Canadians deserve the very best in emergency care . Let's work to restore their confidence in the emergency health care system.

The Brian Sinclair Inquest: Random thoughts in the hope that his death was not in vain


Hospital overcrowding and access block in the emergency department has been an identified issue in Canada since the late 1980’s.
The problem became increasingly apparent and relevant to the emergency medicine community since the mid 1990s when provinces, perhaps in response to the decrease in transfer payments and perhaps on the false promise of a wellness dividend and that of improved access to better home care, slashed acute hospital bed capacity by approximately 30%.
This came at a time when the population started to get older and despite the best hopes of government, the wellness dividend of healthier Canadian never happened and home care never became a meaningful force.
As a result a further 20% of Canadian acute care hospital beds were further occupied by the so-called ALC patients.
Accordingly the cumulative effect was that 50% of acute care bed capacity was suddenly unavailable as a result of these twin forces at the exact same time as the baby boomer generation approached retirement age and the bed capacity was still required.
Regrettably Emergency Medicine was slow of the mark and didn’t respond until the beginning of this century.
As  a result, those who would perpetuate the myth of the “misuse”, “inappropriate use” and “overutilization” of the ED by patients with non-urgent problems had their way and all efforts at resolving overcrowding were quite  wrongly aimed at diverting patients away from the ER.  Of course, none of these efforts have worked, a case in point being the WRHA who have promoted this approach over the past 20 yrs to no avail.  
Thankfully research has finally caught up and there are now many good studies to show that there is no effect of the non-urgent patient on the issue of crowding and access block.
The issue is now known to be that of systemic issues that impede the flow of sick patients from the ER to the wards and ICUs creating a forced and unwelcome occupancy of ER stretchers by patients who need to be elsewhere.  No ER stretchers available = no flow through the department and crowded waiting rooms and delays in ambulance offloads.
Part of this is better management of chronic diseases and part of this is better access to quality home care.  That being said anybody who has ever tried to access home care quickly realizes that its a cruel joke played on the Canadian public.
It is a spectre and a phantom and is not meaningful.
The other part of is the realization that the public is getting older and not in any better health.  Bed capacity both acute and relative needs to be increased.  We need more expensive hospital beds, which can in part be achieved by more appropriate use of the beds currently available and we need more long term care beds.
We now know and in fact have known for years that the effect of crowding is not that of mere patient inconvenience but rather an increased risk of medical complications and death, increased costs to the health care system, system gridlock with ambulances unable to offload their patients and rural hospitals unable to transfer their patients for higher level of care.
Governments of all stripes have tried to “blame the patient” for crowding and suggest that they are abusing the system.
The reality is that the blame rests with governments who have failed to meet the moral imperative to solve crowding.
As the Sinclair inquest heard from Dr. Innes the problem can be solved.  We know the root causes ands we know the solutions.  We used to rely on international comparisons, such as the British who are able to meet treatment target times 95% of the time.
Now in Canada we have the positive experiences of both Ontario and Alberta where real progress has been made.  There simply is no excuse anymore for any provincial government in Canada not to adopt the best practices of Ontario, Alberta and to a certain extent BC to resolve what must be resolved.
Dr Innes has put forth his prescription but in the fall of last year the Canadian Association of Emergency Physicians put forth a guideline to address crowding and therefor there is no reason  why these measures should not be adopted so that we can, as a nation, adopt best practices and put this historical anomaly to rest. 
Unfortunately, provincial governments seem to hesitate to develop their emergency service proactively.  I’m not sure if this as result of a culture of mistrust of health care practitioners or whether its dollars and cents. 
So if governments don’t plan how are advances made in Canadian emergency health care. how is it done?   Regrettably, it seems that far too many Canadian advancements have been made on the basis of coroner’s inquests and adverse publicity on high profile events.
The death of Kyle Martyn in Mississauga forced the Ontario government and subsequently other provinces to adopt the CTAS guidelines where before they had been relucatant to do so.  The inquest into the death of Joshua Fleuelling led to the end of the practice of ambulance bypass.  The death of Claude Dufresne in Quebec forced the government to act on rural staffing of ERs and the Ontario death of Stella Lacroix forced the Ontario government to introduce Critical care hotlines.
There have been an number of anecdotal press reports of deaths in Canada related to Crowding (Pat Vepari, Vince Motta, Dorothy Madden) and more than a few have come from the peg.
The Sinclair inquest is however more directly related to crowding than any previously reported death.  There can be no doubt that his death was entirely preventable and unnecessary and is directly attributed to a crowded ER.  It was an unmitigated tragedy and a sad indictment of the state of crowding in both Winnipeg and our country.
We hope that lessons will be learned from the Sinclair inquest and that all provinces will pay attention.  This time it was Winnipeg but it could happen anywhere.
Dr Innes has spoken a simple truth and his advice should be listened to very closely.  It’s not inappropriate use;  its patient flow.  It can be solved it just requires political will (sadly lacking for the past 20 years!).  The current efforts of the WRHA to solve it will predictably not work.  
Listen to Dr Innes but perhaps more importantly listen to the front line health care workers who staff your ERs.
Winnipeg is truly blessed with highly motivated , innovative and concerned emergency physicians, and nurses.  Involve them with the development of the system.  Winnipeg has commissioned a number of task forces to address crowding.  Fully implement their recommendations.
Inquests are not designed to assign blame but rather to highlight the events leading to a death and make suggestions with respect to how future such deaths can be prevented.  That being said, there can be no doubt that the Manitoba government has been discussing hallway medicine, access block and ED crowding since the early 1990s.  Given the advanced understanding of hospital overcrowding and ER access block there can be simply no more excuses for continuing to get it wrong.
It is to be sincerely hoped that the unfortunate death of Mr. Sinclair will lead to concerted political will from the Manitoba government to never let this happen again and to adopt a mainstream approach to crowding.  It is also to be hoped that the Sinclair family can find some solace in knowing that the death of their loved one will force all governments in Canada to finally and meaningfully address the unacceptable situation that is crowding in our nation’s emergency departments

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