The chief of the province’s second busiest emergency department says record-breaking overcapacity issues are making it increasingly difficult for them to fill the gaps of a primary care system in crisis.
“Our capacity at best is probably 140 a day, and we’ve been averaging over 150 a day fairly regularly and more in the last month,” Cobequid Community Health Centre emergency department chief and chief of medical staff Dr. Mike Clory said in an interview.
“We had 181 show up (June 13), which was our busiest day on record, and we’ve had in the 170s a number of times…The top 20 busiest days have been in the last several months.”
Open daily from 7am to midnight, Clory said the Cobequid Community Health Centre sees more patients in the 17 hours it’s open than the Dartmouth General Hospital, Cape Breton Regional Hospital, or the Valley Regional Hospital each see in a 24-hour period and per year.
When open, it also registers the same number of patients per hour as the Halifax Infirmary — the province’s busiest department.
The number of emergency department visits to the Lower Sackville facility have more than doubled in the last decade, with an estimated increase of about 2,000 visits per year. While primary care in the province has been at a crisis level for quite some time, Clory said emergency department capacity is now at “a highly concerning level.”
Earlier this month, the chief of the IWK Health Centre said its children’s emergency department was facing “unknown territory” as visits to their facility reached record numbers.
‘Lining up in lawn chairs’
Clory doesn’t see things settling down at Cobequid’s emergency department any time soon.
“A trend (over the last couple of months) is people are now showing up at seven in the morning lining up in lawn chairs,” Clory said.
“Not because they’ve had chest pain through the night, but because they don’t have a family doctor and they’ve had the sore knee or they needed blood pressure medication and they can’t get into a walk-in clinic and this is their only option and they want to make sure they get seen.”
While the Cobequid emergency department has the capacity to care for patients arriving with serious and life-threatening conditions, those who show up with non-emergency issues could soon be out of luck.
“We certainly can’t provide the level of emergency care that we used to provide in that we had capacity to see people who didn’t have life-threatening problems in a reasonably timely manner,” Clory said.
“It’s getting to the point now where more and more of our resources are going to have to be just for true, life-threatening or potentially life-threatening conditions that can’t be dealt with elsewhere. We don’t have the resources to deal with the primary care needs that are unfulfilled.”
Clory said that inability to deal with primary care needs creates a “vicious circle.” When those needs aren’t being met, it can lead to life-threatening medical situations. As an example, he points to people living with chronic obstructive pulmonary disease (COPD).
“When they decompensate, they come in very sick so then it becomes a true life-threatening condition because they don’t have access to (a primary care provider to) monitor them and make sure they’re doing all right,” Clory said.
“There’s a safety net for all the people who can’t get access to primary care, and that’s failing and it’s failing dramatically.”
The Cobequid emergency department’s overcapacity procedure is based on monitoring the number of patients arriving and the numbers waiting to be seen.
Clory said they’re hitting that overcapacity number earlier each day.
“The people who are coming in after supper? Well, we’re already at capacity,” Clory explained.
“They’re thinking, ‘Well, they don’t close until midnight and I’m here at 5:30 or six,’ but we’ve already got patients that the doctors and nurses will be working fully to see.”
Clory said it’s important to remember that even when they hit capacity early in the day, they don’t close up shop or stop seeing patients needing immediate and urgent care.
The Canadian Triage and Acuity Scale (CTAS) is a tool used nationally and internationally in emergency departments to “prioritize patient care requirements.” Patients who present with non life-threatening issues are designated a four (less urgent) or five (non-urgent) according to the CTAS system.
Level one is deemed most urgent and includes people who have major trauma, are having an active seizure, severe respiratory distress or arrest, cardiac arrest or unconsciousness.
Level two on the CTAS scale applies “when there are conditions that are a potential threat to life, limb or function, requiring rapid medical intervention,” according to a CTAS manual. Level three is considered urgent and includes shortness of breath, moderate abdominal pain, and high blood pressure.
‘Don’t stay away’
“Even at Cobequid when we’re at overcapacity, we’re there,” Clory said. “So if they’ve got a problem that could be potentially dangerous, they’re getting a nursing assessment and a physician looks at them.”
For non-urgent issues that can wait, patients will be advised to go elsewhere or return to Cobequid when it reopens early the next morning.
“I know people are frustrated by this, but it’s very important that patients don’t stay away from the emergency department if they feel they do have a life-threatening problem,” Clory said.
As an example, Clory said if someone comes in with a sore knee they’ve had for a month, even if they can’t address the problem at Cobequid, that patient will undergo an assessment and a physician will ensure it’s not a more serious issue like an infected septic knee.
“I think that can sometimes get lost where people think, ‘Oh, they’re overcapacity. Well, I’m not going to go down and I’m not going to be seen,’” Clory said.
“That’s where I think it’s dangerous.”
Despite having a hard close of midnight to ensure all staff can leave the Cobequid facility by 1am, Clory said flow issues at the Halifax Infirmary are increasingly resulting in nurses staying overnight with patients who can’t be transferred to a facility that’s open 24/7.
That adds an additional seven hours to their 12-hour shifts, something he said is now happening about 70% of the time.
“Our worst night for that was 11 patients, and that had major ramifications on our capacity the next day because (we had) 11 patients in beds and a physician who came on at seven in the morning,” Clory said.
“He wasn’t available to see any new patients because he had to go see all of these patients and all the nurses were tied up looking after these patients. We had 20 patients show up at seven in the morning that day and they weren’t being seen for a couple of hours.”
‘You may not be seen’
Clory believes at Cobequid, they’re headed towards a situation where they’ll be forced earlier in the day to inform patients at triage who aren’t in those first three CTAS levels that they “just can’t offer them any care.”
“At two o’clock in the afternoon we know that there’s 12 hours of patients that are going to be coming in with more significant things,” Clory said.
“And we can’t commit and say ‘Well, you wait eight hours and we’ll see you,’ because we know in eight hours time there’s going to be chest pains and all sorts of problems that are going to be showing up that we need to address.”
Clory — who also serves as enhanced skills program director with Dalhousie University’s Department of Family Medicine — said impacts of the Cobequid regularly hitting capacity are being felt throughout the community. He points to the lack of family physicians in HRM (and across the province) as having contributed to the “system issue.”
The latest available data from May (published in June) shows that as of June 1, 94,855 Nova Scotians were on the province’s Need a Family Practice Registry. This doesn’t account for those without a primary care provider whose names aren’t on the list.
In the Central Zone, 34,916 people were on the list for a primary care provider as of June 1.
No room at the walk-in
Another factor Clory said is contributing to the rise in emergency department visits for non-urgent issues is a decrease in walk-in clinic availability.
At Cobequid, they frequently hear from patients who start calling walk-in clinics (many of which are now appointment only) as soon as the phone lines open only to be told all the spaces are already taken.
“If the clinic doesn’t have a doctor for the evening or for the morning, the public doesn’t know there’s not a doctor there,” he said. “They just know that the same-day appointments are all full by nine o’clock in the morning.”
Clory said the recent retirement of two Lower Sackville-area family doctors has added to the pressure felt by his department as 7,500 patients were left without a primary care provider. With fewer available walk-in clinic spaces and no family medicine practitioner, the emergency department is the only option many patients have for non-emergency care.
While he described the walk-in clinic issue as “multifactorial” and partly due to a lack of physicians, Clory said it’s “primarily” being driven by a 2018 government policy intended to encourage family physicians to work in family practice rather than walk-in clinics. That fee code change resulted in walk-in clinic physicians being paid less than those seeing patients in a family practice.
“A lot of the walk-in clinics were supported by some family physicians who might do a four-hour shift once a week or twice a week, so they no longer do that,” Clory said. “Why would you go and do that and be paid less for the same work?”
Clory said the fee code issue could be quickly remedied by the province. While it wouldn’t resolve all the issues, he believes it would be “helpful” from an emergency perspective to make walk-in clinic capacity more attractive to physicians who might have capacity to help out.
“If walk-in clinic capacity were expanded, it would be somewhat easier to do than to get family physicians in place,” he said.
‘It was predictable’
While he applauds the current government for taking steps to fix primary care, Clory said the problem didn’t happen overnight and he blames “poor decisions” made by successive governments over the years.
“Not any one political party is to blame. They’re all to blame because they were all at the helm as Rome was burning, right? It took a long time and then it came to roost pretty much with COVID,” he said.
“And it was predictable because the demographics of the physicians retiring were there, the demographics of how many graduates were coming out were there, and it just wasn’t addressed.”
The morale of emergency department health care workers is also being impacted and worker burnout is real. Clory said the last thing any of them want to do is take five minutes to assess someone and inform them they can’t be seen today and/or that they must go to another facility or return in the morning.
“That’s not why we got into this, but that’s essentially where we’ve been placed. You’re having to deal with the patient who says ‘Well, I don’t have a family doctor. Where can I go? I call all the walk-in clinics. They can’t see me and I need this looked at,’” Clory said.
“We’re having to apologize for the system. At times you’ll get anger directed at you even though they’re not angry with you, they’re angry with their situation.”
Need another community hospital
Although often talked about, operating the Cobequid’s emergency department on a 24/7 basis would be complex and involve many operational considerations. Clory said it would also require resources — including nurses — and they’re already short nursing staff.
Clory said three successive governments have asked him about costs associated with operating Cobequid’s emergency department on a 24/7 basis. The last time was in 2014-15. Annualized for operational costs alone, the figure was estimated at $5 million.
“Forward thinking, there needs to be thought of another community-type hospital in the metro area with an emergency department and inpatient capacity. Cobequid could probably service some of that if there was inpatient capacity so that we didn’t jam up the emergency department with patients waiting to flow out,” he said.
“Then you could have a 24-hour emergency department that did increase capacity, see patients. But if you tried to do one without the other, I don’t think you would realize the benefits.”
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John Ross came up with a plan years ago to only have regional ERs. If we are still moving towards that we need a more reliable EHS system and more primary care.