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The number of "medical incidents" - hospital jargon for treatment errors - has spiked, said the nurse, who agreed to be interviewed on condition that his or her name not be published for fear of reprisals. The nurse said the hospital has prohibited stafffrom speaking to journalists about problems in the ER. In perhaps the most glaring case, a patient who was "gushing blood" arrived by ambulance in the ER and was supposed to undergo a transfusion immediately, but the blood supply was not ready even though it had been ordered in advance 30 minutes earlier, the nurse said. The girl ended up dying because of the severity of her injuries, not the delay in receiving the blood transfusion, but the case nonetheless illustrates the risks involved, the nurse added.

A second source described other "botched" cases, including a boy with a badly fractured femur "who sat in the ER for (eight) hours without it being set until someone actually looked at the X-ray." The are multiple causes for the problems, said the ER nurse and the second source - a lack of staff and unfamiliarity with the new medical equipment, lab technicians who haven't been trained in processing pediatric blood samples, and glitches in the facilities. And all those problems have occurred amid cost-cutting imposed by the provincial government.

"It's a zoo, it's dangerous," the ER nurse told the Montreal Gazette. "Before we moved in, we were told three things: the new ER was going to be more patient-centred; the doctors, nurses and clerks would be working better together; and it was supposed to be more comfortable. I haven't seen any of those things. Nobody works together because we're all preoccupied with our own things. We're running around like dogs. For me, it's falling apart. Patients' lives are in danger."

Officials at the Montreal Children's denied that lives are in jeopardy, but acknowledged that there have been problems in the processing of lab samples, some staffing shortages as well as glitches. At the same time, the medical team has been treating an unseasonably high number of patients with serious illnesses, said Dr. Harley Eisman, director of the emergency department. "I think we all recognize that moving to a new house is a big deal for everybody, and actually, our emergency department has had some significant cases," Eisman said. "We've dealt with many sick children over the past couple of weeks. We've had pretty brisk numbers as well. It hasn't been a quiet summer for us."

Lyne St-Martin, nurse manager at the Children's ER, said although "we have occasional shortages (of nurses), for the most part our quotas are met and our nursing staffis rather stable." Still, St-Martin warned that staff and patients will have to make adjustments for months to come at the Glen site, following the Children's move there from its old address on Tupper St.

"I do want to highlight that we transitioned three months ago, and that in speaking to other hospitals that have actually moved as well, they spoke about a one-year transition time where there is a very steep adaptation, and it will continue for several months to come," St-Martin said. "So none of this is surprising." Among the problems identified by the ER nurse:

At one point, water started pouring from a pipe in the ceiling of one of the treatment rooms. Staff closed the room and protected the medical equipment, but the leak hasn't been repaired yet. In the meantime, staffcan't use the sinks in the adjoining rooms to wash their hands. Eisman said there are other treatment rooms available and the ER flow hasn't been hampered. An emergency psychiatric room for agitated adolescent patients - some of whom are suicidal - has a bathroom that locks from inside and can't be opened by staff, the nurse said. There have been two cases where patients locked themselves in the bathroom and security was called but the guards arrived late. Eisman said that there is now a protocol in place to post a guard next to the bathroom in such cases. He added that glitches like the bathroom lock are being addressed quickly, although some parts are on back order.

Some of the lab techs, who used to work at the old Royal Victoria Hospital, have not been trained fully to process blood samples for children, resulting in delays as long as four hours for medical issues that must be addressed immediately, the nurse said. Eisman responded that "when we opened we certainly raised issues about lab performance. We opened a line of communication with the lab and were immediately on it and the lab performance has improved dramatically."

The Children's ER is consistently understaffed by nurses, and yet more than a dozen have not yet been fully trained to perform all tasks in the department, and there have been delays "in working up infants for signs of meningitis," the nurse said. What's more, many ER nurses are assigned to accompany patients on other floors, resulting in longer waits for emergency patients. As a consequence, frustrated parents have ended up shouting at nurses in the ER. Some of the nurses have reacted by seeking solace in the bathroom and crying in private for up to half an hour.

St-Marin said the ER nurses have been trained to deal with parents who are in crisis, and added "that our numbers show that (patients) are not waiting longer. In fact, we're tending to our sicker patients faster." She did not cite any statistics. The ER nurse accused the McGill University Health Centre of mismanagement, saying it had been planning the Montreal Children's move for years but has not trained staffproperly in using some of the new equipment. For example, some X-ray technicians continue to use portable X-ray machines rather than the new equipment in the ER. The MUHC has also balked at paying nurses to work overtime, yet the ER has ordered great quantities of rarely-used IV filters at $500 a box that sit mostly unused on shelves, the nurse added. aderfel@montrealgazette.com twitter.com/Aaron_Derfel

In Quebec last year there were 3.4 million ER visits, including 2.3 million ambulatory and 1.1 million non-ambulatory patients. (Canada-wide, it's 14 million visits, with roughly the same two-thirds, one-third split.) According to Quebec's health and welfare commissioner, the ambulatory spend, on average, 4.6 hours in the ER. Almost all are discharged home, none the worse for wear (and waiting). The non-ambulatory are a different story. The true emergencies, the trauma cases that are a mainstay of prime-time TV, have an average wait time of fewer than 10 minutes from the time they hit the ambulance bay. Perhaps we should take some comfort in that, but these "code blue" cases make up fewer than 1 per cent of patients. Most people who come to a hospital emergency department by ambulance will be triaged and treated relatively quickly, but then they will wait. These non-ambulatory patients, most of them frail seniors with chronic conditions like COPD or heart disease, wait, on average, 18.4 hours in the ER. Remember, that's an average; waits of 24 to 48 hours are not uncommon. We stick them in hallways, behind curtains or in transformed broom closets.

The commissioner estimates that 60 per cent of patients who go to the emergency room should not be there at all. They should be treated in primary care, by physicians or nurse practitioners. But lots of people don't have a regular doctor and very few of those who do can get same-day appointments for urgent (but not emergency) problems. Healthy people wasting a few hours in the ER waiting room is not, in the grand scheme of things, a big deal, though it doesn't make for good continuity of care. The real worrisome situation is that of the non-ambulatory patients stuck in ER purgatory. Some of the gurney-bound are waiting for a hospital bed, but only about one-third are admitted to hospital. Beds are in short supply because there are many frail seniors already stuck living in hospital with nowhere to go for lack of home care or longterm care beds. The majority of elderly ER patients have the same dilemma: They're not sick enough to be hospitalized, but too sick to go home alone, or back to a nursing home where there is no medical care.

It's a perverse scenario that plays out daily and with increasing frequency. But we know the solution. We don't need bigger ERs. We need to shift resources from hospitals into primary care for the ambulatory and home care and community care for the non-ambulatory. Until we do, our parents and grandparents will continue to fill emergency departments and fester in hospital hallways, gasping for care.

emergency-room doctors and patient advocates blast the policy as potentially harmful to patients

the consumer group Families USA, said the tactic lets hospitals turn away uninsured patients who often fail to pay their bills and are a drag on profits.

There is no data on how many who leave the ER without treatment follow up with visits to doctors’ offices or clinics.

“It seems the point of the policy is to put a financial barrier between the patient and care,” said Anthony Wright, executive director of Health Access California, a consumer advocacy group

The U.S. Centers for Disease Control and Prevention says that about 8 percent of ER visits are for non-urgent problems that could be treated less expensively in a doctor’s office or clinic

Hospital officials say the upfront payments are a response to mounting bad debt caused by the surge in uninsured and underinsured patients, and to lower reimbursements by some private and government insurers for patients who use the ER for routine care. In the past year, for instance, Iowa, Tennessee and Washington state reduced or eliminated Medicaid reimbursements for those visiting ERs for specified non-urgent conditions, such as sore throats or warts.

The HCA payment policy excludes children 5 and younger, pregnant women and those 65 and older.

the company owns more than 160 hospitals in 20 states

Other large chains that have followed HCA’s example include Florida-based Health Management Associates and Franklin, Tenn.-based Community Health Systems.

The upfront payments for non-urgent ER visits are also used by nonprofit hospitals.

the 320-bed hospital has seen a 10 percent drop in people visiting the ER with non-emergencies and a big drop in bad debt

One year after Dr. Parks’s letter was leaked, the government claims the ER wait times issue is under control.

Should we believe the hype?

In October 2010, local media published a leaked letter from the province’s chief emergency room doctor to Health & Wellness Minister Gene Zwozdesky and other government officials warning of “catastrophic collapse” if immediate action wasn’t taken. The letter was written by Dr. Paul Parks, president of the Alberta Medical Association Section of Emergency Medicine

Dr. Parks started to collect examples of substandard care and “adverse events” caused by overcrowding in the ER

When the letters and reports were eventually leaked to the media in 2010, they launched a firestorm.

It’s common to have five-plus EMS units and their medics tied up for hours while they wait for an ER stretcher to be freed up so that they can download their patient and get back on the streets

The situation has gotten so out of hand that we now have patients calling 9-1-1 from the ER

ER was overcrowded because hospitals were overcrowded

A study in the British Medical Journal found that patients whose ER wait times were six hours or longer were more likely to suffer an “adverse event,” such as the need for hospital admission, or even death.

Dr. Parks estimates that Alberta’s large-volume hospitals are still hovering at around 30 per cent of beds occupied by patients waiting to be admitted—meaning that those hospitals are still operating at well over capacity.

Dr. Parks, ER doctors were clear from the beginning of this crisis that the issue of overcrowding in emergency was due to downstream capacity problems, mostly a lack of long-term-care beds in nursing homes.

despite our vast wealth, Alberta has fewer hospital beds than the Canadian average.

The same situation exists for long-term care, where Alberta’s number of beds per capita falls below the national average. But don’t think the province makes up for this by supporting those folks in their homes. Alberta also sits close to the bottom of provinces for home-care spending.

the government opened 360 new hospital beds in Edmonton and Calgary in 2011. It announced plans to open 5,300 new long-term care beds by 2015 (1,174 of them were ready by April 2011), to make additional investments in home care (800 new clients in Edmonton and Calgary) and to improve patient discharge planning. It also announced a five-year plan that includes a primary-care focus

But there’s no plan to increase full long-term care, nursing homes and auxiliary hospitals. This is the category of care that is most needed to take pressure off our hospitals

He also says that even if beds are created, they may not match the needs of hospitalized patients, because of the lower levels of nursing support and the high personal cost for the patient and his family. “Indications are that the private, for-profit care model may actually create barriers to moving patients out of hospital beds,” he says.

One prominent rural ER physician in Ontario rejected the notion that his province's departments are inferior, saying the focus is more on sending the sickest patients to big trauma centres. Across the country, however, wide variations in emergencydepartment standards definitely do exit, said Alan Drummond, a spokesman for the Canadian Association of Emergency Physicians. "It's a crapshoot, when you go to any hospital in this country, in terms of what you're going to get in the type and quality of care," he said. "We have national variability and for 23 per cent of Canadians (who live outside cities), that's unacceptable." About 6 million Canadians live in rural areas, tend to be older on average, have greater health needs, and are more likely to suffer traumatic injury, partly due to the prominence of dangerous professions like farming and logging.

Fleet became interested in the relative quality of emergency service after cutbacks meant his former hospital in Nelson, B.C., could offer only "bare-bones services to a high-risk population." He lobbied for additional funding, but realized there were no published data comparing different Canadian emergency departments. In the most recent study, just published in the journal PlosOne, he and colleagues looked at rural departments with 24/7 service and an ability to admit patients to acute-care beds in their hospitals - 26 facilities in Quebec and 62 in Ontario. If anything, the Ontario ERs appeared more isolated on average, with a greater percentage of them being at least 300 kilometres from a trauma centre.

Yet 92 per cent of the Quebec emergency departments had a local intensive-care unit, compared to 31 per cent of the Ontario ones. Just over 80 per cent of the Quebec ERs had a general surgeon available on call, versus a third of the Ontario emergency departments. Fleet said he is not sure why Quebec's rural ERs are better equipped, given the provinces' spending on health care is similar per capita. It may relate to the fact its rural hospitals have fewer foreign-trained doctors, who may feel less empowered to demand better facilities. But Drummond said Ontario has a different protocol that ensures rural ER physicians are well-trained to provide basic emergency services - such as treating shock and blocked airways - and emphasizes funnelling critically ill patients to trauma centres in larger cities. The province's CritiCall system helps rural hospitals find facilities that can take their patients.

However, he agreed that having a CT scanner is now crucial to emergency departments anywhere making accurate diagnoses; the one his hospital in Perth, Ont., acquired five years ago "changed the way we practice." Just nine of 62 full-time rural Ontario departments had a CT scanner, according to the new study.

P.E.I

Saskatchewan

Now, it’s spreading to other provinces

For Nova Scotia, this began in 2009, when the government sent Dr. John Ross — its advisor on emergency care and a respected emergency room physician — to tour the province’s ERs. His 2010 plan, “Better Care Sooner” found only about 2% of patients going to rural ERs had real emergencies.

Cutting the night shifts in some hospitals, he said, would allow doctors to run more clinic hours.

If you lost the physician, you lost the coverage, so the emergency room just closed.

Now, Mr. Wilson said, patients can get appointments on 48 hours notice, when previously some had to wait five weeks to see a general practitioner.

at the CECs, a doctor, or group of doctors, still cover the busy 12 hours a day. At night, paramedics and nurses are able to treat many of the patients, and are able to quickly transport anyone critical to the nearest full-service ER.

“[If] it’s simply because of a doctor shortage, I really don’t think this is acceptable at all,” Dr. Affleck said. “You need to find the appropriate doctors to staff a true emergency department, if that is what the issue is.”

Mr. Wilson, though, said he is confident in the province-wide paramedic dispatch, which can quickly triage the call and determine whether a CEC or full ER is required.

Manitobans should hope for cuts, in the right places. Patients in Manitoba suffer longer wait times trying to see a doctor in the ER than in almost all jurisdictions across Canada. The numbers have been repeatedly crunched by the Canadian Institute for Health Information, a national health-care analysis agency. Manitobans wait, on average, 5.7 hours in the ER, compared with the national average of just over three hours. Repeated interventions and promises to cut queues here have failed and the lines are growing longer.

But that might have been expected, since data also show that more patients who need admission onto medical wards are lying in wait in the ER, because (for example) there aren't enough nursing home beds for elderly people ready to be discharged. This may explain why the NDP government's strategy to open quick-care community clinics has not eased the pressure on emergency rooms.

And despite the addition of hundreds of millions of dollars more in the health budget, Manitobans are still waiting too long for services such as knee replacements, ultrasounds or MRIs that are key to getting in to see a specialist and then get surgery, months down the road.

There is room to cut costs in government and public services, to use money more efficiently in smarter ways -- Manitoba spends more per capita, and as a share of its GDP, on health than most provinces. Yet, Mr. Pallister, an MLA in the cost-cutting days of the Filmon era, has chosen to tiptoe around the idea of cutting government expenses in the areas of health and education. He has said no frontline workers will lose their jobs, but that still leaves a lot of room for change.

Manitoba hospitals are run and funded much the way they have been for decades, which suits the institutions' needs, not those of patients. Budgets, for example, are funded basically to match hospital spending in the previous year, with a bit more for inflation or for new programs. Other jurisdictions with as good or better systems (including those in Canada) have moved to tie budgets instead to the volume of services delivered. This helps spur innovation that puts patients at the centre of service. Further, European countries, outperforming Manitoba and Canada's medicare system for quality and cost, have universal systems that blend private and public funding.

The fear of private health care is almost palpable in Canada because Canadians can't see past the U.S. model, which sits next door like an elephant waiting to roll over. But Canada has more in common with, and more to learn from, the European experience, where social-welfare systems are equally strong and tied to national identity.

Mr. Selinger's sacred-cow analogy means he will milk the scare tactics to death. Manitobans need a better prescription for what ails our health system. It's up to opposition parties to start talking about that.

Yet there is no guarantee that a hiring blitz will improve things, particularly because hospitals are releasing elderly patients faster than ever.

This is why Halifax, and its Extended Care Paramedic (ECP)Extended Care Paramedic (ECP) program, is so important.

Here, a paramedic — trained in the health needs of seniors — is assigned to a nursing home.

And because of this, in the areas it is practised, ambulances are able to meet the U.K. standard call response time of eight minutes in the vast majority of cases. In Canada, nine minutes is the benchmark for cities but this is often missed.

What is also important is that the ECP program has not required an extra infusion of money. Instead, the system was simply reorganized to give existing paramedics a new responsibility.

While impressive, this is only a pilot project, one that is based on a long-standing policy used in the United Kingdom, and the city of Sheffield in particular

The results proved so successful that an expanded program is now used throughout the U.K.

As a result, well over half of those seen are not sent to the emergency room or even the hospital.

The presence of a paramedic onsite means that calls which once led to emergency rooms visits — falls, wounds and issues relating to palliative care are prime examples — are now dealt with at the nursing home

As for costs, here, too, reorganizing the system rather than hiring a vast number of new staff has helped keep expenses in check. In fact, because emergency room and hospital admittances are down, money has actually been saved.

The main reason for these counter-intuitive reactions to increased demand is the way hospitals are funded. As in most of the rest of Canada, hospitals in Quebec currently receive their funding in the form of global budgets based essentially on the amounts they spent in the past. This kind of lump-sum funding leaves hospitals with a tough choice: Limit admissions or go over budget. There is no incentive for hospital administrators to innovate and become more efficient, since an innovation that reduced expenditures would lead to an equivalent decrease in the hospital's next budget. On the other hand, an innovation allowing wait times to be reduced and more patients to be treated entails increased pressure on the fixed budget.

Almost all other industrialized OECD countries fund their hospitals to a large extent based on services rendered. With such activitybased funding, hospitals receive a fixed payment for each medical procedure, adjusted to take into account a series of factors like geographic location and the severity of cases. The more patients a hospital treats, the more funding it receives. Generally speaking, in countries where activity-based funding is widely used, there is more competition between medical facilities and quicker access to care. Health Minister Gaétan Barrette has said that the Quebec government wants to adopt activity-based funding for medical facilities in the health network. This would make a lot more sense than demanding that MUHC doctors refer oncology and ER patients to other hospitals, as the Health Ministry is currently doing.

But getting rid of Quebec's anachronistic funding of its hospitals through global budgets, while a step in the right direction, should be accompanied by other, complementary measures such as mandatory quality reporting for hospitals. Giving patients and referring doctors access to the information they need in order to determine the best hospital for each case would allow for some healthy competition, leading to quality improvements throughout the system, as has happened in Germany in recent years.

If Brian Day's constitutional challenge now being considered by the British Columbia Supreme Court is successful, two other European measures could also come to Canada: allowing a market for private insurance to develop, and allowing doctors to practise both in the public sector and in the private sector.

International experience confirms that the presence of a mixed health care system is not incompatible with health care services that are accessible to all. Indeed, such measures could improve access to health care by encouraging entrepreneurship without undermining the principles of equality and universality that Canadians hold dear. Jasmin Guénette is vice-president of the Montreal Economic Institute.

ER wait times could be significantly reduced by revamping provincial and municipal housing policies, rewriting provincial and federal taxation codes, initiating programs for middle-class families (and corporations) that encourage universal design retrofits and by rewriting bylaws that alter traffic and parking arrangements for disabled permit holders.

Chloe Atkins is an associate professor and interim director of graduate programs in the department of communications and culture at the University of Calgary.

the risk in emergency departments themselves, even if you actually haven't been on a hospital ward

The paper suggests long-term care facilities might consider using infection control precautions for five to eight days after a resident has been to the emergency department.

September 2008.

Brian Sinclair's death

By the time Sinclair was discovered lifeless, he had been dead for at least a few hours and rigor mortis had set in. He was rushed into the resuscitation room, but was declared dead within a minute.

Sinclair died from a treatable bladder infection caused by a blocked catheter. Manitoba's chief medical examiner has testified Sinclair needed to see a doctor for about half an hour for a simple catheter change and a prescription for antibiotics.

The inquest has heard the emergency room was overcrowded and short-staffed — operating without a key triage nurse — when Sinclair came in seeking care.