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Hospitals in crisis: Emergency personnel in southwestern Ontario sounding the alarm

While Ontario’s COVID-19 Science Advisory Table has warned of critical care bed shortages in the coming months, emergency departments, especially those in non-urban regions, are experiencing unprecedented crowding and providing emergency care in precarious places.

On a recent shift, an emergency physician in southwestern Ontario said he did something he had never done in his decade-long career. In the face of relentless crowding in the department and waiting room, he started seeing patients in ambulances parked in the hospital’s driveway.

“I got in the rig to see a patient because the EMS stretchers could not fit in our department,” said the physician, who asked not to be named. “If this person had needed immediate resuscitation, it would have been in our triage bay, but there was already someone on that stretcher. There were no spots to see people anywhere.”

The situation is dire. According to Health Quality Ontario, many hospitals have reached unprecedented levels of emergency department crowding. In September 2021, the average length of stay for an admitted patient in the emergency department was 16.5 hours – a whopping eight times longer than what is defined as “prolonged boarding,” a health-care system quality indicator that, as it increases, puts patients at risk.

As described in the New England Journal of Medicine, patients boarding in emergency departments are at higher risk of clinical deterioration, have longer in-patient stays and have higher costs of care. Prolonged boarding also increases crowding, increasing the likelihood of human error, violence toward staff and high clinical staff turnover.

Andrea Unger, a 20-year veteran emergency physician in southwestern Ontario, says the causes of crowding in her department are no different than in other regions across the province: Shortage of nursing staff and large numbers of admitted patients waiting for long-term care beds or home-care services mean she cannot move patients from the emergency department to hospital floors.

“Our ER has been reduced from 30 acute care stretchers to see 100 patients per day down to 10 because the other stretchers are filled with 20 people waiting to be admitted,” she says. “We have seen a 100-per-cent increase in length of time people are waiting in the waiting room (since before the pandemic), and patients frequently exceed the number of chairs in the waiting room.”

Unger loses sleep thinking about the one in 20 patients who now leave her emergency department without seeing a doctor – a number that has skyrocketed in the past year. “These are the people who leave in frustration and come back with heart attacks or come back with a ruptured appendix.”

When asked about the emergency physician in her department seeing patients in ambulances, she says, “That afternoon there were eight ambulances parked outside without even room for one more stretcher to come through the sliding doors. This was a new low.”

Nearby, Norfolk General Hospital responded to nursing shortages by shutting down hospital services. This fall, it was the labour and delivery unit, meaning pregnant women have had to travel to other communities to deliver. Norfolk now also routinely receives ambulances that are diverted from larger area hospitals due to overcapacity, an occurrence that was relatively unheard of before the pandemic.

Rejean Duwyn, chief of the emergency department at Norfolk General Hospital who has worked in a variety of rural and remote settings in Ontario, says the current staffing crisis in the region is the worst he has ever seen.

In September 2021, the average length of stay for an admitted patient in the emergency department was 16.5 hours.

Norfolk General has a 15-bed emergency department, and in overnight hours only three nurses and one physician. A shift with one nurse short is now a more regular occurrence, says Duwyn, and creates a precarious situation if a patient arrives needing definitive treatment at a larger hospital.

Describing a patient who would face delays in care for a heart attack or a brain bleed, for example, Duwyn says, “These situations are a worst nightmare. At times, there are not enough staff to physically transfer someone and keep the emergency department open. It is one thing when it is beyond your control (like dangerous weather conditions in a remote location), but it is another when it is because of staffing levels.”

According to Anthony Dale, president and CEO of the Ontario Hospital Association, system overcapacity has been years in the making, especially in non-urban regions.

“We are looking at a 20-year period where the needs of rural and northern communities, with respect to hospital services, have been more or less overlooked,” says Dale. “Now the pandemic has revealed to all, not just rural and northern communities, the system is extremely fragile everywhere.”

With a hospital system running at or over capacity at all times, the highest proportion of acute care beds ever occupied by alternate level of care patients, higher vacancy rates in the health-care workforce, difficulty recruiting and retaining staff and workforce burnout, Dale predicts the situation in acute care hospitals over the coming months is precarious at best.

But it is not just in hospitals where the dangers of crowding are evident. Russell King, chief of the Brant/Brantford Paramedic Services, says because of emergency department crowding, his paramedic crews are unable to offload patients in a timely manner, causing what are called “offload delays.” These delays can result in worst-case scenarios called Code Zero, or when there are no ambulances available to respond to a 911 emergency in the community.

King says these delays have skyrocketed this year. With the average team waiting nearly an hour and a half to get back on the road, “each month we equivalently lose five full days on the road.”

With a fleet of only nine ambulances in the daytime and six at night, the region has had 500 instances this year when they have had to rely on neighbouring municipalities to respond to calls when no ambulances were available.

“Everywhere from Paris to Brantford is not covered,” he says. “If we start using vehicles from other jurisdictions, we take from them, and then they have to rely on other areas’ services too. It is a domino effect.”

Similar situations are occurring across the country. Quebec’s coroner is investigating after a man died after waiting two hours for an ambulance.

Unger, King and the emergency physician treating patients in the back of ambulances all agree: the solutions must come with input from the front lines.

“I have done every procedure you can think of, save a genital exam, in the hallway,” says the physician. “It is to the point that we are so gridlocked, if there is a spot to lay down, we are using it. Get the boarded patients out so that I can take care of my patients, talk to them, and do procedures in a place that I don’t have to pause to allow a stretcher to go by.”

King says he believes it is only the dedication, hard work and integrity of individuals that keep the whole system from collapsing – from the nurse working extra shifts in long-term care homes to the paramedic and emergency department teams that get ambulances out when there’s a three-car pileup or child without vital signs.

“People on the ground think (the system) is breaking. But the will of the people who are out there right now, the hard-working front-line individuals no matter where they are, will do their best not to let it.”

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9 Comments
  • Kerry says:

    As a Norfolk county resident I have to say these Hospital administrators putting mandates in place should think of the community they are putting at risk! Shutting down services over a virus that can be spread by vaccinated and unvaccinated alike is ludicrous! Firing of hard working people who served throughout the pandemic is a horrible idea and not in the best interest of your community. These hospitals are on the verge of catastrophic shortages and it’s their own fault. Hope the CEO’s sleep well at night while their remaining staff struggle. You should be ashamed of yourselves.

    • Mary says:

      The loss of the labour and delivery department at NGH has nothing to do with the vaccine mandate. An exodus of nurses retiring or leaving due to burnout. They offered $10,000 signing bonuses but no applications. Stop blaming the mandates! Nurses follow science and are vaccinated.

      • Kerry says:

        The hospital is losing many health professionals over the mandate, services previously shut down were due to already being short staffed but wait and see what happens now….

  • Cheryl says:

    As a former resident of Norfolk County I have to agree that the staffing crisis at the Norfolk General Hospital is a huge problem. My elderly parents have both gone to emerge and waited hours before leaving not being seen by anyone, and now the residents of the area have to drive 40 minutes to Brantford to deliver their babies if they can get there in time. So why, in the midst of such a dire situation would hospital administration choose to fire staff? I know of many who are being let go at this hospital due to the vaccination mandate that the government has deemed unnecessary for hospitals and yet the NGH is enforcing anyway. This includes a surgeon, multiple nurses and support staff. Get your priorities straight NGH! This is only going to get worse for the residents in this area of they don’t cancel this mandate!

    • Justice says:

      Doing it to themselves!!! Putting the communities at risk! People need to demand the rehire of all staff let go! Get it together NGH/BGH! These mandates are nonsense!

      • Carrie Walters says:

        Staff shortages were every where across the province in health care before the mandate of a vaccine. Lets NOT forget the cuts made at the provincial level before COVID hit us.

  • Nancy L says:

    As a citizen I want the provincial and federal government to stop using the hard-working Health-Care Professionals(doctors, nurses, technicians, emts) to prop up the integrity and safety of a hospital. Government need to demand a better hospital structure from the people who run hospitals at the top. I want the people who hold top office positions in hospitals, and board member positions to truly care about the health and well-being of hospital staff and patients. A hospital is not a corporation and I think these ceos, executive directors, cfos, and any other corporate title that exist need to be held accountable to the crumbling conditions.

    • TW says:

      I would not agree to surgery on myself with unsterilized instruments, so why would I approve of having personnel who are vectors for an airborne disease hovering around me? You can’t perform a medical task if you are unqualified; think of being vaccinated as just another qualification. If you can’t do it, then please find some other way to earn your living.
      The efficacy and safety of the vaccines have been clearly and substantially demonstrated, with billions of doses having been administered in every population.
      Just do it!

      • Kerry says:

        And loads of adverse reactions as well. I suggest doing some research on the transmission aspect as vaccinated carry and spread it the same as unvaccinated making your “surgery” just as dangerous either way. For all you know your surgeon is HIV positive.The mandates are to force people into getting vaccinated and nothing more. You are protecting no one but yourself getting vaccinated and that looks to be faulty as well unless you get boosters every 3 months.

Author

Catherine Varner

Deputy Editor

Catherine Varner is a Toronto emergency physician, clinical epidemiologist and freelance journalist. She is on the deputy editorial team at Healthy Debate.

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