Pediatric emergency departments across the country are seeing record numbers of visits, in large part because some walk-in clinics and community family practice groups won’t see children if they suspect COVID is at play.
Children with mild viral colds who register at the bottom of triage acuity scales account for much of the surge that has tripled typical seasonal patient volumes in some centres. But families can’t get in to see their family doctors or walk-in clinics, so they decide there is no choice but the emergency department.
“It’s not a great time for us and we are very worried about the coming winter season,” says Antonio D’Angelo, the pediatric emergency chief at the Centre hospitalier universitaire Sainte-Justine in Montreal, where volumes have spiked sharply.
More patients mean longer wait times, adding stress to families and, in some cases, hindering care for children with genuine emergency conditions.
Families report multiple reasons for resorting to emergency departments. Some say it is because they are told they must wait up to 48 hours for results of a COVID test before they can be seen. Others are explicitly told to go to an emergency department after a virtual session. Still others report they feel their doctor is seeing fewer patients or that they thought the office was closed because it was closed earlier in the pandemic.
It’s a frustrating dilemma for hospital administrators.
“What is unclear to us is how much of this is perception versus reality,” said Jason Fischer, chief of pediatric emergency at Toronto’s Hospital for Sick Children.
Medical colleges in British Columbia, Ontario and Nova Scotia have urged primary care doctors to return to in-person care.
On the other side, Roetka Gradstein, a family doctor in Halifax, says that “family doctors are not working in a model they are accustomed to.”
General practices were told to cut their waiting room capacity in half, ensure patients don’t stay in a clinic too long, keep appointments on time, ensure appropriate distancing, clean rooms between patients, but also see more patients in person because of the busy emergency departments.
“How can we balance all this?” Gradstein asks frustratedly.
Most family doctors are busier, facing higher demand, and seeing more patients requesting appointments or dealing with inappropriate appointment requests, says Gradstein. Another challenge is the double-appointment phenomenon, where a person is seen virtually or by phone and then requires an in-person appointment.
Although virtual care raises questions about its new place in the system, it is an effective way to triage patients and can provide better access and better health equity across the system.
But as Fischer points out, it “needs to be used the right way and we need to avoid causing more fragmentation of the patient’s journey.”
More patients mean longer wait times, hindering care for some children with genuine emergency conditions.
Wait times have tripled at the Hospital for Sick Children emergency department, and a similar trend has been seen at BC Children’s Hospital, where children at the bottom of the acuity scales wait longer to be seen by a doctor and stay longer.
It’s not just increased numbers of patients, says Fischer, but also the awkwardness of the new infection control measures in the time of COVID.
“The real challenge is how we move patients around that are waiting,” says Fischer.
What can be done?
Hospitals are looking for collaborative solutions with family doctors and walk-in clinics. Improved communication between each setting, pediatric assessment clinics to see children with viral illnesses, and more support and involvement of primary care are just a few that have been suggested or tried. Extending hours in the evenings in family doctors’ offices and walk-in clinics has also been discussed.
Gradstein is concerned that many of the policies and procedures that have been put in place have left community access points to health care out of the process. For example, Nova Scotia and Ontario don’t allow family doctors to conduct COVID tests. Solutions need to focus on including family doctors and not undercutting or undervaluing this part of the system, Gradstein says.
Fischer agrees: This isn’t about the emergency department versus family doctors and walk-in clinics. Both need to find solutions to help everyone through the winter safely.