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as the pandemic entered its third summer last june, a group of 60 emergency room doctors sounded the alarm about what they considered to be the deteriorating safety of ers in the province.
“it has become a daily occurrence that more than 50 per cent of the stretchers in emergency departments are occupied by patients who are waiting for a hospital bed, and these patients are staying in ers for longer than 24 to 48 hours,” dr. marie-maud couture wrote in a letter on behalf of the regroupement des chefs d’urgence du québec.
far more worrisome, couture warned, is the reality that “increased admission times from the emergency department to the hospital wards is associated with a greater risk of patient mortality and complications.”
without going into specific cases, couture nevertheless recalled that “several potentially preventable deaths have been reported by emergency chiefs in recent months, for lack of access to a stretcher and the care required by the condition.” by november, she wrote in a new letter to health minister christian dubé that quebec ers had reached the “breaking point.”
a montreal gazette investigative series published in february documented six patient deaths in the emergency room of lakeshore general hospital since 2019, raising questions about the impact of sustained overcrowding in an er beset by a shortage of nurses, defective medical equipment and lax oversight.
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and now, new data on daily er wait times that the health ministry began making public on its website since february add to concerns about the safety of the province’s emergency rooms, even after dubé launched his “cellule de crise” last fall to try to fix the problem. this data — coupled with the most recent statistics on quebec’s er fatalities since 2018-2019 as well as figures released by the non-partisan canadian institute for health information (cihi) — suggest that the province’s emergency rooms are unwittingly flirting with danger more than ever.
“if you look at the guidelines, everybody should be seen within two hours after arriving in the emergency department,” said dr. gilbert boucher, president of the association des spécialistes en médecine d’urgence du québec. “but that’s just not going to happen.”
dave sidaway
/
montreal gazette
a gazette review of the data has found a deterioration in each of the key er indicators that are viewed as a proxy for safety — from average er stay to deaths — since before the pandemic. each deterioration has occurred as ers have struggled with fewer nurses (many of whom quit during the covid-19 crisis), with the remaining staff treating older and sicker patients as never before.
“of course, bad outcomes are bound to happen when you see numbers like 140, 160 and 180 per cent er occupancy,” said dr. judy morris, president of the association des médecins d’urgence du québec. “patients are bound to be cared for less optimally.”
“if you look at what was the average percentage of occupancy of each er in previous years compared to now, before we would be in crisis mode in january and february or some other times during the year only for a day. now, for the past year with the shortage of personnel, we’re seeing this all the time.
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“for us, it’s hell when it’s 160 or 200 per cent occupancy and we genuinely fear for the next patient,” morris continued. “where am i going to put the next critical patient in the er, or from which patient am i going to remove the cardiac monitor for the next one that needs it more? these are decisions that we’re used to dealing with all the time now and we’re fed up with it.”
consider er mortality as one indicator of the worsening state of the province’s ers. given that many individuals who seek care in an er are very sick to begin with, it’s not unexpected that some patients will die despite the best efforts of doctors and nurses. but what happens when er deaths keep rising markedly?
quebec’s health ministry tabulates er deaths according to a fiscal year running from april 1 to march 31 in the following calendar year. since 2018-2019, the total number of er deaths has been rising steadily: 5,904 in that fiscal year; 6,075 in 2019-2020; and 6,566 in 2021-2022.
the gazette obtained statistics for the 2022-2023 fiscal year up to march 2, and the partial number has already surpassed the previous year’s entire tally: 6,877.
what’s more, deaths as a percentage of total er visits have been climbing, too. for example, the er death rate stood at 0.16 per cent in 2018-2019. in the most recent fiscal year up to march 2, quebec’s er death rate reached 0.21 per cent.
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“we hit a wall last may when they (ended many pandemic) measures,” said dr. gilbert boucher, president of the association des spécialistes en médecine d’urgence du québec.
“that’s when we discovered all the hospital staff that had left for different reasons. that’s when the population came back to a near normal amount of demanding service, not only in the emergency but in the hospital, and that’s when we started having a lot of people quitting on us and a human resources crisis.
“we were all hoping that at the end of august the vacations would solve the problem,” added boucher, who is also a member of dubé’s crisis cell. “but since then, i can tell you, it’s the number one problem in everything we want to do right now. we just lack the human resources.”
“of course, bad outcomes are bound to happen when you see numbers like 140, 160 and 180 per cent er occupancy,” said dr. judy morris, president of the association des médecins d’urgence du québec. “patients are bound to be cared for less optimally.”
pierre obendrauf
/
montreal gazette
in 2019-2020, quebec employed 60,143 nurses. by march 31, that number dropped to 58,723 — for a net loss of 1,420 nurses. what those numbers don’t tell is that ers have been disproportionately affected by the loss of nurses. many er staff have also gone on burnout leave.
another critical er indicator is median length of stay of an admitted emergency patient. that’s a patient who is waiting to be transferred to a hospital bed and is receiving care temporarily in the er. in 2018-2019, quebec’s median length of stay for an admitted er patient was 16.4 hours — by far the highest of any province, according to the canadian institute for health information.
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in its latest report, cihi observed that quebec’s median length of er stay for an admitted patient jumped to 19.4 hours in 2021-2022 — again, the highest of any province in the country. by comparison, the median length of er stay in ontario was 12 hours. (the median is the value in the middle of a data set, as opposed to an average.)
quebec’s average length of er stay is high, too. just last month in the montreal area, some ers reported average lengths of stay for patients on stretchers of more than 30 hours. in the most dramatic example, the lakeshore er’s average length of stay in that category was 52 hours and 23 minutes on march 29 — likely the highest in the country.
it’s risky for such admitted patients to be spending so many hours in the er and not in a dedicated hospital ward to treat their ailments, contends dr. eddy lang, who used to work in the emergency room at montreal’s jewish general hospital before moving to calgary 13 years ago.
“these patients are often in situations where there is no confidentiality, there’s no easy access to a bathroom, there’s often inadequate nursing monitoring in the er and bad things start to happen,” said lang, who is now scientific director of the alberta health services emergency strategic clinical network.
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“patients get into trouble. there are no call bells in the hallways. they can’t alert the nurses if their pain is increasing or they’re short of breath. so it’s these constellation of things where people are getting sub-optimal care because of prolonged stays in the emergency.”
to put the quebec numbers into more context: in alberta, five out of 10 admitted er patients (the median) waited 5.5 hours at the end of december for a bed on an upper floor at the peter lougheed centre — a hospital comparable to some of montreal’s larger institutions.
lang cited a study last year in the british medical journal that found that for every 82 admitted er patients whose transfer to a hospital bed on a ward was delayed by more than six to eight hours, there was one extra death.
the quebec health ministry’s target is that no admitted er patient should wait longer than 14 hours before being transferred to a bed on a ward. but on march 29, 34 admitted er patients at the royal victoria hospital had been waiting for more than 24 hours, and another 17 were languishing for more than 48 hours. that’s a total of 51 patients waiting considerably longer than the government target in an er with a 33-stretcher capacity.
“these are people who need admission to a bed on a floor, because if they didn’t need admission, they wouldn’t be spending that much time on a stretcher in the er,” lang explained of the royal vic’s stats.
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lang added that it’s not uncommon for the medical condition of some admitted er patients to suddenly grow worse.
“thank goodness most patients with pneumonia respond to oxygen, respond to antibiotics. but a good 5 to 10 per cent don’t, they get worse, and they might need to go to the intensive care unit. but if they’re in a crowded emergency department waiting several hours for their bed upstairs and that deterioration is not recognized, there will be a bad outcome.”
(in the six deaths that the gazette documented at the lakeshore, the medical conditions of four patients declined sharply while they were waiting in the overcrowded er. one patient suffered a fatal heart attack while on the phone with his wife.)
yet another er indicator — one that has been available publicly in quebec since last month — is the average length of time it takes for a patient in the waiting room to be seen by an er doctor. on april 3, it was 5 hours and 19 minutes at the hôpital et centre de réadaptation de jonquière, and at a hospital in sherbrooke it was 4 hours and 38 minutes.
a lineup of ambulances waiting at a montreal hospital: as many as eight sometimes queue up outside some congested ers, with the paramedics often waiting hours to discharge their patients for triage.
paul chiasson
/
the canadian press
those lengthy waits would appear to exceed canadian triage guidelines. for example, a priority 5 patient — considered the least urgent case — should be seen by a doctor within two hours. yet at the royal vic on april 3, the average length of time it took for an er patient in the waiting room to be seen by a doctor was 4 hours and 17 minutes.
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“if you look at the guidelines, everybody should be seen within two hours after arriving in the emergency department,” boucher said. “but that’s just not going to happen.”
the gazette discussed with boucher the er stats of a hospital that has made some progress, charles lemoyne in longueuil. still, on march 15, the average length of stay in the waiting room to be seen by a doctor was five hours at charles lemoyne. in addition, the average length of stay of a patient on an er stretcher was 23 hours and 16 minutes.
“we’re setting (the stage) for bad things,” boucher conceded of those numbers. “we’re not happy with that.”
he then added: “at least we have the statistics now. we didn’t have them a year ago. to me, that’s the starting point. at least we have some kind of benchmark.”
but the newly available stats still miss an ominous trend: the phenomenon of as many as eight ambulances sometimes queuing up outside some congested ers, with the paramedics often waiting hours to discharge their patients for triage. when that happens, there are fewer ambulances on the road to react to emergency calls and response times increase accordingly.
“many places have a problem getting ambulances to offload patients, so of course that’s going to translate into delays in ambulance responses in the community,” lang said. “so if you can’t get your ems team to respond in a reliable way because they’re all tied up in er corridors, and unable to offload their patients, well, it’s not just people in emergency waiting rooms that are going to have bad outcomes but the people who are waiting at home for an ambulance to arrive.”
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hal newman, a former paramedic with 40 years’ experience who now works as an independent journalist, has chronicled the deaths of quebec patients (including infants) in which lengthy ambulance responses were cited by coroners as contributing factors.
“within the last 12 months in quebec, there have been three cases where children have died where there were extended ambulance response delays,” newman said. “unbelievably, people don’t look at the number of ambulances queued up outside of an er as a contributing factor.”
newman has also observed the pandemic’s fallout on paramedics and er staff: “it’s remarkably worse. the system was in need of very serious renovation before the pandemic started. the pandemic has only exacerbated all of the failures of the system and created this massive wave of exhaustion and burnout among the staff.”
ers have been overcrowded in quebec since the 1980s. but the patients being treated in ers today are much sicker than they were even a few years ago, boucher and morris noted. some patients were unable to see a doctor during the pandemic and may not have sought care for a medical issue until it got much worse. for others, their cancer was diagnosed at a more advanced stage because they didn’t undergo a ct scan in time when hospitals were overwhelmed with covid cases.
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at the same time, quebec’s population is aging, placing a greater burden on the health network just as hospitals are grappling with shortages of personnel. and all of these problems tend to manifest themselves in ers.
“i don’t remember the last time i saw a patient with a sore throat or an earache or a sprained ankle,” boucher said. “i mean, those guys don’t make it to the main emergency rooms in montreal anymore.”
since dubé formed the er crisis cell, boucher acknowledged there have been some improvements. hospitals now activate overcapacity protocols when their ers become severely overcrowded. that means sending up some patients to wards even though they may be full. instead of the patient lying on a stretcher in an er hallway, that same individual is placed on a stretcher in a corridor in the ward until a regular bed becomes free.
charles lemoyne and some other hospitals are running outpatient clinics for longer hours during the week to prevent er visits. the jewish general hospital, meanwhile, has established a command centre to ensure that patients don’t stay on wards longer than they need to, liberating beds for those from the er. the government has also opened a handful of clinics in the montreal area that are operated by nurse practitioners.
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“we’re moving in the right direction,” boucher said. “things seem to be settling down. we’re finding a groove where we’re a little more comfortable.”
but his optimism is restricted to viewing the future one week at a time, not longer, given the enormous pressures and unpredictability of health care.
“we like to think of the next week to stay positive. that’s one way of looking at it.”
morris, for her part, was less sanguine.
“i think it’s going to be a rough few years,” she predicted.
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