the rise of er 'chair care': canadian patients examined in waiting rooms, closets, washrooms amid bed shortage
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uncontrolled, undetected internal bleeding, an emergency medicine “time bomb,” can kill within hours.
so, when dr. fraser mackay saw a young woman recently with a minor shoulder injury from a fall who seemed in an inordinate amount of pain, his gut told him something was off.
she was seated in a chair in a very public, high traffic area of a saint john, n.b., emergency department. no space for a proper assessment. nowhere to assess her privately. mackay decided she needed a bedside ultrasound of her abdomen. a proper ultrasound requires laying the patient down and lifting their clothing. except there were no empty stretchers. so, she just sat there, in pain.
with his shift over, mackay told the on-coming doctor, “until we get a stretcher, she can’t go home.”
her stomach was finally scanned, an hour or two later. the test showed internal bleeding requiring emergency surgery to find and stop the source of bleeding.
“it would have been very easy to say, ‘well, if things get worse, come back later,'” mackay said. “who knows how long she could have sat there. and what if that stretcher hadn’t become available, and her bleeding had gotten worse? she shouldn’t have been assessed in a chair in the first place.”
except “chair medicine” and “waiting room care” have become routine and common, default responses to canada’s severely gridlocked emergency rooms, mackay and other emergency physicians are reporting.
“er chair medicine in ontario (the awful cousin of hallway medicine) is unacceptable. full stop,” toronto emergency physician dr. raghu venugopal posted on x.
“we need to get rid of it. we must fund hospitals and fix the problem of critically ill patients put in a chair. there is zero exaggeration here. i am sounding the alarm. hear it.”
venugopal posted that he witnessed people in “extremis from pain” being “put and kept in a chair.”
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extremis can mean uncontrolled, doubled-over-in-agony pain. “generally speaking, those patients shouldn’t be in a chair,” mackay said.
but as backed-up emergency departments desperately try to manage more demand than they have the capacity to meet, more people are being assessed in “unconventional spaces,” the official euphemism for spaces never designed, or equipped, to provide emergency care: no access to oxygen or suction, no nurse call bell, no easy access to a washroom or sink, no shred of privacy.
“unconventional spaces” can include any carved-out space. hospitals are converting ambulance bays into patient wards. “no heating, no plumbing, but, ‘hey, it’s great — we’re taking care of our patients by sticking them in a cold garage,'” said mackay, chair of the canadian association of emergency physician’s rural, remote and small urban section.
patients have been examined in closets and washrooms. doctors are wading into waiting rooms and pulling sick patients into corners and cubby holes. blankets are being hung off iv poles to create makeshift curtains for people stranded in chaotic hallways. while it may give the illusion of an acceptable version of medicine, care is “guaranteed being comprised by the concept, ‘we can just see a patient in a chair,'” mackay said.
he’s had several “near misses” involving patients treated in chairs — close catches where a disaster was narrowly avoided because of, in the internal bleeding case, vigilance. “i got a bad vibe, which is honestly a big part of being a doctor.”
the pressure to provide treatment in whatever space they can is creating a moral, “damned if you do, damned if you don’t” dilemma for emergency staff across canada, said medicine hat, alta., emergency physician paul parks.
“you don’t want to watch suffering and see patients not doing well and lingering in the waiting room. but you also know that, when you walk out there, you don’t really have a nurse, you don’t have monitoring, you don’t have the standard things you would have if you had a normal care space,” said parks, a past president of the alberta medical association.
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“you, by definition, are basically kind of macgyver-ing it and giving suboptimal care to a degree.”
but while some care, some intervention, may be better than nothing, “this is just a band-aid on a massive, gaping wound,” he said.
an average of 1,390 people seen in an emergency room on any given day in ontario in 2023-24 received care in an unconventional space, a metric first tracked by the news outlet, the trillium.
not every person who lands in emergency needs to be in a space with monitors and a gurney or stretcher — the old school thinking of the 90s.
over the years, emergency departments pulled together “minor treatment” spaces. at parks’ medicine hat hospital, that meant three chairs separated by office space dividers in a public hallway outside the waiting room.
thus, “chair care” was born.
more recently came “rapid assessment zones” designed for the “less acutely unwell” who can be safely seen in an internal waiting area or chair space — people with sprains, cuts needing stitches, sore throats, ear infections. there are comfortable padded recliners, perhaps a bed or two. the aim, to increase patient flow — assess, treat and move people out, quickly. “it maximizes your space and allows good throughput,” said ottawa area emergency physician dr. michael herman.
the potential danger occurs when the emergency department gets “jammed up with admits,” meaning every cubicle or hallway stretcher already filled with people who need to be admitted to the hospital, but with no empty beds on the wards to move them to, because those scarce beds are filled, often with people who no longer need to be there but can’t leave because there’s nowhere for them to go — no space in a nursing or long-term care home, no home care or rehab bed. what’s known as “access block,” another administrative euphemism.
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suddenly, people with more serious complaints trickle down to the fast-track zone, “where it’s really not optimized for that person or that complaint,” herman said.
“it slowly becomes normalized — the frog in the boiling water. ‘we just wanted to see them to get things started or get things moving along,’ and then it becomes two patients, then eight, then 10.”
“you’ve normalized a patient population through one of these zones that isn’t appropriate for them,” herman said.
that can be risky with “undifferentiated” patients: is the chest pain acid reflux, pneumonia or an evolving heart attack?
“that’s the five-alarm fire situation many of us worry about every day,” herman said.
“chair” and “waiting room” medicine have become routine and common, default responses to canada’s severely gridlocked emergency rooms, doctors say.
peter power/postmedia
when hospitals are running at 100 per cent capacity, and the congestion backs up into emergency, “the goal posts move, and the appropriateness goes out the window,” mackay said.
“you cannot appropriately examine a patient in a chair, physically, or from a patient privacy perspective. you have to lift up shirts, take off pants, put on monitors, get your stethoscope out.”
and when the rapid-access zones and other chair areas are overflowing, including with now very sick patients needing more prolonged care, and those areas get gridlocked, “then we’ll go out into the waiting room,” parks said, to try to find the near misses and avert another waiting room disaster.
even then, there often aren’t enough personnel to help. parks said it’s not uncommon for doctors to see waiting room patients with lower, right-side abdominal pain and fever that looks suspicious for appendicitis. blood work, a ct scan and antibiotics and pain meds can be ordered. “but, while the blood work and maybe ct scan gets done, there’s no one available to deliver the antibiotics or pain medication,” parks said. hours later, the patient is still in the waiting room, with no comfort or pain relief. “and you get the ct scan back and, indeed, it is appendicitis and they go straight to the operating room,” after having spent eight or nine hours in the waiting room.
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it’s a “duct tape,” workaround solution that’s sparked ongoing ethical debate among doctors.
“what is more important,” mackay asked. “do we compromise care to at least do some sort of assessment, which then perpetuates and even normalizes substandard care as a result of half-assed status quo system policies that lack accountability, versus we stick to the high ground of, ‘i will not see a patient until i have the capacity to do so to the best of my abilities in an appropriate site.’
“more and more we’re recognizing that we just want to see the patients. we want to try and find those ticking time bombs. we want to get people out of the department that have been there for 12 hours.”
earlier this month, a patient was discovered dead in the waiting room of an overcrowded emergency department at edmonton’s royal alexandra hospital. in late december, prashant sreekumar, a 44-year-old father of four, died at edmonton’s grey nuns hospital. after waiting eight hours in an emergency with chest pain, he collapsed within minutes of being called to a treatment area.
“my heart goes out to our triage nurses who have the impossible task of looking through a packed waiting room and trying to figure out who’s the needle in the haystack,” herman said. “they’re being set up to fail by the system that doesn’t allow them to flow these patients into the care spaces they need to be in, in a timely manner.”
sreekumar had complaints that likely required cardiac monitoring and a nurse-staffed bed, herman said. “what so-called ‘unnecessary’ visit was sitting in the bed that he needed to be in? was it an ankle sprain? of course not. it was another equally sick person or admitted patient who wasn’t able to get out of that space so he could get in.”
everyone fights over that one final stretcher, he said. “we put people in these suboptimal environments and then act surprised when suboptimal things happen.”
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one of the biggest indicators of a system in free-fall is assessing, treating and discharging an acutely ill patient in a chair, mackay said. “and that is driven by the pressure we have. we are not taught to do that. it goes against our training. one of the fundamental aspects of training a physician is patient respect. patient privacy.
“you don’t undress patients in a hallway. you don’t ask patients their deepest, most personal questions when there’s someone sitting in a chair next to them.”
the emergency department at the royal alexandra hospital in edmonton on friday, march 7, 2025.
shaughn butts
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postmedia
it also does nothing to reduce what’s been described as the “barbaric” and growing practice of boarding — keeping admitted people, like an 80-year-old with a fractured hip, on a hallway stretcher for one, two, three days, with 24/7 light and noise, and no sleep, waiting for a ward bed to open. a recent systematic review found strong evidence linking boarding with higher death rates in hospitals, longer hospital stays, more medication errors and worsening burnout for staff.
canada’s chronic hospital bed shortage is a major driver of emergency department crowding, but in addition to more beds, a more integrated health system overall is needed, mackay said, including more community supports — more long term care, more physiotherapy — to discharge patients wherever they need to go.
“none of this has anything to do with the emergency department. that’s the frustrating part,” he said.
“but it’s a huge burden on staff and a huger burden on the patients, because they’re not getting the care they need in the place they need it.”
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