Challenges, Innovations and Coping Strategies in the EM Crisis
My blog has been on pause for more than a year. Partly, like most people, I have been busy, but I have also been unsure what to say at this particularly challenging time. Yet silence doesn’t feel right, either, so this entry is more personal than my usual blog entries. And while I am writing mostly from my experience in practice and as an emergency system leader in Ontario, most of these comments are relevant nationally and internationally, as well.
Experiences early in the pandemic included short but tragic waves of COVID-19 in some communities, anxiety about staff safety in others, and concerns about personal protective equipment supplies more broadly. At the same time, we had generally good patient flow and personnel levels due to a combination of patients’ avoidance of the emergency department (ED), activity limitations precluding the usual causes of many visits, good staff availability (essentially none on vacation or ill), and high bed capacity due to restrictions on scheduled surgeries. As well, society was mostly supportive of our efforts, with health care workers lauded as heroes.
However, as vaccination rates rose and activities inside and outside hospitals returned to near-normal levels, ED volumes increased and flow generally deteriorated. Then, in late 2021, Omicron hit and we entered a period of higher patient volumes, higher rates of staff absence due to illness or the need to care for ill family members, and greater social polarization. Some demonized health care providers as much as we had been celebrated earlier.
Pandemic fatigue, workload stress related to staffing shortages, long ED wait times, and abusive behaviour toward staff all contributed to a crisis in morale and an epidemic of burnout. Many physicians and nurses retired or left health care, or they found less stressful job opportunities that exacerbated the staffing exodus from EDs. In general, the shortages have been worse in small and rural hospitals than in larger, urban ones and among nursing staff. These factors led to waves of ED closures in small and even some medium-size EDs this spring and summer and to long wait times in larger EDs. Then, in fall 2022, a surge in respiratory viruses seemed to have been poised as the straw that could well have broken EDs’ backs.
Current challenges in the Emergency Medicine crisis
So, here we are with winter 2022 about to start. Infection prevention and control precautions related to COVID are ever present. We are facing a deluge of patients with influenza and respiratory syncytial virus. And we continue to struggle with crushing staff shortages, huge flow challenges, and seas of worried and sometimes angry patients and families.
To me, perhaps most disturbing of all is the fraying of the social safety net. Toronto, Ontario, where I live and practise, has grappled with addressing the needs of heartbreakingly large underhoused populations for decades. However, the numbers of patients I’ve seen recently who are on the streets as winter sets in, with shelters full; who are elderly, have chronic illnesses, have disabilities, are cognitively impaired, or have trouble accessing services in languages other than English; or are otherwise distinctly disadvantaged in trying to survive are unprecedented in my four decades in emergency medicine.
Where can we find hope for better times and reasons to carry on?
Coping strategies in the Emergency Medicine crisis
For me, an essential part of coping is situational awareness. On duty in the ED, we have to focus on the patient in front of us, but we also need to be aware of the overall ED context. As a possible diagnosis forms and a care plan takes shape in our minds, we need to consider the time of day, day of the week, and resources available to us. A general sense of the number of patients waiting to be seen and the time left in our shift will affect our approach; most of us were not surprised by the Predictors of Workload in the Emergency Room (POWER) study findings that indicated emergency physicians spent more time with patients when fewer were waiting to be seen . And in our current crisis in emergency services, while many of the day-to-day strategies are inherently local, knowing that our situation is shared broadly across EDs provincially, nationally and internationally—and in health care, generally—greatly informs my attitude [2,3].
For one thing, I don’t waste energy on anger. I’ve seen it exacerbate situations in EDs as some staff perhaps feel they sacrifice more than others or they blame their administration for the mess they are in. While individuals and administrations need to be held accountable, it’s a difficult time to be a health care administrator and most (if not all) hospitals are experiencing similar difficulties. From my observations, EDs that have been able to maintain cohesion and avoid the blame game are faring better.
Similarly, there is anger aplenty directed at governments, and much of it is truly understandable and perhaps justified. Still, the crisis is affecting provinces and territories in Canada with governments of different political stripes and ideologies, and internationally in systems as diverse as those of the United Kingdom and the United States. So, while I share this frustration I choose not to dwell on it, and that helps me stay focused and resilient.
I am also buoyed by the creative ideas and energy of my colleagues. In Ontario, eight years of advocacy have led to the development of a peer-to-peer physician support service for small and rural EDs where docs are in single coverage, similar to the Rural Urgent Doctor in-aid (RUDi) service in British Columbia [4,5,6]. We received approval this summer and called for applications for an inaugural leader of the service, resulting in many excellent applications. We had figured we would need about 20 ED physicians with specific skills to launch the service, and we wondered whether we would attract enough candidates with the background and personalities we sought. We should not have been worried, as we received more than 100 applications! To me, the response reflected the potential value of the service and the fact that, despite staffing shortages, emergency physicians remain remarkably committed to their discipline and their communities.
Uptake of virtual care exploded during the pandemic, but recently there has been concern about striking the right balance in terms of the proportions of overall care and financial resources that should be committed to it. This has been particularly contentious in Ontario. But I’ve seen some approaches developed and led by ED colleagues that are remarkably precise in adding value to a stressed system with constrained resources. Colleagues in Ottawa, Sudbury, and Hamilton have developed a pre-hospital model in which a physician is available in real time to support paramedics on the scene of 911 calls involving patients whose care may be managed appropriately with something other than a transfer to the ED, thus avoiding the risk of delayed transfer of care at overstretched EDs and the resultant tying up of scarce paramedic resources (Dr. Michael Austin, The Ottawa Hospital, email, December 8, 2022). Other approaches that seem especially promising to me are virtual consults for long-term care facilities and for follow-up with recent ED visitors, as both have the potential to reduce resource-intensive and disruptive transfers to the ED and avoidable return visits.
Another creative idea was brought to life by a colleague who almost single-handedly launched a program to provide marginalized patients with cellphones so they could be reached for follow-up appointments, informed of abnormal test results post-discharge, etc. It is a small but impactful strategy to improve continuity of care, reduce duplication of services, and enhance patients’ sense of dignity . Expanding the employment of peer workers with lived experienced relevant to our marginalized patients represents another potential game changer if we can organize and scale our programs.
The most stressful jobs feature the relative powerlessness of employees. We are better able to face substantial challenges when we have a sense of agency. Advocacy can give us that sense of agency—and by advocacy I don’t mean venting endlessly on social media (although that can have its place), but rather developing and supporting constructive strategies. Advocacy can be directed within your own ED, hospital, region, or beyond. You never know where a good idea might take root. As mentioned, it took me and my colleagues in Ontario eight years of advocacy to create a peer support program. So, I believe advocacy at one level or another is a critical component of a coping strategy in tough times like we face now.
Take home message
There has been tremendous focus on the staff we’ve lost, with seemingly endless news reports, social media posts, and profiles of individuals. Fair enough; we all grieve for the colleagues who have left and the skills and experience they took with them. Right now, I’m more focused on those who have stayed, despite everything. I often say I’d like to see just one headline before I die: “Emergency staff show up for work again today, continue to do their best under difficult circumstances.” What keeps us going? I think for most it’s the esprit de corps, the sense of shared mission, the pride of being part of a true calling that sustains us. The ED holds a special place in our societies as a modern-day sanctuary that is open to all. I’m proud to be involved in this noble calling and work with such committed colleagues. What keeps you going? I invite you to add your thoughts in the comment box below to share ideas and generate discussion.
—Dr. Howard Ovens, December 2022
- Dreyer JF, McLeod SL, Anderson CK, Carter MW, Zaric GS. Physician workload and the Canadian Emergency Department Triage and Acuity Scale: the Predictors of Workload in the Emergency Room (POWER) study. CJEM 2009;11(4):321-329. Available from: https://www.cambridge.org/core/journals/canadian-journal-of-emergency-medicine/article/physician-workload-and-the-canadian-emergency-department-triage-and-acuity-scale-the-predictors-of-workload-in-the-emergency-room-power-study/8A303E1E3D72C02F0DE7FAA4D575DBB7. Accessed December 11, 2022.
- Summers L. Why we should worry about what is happening in A&E. BBC News. December 6, 2022. Available from: https://www.bbc.com/news/uk-scotland-63859908. Accessed December 7, 2022.
- Janke AT, Melnick ER, Venkatesh AK. Hospital occupancy and emergency department boarding during the COVID-19 pandemic. JAMA Netw Open. 2022;5(9):e2233964.
- Emergency Department Peer-to-Peer Program. Toronto, ON: Ontario Health; 2022. Available from: https://www.ontariohealth.ca/providing-health-care/clinical-resources-education/emergency-peer-program. Accessed December 7, 2022.
- Rural Urgent Doctors in-aid (RUDi). Vancouver, BC; BC Emergency Medicine Network. Available from: https://www.bcemergencynetwork.ca/rtvs/rudi/. Accessed December 7, 2022
- Rabski-McColl A. Moose Factory hospital finds success in peer support program. December 15, 2022. Available from: https://www.timminstoday.com/local-news/moose-factory-hospital-finds-success-in-peer-support-program-6234823 . Accessed December 16, 2022
- Free phones dialing up health equity for vulnerable people. Toronto, ON: University Health Network. April 17, 2020. Available from: https://www.uhn.ca/corporate/News/Pages/Free_phones_dialing_up_health_equity_for_vulnerable_people.aspx. Accessed December 7, 2022.