Ontario ED Staffing Struggles Highlight Chronic Shortfall

Ontario’s physicians are seeking to draw attention to chronic staffing struggles that have caused a rapid increase in temporary closures of emergency departments, even with hospitals more heavily relying on a program started in 2006 as a temporary fix for staffing shortages.

Sean Moore, MD, chief of staff at Lake of the Woods District Hospital in rural Kenora, Ontario, Canada, recounted a recent scramble to keep the emergency department open in an Ontario Medical Association video.

“We were at risk of having to close because we had nine of 12 shifts open for the weekend,” Moore said on the video, posted on the Ontario Medical Association (OMA)’s YouTube channel in October. “We have half of our shifts being covered by people who are flying all the way from Toronto or Ottawa, coming to our community, doing an 8- to 12-hour shift, and then flying home.”

“We just have to rethink the system so that we can get people who want to come and stay in these communities,” added Moore, who is also an emergency physician.

Temporary Closures Likely to Continue

The OMA last month announced an arbitration agreement between physicians and the provincial government with a 9.95% compensation increase for the first year of a 4-year agreement. That award is retroactive to April 1, 2024. OMA in September said the next 3 years of the Physician Services Agreement will continue to be negotiated.

Anthony Dale, president and chief executive officer of the Ontario Hospital Association, told Medscape Medical News that physicians are readying for continued contract talks with the provincial government. But he also noted that hospitals in rural and northern communities have faced systemic pressures for many years, leading to temporary closures of emergency departments.

“This is the most difficult decision any acute care hospital will ever have to make, and only takes place when there is no other option left available,” Dale said.

Unplanned closures of emergency departments were rare before 2019-2020, but have become far more frequent in recent years, the Office of the Auditor General of Ontario said in a December 2023 report that examined this issue.

There were 203 temporary emergency department closures involving 23 hospitals between July 2022 and June 2023, the report said. Most of these occurred in rural hospitals.

Another 400 potential closures were averted in this period through use of the locum program. The program began in 2006 as a temporary stopgap measure to address staffing shortages, but its use has more than doubled in recent years.

The locum program covered 60,200 hours of care at a cost of about $11.8 million from 2022-2023, up from about 27,400 hours of coverage for a cost of $5.7 million in 2018-2019, the report said.

Since the introduction of the program, only four unplanned emergency department closures were a result of physician unavailability, according to the report. Most temporary closures were caused by a shortage of nursing staff.

The greater job flexibility and higher pay for agency nurses have resulted in some loss of permanent hospital staff. For example, an agency-registered nurse working in an emergency department may be paid more than $75 an hour, compared with about $35-$50 an hour for full-time permanent nurses employed by a hospital. In addition, collective agreements with nursing staff limit hospitals’ ability to move them between units, due in part to concerns about training.

Notably, the persisting crisis in Ontario’s emergency departments is part of a larger problem of short staffing in Canada’s healthcare system. According to CBC News, there were protests this summer in northeastern British Columbia about a string of temporary emergency room closures, with similar shutdowns reported in Alberta, Quebec, and Prince Edward Island province.

Medical Societies Respond

The Canadian Medical Association in August called for broad reforms in emergency care, including increased retaining, training, and credentialing of medical professionals. The physicians’ group argued for more planning and accountability in government decisions that shape Canada’s workforce.

“More sustainable funding will be needed, but money alone is not the answer,” Kathleen Ross, MD, the most recent past president of the Canadian Medical Association, told Medscape Medical News. “We need to have a way of tracking those investments and, at the moment, we’re really not doing a great job with that,” said Ross.

The Canadian Association of Emergency Physicians (CAEP) also has been working to draw attention to the staffing shortages. The group in March released a wide-ranging report, EM:POWER: Task Force Report on the Future of Emergency Care, which included recommendations on preventing closures.

Taylor Lougheed, MD, a member of CAEP’s rural remote and small urban section, told Medscape Medical News that some of the staffing issues might be addressed through initiatives like those underway at the Northern Ontario School of Medicine (NOSM).

NOSM describes itself as a “made-in-the-North solution” to regional healthcare inequalities. The school said more than half of the 971 physicians who have graduated from it have stayed in Northern Ontario.

But in the near term, greater efforts have to be made to move away from stopgap solutions such as relying on short-term locum employment contracts, said Lougheed, who is chief of emergency medicine at the North Bay Regional Health Centre Emergency Department. Lacking provincial or regional strategies to address shortages, Canadian hospitals in rural areas end up competing in an “arms race” to lure doctors from other regions to fill urgent needs.

“You’ve got physicians coming from southern Ontario or other large population centers to work shifts in an underserved area at a significant bonus,” he noted.

“That can create a bit of a toxic milieu for the existing staff,” he said. “They’re overwhelmed and at risk of burnout, and this can increase the risk of burnout or the risk of moral injury, where they’re getting paid relatively at a discount to work in the same location.”

Ross and Lougheed have disclosed no relevant financial relationships.

Kerry Dooley Young is a freelance journalist based in Washington, DC. Follow her on LinkedIn, Threads, and Bluesky.