132 ER doctors warned officials last year of 'major risk to patient safety'

More than 100 emergency room physicians warned Health Minister Dorothy Shephard and the two regional health authorities a year ago about the "major risk to patient safety" at ERs across New Brunswick, a letter obtained by CBC News shows.

The doctors expressed "grave concern" about the "unimaginably long waits and poor outcomes" patients face on a daily basis.

They also accused the Horizon and Vitalité health networks of misleading the public about "high patient volumes" causing the long waits in emergency departments, when volumes were actually starting to return to pre-pandemic levels.

"The current overwhelming combination of staffing shortages, access block and systemic misuse of EDs by our health care system has resulted in a provincial emergency care crisis that none of us have ever seen before," said the letter dated Aug. 26, 2021.

Without urgent intervention, the doctors said, they feared "the complete failure of emergency care services in New Brunswick is inevitable."

The revelation comes after a patient died in the waiting room of the Dr. Everett Chalmers Regional Hospital's emergency department early Tuesday morning while waiting for care.

Witness John Staples said the man, a senior, had been waiting alone in a wheelchair, in visible discomfort for hours when he appeared to fall 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, said Staples, and he saw a few people leave without being treated while he was there.

The Horizon Health Network has confirmed "an unexpected patient death took place" and says a review is underway.

Opposition politicians are calling for the resignation of the health minister and an immediate coroner's inquest.

Shortages 'untenable' says medical society

In the six-page letter, the 132 emergency room doctors requested an "urgent focus" on the ER crisis with clear direction and support for innovative solutions and process improvements within both health authorities.

They identify four major issues facing emergency services, in order:

• Nursing shortages due in part to high turnover, including a 42 per cent one-year loss at one major ER.
• Recruitment and retention of certified emergency physicians.
• Keeping admitted patients in the ER while they wait for a hospital bed.
• Use of ERs for non-emergency purposes, stemming from poor access to alternatives in the community for unscheduled care.

The Department of Health, Horizon, and Vitalité did not respond to requests for comments, including what, if any, actions were 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 the ER doctors, said president Dr. Mark MacMillan.

"The health human resource shortage has reached an untenable point — we need to act immediately and collaboratively with all health-care stakeholders and communities to address the challenges facing the health system," he said in an emailed statement.

MacMillan also offered sincere condolences to the family and loved ones of the patient who died.

"While we can not speak directly to the circumstances involved, losing a patient while they are waiting for care is tragic and concerning," he said.

"We trust the health authority will use its review to learn more about what happened and how to keep this type of situation from occurring again."

Rise 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 "numerous" days when more than 40 patients left single ERs without being seen. On June 6, for example, 52 patients left the Saint John Regional Hospital's ER, and another 32 patients left the following day, according to the letter.

"A growing number of these patients are deteriorating and returning with serious complications due to delayed assessment."

Although the public messaging from the regional health authorities on social media attributed ER delays to "high patient volumes and staffing challenges," the average daily attendance numbers were no higher than they were in 2019, according to the doctors.

The number of patients requiring acute care and hospital admission, however, continues to grow, they said.

"Our waiting rooms are full and ambulance stretchers line our corridors waiting to offload patients, many of whom have serious medical problems and will require admission." Some patients wait in hallways for hours, which also ties up paramedics and creates problems for Ambulance New Brunswick providing responses to 911 calls.

'Dangerously overstretching themselves'

Nurse staffing challenges are a "major issue," the doctors said. ER nurses are highly skilled and require years of training, they noted, and some emergency patients require one-to-one nursing.

"When nurse staffing levels drop below required numbers on 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 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 had to rely on a "below critical workforce" of one nurse and one licensed practical nurse while remaining fully open, putting patients and themselves "at serious risk," the doctors said.

"This situation is placing enormous pressure on remaining staff, potentially resulting in significant adverse events and further loss of our valuable nursing resources," they warned.

"ED physicians are dangerously overstretching themselves in order to avoid closures, with many having to work shifts of 24 to 36 hours and a weekly hour workload that is triple our norms."

The shortage of ER doctors and nurses forced some ERs to reduce services or even temporarily close during the summer months, they noted — a situation that has occurred again numerous times already this summer.

Many ER beds occupied by admitted patients

Another part of the problem, according to the doctors, is the number of ER beds occupied by patients who have been admitted to hospital but are waiting for a hospital bed.

In Saint John, for example, there are 24 monitored ER beds. In the month prior to the letter being sent, there were frequently more than 20 admitted patients occupying those beds, which are actually examination stretchers and not designed to be occupied for more than a few hours.

Some of the patients remain in the ER for more than three days, which leaves only a handful of monitored beds to see about 100 acute-care patients per day, of which on average 22 will be admitted.

Lengthy ER stays.have been shown to increase the risk of poor outcomes, according to the letter. The "hectic, noisy, brightly lit environment of the ED is not conducive to caring for admitted patients," it said.

Community hospital ERs have had admitted patients stay for weeks, the letter said.

"Emergency departments are designed and staffed to rapidly screen, assess, investigate and treat patients with undifferentiated serious illness and injury."

Patients should be moved out in a timely manner to free up resources to deal with the next patients.

But the ERs have "over time become a failing system's default waiting area, urgent outpatient clinic, discharge lounge, pre- and post-operative care ward, outpatient overflow and extramural extension as well as primary care default access and community elderly care referral centre." the doctors contend.

Nova Scotia model encouraged

They urge the government to follow the lead of Nova Scotia, which had recently introduced a ministerial directive of patient flow and ambulance offloads.

Admitted patients must be moved to inpatient units within 12 hours of registration and ambulance patients must be offloaded within 30 minutes of arrival at an ER. The president and CEO of health authorities must report on adherence on a monthly basis.

"This directive will ensure that hospital administrators prioritize initiatives that improve patient flow in their EDs which have a direct impact on improving patient outcomes," the doctors contended.

They called on the government to provide the appropriate resources to ensure its success.

"None of these issues can be solved by the emergency medicine leadership alone — so we need the help of our colleagues in primary care, inpatient services, hospital administration and government to enable us to provide the emergency services our society expects and deserves.".