More than 100 emergency room doctors warned Health Minister Dorothy Shephard and the two regional health authorities a year ago about the “high risk to patient safety” in New Brunswick emergency rooms, according to a letter obtained by CBC News.
Doctors expressed “great concern” over the “unimaginably long waits and poor outcomes” that patients suffer on a daily basis.
They also accused the health networks Horizon and Vitalité of misleading the public about the “high volumes of patients” that caused long waits in emergency services, when volumes were actually beginning to return to pre-pandemic levels.
“The current overwhelming combination of staff shortages, blocking access and systemic misuse of EDs by our health care system has led to a provincial emergency care crisis that none of us had ever seen,” said the letter dated August 26, 2021.
Without urgent intervention, doctors said, they feared that “the total failure of emergency care services in New Brunswick is inevitable.”
The revelation comes after a patient died in the waiting room of Dr.’s emergency department. Everett Chalmers Regional Hospital early Tuesday morning while waiting for care.
John Staples said witnessing the death of a patient in Dr. ER’s waiting room. Everett Chalmers Regional Hospital, on the verge of receiving care, was a “clear and gloomy awareness” that New Brunswick’s health care system is “so badly broken.” (Joe McDonald / CBC)
Witness John Staples said the elderly man had been waiting alone in a wheelchair for hours, with visible discomfort, when he appeared to have fallen asleep. It was only during a routine check of people in the waiting room that a hospital employee realized the man had stopped breathing, he said.
Some people had been waiting at least eight hours, Staples said, and saw some people leave unattended while he was there.
The Horizon Health Network has confirmed that “an unexpected death of a patient has occurred” and says a review is being done.
Opposition politicians are calling for the resignation of the health minister and an immediate forensic investigation.
The shortage is “unsustainable,” the medical society says
In the six-page letter, the 132 emergency physicians called for an “urgent approach” to the Emergency Crisis with clear direction and support for innovative solutions and process improvements within both health authorities.
They identify four major problems facing emergency services, in order:
- Nursing shortages are due in part to high turnover, including a 42% one-year loss in a major emergency room.
- Recruitment and retention of certified emergency physicians.
- Keep patients admitted to the ER while waiting for a hospital bed.
- Use of emergencies for non-urgent purposes, resulting from poor access to alternatives to the community for unscheduled care.
The Department of Health, Horizon and Vitality did not respond to requests for comment, including actions, if any, to address the concerns and criticisms raised in the letter.
The New Brunswick Medical Society, which was copied in the letter, shares the concerns expressed by ER doctors, said the president, Dr. Mark MacMillan.
Dr. Mark MacMillan, president of the New Brunswick Medical Society, called for immediate and collaborative action to address ER problems in the province. (New Brunswick Medical Society)
“The shortage of health human resources has reached an unsustainable point: we must act immediately and collaboratively with all health care agents and communities to address the challenges facing the health system” , said in an emailed statement.
MacMillan also offered his sincere condolences to the family and loved ones of the patient who died.
“While we cannot speak directly to the circumstances involved, losing a patient while they are waiting for care is tragic and worrying,” he said.
“We are confident that the health authority will use its review to find out 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, a growing number of patients were leaving emergency rooms without being cared for or treated last summer.
There were “numerous” days when more than 40 patients left individual emergency rooms unseen. On June 6, for example, 52 patients left the Emergency Department of St. John’s Regional Hospital, and another 32 patients left the next day, according to the letter.
“A growing number of these patients are deteriorating and returning with serious complications due to delayed assessment.”
Many of the patients waiting for hours in ambulance bunks in the hallways have serious medical problems and will require admission, according to the letter written by emergency physicians. (Paul Chiasson / Canadian Press)
Although public messages from regional health authorities on social media attributed ER delays to “high patient volume and staffing challenges,” the average number of daily care did not exceed what they were in 2019, according to doctors.
The number of patients requiring acute care and hospitalization, however, continues to grow, they said.
“Our waiting rooms are full and ambulance bunks line our aisles waiting to unload patients, many of whom have serious medical problems and will require admission.” Some patients wait for hours in the hallways, which also binds paramedics and creates problems for Ambulance New Brunswick which offers answers to 911 calls.
“Stretching Excessively Dangerous”
Nursing staff challenges are a “major problem,” doctors said. ER nurses are highly qualified and require years of training, they noted, and some emergency patients require individual nursing.
“When nursing staff levels fall below the required numbers in a shift, emergency assessment beds are forced to close and undifferentiated emergency patients wait longer to be assessed.”
The weekend before the letter was written, the shortage of emergency 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 had to rely on a “below-critical workforce” of a licensed nurse and practical nurse while remaining fully open, putting patients and themselves “at serious risk,” doctors said.
“This situation is putting enormous pressure on the remaining staff, which can lead to significant adverse events and a further loss of our valuable nursing resources,” they warned.
“ED doctors are stretching dangerously to avoid closures, and many have to work 24- to 36-hour shifts and a weekly workload that triples our standards.”
The shortage of emergency doctors and nurses has forced some emergencies to reduce services or even close temporarily during the summer months, they noted, a situation that has already recurred many times this summer.
Many emergency beds occupied by hospitalized patients
Another part of the problem, according to doctors, is the number of emergency beds occupied by hospitalized patients but waiting for a hospital bed.
In Sant Joan, for example, there are 24 emergency beds. In the month before the letter was sent, there were often more than 20 admitted patients occupying these beds, which are actually scanning bunks and not intended to be occupied for more than a few hours.
Some of the patients remain in the ER for more than three days, leaving only a handful of beds monitored to see about 100 acute care patients a day, of whom an average of 22 will be admitted.
Long stays of ER have been shown to increase the risk of poor results, according to the letter. “The hectic, noisy and brightly lit environment of ED is not conducive to caring for admitted patients,” he said.
Community hospital emergency rooms have been admitting patients for weeks, according to the letter.
“Emergency departments are designed and staffed to quickly examine, evaluate, investigate, and treat patients with undifferentiated serious illnesses and injuries.”
Patients should be relocated in a timely manner to free up resources to treat future patients.
But emergencies have become “over time the default waiting area for a failed system, urgent outpatient, discharge room, pre- and postoperative care room, outpatient overflow and extramural extension, as well as the default access to primary care and the community center of reference for the care of the elderly. “answer the doctors.
The Nova Scotia model is encouraged
They urge the government to follow the example of Nova Scotia, which had recently introduced a ministerial directive on patient flows and ambulance discharges.
Admitted patients must be transferred to hospital units within 12 hours of check-in and ambulance patients must be discharged within 30 minutes of arrival at an emergency room. The president and director general of health authorities must report monthly on membership.
“This directive will ensure that hospital administrators prioritize initiatives that improve patient flow to their emergency departments that have a direct impact on improving patient outcomes,” the doctors said.
They called on the government to provide adequate resources to ensure its success.
“None of these problems can be solved just by the leadership of emergency medicine, so we need the help of our primary care colleagues, hospitalization services, hospital administration and government to allow us to offer the emergency services that our society expects and deserves. “