Quebec Hospitals Reach Critical Juncture

An insider's look at how the Omicron variant is unraveling emergency rooms.

By Hal Newman

The elements that make up our health system are in simultaneous freefall. 

We have reached that moment when every decision is critical. Quebec’s emergency rooms are operating at levels where they have outstripped their capacity, their infrastructure, and even the remarkable abilities of the people who somehow continue to allow them to operate against all odds. 

Quebec’s emergency rooms are at 100 per cent capacity. This time last year, they were at 88. As of today, the busiest ERs across the province are: Riviere Rouge 200% Argenteuil 200% Le Gardeur 194% Pierre Boucher 183% Laurentien 178% Honore Mercier 165% Suroit 162% Thetford Mines 160%.

I’ve been tracking Emergency Department overcrowding in Québec since May 2020. 

If you're wondering why it matters so much if Québec's ERs are overcrowded, in our healthcare system ERs are used as an almost-exclusive gateway to healthcare. So healthcare isn't so much a verb as it is a physical location. You need to be seen in an ER - triaged, assessed, treated, stabilized and then, quite possibly, referred to other specialists for further care. If your needs are in-hospital, e.g., surgery - you still make your entry via the ER. If you need more specialized care in another hospital, it's the ER staff who will arrange for your transfer. 

In Quebec, ERs are a significant chokepoint for the healthcare system. If you need expert guidance beyond the scope of the nurses at 811, they will refer you to the ER. If you're treated by first responders and then paramedics, chances are good you'll be transported to the ER.  

So when all the ERs are overcrowded, there are cascading effects throughout the system. Example: Paramedics are left waiting at triage - their patient still on their stretcher - cued up to see the first available triage nurse. Meanwhile, life continues to unfold outside. There are all the normal calls except now there are also response delays because there are less paramedics available to treat and transport patients. And in more distant and rural regions, patients may be transferred from one ER to another - which entails long transport times. 

Meanwhile, people are still arriving at the ERs - waiting to be seen. The staff - who have been overwhelmed since the beginning of the pandemic are doing their best to hold the line while providing the best possible care to their patients. They are, in the words of a friend who works in an hospital in Montreal, “emotionally overdrawn and physically bankrupt.” And so it goes.

“All of our patients are suspected Covid patients and that’s also a huge stress for everyone,” said Dr. Judy Morris, an ER physician at  Hôpital Sacré-Coeur de Montréal. “All the changes in directives, the challenges experienced, the impression that the threat of Covid was not always taken seriously by the authorities while our work environment and our emergency room teams grow more and more fragile have placed an enormous stress on the emergency department team. Often overlooked – like the people working in the prehospital sector – the emergency room teams have, from the very start of the pandemic, had to work with patients who have not been diagnosed with Covid.”

Dr. Morris says the system has had to cannibalize itself to keep going.

“For the current wave, some teams have been very weakened in terms of the numbers of available staff which adds to the fatigue of the remaining members,” said Dr. Morris, who is also the President of the Association des médecins d’urgence du Québec. “Teams have also had to recruit staff from other emergency departments to cover their on-call list. Being part of a collaborative network helps us lend support where it is needed.” 

Of course, when a network has to start loaning emergency department physicians from one ER to another, it is nearing collapse. We have already seen rural hospitals (eg., Coaticook) and even in urban centres (eg. Lachine) temporarily shuttering their emergency departments due to staffing shortages.

We have just seen the first Omicron patients transferred to intensive care units. An intensive care doctor I spoke with told me there was a 10-14 day delay between hospitalizations and admissions to the ICU. He said that the first few days after the patient presents to the emergency room are critical - trying to determine the exact onset of symptoms, then making sure that seven days have passed before starting patients on steroids. I asked if there was anything in common for those who go to ICU and he told me that they are usually not vaccinated and often have a disease affecting their immune system. 

I asked Dr. Morris if this was also true for the patients she and her colleagues see in the emergency room. 

“To date, the sickest are more often the unvaccinated like those patients requiring intensive care. The daily hospitalization data also reflects this over-representation of unvaccinated patients in hospitals today. We only keep in hospital those patients who are quite sick. We are still discharging many people if their vital signs and tests are reassuring, and they are able to hydrate and eat adequately at home (with detailed advice to come back if they are not better).”

Emergency room overcrowding is nothing new but the past few months have been extreme in terms of the number of patients seen by emergency doctors. So how do we unburden the system?

“The first step in doing this will be to convince managers, administrators and other professionals (other MDs, too) that the problem of emergency overcrowding lies in several places,” said Dr. Morris. “In the care facility itself. If patients are 200% in the emergency room, it’s because they have no room to be admitted to the hospital. It is therefore necessary to improve the patient turnover in hospitals, to make them more efficient, to have more extensive technical platforms (virtual hospital, radiology, etc.). It's going to take a buy-in from everyone in the hospitals and accountability if the goals aren't met. 

“(There is a) lack of access to reliable data for hospital stays. To see where the delays are in the network, it is necessary to have access to more and more data on where the bottlenecks are in the system. Problems with discharge, problems with access to consultants, problems with access to other stakeholders, problems with access to post-acute beds (CHSLDs, convalescence, etc.) for patients in hospital with whose discharge papers have already been signed. A lot of data is available for emergency departments but still too little for hospital stays. 

“This would allow resources to be put in the right place to improve hospital fluidity. The Jewish General Hospital and the Cité de la Sante de Laval are pioneers in this area and have had great success in this regard. Data of this type must be available for all hospitals in Quebec. 

“The front line. Obviously, alternatives for outpatients who can be evaluated elsewhere must continue to be explored. Re-direction and clinical reception from the emergency are interesting and proven tools. Interesting projects are also being developed through prehospital (community paramedicine) and SIAD (Soins Intensifs à Domicile) providing intensive home care by certain family medicine groups like the one in Verdun – each with the goal to avoid emergency room visits. Consultations by other professionals on the front line would also be interesting to give more options to patients (eg physiotherapy for musculoskeletal complaints). Many of these successes and solutions deserve to be shared with all to inspire others.”

The Minister of Health announced that Covid positive healthcare workers would be assessed on a case-by-case basis and could be ordered to return to work. 

“The risks are having workers still contagious who risk infecting patients and their colleagues,” Dr. Morris said. “The science and contagiousness data when infected with the Omicron variant will have to be closely monitored so that this measure does not entail more risks than benefits for caregivers and patients. And the logistics of all this will have to be well orchestrated. Questions arise, will we make different restrooms and changing rooms available for the infected and uninfected? And how do you make sure workers are ready to return? Symptom-free? Tests negative? 

“Above all, there must be no slippage and people should not be forced to return to work too early by their employer while still sick.”

Is there an ethical dilemma in having Covid positive caregivers providing patient care? 

“Yes, we should also mention to the patient that their caregiver is positive on covid,” Dr. Morris continued. “It is hoped that if positive workers return to work, that they will be returned under the strictest rules (n95, proper personal protective gear) and ideally in covid units only.”

While Premier Legault mentioned in a recent press briefing Quebec has adequate supplies of N95 masks, organizations such as Montreal-Laval’s ambulance service Urgences-santé are warning their paramedics to be conservative in their use of N95s and to make do with other masks until supplies are replenished. 

I asked Dr. Morris if there are protocols in place for the assessment of these healthcare workers. 

“Infection prevention teams are already facing challenges given the large number of tests to manage. Some delays in obtaining results are experienced in the field. It will also be difficult to add the management of returns on a case-by-case basis and with tests even if it is the most sensible thing to do.”

11h30 January 3, 2022.

Quebec ERs Vital Signs: Network occupancy 104%. Last year on this date/time it was 90%.

Busiest ERs now: Pierre Boucher 217% Riviere Rouge 200% Anna Laberge 191% Le Gardeur 186% Laurentien 178% Argenteuil 175% Le Royer 170% Honore Mercier 169% St Jerome 162% Royal Vic 161% Sept Iles 160% Suroit 156% Arthabaska 150%

---

About the author…

Hal Newman is a former paramedic/firefighter who has more than four decades of experience in emergency health services. Newman has always believed an essential part of his job was listening attentively to people's stories and then leveraging those narratives to advocate on their behalf. Newman has a BA in Communications from Bethany College in West Virginia.