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ERs are over capacity and in crisis, but there’s another backlog making the problem worse

Canadian emergency rooms are overflowing while an array of respiratory illnesses — COVID-19 included — keep circulating. And it's happening against a backdrop of behind-the-scenes backlogs that turn front-line ERs into dangerous choke points.

Staff shortages, respiratory illnesses pose challenges, alongside long-standing hospital bed capacity crunch

A paramedic loads his stretcher back into the ambulance.

This story is part of CBC Health's Second Opinion, a weekly analysis of health and medical science news emailed to subscribers on Saturday mornings. If you haven't subscribed yet, you can do that by clicking here.

A newborn with a fever waited five hours to be seen by an emergency physician near Toronto.

Patients were surrounded by garbage and urine as they waited 18 to 20 hours for care at a hospital in Fredericton.

And in Alberta, Red Deer's long-beleaguered hospital was forced to hang tarps to create makeshift treatment spaces.

Those headlines come from different hospitals and different provinces. But they all point to the same grim problem: Emergency rooms are overflowing while an array of respiratory illnesses — COVID-19 included — keep circulating. And it's happening against a backdrop of behind-the-scenes backlogs that turn front-line ERs into dangerous choke points.

The numbers are staggering. More than 10,000 people are in hospital at once across B.C., the most the province has ever seen, while Quebec grapples with the highest level of patients in its emergency rooms in five years.

In Ottawa, the Queensway Carleton Hospital recently said it was operating at 115 per cent occupancy. By midweek, most Montreal emergency rooms were above full capacity, with some operating at roughly 200 per cent.

The usual slate of viral threats, from influenza to respiratory syncytial virus, or RSV, make this time of year particularly challenging for hospitals thanks to the ongoing influx of sick patients. Canada's health-care systems are also adapting to a new normal where COVID-19 is now firmly in the mix.

And while federal data suggests COVID-related hospitalizations, ICU admissions and deaths at this point in the pandemic are lower than before, the virus is still infecting thousands of patients in Canadian hospital beds at any given time — putting sustained and added pressure on a system that's already under strain.

Pressure from COVID infections, surgery backlogs

Manitoba officials warned in December that overcapacity hospitals aren't just seeing more patients with respiratory illnesses, but that the patients coming in are sicker by the time they arrive.

On Wednesday in Quebec, Health Minister Christian Dubé told reporters that there are 3.6 million visits to the province's ERs in a typical year, or about 10,000 per day. But recently, there have been approximately 1,000 more visits each day — a 10 per cent increase.

Respiratory viruses are a big part of that spike. Last year, roughly 1,000 people went to the province's ERs every day with the flu, COVID, or RSV, he said, but this year that number nearly doubled.

And COVID's impact is really two-fold — both acute and lingering.

The mass shuttering of surgical sites during the pandemic to make room for deathly ill patients infected with the virus led to massive surgery backlogs. Hospitals are now playing catch-up, rather than risk more patients suffering while they wait for various procedures.

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Throughout the year, a rising number of Canadian ERs also closed down entirely, usually due to staffing constraints.

In Nova Scotia, the number of hours emergency rooms were unexpectedly closed jumped to 41,923 — a 32 per cent increase from a year earlier. And in Ontario, one advocacy group said the province broke an all-time high for emergency room closures, totalling more than 860 throughout 2023.

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'Access block' stops flow of patients

But pointing a finger at the current issues — sick patients, staff shortages, surgery backlogs, and clogged ERs — doesn't capture the deeper problem plaguing Canadian hospitals.

"The inability to move patients [who were] previously seen and admitted is, in my experience, the No. 1 reason wait times are excessive," Dr. Paul Ratana, the medical director for the emergency department at Winnipeg's St. Boniface Hospital, said at a provincial press conference earlier this week.

"We refer to that as 'access block,' and it prevents patients from getting out of the waiting room and into treatment places."

"Access block" is one way to put it. The issue is linked to another bit of hospital jargon: Patients who are dubbed "alternate level of care," or ALC.

That clunky term refers to people who occupy a hospital bed, but really shouldn't be there because they don't actually need the intense level of services that hospitals are able to provide. That could mean someone who's stuck waiting for a space in a rehabilitation centre, long-term care home, palliative care, a hospice, or care at home.

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Doctors in multiple provinces are sounding the alarm over long waits and over-capacity hospitals as respiratory illnesses spike and medical staff are overworked. Some are even warning some patients to stay away from the ER.

It's a longstanding issue, predating the pandemic.

"Almost 20 [per cent] of the acute care beds in Kingston are unavailable for admission of new patients. How can this be?" wrote Ontario-based physician Dr. Stephen Archer, a Queen's University professor, back in 2016.

"In fact, these 93 beds exist," he continued, "however they are occupied with a growing cohort of people who everyone agrees should not be in hospital."

It's just one example from one city, but clinicians say the problem remains widespread, causing an ongoing crisis of hallway health care where patients are forced to wait for beds.

"This is a reflection of problems with the capacity in hospitals, and also capacity in long-term care, because it just snowballs backwards — and we see the result in the emergency departments," said Dr. Michael Howlett, president of the Canadian Association of Emergency Physicians, in an interview with CBC News.

"It's basically a problem of a lack of good planning efforts for the last 20 or 30 years in all jurisdictions," added the physician, who works in rural and urban ERs in Ontario for Lakeridge Health.

"And so now we are facing the consequences of that."

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Patients dying in hospital before being discharged

In Ontario, one research team recently explored the issue of ALC patients, in a population-based, retrospective study published this week in the British Medical Journal.

The researchers looked at more than 50,000 acute care hospital admissions in Ontario that were deemed to be ALC patients between January and December 2021, with a follow-up window of roughly three months, until a patient was discharged or died.

Nearly one-fifth of the patients died within the 90-day follow-up period. Of those, more than a third were never discharged — so they ended up dying in hospital before getting to a more appropriate setting, like their own home or a hospice.

Those patients were all essentially "stuck in hospital, with nowhere to go," said study author Aaron Jones, an assistant professor in the department of health research methods, evidence and impact at McMaster University in Hamilton and an adjunct scientist with Institute for Clinical Evaluative Sciences.

"And the flip side of the ALC crisis is the effect it has on the patient flow. They're sitting in a bed that they don't necessarily need… and then you end up with hallway medicine and these huge weight times in the [emergency department]."

Health care 'doesn't seem to be a priority'

It all paints a picture of country-wide health-care systems under severe strain, with no end in sight, particularly as Canada's population continues to age — which experts warn could lead to more demand for long-term and palliative care, more ALC patients, and more seniors vulnerable to severe illness from COVID and other respiratory threats.

It's an issue compounded by the fact that millions of Canadians lack access to primary care such as a family doctor or nurse practitioner, pushing them into the hospital system in the first place.

"We are facing a primary care crisis in this country, and we urgently need to find solutions," wrote Dr. Kathleen Ross, president of the Canadian Medical Association, a national physician advocacy group, in a statement this week.

Ross' organization, along with Howlett's group representing emergency physicians, are calling for overhauls of provincial systems to tackle the range of issues hospitals keep facing year after year.

So are provincial officials listening?

"This particular issue doesn't seem to be a priority," Howlett warned this week, in his call with CBC News. "There seem to be other issues that take precedence."

Last fall, his association of ER doctors met with provincial and territorial health ministers to discuss how they could team up at a national forum this spring to find fixes for the overcrowding in emergency rooms.

But so far, Howlett said, no jurisdiction has responded to that invitation.

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