​Enough is enough: Time for Action on Pre-Hospital Care

Green Party leader, David Coon, described by many as a very thoughtful, insightful politician, got headlines recently in expressing shock and horror at the conditions he found in the DECRH Emergency Department when he went for treatment recently.  He described overcrowding, confusion, and very long waits in the Emergency Department.

In the fall of 2020, I was called to give some advice to people dealing with what turned out to be a tragic case in which the patient was misdiagnosed in emergency and sent home.  Shortly after that, I heard from another family with a similar story in which the results were staggering.

Then comes the Lexi Dakin, case in which a distraught teen was forced to sit in an uncaring waiting room for hours before she gave up and the rest of her story is sad history.

There was, just recently, the case of the young mother, having delivered a baby a few hours earlier, coming to the hospital with post-partum hemorrhage and told to wait.  She went to the Dumont, across town, and was cared for immediately.

A young mom arrives at Emergency with a child showing upper respiratory challenges.  Her direction was to wait in the car which she did, with a sick infant, for 6 hours, according to the report.

After the 12th trip to the hospital by ambulance for the same reasons in the space of less than a year, a person was deemed to need care that the hospital could not provide and, in that case, I had to intervene at various levels.  I’m retired but people know that I understand how the system is intended to work, not necessarily how it works! The calls take the form of: “help, what can we do?  How do we get care?” 

A 92-year-old lady with history of chest and breathing issues, arrives at the hospital mid evening and sits in the cold waiting room until nearly midnight.

It was reported on July 14, 2021 in the Telegraph Journal that the reduced hours in certain outlying emergency services (these are not rural) is placing a significant strain on Horizon regional hospital emergency services.

You can’t make this stuff up!  In recent months there have been public pleas from hospitals for the public to stay away from hospital emergency departments unless they are a legitimate emergency case. 

This is not some foreign impoverished country; it is a wonderful, beautiful province populated by some of the finest humans on the planet.  Our leaders have not stepped up to the plate for decades to see that this issue is fixed.  This is not new; the symptoms have been visible for years.  This in a province with a largely government-regulated and funded health care system which has more health professionals than other provinces.  It is not about resources!  It is about organization and focus.

What is the solution?  Actually, previous commentaries have referred to options but I was always taught that “if you can’t name it, you can’t fix it!”  Engaging in recruiting more doctors and increasing nursing class size are conversations that simply distract from the real issues.

What is the issue, you say?  Simply stated:  The Organization and Management of Pre-Hospital Care.  The symptoms will not go away until:

1. Emergency Departments are organized and managed to do what they are designed for:  care of those that present with ‘imminent danger to life or limb’.
2. Access to primary care services is fixed:
   1. All residents are either rostered with a family doctor practice or are rostered in a multi-disciplinary primary care clinic.
   2. Urgent Care Centres are developed and managed by the regional hospitals to provide service to the huge numbers of persons who show up at Emergency Department with non-life-threatening issues (said to be 80% of the volume of the emergency departments).  A unique funding model needs to be developed for integrated care practice in Urgent Care Centres.
   3. After hours clinics are eliminated in favor of structured, organized Urgent Care Centres.
   4. Seniors’ primary health care clinics where proper geriatric health care can keep seniors safe at home.

Political and civil service leaders who seek to lead this level of change will face stiff opposition because dealing with the symptoms has been kicked down the road by previous governments for decades.  After hours clinics and emergency departments shifts has become a way of life and seem, now, to represent a major portion of the income stream of a cohort of physicians.  After-hours clinics are sources of good income for physicians and good business for pharmacies that are co-located.  The last time I visited an after-hours clinic with my grandson, we were there for 3 minutes enabling the physician to bill something like $40.  So, if he saw 10 patients like us, that could total $400 per hour.  This represents an interesting and lucrative way to engage medical skills, earning good income while limiting, if not eliminating the pressures that an office practice presents for physicians.

But I think physicians and nurse practitioners, once they get accustomed to working in an Urgent Care Centre, one that is properly organized and managed based on best practices, would find it a very satisfying way to practice their profession.  Major benefits to the public would be much more efficient care, reduction/elimination of huge wait times, care integrated with health authority information systems, huge reduction in public complaints, much less confusion in emergency departments.

The very idea of patients and families having to sit for 6-10 hours simply to see a primary care practitioner is not a standard that could possibly be held up as acceptable.  In a proper Urgent Care Centre, the “time to care” should be no more than 15 minutes and in the emergency department, except in times of some disaster, “time to care” should not exceed 30 minutes.

Simply asking the health authorities to form a new committee or engage an old one is not helpful.  Asking the Department of Health to form a committee would be equally unhelpful.  No, this has gone on so long that new thinking is needed that will lead to serious change, not simply symptomatic relief.  There is nothing wrong with simply admitting:  we need to do something different here!  We do have great people in the system but the organization of the systems has simply perpetuated conventional practices.

I would look for someone (s) who have a reputation for running superb systems elsewhere and ask them to work with us for a while to get from where we are to where we need to be.  That could be someone from Ontario, BC, Virginia, Great Britain.  There are illustrations of systems that function better elsewhere.  Get a core of our good people and inject some new thinking in the form of someone(s) who manage for success and push to develop systems that require no apology but deserve praise.

Imagine going to Emergency and being triaged to an Urgent Care Centre staffed with Physicians, Nurse Practitioners, Social Workers, Mental Health intake personnel, Geriatric Nurses…. people who can ask the pertinent questions so that you aren’t back a few days hence with the same issues. 

Change is difficult, it requires political capital; those who resist the most are probably primary causes of mediocrity.  But two years from now, when time to care is consistently within best-practice guidelines, both professionals and the public will be happy that someone invested the political capital and energy to make it happen. 
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Ken McGeorge is a retired CEO in major teaching hospitals and long-term-care facilities. He was co-chair of the New Brunswick Council on Aging and is a columnist with Brunswick News and is the author of Health Care Reform in New Brunswick, available at www.kenmcgeorge.com;  His email address is kenmc1@bellaliant.net.