Forty doctors warn of ‘crisis’ at St. Joseph’s emergency department in Toronto

A formal shutdown of ambulatory care due to a lack of nurses. Patients on stretchers jammed into hallways for hours on end. No functional resuscitation area. A sick child unmonitored.

This is the picture of chaos over a July weekend painted by 40 physicians at St. Joseph's Health Centre's emergency department - one of Toronto's busiest.

In a letter to hospital management and the heads of Unity Health - the health-care network that includes St. Joseph's - the emergency doctors describe a system teetering on the brink as they express their grave concern" with a lack of nurses and beds in the department while pleading for help from Unity's leadership.

Our observation is that St. Joseph's Health Centre Emergency Department is in crisis. It cannot serve the vision of Unity Health," the doctors state in the letter, dated July 25, which was obtained by the Star.

The situation is a threat to patient safety, patient quality of medical care, and patient experience. We witness a demoralized, frustrated and burned-out staff. The department is routinely an unsafe space for professional practice as well."

The letter, which recounts disturbing events in the emergency department during the weekend of July 23-24, follows another letter written by many of the same doctors to hospital management in March expressing concern over nursing attrition.

It is out of respect for the nursing profession, and the crucial role it plays in the delivery of medical care, that we are expressing our concern. The quality, timeliness and compassion of our work as physicians is a direct reflection of nursing staffing," they wrote in the letter dated March 10. To be inadequately staffed with nurses who are familiar with our department is putting our patients at risk and is a risk to our community reputation."

Together, the letters serve as a warning of the imperiled state of Ontario's health-care system and a rebuttal of the official line coming from provincial Health Minister Sylvia Jones.

The minister has stated in recent days that despite the closure of emergency rooms in some 20 hospitals across the province over the past few weeks, the situation is not unprecedented and that to suggest the health-care system is in crisis is completely inappropriate."

Let's be clear: There is not a crumbling system in the province of Ontario. We have a very strong health-care system in Ontario," Jones told reporters last week.

Ontario Health reports that in June, patients waiting for a first assessment by a doctor in emergency waited 2.1 hours on average. The length of stay in emergency for patients waiting to be admitted to a hospital was, on average, 19.1 hours, down slightly from May's record of 20.1 hours.

In response to the issues raised in the doctors' latest letter, Unity Health told the Star that staffing shortages are the number one challenge" facing hospitals across the province and that the network is doing the best we can to safely manage in this very challenging time."

We are proud to have a culture where our teams advocate for their patients and colleagues because that is how we work together to create solutions," said Unity Health spokesperson Jennifer Stranges in an emailed statement. We acknowledge the pressures that our Emergency Department teams are under and we continuously work with them every step of the way to get through this together."

Our Emergency Departments are important safety nets for the communities we serve, and so it has been an all-hands-on-deck effort by all of our clinical and support teams to manage patient flow through our sites and across the system with our partners, to make sure they get the care they need."

The Star asked for an interview with Unity Health CEO Dr. Tim Rutledge, but the network said he was unavailable.

Stranges stressed that St. Joseph's is a safe place to come for urgent and emergency care" and that like all health-care providers, we're working as hard as we can to assure access to high quality care for our patients."

In their letter, after making a plea for acknowledgement and direction" from Unity Health leadership for the deteriorating situation" in the emergency department, the 40 St. Joseph's doctors go on to recount a number of scenarios they say confronted both patients and staff due to personnel shortages beginning July 23.

First, doctors were asked to fill in for nurses during the evening and overnight shifts, a circumstance the writers note would further demoralize nursing colleagues who would make much less for doing the same work."

Next, the hospital's Ambulatory Care Centre (ACC), also known as outpatient services, had to be formally shut down due to a lack of nurses. The doctors note that ambulatory care is the only place where they see the vast majority of newly arrived patients and that shutting it down effectively eliminated any actual working space or nursing staff dedicated to caring for patients presenting for emergency care."

The doctors note that, as a result, the entire emergency department was reduced to one to two beds for assessing new patients.

At the best of times, ACC is an unsafe place to practice medicine and nursing, and unsafe for patients. Yet even this last remaining corner in which we could offer care was closed on the evening of July 23-24, which posed an unprecedented challenge to physicians on duty."

The doctors add that even outside the weekend in question, ambulatory care is generally staffed by just two nurses who routinely manage between 50 and 60 emergency patients while any remaining nurses in the department care for admitted patients.

Adding to the challenges of that night, the emergency department's resuscitation zone was also closed due to a lack of nursing staff.

The lack of a functional resuscitation area in an emergency department is an institutional threat and portends a catastrophic patient outcome in the making," the doctors state bluntly.

At one point during the night, the doctors say, the nurse in charge appealed to a manager for EMS diversion, a strategy to reduce ER crowdedness by diverting incoming ambulances to other hospitals. The doctors allege the manager declined to take action and instead told the nurse to be creative."

This response is unacceptable," the doctors tell their bosses. We need more guidance and support from hospital leadership than to be creative with minimal to no resources."

The writers also highlight specific patient experiences on the night of July 23-24, including a child who was first assessed in the unmonitored, de-facto closed" ambulatory care area before being admitted. The doctors say that when the patient's mother saw what the doctors call the deplorable conditions" of outpatient care, she begged to be allowed to stay in ACC."

It is a condemnation that a parent's instinct told her that her sick child would be better served in an unmonitored and un-nursed area than to remain in a space designated for patient care,'" the doctors write.

They also note that more patients than ever before" were lined down hallways and that some were waiting to be offloaded from EMS stretchers for longer than their attending physicians' shifts, prompting this warning: EMS patients awaiting offload are where we suspect there may soon be a critical event or death, right in the ED itself."

The Ministry of Health would not comment specifically on the situation at St. Joseph's Health Centre, but spokesperson Bill Campbell said in an email that Ontarians continue to have access to the care they need when they need it."

He said the province has added more than 3,500 new critical care, acute and post-acute hospital beds and more than 10,700 health-care workers, including nurses and personal support workers, in addition to 762 internationally educated nurses.

We know more work needs to be done and continue to work with all partners, including Ontario Health and the 140 public hospital corporations, the regulatory colleges, and health sector unions, to address any challenges on the ground," Campbell added.

Cathryn Hoy, president of the Ontario Nurses' Association, said what the St. Joseph's doctors describe in their letter is indicative of the staff shortages and resulting problems at other Ontario hospitals.

She also said that simply throwing more nurses at the situation isn't a realistic solution, because if those nurses are inexperienced, they may not be able to handle every trauma coming into the emergency room.

Nursing builds on skill and also on specialties," Hoy said, noting that each experience is a building block for each different area that you work in. Having a heartbeat, a stethoscope and a pen does not make me an ER nurse, OR nurse. It's experience."

When asked what risks the situation described by the St. Joseph's doctors presents to patients, Hoy didn't skip a beat: People will die. It's that simple."

Kenyon Wallace is a Toronto-based investigative reporter for the Star. Follow him on Twitter: @KenyonWallace or reach him via email: kwallace@thestar.ca