The end of hallway medicine?
As the number of patients visiting emergency rooms approaches pre-pandemic levels, a debate has erupted over whether COVID-19 has changed emergency medicine in Canada forever.
The scrutiny centres on one of the healthcare system’s chief flashpoints – hallway medicine. Prior to the pandemic, corridors crowded with patients on stretchers had become the norm in many hospitals. According to a CBC News analysis of 169 Ontario hospitals published in January, 83 were beyond full capacity for more than 30 days, 39 hit 120 per cent capacity or higher for at least one day, and 40 averaged 100 per cent capacity or higher in the preceding six months.
That all changed when COVID-19 struck. Not only did fear keep Canadians away from emergency rooms but hospitals purged patients from inpatient units, cancelled elective surgeries and made sure social distancing was enforced in waiting rooms and, yes, hallways. Within a week or two, emergency department visits were down to a fraction of their usual numbers. Some doctors and hospital administrators envisioned an end to the era of hallway medicine.
Andrea Unger, chief of emergency services at Brant Community Health in southwest Ontario, insists her department cannot return to the overcrowding so common in pre-COVID days. “What was previously the personal humiliation and discomfort that accompanied being cared for in a hallway has now become a case of putting patients’ lives at risk,” she says.
Not everyone is optimistic. According to Ontario Health’s guidance for resuming elective surgeries released in early May, the expectation is that hospitals will either maintain occupancy at 85 per cent or, if full, that they will be able to immediately boost capacity by another 15 per cent in the event of a surge in admissions.
However, emergency department chiefs like Unger are skeptical hospitals can keep 15 per cent of beds on “stand-by” given Canada’s long-standing shortage of beds. According to the Canadian Institute for Health Information, Canada has fewer than two acute care hospital beds per 1,000 people, the lowest of any OECD country other than Mexico.
“They have asked us to recreate what we had 30 years ago,” Unger says. “I don’t believe that COVID has changed any of the fundamental problems of hospital flow and it has not decreased the many causes of patients not being able to access care they need, including the ability to see a specialist, get an MRI or urgent follow-up care.”
Gary Bota, lead of emergency services in Ontario Health’s northeastern region based in Sudbury, also sees challenges ahead but is cautiously optimistic that the days of over-crowded hospitals are numbered. He points to improved collaboration among the 40 hospitals serving the the region. In particular, he cites the region’s critical care network that coordinates the care and transfer of the sickest patients to larger hospitals.
“I think we can be very proud of our frontline workers,” he says, adding that his team of emergency physicians working to keep patients safe will continue to make a difference as the pandemic continues. “We have an amazing bunch of people up here. We have 40 little EDs across Northern Ontario that are providing a level of care that is unbelievable.”
Even so, Bota worries that the problems that spawned hallway medicine have not gone away. The emergency department at Health Sciences North has converted adjacent classrooms and offices into examination rooms to ensure patients with COVID-19 symptoms are separated from all others. “We have lost about 40 per cent of our care spaces and portions of our waiting rooms as they left patients too exposed,” Bota says.
The extra space may not be enough. Social distancing is not feasible in crowded waiting areas and roughly half of incoming patients fail triage screening for possible symptoms of COVID-19, meaning they need to be separated from others and must be treated by doctors and nurses in full protective gear.
As Bota acknowledges, “the reality is that hospital capacity for our population is pretty darn low. Do we have the capacity to think differently? I am concerned we don’t.”
Alberta took steps to overcome hallway medicine well before the pandemic struck. At the peak in April, only 87 people were in hospital with COVID-19 compared to more than 1,000 in Ontario.
According to Eddy Lang, head of emergency medicine at the Cummings School of Medicine in Calgary, the province’s hospitals have been in a “honeymoon period” due to increased capacity and lower emergency department visits. He attributes Alberta’s low case count, in part, to pre-pandemic measures designed to mitigate overcrowding in emergency departments.
Two initiatives have been key to limiting the spread of the virus, Lang says. One is direct communication between long-term care homes and emergency departments; the other involves setting up a system for patients to bypass the emergency department for hospital admissions from a specialist’s clinic. These measures, Lang says, have helped prevent the large outbreaks now hampering control efforts in Ontario and will stay in effect for the foreseeable future.
Lang predicts emergency departments will manage to avoid overcrowding in the future. He describes the pandemic as a catalyst for positive change in Alberta enabling many more patients to get the care they need without having to strain emergency room resources.
“Perhaps in some ways, access may be improved between specialists, family doctors and their patients. With expanded access for getting help, emergency departments may not need to be as much of a safety net.”
There is widespread agreement that COVID-19 has highlighted the ability of emergency departments to adapt quickly under pressure but more innovation will be needed.
Both Unger and Bota think that smaller community hospitals may hold at least part of the secret to success as emergency department volumes creep up with the relaxation of physical distancing rules.
As Unger puts it: “Community hospitals have an advantage in dealing with change like this. Although my admin assistant is Siri, the person-to-person communication (in a small hospital) makes change move faster. We all work in one building. We know each other well and trust one another. Nimbleness is the key.”
Lang said he wants to ensure that innovations prompted by the deadly virus are not squandered. “It would be such a shame if we have tragically lost all of these lives to COVID without maximizing the learning and improvement opportunities that are right before our eyes. We need to understand them better and figure out a way to maintain them so that we don’t go back to the old normal.”