The Decibel - City Space: Why are ER wait times so bad in Canadian cities?

Episode Date: July 14, 2023

Burning hours in an ER waiting room has long been a fact of Canada’s public health care system, but that wait time is starting to spike. Now, in Ontario it hovers at around 20 hours on average. And our cities, home to more people and more various determinants of health than anywhere else in the country, bear the brunt of it. In this episode, we’re looking at some issues that impact the growing hospital emergency room wait times: What factors are contributing to the problem? And can anything actually be done to alleviate it or is it a pipe dream?

Hi, it's Meenika here. Today, we're bringing you one of our favorite episodes of City Space, another podcast from The Globe and Mail. Hope you like it. No one ever wants to have to visit an emergency room. And yet, if you're Canadian, there's about a 42% chance that you spend time in one in the last two years. At best, the trip was probably inconvenient. A missed day of work, a sleepless night sitting in a chair waiting to be assessed by a doctor. And hopefully the treatment, when it did come, was relatively minor. A few stitches or a cast for a fractured ankle. And then you were able to go home, maybe a little tired and frustrated, but long-term, no worse for wear. But there are stories across the country where those wait times weren't just an annoyance.

They had a serious effect on a patient's care and recovery. Treatment delays for those who do require urgent care can often lead to complications, and in rare cases, death. Lengthy ER wait times have long been a fact of Canadian life in our public health care system. But the problem feels like it's getting much worse. In Ontario, people are waiting more than 20 hours on average, from when they arrive in the ER to when they are admitted to hospital. And only about a quarter of Ontarians are admitted within the provincial target of eight hours. The pandemic has definitely been a part of this wait time story, but there are other factors at play. Canadians are living longer. The average

lifespan went up by more than four years in the last three decades. And as it's been recently reported, kids who are five years old today will likely live to 100. But getting older doesn't eliminate illness. It just delays it. And as we start to crest a silver tsunami of aging baby boomers, we're seeing more people spend more time on trickier issues in our hospitals. This is a crisis in hospitals across the country, but in many ways, it's really playing out in cities. They're home to our biggest populations,

and in cities, complex issues like addiction and homelessness are woven even tighter. And since our largest and most advanced hospitals are in our cities, and since our country is so geographically vast, cities are often where rural care centers send their toughest and most urgent cases. These things are all adding up to a chaotic traffic jam at the emergency departments dealing with the most people. And that's especially true in Canada, which has one of the highest per capita rates of emergency room visits in the world.

In fact, we're even seeing a reverse of what you might expect because of that. A growing trend of people heading out of cities to get faster emergency care in more rural hospitals. Welcome back to City Space, the Globe and Mail's podcast about how to make our cities better. I'm your host, Adrian Lee. In this episode, we're taking a look at one of the many ways that the healthcare system intersects with city life. What's driving increased ER wait times? And how are these wait times hurting both patients and medical staff? And what can be done to ensure Canadians have access to urgent care when they need it?

More on that after this. After five years of medical school at Dublin's Trinity College, and then another five years completing a residency in emergency medicine at the University of Toronto, Dr. Connor Lavelle was just looking forward to getting started on his career as a staff physician in an ER. But he finished his residency in 2019. just looking forward to getting started on his career as a staff physician in an ER. But he finished his residency in 2019. In short, it was a wild time to start a career in emergency medicine. Yeah, it's funny, actually. My parents were saying that when the pandemic hit. They were like, I can't believe you started working in the emergency rooms as a staff physician.

And then in comes the first pandemic in 100 years, and they were just kind of laughing. You know, it was just, what can you do? You just laugh about it and get on with it. Today, Dr. Lavelle is an emergency medicine physician at St. Joseph's Healthcare in Hamilton, Ontario. There, he's seen the ER wait time crisis play out firsthand. And one thing he's really noticed is a bottleneck in the ER waiting room for non-urgent issues. Your whole system is built to be equipped to address the high acuity stuff, and then you're subsequently spending a lot of resources juggling the non-acute stuff, then there's a threshold beyond which the non-acute stuff actually starts to

impede the care of the acute stuff. And I think that that's the threshold that people are starting to navigate in the Canadian healthcare system over the last 12 to 18 months. That's a big problem. Emergency rooms are meant for, well, emergencies, not situations that could wait until you can next see your family doctor. But so many Canadians are still relying on the ER for non-urgent care. And that's adding pressure both in terms of the sheer number of patients in the waiting room, but also for doctors and nurses who are just trying to prioritize the cases as best they can. Patients are seeking medical care in the emergency department for non-acute issues because two different things. One is that they actually misperceive their issue to be

something that is a true emergency and so they therefore seek care for it, which again it's not up to them to decide. That's what we're there for. So, but then the other situation is that patients know that it's not necessarily an acute emergency, but they also know that it has to be dealt with and they don't have any other way to get it dealt with. And so they are showing up to the emergency room. And some of them are actually articulating that to us very, very clearly from the outset saying, I'm sorry I'm here. You know, I don't want to be here. I know that you guys are busy. And, you know, we get a lot of that.

This may well be the core problem. People who are at their limit but feel they can't get the care they need fast enough, they just head to the ER. And that's creating a domino effect that's plugging the emergency medical system. The biggest problem in Canada that doesn't exist in other countries, I think, is that our emergency room is essentially the front door to the health system. And it shouldn't be. It should be the emergency door. That's Andre Picard, a staff writer and columnist for the Globe and Mail. He's been reporting on health care in Canada for decades. You know, it's seen as the place where they never say no to anyone.

So by default, they get everybody else's problems. For Andre, it comes down to what people expect out of their health care system and what they can actually get. What Canadians need is primary care. Someone like a family doctor or a registered nurse who is a generalist and can be on the front lines and assess people's problems and tell them to go where they need to go. That's really different from emergency care,

which is a specialty that's mainly about responding to the most urgent life and limb issues. But because not all Canadians have access to that kind of primary care, and because it's not available 24-7, we just keep walking through the front door of the place that is always open, the one where we know a medical professional will at least try to see us in a few hours. People in Canada talk a lot about their right to health care, and they don't talk enough about their responsibilities. You know, if your illness is not that serious, you should wait to go to the doctor. You shouldn't be schlepping off to the ER and clogging it up. I mean, that's good and rational advice.

But when you or someone you love is in pain, the rational part of one's brain usually goes out the window. You just want it to be over with as soon as possible. So is it really up to the patient to decide when something is an emergency or a non-emergency when something feels off? Here's Dr. Lavelle. When someone's in pain at home or they're having an issue, they're coming up against frustration after frustration trying to get care for an issue that they have, like their diabetic foot ulcer that has been there for two or three months or whatever the case may be. And they elect eventually to say you know what that's enough I'm coming to the emergency department almost more out of frustration

than out of an acute issue. I don't know that we can fault the patients themselves for not knowing what to do and not knowing how to better navigate the health care system and I wish there was more education and maybe more knowledge in the general public about what the emergency room can and cannot do. But I also think that trying to expect the masses, you know, the general public to understand exactly what the emergency room is for versus what it's not for when they're sitting at home with a complaint and an issue is kind of an unrealistic expectation. Patients aren't the only ones who suffer because of this collision of interests and expectations. You might remember we used to call hospital workers heroes in the thick of lockdown. And even though we're not at that pandemic peak anymore, it's still pretty heroic to devote your life doing stressful work to help others on what's

often one of the worst days of their lives. That can take a huge toll on hospital staff. But Dr. Lavelle says that's not really why we're seeing huge levels of burnout in the industry, which is causing doctors, nurses, and hospital admin staff to leave the field altogether. After all, he says, they knew the work would be really hard while studying for years and years. Instead, he thinks the burnout is actually a response to patients expecting to be seen quickly, and then losing their temper at hospital staff when things don't move quickly enough. And I think that it's quite like people who have a, you know, a scheduled flight, and they show up, and they, you know, check through security and the security line is longer than they thought.

And then the flight is delayed. And now, you know, they're trying to find a place to talk to some people who work for the airline to try to get like information about what the next steps are. And no one can help them and no one can answer their question. It's this sense of kind of being lost in limbo that I think really, really infuriates patients. But as a result of that, I think that just the nature of humans, they tend to direct that frustration towards the nurses, first and foremost, I think, and towards the physicians, also towards clerical staff, the administrative support of the emergency department.

Unfortunately, we've seen people getting yelled at, spit on. I've had things thrown at me. People have been assaulted. It can be quite stressful from that perspective. And so that obviously leads to people feeling burned out because they feel, I'm already working unsociable hours doing a stressful job. And now I'm in a situation where all of the work that I'm doing is not being necessarily appreciated. And it's actually being scorned and kind of criticized. You signed up for this career and caring for people and helping people. And now you're, you know, dreading the

next encounter. And instead of looking at patients as people you could help, I mean, people who are truly burned out, they describe looking at patients as nothing but, you know, a potential conflict or a burden or, you know, it's not something that they have the empathy to then offer anymore. This burnout isn't just bad for doctors and nurses. It has consequences for patients and society at large, too. I think invariably we're going to face a certain amount of attrition every year that it goes on the way that it is. We're losing nurses, we're losing doctors, and it's going to just continue until it gets fixed.

I think that part of it. It's such a waste in many ways. It's a waste on the micro level that like the personal level for the person who's invested so much time and energy and resources and often debt into getting to where they are with a view to having longevity to their career. But it's also a major drain and burden to the system itself because you're losing people with experience. You're losing people who you, you know, your tax dollars help to subsidize their training. And so, you know, when you have these people with amazing amounts of experience and expertise. It makes sense to me

that you should value those people in such a way that you actually listen to their input and make decisions based on some of the insights that they have, rather than having them feel disenfranchised and made to feel as though the experiences that they have don't actually have value and that the insights that they're willing to share are not something that's necessarily worth listening to. Those frustrations, I think, are a part of what leads to people's burnout as well, is not feeling heard, not feeling valued. I've heard that from not just nurses and doctors, but as I said earlier, also clerical staff, people who just feel like I'm yelling into the void. No one's actually listening to our experiences and our insights here. In many ways, our impossible

expectations of what an emergency room is supposed to do is actually making it even harder for ERs to actually do the work we need them to do. Here's Andre. Medicine, healthcare is way better today than it was 30 or 40 years ago, but our expectations are so much greater so that the gap is growing. You know, the health medicine's way better, but we want it to be even better and we want it to be faster. And it's just not a realistic expectation. But we've known about these expectations and the shortage of primary care doctors for decades now. So why aren't we doing something about it? Especially now, since medical staff appear to be quitting in droves. Okay, that's oversimplifying the question. I mean, the healthcare system is such a complicated thing.

And it's not just about all the people coming in the front door, either. After the break, we'll look at the problems at the other end of emergency care. That is, sending people where they need to go afterward. And we'll look at some ways we might be able to rethink our approach. Dr. Paul Atkinson has worked in emergency departments in four different countries over the last two decades. Still, in the last few years, he's seen some things that shake him. To see a patient being resuscitated in a hallway, to not have an open bed or a staffed open bed for someone who's having severe hemorrhage

and who ends up being treated on the floor, to see children waiting hours and hours and hours with serious conditions and infection, not because there was no willingness to treat them, but because there was no resource. Today, Dr. Atkinson is also a professor of emergency medicine at Dalhousie University and the deputy editor of the Journal of Emergency Medicine. Last year, he wrote in that journal about how Canadians are increasingly depending on ER care to make them better ASAP. We've become a bit of a supermarket of healthcare. Maybe it's not where you go to buy the finery and the top-end materials and clothes and food,

but you can absolutely get most things you need. But we are designed and staffed to provide essentially where if your care was not provided in a timely manner, your outcomes would be worse. We are trained in a breadth of conditions, but we are trained in the emergency or urgent components of those conditions. So my training would have focused in and around multiple specialties, intensive care, neurocritical care, anesthesia, surgery, medicine, pediatrics, with a focus on dealing with critically ill patients, those whose condition could lead to their demise if not treated appropriately. And that really was always the goal for training in emergency medicine. Currently, I think the skills that perhaps

would have been more useful might be some additional training in geriatric medicine, some training in palliative care, some training in family medicine, some training in community pediatrics, mental health, some training in addictions and social care. While yes, I still need to be able to intubate, I still need to be able to defibrillate, to manage a stroke, a heart attack, to manage a cardiac arrest, to manage a very sick child. I have to be able to do all of that. There's no one else will do that when you're sick. But it's an increasingly minor part of the job. It's a nasty cycle. Canadians expect an ER to see them, regardless of whether it's an emergency. ERs are asked to do more and more.

Then ERs get some more resources to respond to this wider array of issues, but not quite enough to accommodate all the new roles they have to take on. And those resources just raise people's expectations. Here's Andre. Well, I think almost by necessity, our emergency rooms are equipped to do almost anything. They do way too much primary care. The big ones can do trauma care. They're places where they're almost the front door of the health system today. So they do a lot of things. They do an amazing amount of things. And the question I think is, should they be doing all of these things? Because they can't do all of them well with the personnel

they have and the setups they have. But if we really want things to change, then governments and policymakers need to take down the enter here sign that too many Canadians think is hanging on the doors of emergency departments and put out a welcome mat in front of primary care instead. I think the lesson we can take from every European Nordic country with universal health care is that the front door has to be the primary care provider. Everyone has to have primary care, a doc or nurse practitioner, and they're responsible for navigating them through the system. That has to be your number one. And in Canada, we don't have that. You can't just go to your doctor and say, I have this sore back today, because they'll say, yeah, we can see you in a month. You know, so you end up at the ER. It all begins and ends with reforming primary care. On this, other countries may offer a way

forward. In many of these northern European countries, if you have an urgent medical need, there is a way for you to call a number, let's say it's similar to 811, to be connected through to the appropriate care provider, whether that's a nurse practitioner, whether it's your family doctor or the family doctor covering your area, to allow you to access that care now, either virtually or in person, locally. And only if they're unable to accommodate you, will you then be referred up to the hospital. So let's say you call up and you're having chest pain, suspicious of an MI, you're having symptoms that could be a stroke, you've badly injured yourself, you're bleeding. They will get you rapid access to emergency care. And it's free, and it's appropriate,

and you're right in there. And that emergency department will not be overcrowded by all those other folks who are getting their chronic care or their semi-urgent care or their unscheduled care because they're getting it elsewhere. Now, they do have a sort of reward penalty type thing in place. So if you don't go through this universal access number and it turns out that you really had a minor problem, you're actually, you have to pay. So there's a penalty. And I think obviously there are potential concerns with that and you would worry that somebody might not seek help. But the fact is that they do have an avenue to access care.

They have a community-based healthcare team that they can see in the evening, on the weekends. And that is the future. Sounds pretty good, right? But what if I told you we already have a widespread model right here in Canada that offers a way to relieve pressure from emergency rooms by assessing and diverting potential ER visits? Here's Dr. Lavelle.

I think an example of that that's actually in practice already is the labor and delivery ward. And the way that that's set up is that they have their own triage system. And if you're, you know, a term pregnancy or maybe, you know, in your third trimester and you're having issues with vomiting or belly pain or vaginal bleeding or whatever it may be, those patients have the ability to actually call the labor and delivery ward, tell them what's going on. They can direct them in and say, yeah, we'll come on in. We'll assess you. They're seen there. An assessment is done. And then based on the assessment, they can decide, okay, we want to admit you here for further care. Or they can say, no, you know what? You're actually fine to go home.

And then a third group of them will say, we don't have any acute concerns from the pregnancy perspective, but we're worried about that other symptom that you're having, whether it be chest pain or leg pain or shortness of breath or whatever it is. They say, we're thinking that you should probably go down and see our colleagues down in the emergency room. This kind of first-step, on-call triage could be applied more broadly, including in the form of post-operative clinics and post-treatment care for various chronic diseases. But instead, we have the system we have, one where emergency departments are the central hub, where the gravity of the wider healthcare system is pulled, for as long as that hub can hold. But while

there are lots of people jamming up the front door, there's another problem when it comes to arrival to admission wait times, the people who can't get out the back door. We're talking about the people who have nowhere to go after they do receive emergency care, forcing ERs to have to do even more work when they're unable to discharge them or transfer them to the appropriate specialty. About one in every 10 Canadians who goes to emerge is there for more than 40 hours, a data point that really captures these people caught in purgatory after the ER. So the large problem of these waits, we haven't

talked about that yet, in ER is all about throughput. We just have all these people stuck there because there are no beds in hospital. And how do you free those up? Well, you have more home care, you have more long-term care beds. So ER really gets it from both ends. They have people coming in there who shouldn't be there, and they have all these people that they can't process. They can't get them out of the emergency room. So it's just this big clog in the drain. What this all adds up to is a crisis in emergency care that's a symptom of an even greater sickness in the system.

It's the canary in the coal mine telling us that we have even bigger problems across the board, that people are going to emergency care because they don't have access to primary care. That there's not enough focus on people with chronic diseases, who so often find themselves with an issue that they need an urgent answer for. Or that there's a growing number of people who stay in the ER for far longer than they could imagine or even need to, because after they receive the emergency care, there aren't enough long-term care homes or access to home care. Cities work like this too. A flare-up in one part of the system usually means that there are bigger problems we have to think about, and those problems can feel as intractable as concrete and steel. But cities offer hope too.

If they didn't, so many of us wouldn't be living in one. Every day, we're seeing new ideas and new ways to be more inclusive, more accessible, more supportive of people's lives and cities, to be better, sometimes in radical ways. Maybe our healthcare system, home to heroes and medical miracles and inspiring empathy, can find a way to do the same. Here's Dr. Atkinson. I would say that Canada is faring better than some other developed nations in terms of our ability to cope through this crisis.

I think we have a committed group of physicians, nurses, and other professionals. And yes, people have left, but many people, in fact, most have stuck with it and are pulling through. And we still have hope that we just don't think enough about in our cities. And that's seniors. The number of Canadians older than 85 has doubled since 2001. And with most baby boomers now in their 70s, that number is expected to triple by 2046. But who's going to care for this generation? Where will they live? Why do seniors issues matter for every person, regardless of your

age? And how can we design our cities to serve this growing group better? City Space is produced by Julia De Laurentiis Johnston and Kyle Fulton. Our theme song is by Andrew Austin. Our executive producer is Kieran Rana. Thanks to Dr. Paul Atkinson, Dr. Connor Lavelle, and Andre Picard for joining us today. If you like what you heard, give us a rating and review on Apple Podcasts. And tell your favorite city dweller about city space, too. I'm Adrian Lee. Thanks for listening, and talk to you soon.