Howard Ovens

Emergency physician, Chief Medical Strategy Officer, Sinai Health System, comments on issues in public policy and emergency and hospital services.

[Howard Ovens @HowardOvens]

Hey ER guys - docs, nurses, RT’s etc - on the front line. What is the opposite of a playoff beard? We all need to get clean shaven till this corona virus passes! Masks gotta’ fit right!

[Howard Ovens @HowardOvens]

Please consider a donation. Great guy. Great cause!

[Dr. Brian Goldman @NightShiftMD]

For decades, Dr. Grant Innes has been a leading light in emergency medicine in Canada. He has long stood for better and more accountable ED care and has chosen SREMI and @CAEP_Docs to lead his legacy project.
No Patient Left Behind: The Full Story (4 minute video):
https://t.co/tJAvMc9NYL

[Howard Ovens @HowardOvens]

@BrockLabour @jordanlhouse That’s my boy!!! Great choice. Congratulations @jordanlhouse

[Howard Ovens @HowardOvens]

https://t.co/WOb2p7DPbt

[Howard Ovens @HowardOvens]

@CAEP_Docs @SREMI_MSH https://t.co/Cnah007dKO lets try that link again

[Howard Ovens @HowardOvens]

EM Day Webinar - May 27, 13:30 CEST - Emergency Medicine Day

[Howard Ovens @HowardOvens]

@CAEP_Docs @SREMI_MSH https://t.co/Cnah007dKO lets try that link again

[Howard Ovens @HowardOvens]

@CAEP_Docs @SREMI_MSH https://t.co/Cnah007dKO lets try that link again

[Howard Ovens @HowardOvens]

Join us next Wednesday, Emergency Medicine Day, for this webinar; https://t.co/Cnah007dKO @CAEP_Docs @SREMI_MSH

[Howard Ovens @HowardOvens]

Watch for the updated CAEP overcrowding statement coming this spring!

[Ken Milne MD @TheSGEM]

@JesseJesseaben @CMA_Docs @OntariosDoctors @CAEP_Docs This problem has existed for decades.

The Canadian Association of Emergency Physicians (CAEP) wrote a position statement about this 13 years ago.
https://t.co/4e85suAMIl

@HowardOvens @alandrummond2 @PfParks

[Trevor Jain @TrevorJain]

Thinking of the families and everyone who responded to the GSW MCI in BC. MCI’s can happen anywhere including rural Canada. Emergency departments across Canada plan for these rare events. When they happen it’s horrible and tragic for family and the care providers. #moralinjury

[Howard Ovens @HowardOvens]

Here is their review;

[Howard Ovens @HowardOvens]

6 Podcasts About Medicine and Health Care https://t.co/FcapFnNYnz via @NYTimes Huge kudos to @EMCases for this shout out - so well deserved! @SREMI_MSH @SinaiHealth @NYGH_News

[Howard Ovens @HowardOvens]

6 Podcasts About Medicine and Health Care https://t.co/FcapFnNYnz via @NYTimes Huge kudos to @EMCases for this shout out - so well deserved! @SREMI_MSH @SinaiHealth @NYGH_News

[Dr. Raj Sherman @RajSherman]

Data and facts matter, so let’s ground this in reality.

Edmonton Zone:
-Hospitals were operating at 100–113% occupancy in August, before flu season.
-500–600 ALC patients occupy acute-care beds daily but should be in rehab, transition units, LTC, hospice, or supported home care.
-Edmonton serves a vast, under-resourced northern catchment and receives roughly 4X more out-of-town transfers than Calgary (which is also severely strained). -There are 275 ER beds across 5 hospitals, but on most days 200–250 are occupied by admitted patients boarding for days.

➡️ That leaves only 25–75 functional ER beds to serve ~2.5 million people.

What ERs Face, Simultaneously:
-Emergency departments care for many life-threatening conditions at the same time, not just chest pain:strokes, sepsis, major trauma, airway failure, GI bleeds, ruptured aneurysms, septic seniors, obstetric emergencies, and critically ill children and all requiring monitored beds and immediate care, then specialist in-hospital care after diagnosis and stabilization as well as minor cases that need a family doctor (but this is not the cause of the crisis and long ER waits).

Every ER sees many chest-pain patients, ranging from minor to life-threatening. We don’t know which is which until an ER physician assesses, investigates, and treats them. Serious cases often require advanced treatment beyond the ER.

Chest pain can be fatal not only from heart attacks, but also from:
-Aortic dissection
-Pulmonary embolism
-Pericardial tamponade
-Tension pneumothorax
-Severe pneumonia
-Esophageal rupture

The Core Issue: This was never about “how many chest-pain patients walked in.” It’s about whether a monitored ER bed was available when one was needed.

When wards are full, beds are blocked by ALC patients, and admissions are capped, even properly triaged CTAS-2 and CTAS-3 patients cannot be moved, reassessed, or safely escalated.

That doesn’t excuse poor care, it explains predictable harm during a severely strained health system in gridlock.

Why an Independent Review Is Needed: While Covenant Health and Acute Care Alberta must conduct internal reviews, the public deserves an independent case and system review.

That’s why we need a non-political, evidence-based HQA review to determine whether this was individual error, system failure, or both and how to prevent the next one.

We also need to immediately decant hospitals of ALC patients into appropriate settings: rehab, transition units, long-term care, hospice, and supported home care, so the system can pull back from the edge.

This is the worst ER crisis I have seen in 35 years as a frontline emergency physician.

Blame won’t fix this, solutions, capacity and flow will.

P.S. This is an important conversation, so I’m looping in medical leaders for their input and insight: @YYCCowboy @PfParks @NightShiftMD @raghu_venugopal
as well as political leaders for their awareness and education: @ABDanielleSmith @MattJonesYYC @JasonNixonAB @nenshi

.

[Howard Ovens @HowardOvens]

If affiliated with a hospital a UCC that’s well positioned geographically will be a staff recruitment asset, provide complex ambulatory care and seamless transition for patients needing more complex care. And we also need better after hours access to primary care. 2/2.

[Dr. Anmol Kapoor @AnmolMD]

When I was doing training in Internal Medicine in Edmonton, I did work at the Grey Nuns Hospital in early 2000s. It was a great experience and my mentors were exceptional.

When I heard, and listen to what happened to 44 year old man that presented with Chest Pain, and somewhere along the way it got Mis-Triaged. It’s possible the triaging nurse made the wrong call or the ER was too busy and they didn’t have empty beds. As per my understanding, the Cardiology wasn’t called and unfortunately this person passed away. In my differential diagnosis, PE, Aortic Dissection could also be the reason, and medical examiner will be able to shed some light on the cause of sudden cardiac arrest, and if proper ACLS protocols were followed by ER Teams at the time of arrest. It does look like he got intubated, question will be if ACLS was deployed the right way? Often doing ACLS the right way, sometimes we can’t save the person. It has happened to me many times, and many times I was successful in bringing person back to life.

I am also noticing that this issue has taken over international media, and many people are blaming immigrants, politicians, overall systems, and ever changing policies within governments in Alberta. I want to mention that its not Alberta issue alone, BC has different political party but we have seen similar stories. Ontario and other provinces are not different.

When @jkenney was a Premier of Alberta, I purposed a solution of Urgent Care center in Alberta. During election time, he agreed and even sent supporting letter when this center was opened in Calgary. I met many health executives to make a small change in the billing code, make Urgent Care Code applicable at the privately run but publicly funded Urgent Care Center. I invested over a million dollars, installed Xray machine and onsite labs, ECGs etc with an intent to remove extra burden from the ERs, so that true emergencies like these could be tackled properly And people with minor issues can be tackled at the UCC. This project failed, why? EMS was not allowed to drop off patients with minor issues at UCC, ER Doctors were against this idea and didn’t support, despite Premier supporting this idea his team didn’t provide any service. We even we had “red tape” reduction minister came for tour of the facility in Calgary NE and expressed support, but none of the ministers or healthcare leadership was able to make a small change: make UCC billing code applicable in the NON AHS facility. Over time, doctors were not making much money and clinic started to lose investments. It became a net loss maker, and I had to shut it down after exhausting all avenues. I didn’t want to charge patients and kept it funded through regular billing codes. There was no memberships to be bought or pay for access. It was my honest attempt to prevent tragedies like these, but system refused to change. In this everyone played the role: AHS, ER docs, Politicians, Everyone.

A very good intention, failed.

If this project would have succeeded, this would have allowed us to open many such centres across Alberta (essentially Step Up Family Medicine clinics with Onsite facilities) and relieve burden on ERs. This would have shaved off long hours people have to wait in ERs of Alberta, and allowed staff triaging and working in ER to focus on real emergencies.

It can still be done, IF There is a Real Intention. I am mot blaming anyone, rather showing to people that an immigrant doctor who saw what is wrong with the system, tried his best but wasn’t successful despite having best intentions and plan.

Our systems are designed to penalize novel ideas and reward status quo’s. From regulators to politicians, all want to maintain the status quo’s. Why?

We have alot to learn from our southern neighbours, we don’t have to privatize everything. We can run Urgent Care Clinics across Alberta, within public health systems if we want. They have shown to reduce wait times and improve access in USA. Its time!

[Howard Ovens @HowardOvens]

Free standing UCCs are not the answer. They often recruit away emerg docs and nurses and have no incentive to do complex ambulatory care (suturing, casts and splints, slit lamp eye care etc). UCCs should be part of a hospital system 1/2

[Dr. Anmol Kapoor @AnmolMD]

When I was doing training in Internal Medicine in Edmonton, I did work at the Grey Nuns Hospital in early 2000s. It was a great experience and my mentors were exceptional.

When I heard, and listen to what happened to 44 year old man that presented with Chest Pain, and somewhere along the way it got Mis-Triaged. It’s possible the triaging nurse made the wrong call or the ER was too busy and they didn’t have empty beds. As per my understanding, the Cardiology wasn’t called and unfortunately this person passed away. In my differential diagnosis, PE, Aortic Dissection could also be the reason, and medical examiner will be able to shed some light on the cause of sudden cardiac arrest, and if proper ACLS protocols were followed by ER Teams at the time of arrest. It does look like he got intubated, question will be if ACLS was deployed the right way? Often doing ACLS the right way, sometimes we can’t save the person. It has happened to me many times, and many times I was successful in bringing person back to life.

I am also noticing that this issue has taken over international media, and many people are blaming immigrants, politicians, overall systems, and ever changing policies within governments in Alberta. I want to mention that its not Alberta issue alone, BC has different political party but we have seen similar stories. Ontario and other provinces are not different.

When @jkenney was a Premier of Alberta, I purposed a solution of Urgent Care center in Alberta. During election time, he agreed and even sent supporting letter when this center was opened in Calgary. I met many health executives to make a small change in the billing code, make Urgent Care Code applicable at the privately run but publicly funded Urgent Care Center. I invested over a million dollars, installed Xray machine and onsite labs, ECGs etc with an intent to remove extra burden from the ERs, so that true emergencies like these could be tackled properly And people with minor issues can be tackled at the UCC. This project failed, why? EMS was not allowed to drop off patients with minor issues at UCC, ER Doctors were against this idea and didn’t support, despite Premier supporting this idea his team didn’t provide any service. We even we had “red tape” reduction minister came for tour of the facility in Calgary NE and expressed support, but none of the ministers or healthcare leadership was able to make a small change: make UCC billing code applicable in the NON AHS facility. Over time, doctors were not making much money and clinic started to lose investments. It became a net loss maker, and I had to shut it down after exhausting all avenues. I didn’t want to charge patients and kept it funded through regular billing codes. There was no memberships to be bought or pay for access. It was my honest attempt to prevent tragedies like these, but system refused to change. In this everyone played the role: AHS, ER docs, Politicians, Everyone.

A very good intention, failed.

If this project would have succeeded, this would have allowed us to open many such centres across Alberta (essentially Step Up Family Medicine clinics with Onsite facilities) and relieve burden on ERs. This would have shaved off long hours people have to wait in ERs of Alberta, and allowed staff triaging and working in ER to focus on real emergencies.

It can still be done, IF There is a Real Intention. I am mot blaming anyone, rather showing to people that an immigrant doctor who saw what is wrong with the system, tried his best but wasn’t successful despite having best intentions and plan.

Our systems are designed to penalize novel ideas and reward status quo’s. From regulators to politicians, all want to maintain the status quo’s. Why?

We have alot to learn from our southern neighbours, we don’t have to privatize everything. We can run Urgent Care Clinics across Alberta, within public health systems if we want. They have shown to reduce wait times and improve access in USA. Its time!

[Dr. Raj Sherman @RajSherman]

Anmol, my long-lost friend. You were my resident years ago and one of our brilliant cardiologists. I hope you and your family are well.

ER physicians are not opposed to Urgent Care Centres (UCCs) or community investments. In fact, we don’t even want more ER beds or ER staff. When an investment improves care, addresses system problems, and reduces costs, we support it.

The ER crisis exists because 60–100% of ED stretchers are occupied by sick, already-admitted patients, while hospitals are blocked by ALC patients, insufficient acute-care capacity, inadequate full-service family medicine, and poor chronic-disease management.

The problem is not minor cases. It is very sick patients needing hospital-level care waiting in chairs and hallways.

Data from #yeg and #yyc show CTAS 1–3 volumes are up, while CTAS 4–5 are down. CTAS 1–3 patients presenting to UCCs must be transferred to the ER: delaying care and creating duplicate visits and costing more.

ERs already devote most resources to high-acuity care. As you’ll recall from the Northeast and Royal Alex, we already run a 24/7 urgent-care function inside the ER (RAZ / Minor Side)and those spaces are now filled with very sick patients and ER docs fee doces are mostly on complex care, not minor cases.

What does work is after-hours, team-based, integrated full-service family medicine, open 12 hours a day, 7 days a week, with continuity of care. These models reduce ER visits and hospital admissions.

Another key opportunity is expanding out-of-hospital transition and rehab units to safely return non-acute patients home with expanded home care and caregiver respite (e.g., CHOICE): freeing up acute-care beds.

Episodic, fragmented care is the real problem, we have too much of it.

Diversionary strategies are costly, have little impact on ER congestion, and often delay care while increasing costs.

The policy goals should be simple:
• Patients that can be discharged from hospital should be within 2 hours 90% of the time
ALC patients transitioned within 24 hours to the community
• Primary care access within 24–48 hours (12/7)
• Admit patients to Inpatient beds within 6–8 hours from the ER

Demand for care is high and health worker capacity is limited, so we must ensure staff and dollars we invest in the right parts of the system.

Belated Merry Christmas and Happy New Year.

P.S. Aljinder says hello ���

[Trevor Jain @TrevorJain]

False. To say he clearly was having a heart attack is asinine and demonstrates a lack clinical acumen. This happening to this poor man is horrific and unacceptable in a the system where doctors and nurses struggle everyday with the poor decisions of managers and administrators trying meet patient needs. The system needs to be investigated and held to account.

[Howard Ovens @HowardOvens]

https://t.co/O7oeh3q498 Beautiful story of listening and learning from our patients and neighbours.

[CAEP @CAEP_Docs]

1/ Why opening more Urgent Care Centres doesn’t fix ER wait times 🧵👇
They sound like a smart solution to divert “non-emergency” visits—but the evidence and experience say otherwise.
#EmergencyMedicine #cdnhealth #CAEP

[Howard Ovens @HowardOvens]

@LisaEsther6 @CAEP_Docs @TrevorJain @picardonhealth @Kapur_AK In many places UCCs took away ED docs and nurses to work there as no one else has the skills to do complex ambulatory care. They made the ED crisis worse. Done properly they have a place but they are no cure for ED wait times. Wishful thinking won’t solve complex problems.

[Howard Ovens @HowardOvens]

@LisaEsther6 @CAEP_Docs @TrevorJain @picardonhealth @Kapur_AK There are many evidence based reviews of ED overcrowding and its solutions. None recommend UCCs as a strategy. Family docs access is a critical issue in its own right. But it’s distinct from ER crowding - fixing ER wait times won’t fix our FD crisis and reverse true too 1/2

[JAMA Network Open @JAMANetworkOpen]

Patients who visited the emergency department within 90 days prior to a cancer diagnosis in Ontario, Canada, exhibited higher mortality risks compared to those who did not. https://t.co/O0KKyrVSSb @kee_gre @HowardOvens