Emergency rooms across Greater Toronto are failing to meet acceptable wait times for patients to see a doctor in critical cases, the Star has learned.

Only about 10 per cent of emergency room patients in the Toronto-area health networks deemed to be at the second-highest priority level — conditions such as a severe asthma attack or drug overdose — were seen by a doctor within the recommended time frame of 15 minutes, according to data for the 2014-2015 fiscal year obtained by the Star from the Canadian Institute for Health Information.

In Ontario, triage nurses are mandated to use the five-tiered Canadian Triage and Acuity Scale (CTAS) as a tool to prioritize patients’ needs. Patients with life-threatening conditions — triage level 1 — are to be seen by a doctor immediately. According to the guidelines, levels 2 through 5 are assigned time frames ranging from 15 minutes to two hours. Data for level 1 patients was not available because the “immediate” time frame is not defined in minutes.

The CTAS wait times were established 18 years ago by the Canadian Association of Emergency Physicians, based on what emergency experts would want for themselves and their family. The guidelines are updated every two years.

“The basic issue here is that, given the state of crowding, the CTAS time intervals are not being met,” said Dr. Alan Drummond, a former head of the Canadian Association of Emergency Physicians. “That should be no surprise.”

Some of the top emergency room doctors are distancing themselves from the guidelines, which they describe as “ideal” and “unrealistic,” while others argue their inability to meet them signals a need for fundamental change in the health-care system.

Lawyer Amani Oakley argues CTAS exists so patients, no matter how busy an ER, can be properly prioritized and seen by a doctor within a safe period of time.

She represents a woman suing a Mississauga hospital for negligence after a client lost parts of her fingers and toes following an extended wait in the ER.

“If a patient needs to be seen in 15 minutes and doesn’t get seen for half an hour, that may be understandable,” she said. “But if you’ve got an illness that needs treatment in 15 minutes, and you don’t see a doctor for hours and hours, you’re obviously at a very high risk of having your condition worsen, with terrible consequences, including death.”

The Star’s findings show little progress has been made in shortening the time it takes to first see an ER physiciansince the release of a damning 2010 report by auditor general Jim McCarter. His in-depth look at three hospital ERs, two of them in the Greater Toronto Area. found that level 2 and 3 patients sometimes waited for more than six hours after triage before being seen by an ER doctor instead of the recommended 15 to 30 minutes.

Although ER physician assessment times in Ontario’s 128 hospitals are reported monthly to the health ministry, the statistic is not published on the province’s emergency room wait times website.

Dr. Howard Ovens, chair of the provincial emergency care expert panel, stressed that although CTAS is useful for categorizing patients, the times are not targets but “aspirational goals.”

Ovens supports the position of the emergency doctors’ association that hospitals across Canada should adopt a median target wait time of one hour for all patients.

Toronto’s Lorena Reinoso is suing Mississauga’s Credit Valley Hospital, doctors and some emergency room staff for at least $2 million, claiming the wait was a key factor in what became a seven-month medical ordeal.

Reinoso says she was warned by a specialist to visit the ER if her serious eye infection worsened. So, at 3:30 a.m. on Dec. 24, 2007, Reinoso checked into Credit Valley, according to a statement of claim she filed in Ontario Superior Court.

According to the claim, Reinoso complained of a fever and swollen right eye, looked pale and felt on the verge of fainting. A triage nurse assessed her as a level 2. Despite a recommended wait time of 15 minutes, hospital records filed in court show she waited 4.5 hours to be seen by a doctor.

Her lawsuit alleges this delay was a key hospital failure that resulted in the development of septic shock, respiratory arrest, multi-organ failure and gangrene. She required three separate amputations. Doctors cut off her toes, parts of her feet and the ends of fingers on both hands.

In its statement of defence, the hospital denies the allegations and states that “at all material times it provided reasonable hospital and nursing care to (Reinoso) in accordance with accepted hospital and nursing standards.” The hospital denies “there was any breach of duty, want of care or negligence on its part or … its employees” and asks for the lawsuit to be dismissed with costs.

A trial date has not yet been set.

“Have you ever seen museum displays of (Egyptian) mummies?” Reinoso told the Star in an interview. “Those were my hands, my feet … they had turned dark, dried and black, and the nails … they were so white.”

At 52, she says, she uses a cane to walk, no longer works, and has trouble doing simple tasks, such as brushing her teeth or doing up a button.

“I’m not the type who stays at home; I’ve never been on social assistance … I was a proud person,” she said in an interview, her eyes welling with tears. “Now, I depend on others.”

“She had an infection. It should have been recognized and treated right away,” said Oakley, her lawyer, who specializes in medical malpractice law.

Ontario was one of the first provinces to mandate that emergency departments adopt the CTAS system. That was in 1999, a year after the death of Kyle Martyn, a 5-year-old who died after waiting three hours for a doctor in a crowded emergency room at Credit Valley Hospital.

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Ovens, director of the Mount Sinai Hospital emergency centre, argues that the Star’s data doesn’t account for when, or how often, a nurse provides care ahead of the doctor’s first contact with a patient.

In Reinoso’s case, hospital records filed in court show she was visited by a nurse once during the 4.5 hours she waited for a physician. According to the guidelines, she should have been seen by a nurse 12 times in that time period.

In an emailed statement, a Ministry of Health spokesperson said the province is investing $94.5 million in 2015-2016 in the Pay for Results program. High-volume emergency departments are ranked and scored against their peers on five indicators to earn funding through the program, one being the time it takes a doctor to see a patient.

The province also said it continues to work with Local Health Integration Networks (LHINs) “to ensure hospitals are providing the right care, to the right person, at the right time.”

While Ontario has invested hundreds of millions of dollars in reducing the overall time patients spend in the ER over the past six years,Drummond warns the province still has a long way to go.

Four high-profile deaths that raised awareness or led to changes in emergency care in Canada.

Kyle Martyn, Mississauga (February 1998)

Five-year-old Kyle Martyn died on Feb. 12, 1998, of toxic shock at Credit Valley hospital in Mississauga. The feverish child waited three hours until being seen by a doctor but by that time he had gone into toxic shock related to the streptococcal “flesh-eating” disease.

The death had a profound impact on the province’s emergency rooms and raised concerns about recent cuts to health care funding. Ultimately, Martyn’s death prompted Ontario hospitals to replace its three-tiered triage system with a five-tiered approach called the Canadian Triage Acuity Scale (CTAS).

Joshua Fluelling, Toronto (January 2000)

A coroner’s inquest into the death of 18-year-old Joshua Fluelling led to Ontario’s formal adoption of a patient priority system. Emergency departments were no longer allowed to turn away ambulances with critically ill patients if they were busy.

The Toronto-area teenager died of a severe asthma attack after his ambulance was redirected from Scarborough Grace Hospital to Markham-Stouffville Hospital. On route to Markham, Fluelling suffered respiratory failure and brain damage. He died later in hospital.

Following the high-profile death, Ontario’s ambulance services would begin using the hospital’s Canadian Triage Acuity Scale to identify patients’ priority and better communicate with emergency dispatch and doctors.

Patricia Vepari, Waterloo (February 2005)

Patricia Vepari was a third-year chemical engineering student at the University of Waterloo when she visited a Kitchener hospital with a high fever, sore throat and nausea.

According to media reports, the 21-year-old was told she faced an eight-hour wait in the crowded emergency room. She returned home, where she died two days later from meningococcemia, a virulent bacterial infection.

Brian Sinclair, Winnipeg (September 2008)

The final report from the inquest into the death of Brian Sinclair found the 45-year-old “did not have to die.” Hospital security footage recorded the double amputee’s 34-hour wait in the Winnipeg Health Sciences Centre’s emergency department waiting room, where he died of a treatable bladder infection. When he was discovered dead, rigor mortis had set in. The report, released in late 2014, made more than 60 recommendations for the Winnipeg Regional Health Authority.

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