Emergency department overcrowding

As an emergency physician who has worked for many years in an urban tertiary care centre, I absolutely support the notion raised by Jane Upfold in her commentary¹ that it is unethical for an emergency department to go on critical-care bypass and refuse a critically ill patient. In the same issue, Anne Walker clearly outlines the duty of both the hospital and the physician to provide emergency care.²

In 1990, I published a review of 4 years of critical-care bypass statistics. The most striking finding was the more than 8-fold increase in overwhelmed status over the previous 4 years. The 3 most frequent reasons for the department “going on bypass” were insufficient nursing staff, no beds and no cardiac monitors. Often, 2 of these reasons were combined.³

One decade later, the Canadian Association of Emergency Physicians and the National Emergency Nurses Affiliation published a position statement on emergency department overcrowding. It stated that overcrowding is a cause of inadequate patient care, prolonged delays in the treatment of pain and ambulance diversions. Overcrowding was again caused by, in part, a lack of beds for admitted patients and a shortage of nursing staff, in addition to a shortage of physician staff. According to the position paper, “the cause of ED overcrowding generally lies outside the ED. Efforts to maximize ED efficiency are important, but overcrowding is a symptom of system failure.”⁴

It is unreasonable and unethical to hold physicians liable for not delivering adequate care to patients they never get to see (because they are diverted to another site), that they see too late (because of patient backlog or space) or that they see without the staff or diagnostic and therapeutic tools required to assess and treat in a timely fashion. Hospital cutbacks have created an environment where emergency physicians cannot reliably deliver the standard of care that is legally and ethically expected of them.

Walker noted that the “Ontario Court of Justice confirmed that, if a hospital wishes to discontinue or curtail its emergency services, it has a duty to take reasonable steps to notify the public of these changes.” A 10-year paper trail of documentation indicates that the hospitals are aware of the problem. More recent evidence suggests that the problem is no longer episodic but constant. As such, hospitals have effectively curtailed their ability to deliver emergency services to meet cost-containment goals. Hospitals now have an obligation to advise the public and the provincial authorities of the actual level of service that they can provide.

Daniel Kollek Associate Professor Emergency Medicine McMaster University Hamilton, Ont.