Emergency departments need urgent care

Hey there, time traveller!
This article was published 17/09/2022 (1355 days ago), so information in it may no longer be current.

There is an emergency care crisis occurring across Canada and in the city of Winnipeg. As a result of many historic and current choices, we are exposing emergency department patients and emergency health-care workers to avoidable and unacceptable levels of harm.

Our recent experience with intensive-care units during the pandemic shows that we can do better.

Last weekend at the Health Sciences Centre emergency department (ED), every major bed was full with admitted patients. At one point, two critically ill patients were placed side-by-side in a resuscitation area designed for one patient, in order to accommodate the next severely ill person. One of the most critical health-care resources in the province was overwhelmed and unavailable.

This system failure is unprecedented, but was not unpredictable. It is not the result of the normal ebb and flow of ED patients. It is a function of how our system chooses to manage risk.

Our health-care system has decided that not one of the 22 admitted patients in the ED who were waiting for a bed in the hospital could be transferred, because of insufficient staff or space on the ward. Numerous ambulance patients lined the hallways and had to be offloaded within a certain time frame because those ambulances had to get back on the road.

Patients transferred from other hospitals or sent from their family doctors continued to arrive — because we have not provided other alternatives — and keeping them in those other settings would be “too risky.” In order to mitigate the risks to others, we have created an untenable situation in the ED — resulting in virtual gridlock and causing significant harm to our emergency patients and the emergency staff caring for them.

It is clear the greatest burden of risk is on the patients who arrive in the ED, and who rightly expect high-quality health care in a timely manner. But the most significant second victims are the nurses and other health-care staff who are forced to do a difficult job, under horrible conditions, with both hands tied behind their backs.

Emergency nurses are constantly working short-staffed, and as a result of overcrowding and a lack of resources, are put in situations that are unconscionable. As the acute treatment spaces in our EDs fill up, we treat sicker and sicker patients in sub-optimal ways.

Doctors go in to the waiting room, discussing sensitive issues in public spaces and examining people in chairs. Nurses in the “minor” treatment areas are asked to administer complex treatments (such as insulin infusions, or giving blood products) to very sick patients in areas with inadequate monitoring and insufficient staff.

Even before the pandemic, our nurses and other support staff faced shocking levels of abuse and violence. This has accelerated as our waiting rooms overflow, as patients get sicker waiting for care and as patients lose faith.

Many long-term solutions have been suggested — but action is required now. There are things we could do tomorrow. Hospitals could develop more flexible policies about where admitted patients can go, and when admitted patients should be moved out of the ED. Ambulance offload policies can be revised to allow for more flexibility when the department is overflowing.

Specialist care should be made available in more places, and in more flexible ways, and should not require an ED visit.

We need to pay emergency nurses and other support staff more, to recognize the ridiculous conditions we are asking them to work in. We need to provide incentives for nurses in other areas to receive emergency training and move into this area of practice.

We need to listen to the nurses who are still fighting in the trenches (and to those who have recently left), to find out what other steps should be taken to stabilize staffing.

A recent model we can learn from is the scaling up of ICU resources during the pandemic. People feared they would not have access to critical care when they needed it, and significant resources were mobilized. There were dedicated federal funding, more provincial support, a huge increase in dedicated beds, incentives for nurses to train and move into ICU settings, and more nursing supports.

It feels like the lives we saved with these efforts are now being lost to the emergency-care crisis. And we have been unable, or unwilling, to respond.

We need to advocate for our emergency patients and for the nurses that care for them. We need a concerted effort from governments and health-care administration to mobilize the resources needed to decrease the heavy burden the health-care system is placing on them and the significant risks we are forcing them to take on.

And we need to think outside the box, to relieve some of the current pressures on our emergency departments.

Merril Pauls is an emergency physician at Health Sciences Centre and a professor in the department of emergency medicine at the Max Rady College of Medicine, University of Manitoba.