ER doctor: ambulance lineups reflect deep systemic problems with health care

COVID is not responsible for long waits at emergency rooms for ambulances and patients, and the situation will not improve when the pandemic is finally over. 

That’s the takeaway from an interview yesterday with Dr. Kirk Magee, the chief of emergency medicine for Nova Scotia Health’s Central Zone. 

Magee said emergency medicine is “the canary in coal mine” for a health care system that has been at the breaking point for so long it is unable to cope with the additional staffing challenge posed by the pandemic.

Some patients wait a day or two in the emergency department because all the beds are filled and ambulances can’t offload new patients and leave to respond to 911 calls.

“If the emergency department were an Olympic swimmer and you threw her a 10-pound COVID weight, she should easily be able to catch that and keep above water and be fine,” said Magee. “But our swimmer is shackled with cinder blocks that have been added to years and years of neglect and now when you throw the extra pressure of COVID, she struggles to keep her head above water.”

In July, the former Health Minister issued a directive that set a goal or benchmark for emergency departments to meet. The benchmarks say major hospitals should admit 90% of patients within 12 hours of arrival at emergency and free up 90% of ambulances 30 minutes after they show up at the hospital. 

On this past Monday, 90% of patients at the Halifax Infirmary Emergency Department waited 40.9 hours to get admitted and 90% of ambulances waited 433 minutes (seven hours) to offload their patients. *

That was a bad day, but it wasn’t any worse than many days in the past several weeks or the ones still to come, said Magee.

“If you think back to Dr John Ross when he called a Code Orange in 2013, that was a horrible day in Emerg,” recalled Magee. “They completely ran out of capacity and had six ambulances in the hallway. That would be a really good day for us now. ”

Last week, the Examiner counted 16 ambulances lined up and waiting to offload patients at the Halifax Infirmary. 

Magee said most major hospitals in the province are experiencing the same pressure and contrary to popular belief, the problem is not people arriving with minor complaints that are easy to deal with but rather the lack of beds to admit people with heart attacks and overdoses and serious disease. Patients wait in hallways and the results are rarely good. 

Yesterday, Magee’s observations were backed up by this article published in the Canadian Journal of Emergency Medicine headlined “Saving Emergency Medicine: Is Less More?” Here’s an excerpt with a familiar story, nationwide:

The Emergency Department (ED) is the default destination for almost all unscheduled care, and 58–80% of ED patients went to an ED because it was the only place they could get care when they needed it. Research confirms that the unbridled demand facing emergency departments arises from poor primary care accessibility, increasing patient complexity, a rising burden of unmanaged chronic disease, physician and nurse staffing shortages, and a lack of hospital beds for admitted patients. None of these factors fall within an emergency medicine sphere of influence. So, is it really emergency departments that need fixing?

So what will it take to make emergency departments better places to visit and work? Magee suggested it will probably take more money to add beds for acute care in hospitals and long-term care in nursing homes. You can’t add beds without adding staff so we are talking about a major recruitment effort. (About 350 patients are waiting to return or be placed in nursing homes but staff shortages in the homes have led to hospitals holding onto patients they are unable to discharge.) 

Without more beds, the emergency departments at most major hospitals in Nova Scotia won’t be able to meet the surge in patients that results from flu season or an emergency such as a plane crash. On Monday, the Halifax Infirmary was at 106% of its capacity and couldn’t have handled a major accident. Magee said in a functioning system, a major hospital should operate at about 85%.

Magee said fixing health care is not about “writing a blank cheque”; equally important is “accountability” for health care leaders such as himself and those who operate Nova Scotia Health, which employs almost 24,000 people. Magee said leaders need the freedom to make change so that the separate parts of the health care system — such as home care, mental health and emergency care — can work together to solve the problems that end up with people waiting all day at emergency. The canary in the coal mine.

Ministerial directives are worthwhile, he said, only if governments (which change often) hold health care managers accountable to explain why they are or are not seeing improvement. 

“If we are looking for a quick fix, we are doomed to failure,” said Magee. “COVID has made this worse but it’s not just COVID — that’s an easy scapegoat. We need to recognize that we need to make a significant change and then we need to give our leaders autonomy and hold them accountable to make those changes.”

* This story has been updated to include more accurate data.

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