Doctors expressed “serious concern” about the “unimaginably long waits and poor outcomes” patients face on a daily basis. They also accused health networks Horizon and Vitalité of misleading the public about “high patient volumes” causing long waits in emergency departments when volumes were beginning to return to pre-pandemic levels. “The current overwhelming combination of staff shortages, blocked access, and systemic misuse of EDs by our health care system has led to a provincial emergency care crisis the likes of which none of us have seen before,” the letter dated Aug. 26, 2021, said. Without urgent intervention, doctors said, they fear “a complete failure of emergency care services in New Brunswick is inevitable.” The revelation comes after a patient died in the waiting room of the emergency department of Dr. Everett Chalmers early Tuesday morning while awaiting care. John Staples said watching a patient die in the ER waiting room at Dr. Everett Chalmers, on the verge of receiving care, it was a “grim and grim realization” that New Brunswick’s health care system is “so woefully broken.” (Joe McDonald/CBC) Witness John Staples said the man, an elderly man, had been waiting alone in a wheelchair in visible distress for hours when he appeared to fall asleep. It was only during a routine people check in the waiting room that a hospital employee realized the man had stopped breathing, he said. Some people waited at least eight hours, Staples said, and he saw some people leave without being treated while there. Horizon Health Network has confirmed “an unexpected patient death” and says an investigation is underway. Opposition politicians are calling for the resignation of the Minister of Health and an immediate forensic examination.
Deficiencies are “unacceptable” says the medical society
In the six-page letter, 132 emergency physicians called for “urgent focus” on the ER crisis with clear direction and support for innovative solutions and process improvements at both health authorities. They identify four important issues facing emergency services in order to:
Nursing shortages are due in part to high turnover, including a one-year attrition rate of 42 percent at one large ER. Recruitment and retention of board-certified emergency physicians. Keeping admitted patients in the ER while waiting for a hospital bed. Use of ERs for non-urgent purposes, resulting from poor access to community alternatives for unscheduled care.
The Department of Health, Horizon and Vitalité did not respond to requests for comment, including what actions, if any, they have taken to address the concerns and criticisms raised in the letter. The New Brunswick Medical Society, which was copied on the letter, shares the concerns expressed by ER doctors, said president Dr. Mark McMillan. Dr. Mark MacMillan, president of the New Brunswick Medical Society, urged immediate and collective action to address ER problems in the province. (New Brunswick Medical Society) “The shortage of human resources for health has reached an untenable point – we must act immediately and in partnership with all health stakeholders and communities to address the challenges facing the health system,” he said in a statement sent via e-mail. McMillan also expressed his sincere condolences to the family and loved ones of the patient who died. “While we cannot speak directly to the circumstances involved, the loss of a patient while awaiting care is tragic and disturbing,” he said. “We believe the health authority will use its assessment to learn more about what happened and how to prevent this type of situation from happening again.”
Increase in patients leaving without being seen
According to the letter, an increasing number of patients were leaving emergency rooms without being seen or treated last summer. There were “many” days where more than 40 patients left individual ERs without being seen. On June 6, for example, 52 patients left Saint John Regional Hospital’s ER, and another 32 patients left the next day, according to the letter. “An increasing number of these patients deteriorate and return with serious complications due to delayed assessment.” Many of the patients waiting on ambulance stretchers in the hallways for hours have serious medical problems and will need to be admitted, according to the letter written by the ER doctors. (Paul Chiasson/Canadian Press) Although public messages from regional health authorities on social media attributed ER delays to “high patient volumes and staffing challenges,” the average number of daily visits was no higher than it was in 2019, according to doctors. The number of patients requiring acute care and hospital admission, however, continues to rise, they said. “Our waiting rooms are full and ambulances line our corridors waiting to drop off patients, many of whom have serious medical problems and will need admission.” Some patients wait in hallways for hours, which also ties up paramedics and creates problems for New Brunswick Ambulance responding to 911 calls.
“They are stretching themselves dangerously”
Nurse staffing challenges are a “major issue,” doctors said. ER nurses are highly skilled and require years of training, they noted, and some emergency patients need one-on-one care. “When nurse staffing levels fall below the required numbers on a shift, emergency assessment beds are forced to close and undifferentiated patients wait longer to be assessed.” The weekend before the letter was written, the shortage of ER nurses in Moncton reached a crisis with only four or five nurses available to cover each shift instead of the usual 15. Many other ERs have had to rely on a “sub-critical workforce” of one nurse and one registered nurse practitioner while remaining fully open, putting patients and themselves “at grave risk,” the doctors said. “This situation places enormous pressure on remaining staff, potentially resulting in significant adverse events and further loss of our precious nursing resources,” they warned. “ED physicians are being dangerously overstretched to avoid closures, with many having to work 24- to 36-hour shifts and weekly hourly workloads that are three times our standards.” The shortage of ER doctors and nurses has forced some ERs to reduce services or even temporarily close in the summer months, they noted — a situation that has happened again several times already this summer.
Many ER beds are occupied by admitted patients
Another part of the problem, doctors say, is the number of ER beds occupied by patients who have been admitted to the hospital but are waiting for a hospital bed. In Saint John, for example, there are 24 monitored ER beds. In the month before the letter was sent, there were often more than 20 admitted patients occupying these beds, which are actually examination stretchers and are not designed to be occupied for more than a few hours. Some of the patients stay in the ER for more than three days, which leaves only a handful of monitoring beds to see about 100 acute care patients a day, of which an average of 22 will be admitted. According to the letter, long ER stays have been shown to increase the risk of poor outcomes. “The hectic, noisy, brightly lit environment of the ED is not conducive to the care of admitted patients,” it said. Community hospital ERs had been admitting patients to stay for weeks, the letter said. “Emergency departments are designed and staffed for the rapid examination, evaluation, investigation, and treatment of patients with undifferentiated serious illness and injury.” Patients should be removed in time to free up resources to treat the next patients. However, ERs have become “over time the default waiting area of a failed system, outpatient emergency rooms, discharge room, pre- and post-operative care ward, outpatient overflow and extramural extension, as well as default access to primary care and community center aged care referral. ” doctors argue.
He encouraged the Nova Scotia model
They are urging the government to follow the lead of Nova Scotia, which recently introduced a ministerial directive on patient flow and ambulance discharges. Admitted patients must be transferred to inpatient units within 12 hours of admission and ambulance patients must be discharged within 30 minutes of arrival at the ER. The chair and chief executive of the health authorities must report on compliance on a monthly basis. “This directive will ensure that hospital administrators prioritize initiatives that improve patient flow in EDs that have a direct impact on improving patient outcomes,” the doctors argued. They called on the government to provide adequate resources to ensure its success. “None of these issues can be solved by emergency medicine leadership alone — so we need the help of our colleagues in primary care, hospice services, hospital management and government to be able to deliver the emergency services that our society expects and deserves”.
