Emergency departments are in crisis now and for the foreseeable future

In recent weeks, hundreds of emergency physicians in Canada have signed open letters describing their inability to provide safe and timely care in overcrowded and understaffed emergency departments across the country.1^,2 Despite the World Health Organization’s recent announcement of the pandemic emergency coming to an end, Canadian emergency departments face another summer of record-setting wait times and closures. 3 June to August will be precarious and exhausting months for emergency care providers, with dire consequences for health system functioning, patient outcomes and provider well-being.

After a dramatic decrease in April 2020, emergency department visits in Canada returned to baseline volumes by the summer of 2022.4 Despite this return to baseline, the capacity of emergency departments to provide care has been outtripped. Hospital staffing shortages and resulting in bed closures have meant admitted patients are subjected to much longer emergency department stays.4^,5 In addition to other contributors, the inability to move patients admitted from emergency beds has resulted in crowding and increased wait times and prevented the delivery of timely and effective care. These problems are plaguing Canada’s health care system.5 This perpetual cycle is not news to most people in Canada, as it is pervasive, has lethal consequences and will continue to exhaust Canadian emergency services and providers.5

As an emergency physician I’ve observed that the trends in use of emergency departments have also changed. Before the pandemic, increased use occurred predictably during influenza season and, to a lesser extent, in the summer months, when patients had reduced access to their usual health care providers and when injuries were more likely to occur. 6 The peaks were brief and sharp and were buffered by long troughs.6

Unlike these short accelerations followed by rapid declines, emergency departments now operate at peak occupancy for weeks at a time. 7 Patient volumes may briefly return to expected levels but quickly rise again, offering little buffer for hospitals to clear backlogs, or for emergency care providers to recover from the moral injury that occurs when they have to treat sick patients in waiting rooms and feel unable to provide high-quality care in overwhelmed emergency departments. 5 The summer months now also a higher risk for climate-related disasters, like the heat dome of 2021 or the wildfires that have already resulted in widespread evacuations this spring, that can quickly exceed the capacity of emergency services and hospital resources.8^,9

This new pattern contributes to the human resource crisis faced by emergency departments, as evidenced by the substantial number of closures of rural and medium-sized emergency departments and of sections of large-volume emergency departments in the summer of 2022.3 Measures recently put forward by the federal or provincial governments, such as recruitment of health care workers internationally or expansion of health care workforce training programs, are unlikely to prevent the same closures in the summer months ahead.10^,11

Attempts to mitigate the effects of this crisis on patients and providers have been made in rural areas of BC and Ontario. In April 2020, BC launched Real-Time Virtual Supports, which includes 4 programs that provide on-demand clinical support for emergency providers working in rural, remote and Indigenous communities throughout BC. 12 This basket of virtual supports is aimed primarily at advancing equitable access to care in BC; an additional goal is to increase the recruitment and retention of the rural health care workforce. Based on interviews of participants using the peer-to-peer pathways, the programs are building capacity, establishing relationships between providers and strengthening the community of practice in rural emergency care. 13

Another pragmatic program that has promised to support rural emergency physicians in Ontario is the Emergency Department Peer-to-Peer program, launched in October 2022.14 This program supports 56 rural and remote emergency departments and gives physicians access to immediate, on-demand peer coaching for all patient acuity levels. Perhaps the program’s secret sauce is that peers are trained to answer the call with, “How can I help?”. Thus, in addition to receiving clinical guidance from a provider with rural experience, callers also feel supported when caring for sick patients in rural hospitals.

These attempts, while laudable, fall short of the necessary, system-wide response to the current crisis, which has been decades in the making and was predicted by emergency personnel and accelerated by the pandemic. 15 For physicians and nurses working in emergency departments in Canada, no end is in sight for growing patient volumes and crowding, and the demand for emergency care exceeds the capacity of emergency medicine health human resources in all regions of Canada now and for the foreseeable future.

Thus, practical and immediate steps must be taken at all levels of the health care system to mitigate harms caused by long wait times for emergency care, to build buffers within emergency services to accommodate external disasters in an already strained system, and to protect the emergency health care providers who are continuing to shoulder the prolonged demand for emergency services that have emerged in the wake of the pandemic.