to happen. Yeah um, and as you see, I mean, you're very well into this life as well with these headlines come and they go. Yeah. And then they come and they go. And then there's an inquisition, and the same 16 recommendations are made, and then they come and they go. Um, and I mean I've only been doing this for seven years and I've I see it already.

SPEAKER_02 43:48

Yeah. You know, even there's even there's a uh idea around living with risk. Absolutely and how comfortable you are in being like, I want to go to my own home and I accept the risk and As healthcare, we often don't want people to do that. We institutionalize them because that's the safest place for them, or we put them in the hospital because we think that's the safest place for them. And people are like, you know what? I'm good. I'm 93 years old. Like, I just want to go home. Like if I fall down, I fall down. And you know, yeah, we have to get used to that too.

SPEAKER_00 44:21

This makes people make it 100%, right? Like this is I have this conversation, I would say, every shift.

SPEAKER_02 44:27

With the patients or with the system?

SPEAKER_00 44:31

With the patients, with their family members, you know, because often an uh an older adult will come to the department and and a very well-intentioned family member will say, Well, you know, I don't, I think it's unsafe if if mom goes home. And so I kind of will take a minute to explore that with them and think and try to figure out what they're concerned about in terms of safety. And, you know, sometimes it's as black and white as having a conversation of, you know, your mom's risk of falling at home is at least the same in hospital here.

unknown 45:04

Right.

SPEAKER_00 45:04

If if not potentially a little bit more, right? Because now you're putting your mom in an unfamiliar environment. Yeah. Um where they where they don't know where that side table is, where they don't know where that door, that door frame is. Um, and so like hospitals are dangerous places. And there's very good data to support that. Yeah. Um, and so I think understanding what the risk is, and and older adults are allowed to live at risk, right? Like for some reason, there's this still this rendering like paternalistic nature of care of, you know, uh I, thou healthcare provider, know best, come into hospital where you will be safe. But that's not what hospitals are. It's a real experience.

SPEAKER_02 45:49

Yeah.

SPEAKER_00 45:50

And and even if they are maybe a little bit safer, if an older adult wants to go home, I will do everything I can to support them to get home. Um, and and yeah, they they may fall, but they might have fallen two weeks ago and they might fall two years from now. Yeah.

SPEAKER_02 46:07

Um or they might have fallen on admission.

SPEAKER_00 46:09

Yeah. And I think trying to manage that risk and have those conversations with them. And you know, it's unfortunate, but now I often see patients coming in, they need admission. You know, they have they need services that can only be provided in an acute care hospital. And they are like, I am not staying in this hospital, I am not staying in that hallway, you will not be admitting me. I am going home. Yes, you know, and and so in some ways, it's actually like the the mentality is flipped for a lot of people and are actually losing a little bit of trust in our system. Yeah, and that's a really sad and potentially dangerous place to be as well. And and I also, you know, as a provider, we'll have very strong conversations with those individuals and explaining that I, you know, I appreciate that they're motivated to get home and I'm glad they are. But yeah, you know, I think that in this instance the risk outweighs the benefit, and we should really focus on trying to get them stay motivated, you know, and hopefully that it's a brief admission as long as you're motivated, you're up, you're moving, you're doing the things.

SPEAKER_02 47:13

Yeah.

SPEAKER_00 47:13

Um, but I I completely agree. Those risk conversations are super duper important. I think if you asked, like honestly, almost every emergency physician I know, if you said, you know, like, do you love it? I love my job, you know. I love, I love being an AD doc. It's a special type of work. It's it's just one of those things I think that people love when you find it. If you are one, you love it. Um but like you said, like it's just it's it's different when you want to do so much more and you're constrained in the system.

SPEAKER_02 47:50

Yeah. Well, thank you so much for taking the time with me today. And I'm sure you're hopefully off for summer holidays a little bit. 24 songs. Well, I will be sure to get this out to leverage the attention it's been getting in the media in the last couple of weeks. And hopefully, people will take some time over their holidays on a long drive, maybe just to listen and consider what kind of system we need to build and and how we can maybe get there together.

SPEAKER_00 48:21

Awesome. Yeah, let me know if there's anything further.

SPEAKER_02 48:24

Thank you so much. Thank you to Dr. Ellis for that insightful conversation. I don't think I will ever stop thinking about ED weights as a straw. What goes in one end must come out the other. And when that stops happening, everything backs up. We have to look at our primary care system to look at how we can better address what's coming in, and we have to look at our community care supports to help us with what's going out. There's not much we can do about changing the straw itself. I also value the conversation about how morally injurious it is to work in a system where you see harm happening to patients on a daily basis. No one is setting out to harm anyone, but it's hard to see people that are being harmed in our system on a daily basis. If you really want to recruit and retain healthcare professionals, this has to be acknowledged and addressed. I left full-time nursing after my experience as emergency nurse in Calgary in 2002, and it wasn't even that bad. But I will point out that even in 2000 to 2002, we were doing hallway nursing in the emergency department. So, yes, that canary in the coal mine died a long, long time ago. If this episode gave you something to think about, share it with one person who needs to hear it. A colleague, a family member, maybe even your MLA. Having more people in the conversation is what drives change. Please be sure to follow Shift Podcast Canada on Facebook and LinkedIn for episode updates and subscribe on your favorite platform. And remember, systems don't change unless we do. This is Shift. See you next time.