Canada healthcare system burns out, but no easy solution
The appendix is just a small, skinny hollow tube. But when it is blocked by a stone or infection, it gets sore and swollen, and as the pressure inside builds up, so does the pain.
Emergency doctor Alecs Chochinov has seen multiple patients with appendicitis who had spent four, six, eight hours in the emergency waiting room, curled up on the floor in agony, sometimes vomiting.
Current wait times at his Winnipeg hospital, like many across Canada, big and small, are miserable, Chochinov reports, and while the word crisis is being tossed around to describe the state of the country health-care systems, it is not so much a sky-is-falling scenario as a slow swirling around the drain, he said. Things were teetering before the pandemic. COVID just sped the deterioration up. Our system is not viable in the longer-term at this rate of decline, said Chochinov, who headed the University of Manitoba department of emergency medicine until 2020.
People are waiting an hour or more in some cases just to be triaged, assessed by a nurse, and assigned a score depending on the severity of their presenting problems. Urgent? Less urgent? Symptoms like chest pain should ideally be seen within 15 minutes. We will frequently have, in a busy emerge like Foothills (Medical Centre) or the University of Alberta Hospital, 10 to 15 patients presenting with chest pain in our waiting room for hours, said Dr. Paul Parks, an emergency doctor at Medicine Hat Regional Hospital and president of the Alberta Medical Associations emergency medicine section.
Which of those chest pains are heartburn, and which one is a heart attack? Where are the unrecognized time bombs,as Saint John emergency doctor Paul Atkinson and his co-authors recently described them: The headaches that are really a subarachnoid hemorrhage, a life-threatening stroke caused by bleeding on the surface of the brain; the leg pain that is necrotizing fasciitis. Their delays in care too frequently cause disastrous outcomes that lead to media headlines, that lead to commissions and inquiries and reports, but few meaningful changes. And while emergency department horror stories are unfolding across Canada an older woman dies after lying on a stretcher for two days in the corner of a North Vancouver emergency waiting room; a man in great discomfort dies in a Fredericton hospital while awaiting care; a man with a shattered femur waits four days in an Ontario hospital hallway for surgery it is not just emergency care that is failing.
Emergency departments are often described as the system safety net. They are more like a lifeboat, Atkinson said. When something goes wrong, when someone falls overboard ” they have a heart attack we are there to take them to shore, to get them to safety.
We were never designed to be the cruise liner; we were never designed to be the cargo ship. But we are being used that way.
Emergency departments have become the de facto route into the system for people who can’t get the care they need anywhere else. A post-op patient who develops an infected wound after an appendectomy who calls the surgeons office after hours and is advised by the recorded message to go to the nearest emergency department. An 80-year-old who has been waiting a year and a half for a new hip who suddenly can’t walk because of the pain and ends up in emergency after falling at home. A cancer patient on chemotherapy with a high fever and low white blood cell count who can’t get in to see her oncologist.
The result: more patients with more complex needs, and frustrated, demoralized and burned-out staff. Paramedic crews queued up in emergency department hallways with boarded is patients on hard stretchers, waiting hours to hand them off to already overloaded emergency staff. Every cubicle filled with people who have been assessed and admitted to hospital, meaning no room to see new patients, but no empty beds to move admitted patients to, because those scarce beds are filled with people, mostly elderly, who no longer need to be there but can’t leave because there is nowhere for them to go no space in a nursing or long-term care home, no home care or rehab bed. The logjam is known as access block.Stop. You cannot go further.
Why are nurses leaving? Why are doctors leaving? Why is the system failing, Atkinson asks. Because the processes we have in place don’t seem to work to get people in, through and out, he said. The lifeboat is full of people we have picked up earlier, so it is hard to help the people who are still in the water.
He is not a Chicken Little guy, a doomsayer. But for the first time in his 27-plus years of practice, Atkinson believes life- and limb-threatening emergencies are at risk. Heart attacks, strokes. Conditions that require time-sensitive treatments like drugs to bust clots and restore blood flow to brains. I think those are under threat right now, Atkinson said. I never thought I would say that. But those of us working in emergency medicine have seen people with serious problems, with hemorrhage, with true emergencies, not be able to access the actual department. People wait on an ambulance gurney, wait in a waiting room, and deteriorate and sometimes die. And it is not acceptable.
He and others see it as a failure of accountability. Who is ultimately accountable to get people to the care they need? No one, it seems. Not really, and that is a big problem, said Aktinson, a professor of emergency medicine at Dalhousie University. Because we promise it to our citizens and residents of Canada. We promise critical care access and access to care in the Canada Health Act. But we have not properly defined who is accountable for each part of it.
Not only do Canadians seek emergency care more often than people in other countries, and wait longer for it. Canada had the highest wait times for specialists and non-emergency surgeries among 11 surveyed OECD countries, pre-COVID. Cancer surgeries are rebounding. But 600,000 fewer surgeries were performed during the first 22 months of the pandemic (starting in March 2020) than were performed in 2019 alone.
An ambulance leaves the Emergency area of Toronto Western Hospital during the COVID-19 pandemic, Thursday January 6, 2022. It’s part of the University Health Network (UHN), which manages three of the GTA’s largest hospitals with more than 1,200 beds and nearly 18,000 staff.
As Canada’s health system burns, Trudeau and the provinces debate the fire hose
Is Canada’s health-care system in crisis? Of course it is, and everybody knows it, writes Terence Corcoran.
Terence Corcoran: Private health care for profit it’s coming
Sylvia Jones, Deputy Premier and Minister of Health takes her oath at the swearing-in ceremony at Queen’s Park in Toronto on June 24, 2022. Ontario has announced a plan today to stabilize the health-care system as a staffing crisis continues within hospitals across the province.
Ontario to fund more private clinic surgeries in bid to stabilize health-care system
Nine hundred thousand British Columbians don’t have a family doctor. One million Ontarians are also searching for one. The College of Family Physicians of Canada recently warned the future of its profession is at risk, the current pressures unsustainable.They pointed to a tsunami of paperwork and administrative burdens, little admin support, rising overhead and labour costs, electronic medical reports that don’t integrate properly with other clinics or specialists and inefficient referral systems. You send a referral to one specialist. It might sit on their desk for a few weeks or a few months before they get to it and say, Oh, actually, I am full. You should refer to this other specialist or, don’t do shoulders, said college president and North Battleford, Sask., rural family doctor Brady Bouchard.
We know we have a supply problem. But it is exacerbated by family physicians not practising that comprehensive, primary care, because they are not supported in it. Doctors are feeling frustrated. Tired comes in a close second. They are really disillusioned with the idea that they are trained to provide a high level of primary care and feel really unsupported by government, at all lev Bouchard said.
Part of it is a generational thing. Marcus Welby, MD, the old-school doctor from the ˜70s American medical drama, did practically everything. Baby deliveries, heart surgery, emergency psychiatric counselling. That solo family practice, the one doctor in a small town is not sustainable, Bouchard said. It is not about working less. Family physicians still, on average work well over full-time. It is about having some work-life balance, Bouchard said. You are not doing your best patient care in your 16th hour of the day.
So, we have been talking for many years about team-based care: A bigger clinic with a bunch of different health-care providers that meet the community’s needs, and that allows everyone to take a break occasionally. Instead, most doctors are paid fee-for-service, meaning per patient, per visit. Fee codes in B.C. have gone up by a small, single-digit percentage for more than a decade. There pressure to get through patients, and with some speed and volume, at a time when an aging population means more people have not one, but multiple chronic conditions.
Still, a 2016 report by Ontario auditor general found that most doctors working in family health team models, where doctors are typically paid a fixed amount of money each month, per patient, were working, on average, 3.4 days a week. Most (60 per cent) were not putting in the evening and weekend hours mandated by their contracts.
No one is pointing fingers, saying, this parts broken.The whole system is broken to a degree, Parks said. Staffing shortages, limited home care and rehab, a shortage of beds, confusion as to who, exactly, is responsible for the person at different times in their care ” all factor in here. While emergency wards were eerily quiet in the first COVID wave, when people were afraid to go to the hospital, volumes are back up. Pandemic-delayed care has left some people sicker. Yet Canada has fewer hospital beds, including fewer intensive care beds, than almost anyone else in the developed world, which is why it took so little to push hospitals, particularly in Ontario and Quebec, to the breaking point during COVID surges, forcing some of the strictest lockdowns in the world and that had ICU doctors preparing for the once unthinkable, a deviation from usual practices rationing life-saving care.
Emergency departments across Canada have temporarily shut their doors. Among ED doctors, what I am hearing, it is the level of emotional exhaustion, said Dr. Michael Howlett, president of the Canadian Association of Emergency Physicians. They can’t spend the effort and time on a case the way they have been taught. With people in every makeshift space, there is no privacy. A woman who is miscarrying has to be seen in a very non-private hallway. A patient with end-stage lung cancer ends up in emergency because they have not been able to access palliative care in their community. Their breathing had gotten worse, more laboured, and they arrive in emerge in extreme, meaning very close to death, said Parks, the Medicine Hat doctor. It is crowded, it is noisy, the lights never go off, there is no room for grieving families. All we can do is provide comfort measures for them and pain meds, until we can get them into a palliative care bed, if one becomes available. People have gone into cardiac arrest while waiting on a stretcher for hours to be offloaded by ambulance crews. By the time they were moved into the emergency department we were unable to save them, Parks said.
We have got doctors going out into waiting rooms and doing waiting room medicine, trying to pick out the really sick patients, Parks said. We know there are patients that are slipping through the cracks because of this environment.
Rates of left without being seen are increasing. At Winnipegs Health Sciences Centre, the rate has been up to one in four. Imagine the faces of the people who leave, said Chochinov. They are often the people who are the most vulnerable. They don’t have someone to say, ˜You need to stay, I’ll look after the kids.
COVID pummelled not just a fragile system, but also the people who keep it (and us) running. Nurses are used to death. A lot of us take great pride that when a patient is dying that we make it the most comfortable for them and for their families, said Cathryn Hoy, president of the Ontario Nurses Association. But we were not built to see the types, and numbers of deaths that we did through COVID.
Some nurses are off with PTSD. Others retired, some just quit, telling colleagues, I can’t do this; I can’t have 15 patients. The numbers keep dwindling, the absenteeism keeps rising and the nurses left are being run off their feet, Hoy said. Medications are late; things get missed. You just can’t keep on top of things, because it is so bad. Hoy tells the story about a nurse working in a small rural hospital. A trauma patient came in. She called up for another nurse to come and help. Shed worked almost a 12-hour shift, not even stopping to eat or drink. Another trauma comes through the door. She was so exhausted, and, l will be very blunt, she wet herself while she was doing chest compressions, because she had no time to have a break and go to the bathroom that day, Hoy said. Staffing levels were already critical before COVID hit. We have been yacking to the government for years ˜You are barebones, you are barebones. But they feel we are the easiest line item to cut. Nurses are feeling disrespected by laws like Ontario’s Bill 124, which caps wage increases for public sector workers to one per cent a year for three years. Some are fleeing to private (but publicly funded) nursing agencies for bigger pay rates and more flexible schedules. One Toronto hospital network is already $6 million over its annual budget for private nurses, Hoy said. Agency nursing is going to bankrupt the system.
It is not just doctors and nurses running ragged. Respiratory therapists, the people who help people breathe when they can no longer breathe on their own, who insert breathing tubes and artificial airways and attach people to ventilators, and who spent hours swathed in protective gear on COVID wards, are showing signs of PTSD, depression, anxiety and stress at high rates.
Even just looking at the staffing board before starting shift, it is like, ˜Wow, this is going to be a rough night, said Vancouver respiratory therapist Alex Parent.
The federal government was predicting a shortage of RTs before COVID hit. Now, Instead of seeing eight patients very thoroughly and doing a good job and spending time with them, you are having to see 15 to 30 sometimes, Parent said. You are just trying to get in, see them quickly, and go on to the next one. It is very demoralizing.
Staff shortages, burnout, backlogs, bed block. Fix the system is the rallying cry. But what does that mean? There is a presumption that there is a force out there that is rational and knowledgeable and has the power to make change. And that is not true, Chochinov said. It is a non-system, with multiple moving and reacting parts that are not working together the way they should. We point the finger at this diffuse system, without really knowing who or what it is, he said. When people talk about fixing the health crisis, It sounds like if we just repair some parts, it will be better. It is not like that. It is more complex than that. Simplistic attempts to fix a complex system often have unintended consequences. Which is part of the reason we are in such a mess.
Ten, 15 years ago, if he walked into emergency and the wait was four hours people would get angry. They told tell me: ˜What the heck is wrong here? I expect better care as a taxpayer in a first-world country.
Now, I come into the room, and the wait is double that, eight hours, and I say, i am so sorry, Mr. Jones, for the long wait. And they all say,˜You know what? I am just grateful someone is seeing me.
There is a sense of resignation, as if we are in Elisabeth Kubler-Ross acceptance stage of grief. We shouldnt be coming to terms with this, Chochinov said. We should not be shrugging our shoulders and saying, guess it is the best we can get.
What people do get when they can access it is often expert care, Atkinson said. We really do have world class care. On Twitter, people have described being beyond grateful for the people who saved their life after suffering a subarachnoid hemorrhage shovelling their driveway last winter, or that a sister, hospitalized with pneumonia and sepsis, is receiving excellent care and not going bankrupt in the process.
The quality of care is amazing. Our access to it is poor, Atkinson said.
Cuts to beds and staffing since the late â80s has created a situation of scarcity, Howlett said. There is no redundancy, he said. Everything has been held together by this very thin wire. Stories of sick patients languishing in waiting rooms and packed in noisy corridors has again renewed debate over state-monopolized medicare, with growing voices asking, why not allow people with the means to pay for it, quicker access to care? Ontario plans to increase surgeries performed at private clinics, but covered by OHIP. For-profit care would be a solution for some people, said health policy analyst Dr. Michael Rachlis. But overall, it would make things worse by making medicare ” physicians, hospital care ” less available to the people who most need it, which, of course, is skewed to people who are poor and have less money.
The premiers are again insisting on more federal money. Paul Martins fix for a generation, his $41-billion, 2004 Health Accord hammered out with the provinces in the wake of the first coronavirus catastrophe, SARS-1, helped improve access to sophisticated cardiac care and radiation for cancer patients. It spurred governments to put more resources into some elective surgeries, mainly things like joint replacements and cataract surgery. But we didn’t fundamentally change the way we did our work, said Rachlis, an adjunct professor at the University of Toronto Dalla Lana School of Public Health.
I think it may have instructive lessons for the time we are in now.
More money would help build capacity. In th70s, Canada had three times as many hospital beds, per capita, as we have now. The workforce also needs to be stabilized, Rachlis said. Numerous groups are again calling for a national health-care human resource strategy. All this talk about foreign-trained professionals yeah, it should be part of our conversation, Rachlis said. But it is going to take a while to get those people.its going to take even longer, years, to train more doctors and nurses and anesthetists and respiratory therapists and other health professionals. Why don’t we start treating them better today so more will show up for work next week? And some of them might even think about coming out of retirement, Rachlis said.
Ontario Premier Doug Ford needs to repeal Bill 124 and say, we are going to negotiate freely,said Rachlis. It doesn’t mean they are giving away the farm. But that is what he has to do, symbolically, to show respect.
Efficiencies can be found. Not every emergency patient needs a CT scan or a full blood work-up. Not everyone needs a bed. Can they be seen and treated in a chair? Central wait lists would send people to the first available surgeon or specialist, instead of people waiting in months-long queues for different doctors. Staffing models can be mixed up. Even in busy, drowning ERs, some beds sit empty because there are not enough nurses. Some work done by registered nurses doesn’t need to be done by RNs. Half of visits to family doctors could be done as well by someone else, said Rachlis. Someone needs a prescription for blood pressure or asthma medication refilled? They don’t need to see a doctor if they are stable, Rachlis said. A nurse could do the follow-up. Or let a pharmacist see the patient. They tend to know more about drugs than doctors.
More robust long-term care and home care is needed, so that the dischargeable elderly frail don’t fill hospital beds while someone unstable and in pain waits in a drowning ER. Beyond money and Canada is already among the highest spenders on health care in the OECD, at $6,666 per person in 2019 are deeper issues, including better management of chronic conditions to keep people out of hospital, and what Atkinson calls those accountability frameworks. Figure out which program is responsible for which patient, he said. A post-op infection? That is a problem for the surgical program. Have someone from the surgical group assume care. People with a minor illness or injury? Get them timely access to same-day primary care. Doctors covering nursing homes should be responsible for out-of-hours problems. Of course, if it is an emergency, then it is emergency medicines responsibility. If you are accountable, you should be resourced, and then you should have to deliver, Atkinson said. You can’t just say, ˜Oh, well, they are in the emergency department. You are accountable. We all must look after our own shops.
We had the solutions for decades, Rachlis said.
We can’t just keep rearranging the deck chairs.
This article was first reported by National Post on Aug. 19, 2022.