Dear Ministers of Health & Premiers: Provinces, Territories and Federal Government of Canada,

Canadian Emergency Care is Being Crushed - and Why that Matters for All of Us

As Emergency Physicians, we are trained to rapidly identify and provide urgent and emergency care, often when people are in the most serious crisis of their lives.

For over 20 years, we, the Canadian Association of Emergency Physicians (CAEP) have repeatedly spoken about the deteriorating state of health care in Canada, but we are now writing to tell you that our health system needs immediate interventions to ensure its survival.

Our Crisis

Canadians are justifiably worried about the current state of emergency medical care. They merit a health care system that can respond to urgent medical needs. The Canada Health Act (CHA) describes five foundational principles to guarantee the provision of medically necessary care for Canadians. Of those, the principle of “accessibility” articulates the expectation that patients have reasonable access to doctors and hospitals. But our country is experiencing a major breakdown of essential health services, as reflected in a daily, unrelenting wave of bad news stories.

In addition to looking after acute injury and illness, Canadian EDs have functioned as a heath care safety net for a wide swath of the population who have nowhere else to turn, accepting patients in crisis 24/7. The dual threats of worsening access block and inadequate staffing have torn that net and, with it, the promise of the Canada Health Act.

We see unprecedented Emergency Department (ED) wait times, delayed response by ambulances, a rash of ED closures, and serious hospital capacity shortages. Our healthcare system is lacking an adequate number of primary care providers and acute care nurses, and it is getting worse.

All Canadians deserve to understand the factors impacting the current crisis and the changes in government thinking and policies that need to happen. Below is a synopsis that describes the view seen from inside the health system.

The Emergency Department Crisis: a symptom of larger issues in our healthcare system:

While attention has been concentrated on emergency and critical care, the forces at play are far wider in scope. Beyond providing the safety net for many parts of the healthcare system, emergency departments are also serving as the default resource for many in a system now unable to meet the demand. This is to the detriment of our patients, their families, and our staff struggling to provide service.”

Root Causes:

The root cause of the current state is that Canadian hospitals have been functioning at well over 100% capacity for quite some time. We now know that in many countries, decades of “health reform” focused on efficiency, have instead created systems of scarce resources.

The political and bureaucratic mantra has starved acute care and removed redundancies which were designed as safety valves, without investing in primary care and communities, or paying attention to population demographics.

As the Baby Boomers enter old age, an increasingly substantial proportion of Canadians are elderly and frail, have complex medical problems and functional decline while the supply of nurses, physicians, home care workers and other allied health professionals has been whittled away.

Consequences of the failure to listen and act:

With the decline of primary and community care, many patients have nowhere else to go now except the ED when they are sick.

The elderly have insufficient community care, and so they remain for weeks in acute care hospitals, where they decline further. These people, who worked hard to build a great and wonderful Canada, are being forgotten.

When hospital wards are full, the doors close to new admissions from the emergency department. Admitted patients in the ED are left to languish while waiting for a bed on a unit. These patients consume a high proportion of ED human resources and space threatening the ED’s ability to provide emergency care to those in the waiting room and to release ambulances back to the community.

This holding pattern is known as boarding.

Boarding is the evidence of a broken system in decline. It inevitably threatens the emergency team’s ability to care for newly arriving patients and is the cause of lengthy wait times. This is not just inconvenient. This problem has lethal consequences. Recent research suggests that one additional death will occur for every 82 patients spending extended periods of time waiting (greater than 6 to 8 hours) in the emergency department for a hospital bed. (Association between delays to patient admission from the emergency department and all-cause 30-day mortality. Jones et al. Emerg Med J. 2022 Mar;39(3):168-173.)

Most Canadian cities will have well over 100 boarded patients in their emergency departments every day. By failing to protect emergency department resources for patients, we are contributing to multiple avoidable deaths across the country daily. Moreover, the difficulty for paramedics to deliver transported patients to the ED in turn causes slow response times when 911 is called. This must stop. There should be no more preventable loss of life related to long emergency department waits.

The Way Out: Short Term Strategies

The healthcare system is complex, but there are short-term interventions for ED boarding that are simple and could be enacted quickly. Protect ED beds for patients requiring emergency care. This could be achieved by capping the number of boarded patients and the length of any single episode of boarding to an acceptable manageable level.

To achieve this goal, we need integrated and coordinated bed management sanctioned by our most senior leaders in our hospital systems, with sharing of load and responsibility for all patients. Indicators should trigger inpatient units to accept a managed quota of over-capacity patient when the need in the emergency department is great. It also entails right sizing bed resources and balancing needs for inpatient resources between specialty groups Similarly, nursing homes and community care agencies receiving discharged patients from hospital need to incorporate timely surge capacity processes. There must be regulatory support to enable human resources to match to areas of greatest need. Actions should include improved resources for assessing and licensing international trained health care workers, national licensure, and financial incentives for the stabilization of staffing in the most important and short-staffed areas such as emergency departments and intensive care units.

Policy Direction: Long Term Strategies

We urgently need positive open and public discourse on the future of health care in Canada. Provincial and Federal governments and their bureaucracies must listen and stop denying there is a problem; the care of our population is so much more important than politics.

We need a shared national strategy for health human resources and system change for primary and emergency care. We need our leaders to agree on focused initiatives that have the best evidence for success, then measure our success. We need to Improve our information on health human resources to plan. For new initiatives to be successful, there must be wise investment, that keeps our patients and their families at the forefront as our primary mission. Simply taking resources from one place to subsidize another does not work.

The following needs to be done:

1. Focused investment in primary care. with multidisciplinary teams providing preventative medicine and continuity of care for all, instead of episodic hospital care as a first response.

2. Focused investment to train, educate and incentivize more of our nurses, physicians, technicians, and personal care workers. Emergency, ICU, home care, and primary care are critical needs.

3. Focused investment on care for the elderly frail in the community, in partnership with primary care, not in acute care hospitals where they progressively get worse.

4. Focused investment to improve our capacity for acute care for the most seriously ill. We must move past inefficient care based on a traditional culture of convenience to a culture of patient and family first. Many hospital systems serve physicians more than they serve patients.

We have outlined the Canadian healthcare crisis and are ready to help with solutions. We know that enacting a paradigm shift in health policy requires a bold and precise approach to hospital and healthcare system management based on action. Without such action, Canadians will unfortunately continue to experience suboptimal emergency care at a time when they are in greatest need.

Please know that as the national voice for emergency medicine in Canada, CAEP is always willing to engage with you. I encourage you also to read the information on the International Federation of Emergency Medicine (IFEM) website on ED overcrowding HERE and the work of our EM: POWER Task Force on the Future of Emergency Care HERE for more information and perspective.

Sincerely,

Michael K Howlett BSc MD CCFP(EM) MHSA FCFP

President, Canadian Association of Emergency Physicians (CAEP)