Overcrowding at the province’s largest emergency department is becoming more common. Patients wait up to 12 hours in the Halifax Infirmary hallway, dubbed “Ambulance Alley.” Paramedics spend entire shifts there, unable to respond to calls. Physicians sometimes see patients in those hallways. This week, StarMetro Halifax talks to people on the ground in a series we call Code Crisis.

HALIFAX — Dr. Kirk Magee doesn’t like to use the word “crisis” to describe the overcrowding at the Halifax Infirmary.

That’s because he doesn’t want people to think they won’t get quality medical care when they need it. But he also believes the situation needs to be named.

“It feels almost like we’re at a tipping point,” Magee said. “As the problem has gotten worse over the years, you begin to almost accept that this is the new normal. It’s tough to change the path of a boulder that’s rolling down a hill once it gets going. That’s kind of what the overcrowding issue is.”

In Day 1 of this series, StarMetro went inside one of the worst days in recent memory at the Infirmary, when patients and paramedics packed the corridors for hours on end as they waited to be seen. As the largest and busiest emergency department in the region, patients come not only from Halifax and surrounding communities but from throughout the province.

“The reality is that internal medicine, which probably is our biggest stakeholder, is frequently running at 105 to 110 per cent of capacity,” Magee said, noting that most studies suggest in-patient units need to operate at 85 to 90 per cent capacity to handle spikes in volume. “It’s hard to squeeze blood out of a stone.”

But the overcrowding problem isn’t unique to the Infirmary, and it harms doctors and patients alike.

“Physicians find it very difficult because they’re often practising in a way that they weren’t originally trained to practise. They’re seeing patients in hallways, seeing patients in family rooms, seeing patients on benches,” Magee said.

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In addition to his work at the Infirmary, Magee’s other roles provide insight into the challenges facing emergency department physicians across the Halifax region. He’s interim chief for the central zone network of emergency departments for the Nova Scotia Health Authority and also serves as interim head of Dalhousie University’s department of emergency medicine.

The province’s aging population means more older patients with complicated medical problems are showing up at emergency departments. Magee said they often bring with them social issues that are challenging to deal with in that environment.

“Someone will come in and maybe they have pneumonia, which is something we’re all very comfortable treating, but that person coming in also has multiple other medical problems and that pneumonia means they can no longer live independently,” Magee said.

“So you’re trying to arrange all the social supports, and then you throw in the fact that maybe their partner is just as frail and maybe they’re the main caregiver and it really compounds the problem.”

Magee said those who can’t be discharged to their homes or to an appropriate facility back up into the emergency department.

“It means we have a lot of boarded patients, so a lot of patients that are admitted but can’t leave the emerg, and that means we don’t have the space to see new patients that are coming in,” Magee said.

“Overcrowding begets more overcrowding, and the problem gets worse and worse.”

One short-term solution, Magee said, would be to implement surge protocols. When in-patient floors near capacity at the Halifax Infirmary, for example, staff will begin to release people who can be safely discharged a little early.

“When that fails, and the emergency department begins to back up, there’s the need for an overcapacity protocol so that when certain targets are reached, patients are moved out of the emergency department onto in-patient units,” he said.

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“At the NSHA there is a working group that is working on a provincial-wide NSHA overcapacity protocol. That is encouraging, and I would say it’s much needed.”

Magee said the lack of emergency physicians is also a nationwide predicament, one “that’s only going to get worse with time.”

In June 2016, the Collaborative Working Group on the Future of Emergency Medicine in Canada released the results of a report commissioned to examine human-resources issues in emergency medicine. It also looked at the country’s emergency medicine training programs.

When the report was released, it noted that Canada had a shortfall of 478 emergency physicians in 2016.

If the country’s residency training position numbers don’t increase, the study projected the shortfall to rise to 1,071 emergency physicians by 2020. That number was expected to increase to a shortage of 1,518 emergency physicians by 2025.

“The current shortfall is equivalent to the student body of an entire Canadian medical school. This represents a very significant shortage, and if urgent measures are not taken ... the situation (will) become dire in five and 10 years,” working group chairman Douglas Sinclair said following the report’s release.

Magee said trying to get emergency physicians to come back to Nova Scotia is “very difficult,” in part because they’re compensated at a lower rate here than elsewhere in Canada.

“I can tell you at the Halifax Infirmary we are currently a little over four physicians short, which means that in order to cover the hours we have, physicians have to work basically overtime,” he said. “They have to give up family time in order to staff the department, and that model is not sustainable.”

It takes up to five years to train an emergency physician out of medical school.

“The longer we wait to implement that solution, the more behind the eight ball we get,” Magee said.

He said implementing more community resources — from long-term care beds to supports helping seniors stay in their homes as long as possible — could also help alleviate overcrowding at the Halifax Infirmary and elsewhere.

Additional funding, while needed, must come with clear accountability. Magee said the solutions are long-term and require follow-through.

“It’s not that today is necessarily 100 times worse than what it was last year, but with each successive year the problems do compound.... It makes it harder to implement solutions,” Magee said.

“The problem is so complicated and it’s gotten to such a degree that when the system does make changes and there are gains, the gains are relatively small compared to how it’s gotten worse over time — and that’s frustrating. It’s frustrating to people who work very, very hard.”

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