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Comment: A new ER reality — a drop in standards of care

A commentary by an emergency physician at Nanaimo Regional General Hospital.

A commentary by an emergency physician at Nanaimo Regional General Hospital.

How did we reach such a low point in patient care, where it has become acceptable to admit a patient to a B.C. community hospital with no doctor assigned as the most responsible physician directing treatment?

As has recently been brought to the public’s attention, several community hospitals are doing just that today.

At our hospital in Nanaimo, I have begun calling these ­admissions IOU patients: ­Inpatients Orphaned and ­Unattached. As emergency ­physicians we believe we owe these patients a far higher standard of care than the cursory knowledge of their presence in our ER and our commitment to intervene if their blood pressure crashes or their heart stops.

But this is the new reality in a significant number of community hospitals — including ours.

These patients, who have become sick enough to require in-hospital care, languish in our already-overcrowded ED hallways, frequently being handed from one emergency doctor to the next, so at least some ­physician knows vaguely about their existence but no one is ­specifically directly managing their in-patient care.

This “new solution” is allowed to go on until a facility’s ­in-patient census falls below a certain threshold and a hospitalist can be assigned to assume in-patient coverage. This is unacceptable, unkind and unsafe.

Our exhausted emergency department nurses and ward aides already can’t provide for a patient’s basic needs to eat, sleep, urinate, have their clothes and bed clothes changed, and have a semblance of privacy, let alone give them a caring hand to hold onto for a second or two.

We have emergency departments to treat the acutely ill, stabilize them and then move on to the next sickest patient, who has frequently already waited far too long to be seen.

Emergency departments can’t function, and were never meant to fill, this gaping new hole in the provision of health care

Why are community emergency departments expected to house these sick patients rather than the wards? It’s because we in the emergency department cannot say no.

We are compelled by our ­hospital administrators, ­provincial medical colleges, ­malpractice insurers and our medical ethics to treat whoever is present. That includes these new “IOU patients.”

Hospital administrators had this knowledge in hand when they made up their minds as to what stop-gap measures to take with this new crisis. “We will house them in the ED,” they decided yet again.

We are the only hospital department that has absolutely zero control over our patient volumes and can set no limits that define safe staffing levels. In our largest community hospitals we cannot restrict our operating hours and must provide comprehensive emergency care 24/7/365.

We are the only option for care when a serious medical event or condition occurs – and now apparently while you are waiting, possibly for days, in the emergency department for a ward bed.

Community hospitals like ours are frequently not close to one another. Many Lower Mainland urban academic centres have diversion options and supervised house-staff in training so they aren’t dealing with these human resource issues.

However, community facilities rely on hospital-based doctors called “hospitalists” to fill this gap. Hospitalist numbers are dwindling for many reasons, some of which can be laid at the feet of government and the health authorities.

If there aren’t enough of these hospitalists and beds available, why don’t we just close shop and divert patients elsewhere? Where would you send patients if you are the largest and most capable centre within 100 to 300 kilometres?

In the past few weeks the terms “dire” and “catastrophic” have appeared in the media. This is not hyperbole. No emergency physician has a selfish angle on this situation.

Our present circumstances are an obvious and predictable outcome following the Doctors of B.C. and Ministry of Health signing a new primary-care agreement without full corresponding moves to retain the vital hospitalist workforce in community hospitals.

A significant number of hospitalists will likely switch back to family medicine. Some already have, and I am unsure whether these “new recruits” are being counted in the ministry’s recently published data of new physicians entering primary care.

Those hospitalists who remain have set threshold limits for how many patients they can safely provide care for on the wards. I have been advised that my hospital expects to lose 25 per cent of its hospitalist workforce by the end of August.

In many facilities such as ours, hospitalists provide in-patient coverage for more than 75 per cent of hospital admissions.

For hospital administrators, we in the emergency department appear to be the only immediately available option. This is despite the fact that we are already bursting at the seams.

In our severely over-crowded emergency rooms, our staff will be forced to house ever-greater numbers of admitted in-patients in waiting rooms, cubicles, offices, closets and expanded emergency department corridors, compounding staff ­exhaustion and post-Covid fatigue.

You and your family will wait even longer. Your loved ones will be impacted.

Undoubtedly over the next 12 months we will likely see a similar exodus of emergency department workers to greener pastures or early retirement and then what is the plan?

Many emergency-department shifts at hospitals on Vancouver Island remain unfilled this summer already.

I have practised emergency medicine full-time for 47 years. Government, the media and the public have grown used to and perhaps even numb to “the ­ongoing crisis in B.C.’s EDs.”

These unacceptable circumstances have gone on now for decades. So, what’s new?

Two things specifically. We have never before admitted patients to hospital with no one assigned to look after their care and we have never experienced such difficulty in providing emergency room physician coverage at multiple locations throughout the province simultaneously.

Morbidity and mortality in the emergency department is directly related to time. The longer you wait to be seen and the longer you remain in the ED, the worse your outcome.

We owe these patients far better. I am left now with only being able to extend our most sincere apologies and regrets to those who will be adversely impacted by these new realities in patient care.

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