The Decibel - The rough state of Canada’s emergency care

Episode Date: October 16, 2024

Emergency rooms across Canada are in a dire state. Wait times in many ERs remain stubbornly high. And in some provinces, the full understanding of how bad the situation has become isn’t even clear ��� with inconsistent or little data to rely on. For many Canadians, that lack of clarity in emergency situations is a life or death matter. Globe investigative reporter Tu Thanh Ha joins The Decibel to break down the details he and data editor Yang Sun dug up and what story the numbers tell about the reality of emergency care. Questions? Comments? Ideas? Email us at [e-mail] 

At some point in our lives, unfortunately, we'll all probably end up in a hospital's emergency department. And when we're there, we'll most likely have to wait. A while. Sometimes this might just be an inconvenience. But sometimes these long waits in the ER could have serious consequences on our health. That was the case for 37-year-old Allison Holtoff in Nova Scotia. Her family launched a lawsuit after she died on December 31, 2022, from complications of a splenic artery aneurysm,

according to court documents. She had been waiting in the ER for seven hours. Dying in the ER may be an extreme example, but how common are these nightmare wait times that we hear so much about? And what does the data actually tell us about how long we're waiting? Globe reporter Duthan Ha spent several months trying to compile an accurate, data-driven picture of ER wait times in Canada. Today, he's on the show to share what he found. I'm Meena Karaman-Wilms, and this is The Decibel from The Globe and Mail. Ha, thank you so much for being back on the podcast. Thank you. So to start off, I just wanted to ask ask what prompted you, as well as our colleague, Yan Sun, to look at the performance of emergency departments in Canada?

I think anecdotally, a lot of people would tell you that they spend long periods of time waiting for care when they show up at the emergency. It's become part of a Canadian law. And we want to be more specific. We wanted to look at numerical indicators for that. And these do exist, even though they're hard to find. And we also wanted to look at them because even though people have been saying that emergency departments have been overcrowded for years, Is the situation worse because of a pandemic? We have a population which is aging. We have a population which has been increasing. And the challenges for healthcare are more acute.

And we're definitely going to look at the numbers that you looked at. But to come back to this broader idea of, yes, wait times are usually bad. We know this across the country. Can we talk about some specific examples of this, Ha? Like at specific hospitals, how long are people waiting for? We found things which may not come as a surprise to people who are in the system. For example, at the Montreal General Hospital, people can expect to wait on the stretcher for 24 hours. There was a hospital in Saskatoon where the wait time for people who would be admitted after going to the ER was over 50 to 60 hours. So that's almost the two days.

And what we found from the data that we collected is that the things have not returned to the level of 2019, not yet. And just to be clear, the different types of wait times, the ones that I mentioned here that we focused on, the wait time from the moment when you are triaged to the moment that you leave the AR to be admitted into the hospital. Okay. We said some kind of big numbers, the length of time that people are waiting. What is the targeted time, like kind of the ideal time that hospitals say people should be waiting before they're seen? There's a target of eight hours wait time for patients who are admitted. It is something that was recommended by the Canadian Association of Emergency Physicians.

Eight hours is still a long time to be in an emergency, but that's the benchmark. Yes. And again, like you have been triaged. In theory, you have been stabilized. In theory, depending on the category of triage, like the severity of your condition, it spells out like how often you should be checked too. Ha, you mentioned that you hear from people sometimes about their stories waiting in the ER. What have you heard? Like as a result of these long wait times, how are patients being affected? So these are like some of the emails that I've received,

and I've gotten permission from the one who sent this, who said that she came in, she was triaged, and then she waited for nine and a half hours on a chair. She said, I waited in pain in an uncomfortable ER chair for nine and a half hours on a chair. She said, I waited in pain in an uncomfortable ER chair for nine and a half hours. Another person who emailed me said that they waited for 11 hours before being seen. And in the same ER, they saw a man in his 80s with brain bleed who was there for 10 hours. And a pregnant woman with a broken arm who was pacing back and forth in pain. She was there for 14 hours.

Wow. Okay. Yeah. So this is really affecting people very, very directly. What about doctors? What have doctors and emergency departments said about how bad it is? Yes, it is unpleasant for patients, even though they have already been assessed. But doctors say that also hallway medicine is not optimal medicine.

I talk about hallway medicine because these are people who, after they've been seen at the emergency ward, are now waiting in that open space there to be taken to have tests or to be admitted to a hospital. So there was a paper in the Journal of Emergency Medicine two years ago. This is a paper from the US, but a lot of these things would apply very much in Canada too, which lists some of the reasons why hallway medicine is substandard medicine. So first of all, there's no privacy, which means that it's kind of hard to take the history of a patient, to give them a good physical examination, to ask them private questions.

To be clear, this is basically patients on a stretcher in the hallway. They don't have a private room yet because they can't get to a room yet. Yes. And the nursing care is also affected because it's care which is fragmented, which is not consistent. It's also a place where unfortunately there's violence sometimes because some people come in and have substance abuse or mental health issues. And also hospital personnel have noticed that people are much more aggressive since the pandemic.

There could be a hallway transmission of respiratory diseases and infections. And since we mentioned that it's hard to have consistent care, also people might get bumped from one space to another. And again, it makes it hard to follow up, to give them medication. So

this is not an ideal place for their care, let alone the fact that it's not a pleasant experience for them. Has this always been a problem in Canada? Have we always seen really long wait times? This has been going on for years. People have brought up these concerns decades ago, but we have been told by doctors that things have gotten much worse since the pandemic. Of course, in the early days after COVID arrived, there was actually a wait time drop because everything was locked down and people were staying home. But then afterwards, it got worse. It got much worse because people came back. There was catch-up to do. Their conditions were worse.

At the same time, they were losing staff. They were losing staff who were infected and had to be quarantined. They were losing staff who were retired and quitting and going into the private sector. So let's talk about, I guess, the reasons why we're seeing this. Is this strictly an issue of too many patients, not enough doctors and nurses? Or what is the issue? Yeah, like often people mention that like there's an issue, I don't have a family doctor and I had to resort to going to the ER even though, you know, I didn't think that it was like an urgent matter. The problem is that it's not just the inflow, it's also the outflow. That it's not just people coming in, but also the trouble in getting

them out of the ER and they end up being parked in hallways. To the point where, for example, in one of the Saskatoon hospitals, the fire department had to intervene because they said there were too many stretchers in the hallways and it was a fire hazard. So in theory, emergency would be for urgent cases, but since access to healthcare is challenging because a lot of people don't have access to primary care, access to family doctors, they will have to turn to their hospital. Now, in theory, this should not be a problem for the emergency department and emergency doctors say that, if you have an issue, don't fret away. Do show up. We'll look after you anyway.

We're not in the business of turning people away. So in theory, when you come in, if it's not urgent, it just means that you'll wait longer if it's overcrowded. But as I mentioned, they said the problem is the outflow. Mm-hmm. Okay. So we talked about the inflow problem. You also mentioned how the other side of it is the outflow. So what is causing the bottleneck there? Okay. So you go into the ER and if your condition is severe enough that you're not one of these people who just have to wait and then

they eventually discharge. But instead, the doctor says, it's bad enough that you have to be admitted to hospital. At least you have to stay here so that we keep you under observation and we give you some tests, some scans, some blood tests and all of that. There's no hospital bed for you. So why is there no space upstairs? Because hospitals are overcapacity. Sometimes it's because there would be like an outbreak of respiratory disease, but there's another phenomena, which is elderly patients who are in hospitals, are treated, and then at some point they no longer need hospital care, but they're not in shape to go home without having some arrangement for home care or to be sent to a nursing home, a long-term care facility. So in the jargon, these are called ALC patients, alternate level care patients,

and they are a big cause for the blockage in accessing hospital beds, which then just reverberates into the emergency department. It's really interesting when you're saying all this, we can really start to see how these different parts of the healthcare system are interconnected and how an issue in one part really affects all the others as well. Yes, from primary care, your family doctor, to the ER, to the patient bed inside the hospital, to the nursing home. But this is life in Canada. I've kind of made this joke before how you begin your life by being in a queue waiting for child care and kindergarten spot, and then you'll end your life waiting for a nursing home bed. And it's inherent to public healthcare in that there's a finite amount of resources and an ever-expanding number of patients. So there will be rationing, there will be queues, and there'll be wait time. And so the question is, how do you manage those wait time? How do you minimize, optimize those wait times?

And for that, you need to measure them. You need to have metrics. We'll be back in a moment. So Hao, you actually did measure these things. You actually did look at metrics. You and our colleague Yang Sun tried to compile a national data set of how emergency departments are functioning. So let's talk about this data a little bit. I guess first, I just want to understand, is this the first time that we've seen this data all put together in this way? There is actually an organization which compiles healthcare data across the country. It's one which is very reputable, which doctors have told me that it's exceptional that we have this in our country because other countries don't have

that. You're talking about CHI-HI? Yes, we're talking about CHI-HI, which is the acronym for the Canadian Institute for Health Information. CHI-HI actually does have a database that includes statistics about emergency. It's a very thorough database in certain ways. It's called NACRS, which stands for National Ambulatory Care Reporting System, which means that it's not just emergency services, but also things like day surgery, for example. And NACRS is very thorough. It tracks like about 190 different data points. Things like the demographic characteristic of a patient, at what time the ambulance arrived, how you were triaged, how you were categorized in triage, whether you received a blood transfusion,

if it was a car accident, whether you were wearing a seatbelt, whether you were wearing a helmet. So it's very detailed, but accessing it is not straightforward. And it also has some gaps because provinces decide what they contribute to CHI-HI. And some provinces don't contribute at all to this database of emergency data. Some provinces only contribute partially. Okay. So it is really, as you say, patchworked across the country because it's so different province to province. Is this data available though, Hala? Can anyone kind of go online and see what their local hospital's

wait times are, what these stats are for where they live? So, CHI-HI releases some data that are readily available. They would have tables with the wait times, details, but by provinces. It's broken up by provinces. But we wanted to find out more because do you want to know how your hospital is doing? Like knowing how Ontario is doing is not very helpful. It's not very enlightening. You cannot compare regions because within a region, you have hospitals of different sizes and different missions. So a small hospital in a rural area is different from a teaching hospital,

university hospital. Okay, so from what I understand from what you're saying here, Ha, it's hard to kind of get a complete picture of this because it's so specific province to province, hospital to hospital. I know that you and Yang actually tried to fill in some of the gaps that you found with this data. What challenges did you run into, though, when you were actually trying to get this data?

Yeah, so we asked Kaihai, like, you know, can we get a breakdown by hospital? Then Kaihai pointed us to one of their online portal. It's something called the Your Health System. And I would encourage people to look it up

because it's actually quite interesting. It's a bunch of indicators that they make available and you can pick either your hospital or your city or your region or your province and you can compare it with hospital or your city or your region or your province,

and you can compare it with other regions, other cities, other hospitals. So in theory, this solved our problem, even though you would have to enter every hospital. But the problem is that some of those indicators are not managed at the hospital level, but rather at the level of the hospital network. So that when you look at the emergency times, wait times for indicators on that portal, in some cases, you don't get a specific hospital, but you get a university network. So we realized that, okay, so should we just go straight to the source? And so we contacted every Ministry of Health and every regional health authorities across Canada.

Wow. Okay, so you got back a bunch of different data, not always consistent across the country, but you got back some information here, huh? Did the data you collected back up the anecdotal evidence, I guess, that we've heard about long wait times? Like, is this the case then that these wait times are quite long across Canada? Yeah. And those are the examples that I mentioned earlier is that we see a lot of things getting worse during the pandemic. Well, first, like a little dip at the start when things are better and then things get much worse and things have not recovered

in most cases. But there were also interesting cases where we found that the wait time was low. So some of the wait times for admission, we focus initially on wait time for people who are admitted because it means these are people who have serious conditions and some of them have explanations. So for example, Sunnybrook has very long wait time and they say it's because they're a trauma center. So the patients that they see, they tend to be very serious, heavy duty cases. This is a hospital in Toronto, yeah. Yes. The Montreal General Hospital, they say that the issue is that their clientele, their patients tend to be older.

And older patients, well, you know, already the beds are taken by other ALC patients. Okay. So we have all this data now, huh? Let's actually talk about what we can do with this. Let's start with governments. How would a government use this data to improve things? Yeah. So Kaihai was telling me that they have been working on ways to computerize and standardize patient information, not over record, but just a summary of it. And they are hoping that this will make this information more transportable, more accessible, that it would also help provinces that are not contributing, make it easier for them and contribute to more data being contributed to their NACAs, their database that has emergency data. And this is like in the part of this stream of work that

CAIHAI is doing on improving healthcare indicators. This stems in part from the announcement last year by Prime Minister Trudeau of billions of dollars in additional funding and has happened in the past with the federal government. Sometimes they give money, but they want to tie it with performance indicators to make sure that there's accountability. And as part of this announcement, Kaihai agreed to help develop these indicators.

Have we seen anyone take kind of these big numbers, this big data, and actually use it in a way that could be improving things in a hospital? Well, when we looked at the data, in the Toronto region, there's one hospital that stuck out. It's Humber River Health. They had numbers which were around five, six hours when compared to a full day elsewhere. So it struck us. Because it's not a small ER. Actually, they get quite a lot of inflow.

And it's intriguing. So they tell me that there are two things they've been doing with data. One is which is already in place. It's like a command control where they try to track thing in real time. And the other thing they will do is try to come up with an artificial intelligence system. So first, better flow through the use of better information processing and also better forecasting because they want to be able to be in position where they can tell people, it will take you this much time before you're seen by a doctor. And if the situation is not severe enough, people can decide maybe they can want to go back home and wait.

This example kind of gives us a sense of how this data can actually be used then to make an ER, to make a hospital more efficient and more effective. Yes. And in general, like, you know, it's a matter of accountability to know what is the performance of your hospital, but also to use that data to find where the issues, where problems are and fix them. Thank you so much for taking the time to be here and walk us through all this. Thank you for having me. That's it for today. I'm Mainika Raman-Wilms.

This episode was edited and mixed by Kevin Sexton. Our producers are Madeline White, Michal Stein, and Allie Graham. David Crosby edits the show. Adrian Chung is our senior producer, and Matt Frainer is our managing editor. Thanks so much for listening, and I'll talk to you soon.