Inside SickKids: An overworked emergency department prepares for a new surge

A baby screams in the distance as a security guard stands watch over the waiting room at the emergency department of Toronto's Hospital for Sick Children.

Parents cuddle their sick kids while others rock their little ones in strollers. A toddler sits on a bed sucking on a soother as tubes under her nose help her breathe.

Everyone is exhausted.

The wait to be seen on this recent afternoon is about three hours - far shorter than what it was just a few weeks ago, when the country's largest pediatric hospital saw an unprecedented surge in children with respiratory illnesses.

At that point, waits had soared, frustrated parents' tempers flared and the hospital had to hire a security guard for the first time to protect staff. The emergency department is now back to volumes typical for this time of the year - about 240 children daily - after taking several steps to ease the pressure.

Staff are now bracing for another wave to hit at the worst time: the always-busy holiday season. And they're already worried.

“I get yelled at a lot,” says Dr. Sasha Litwin, who just finished a shift.

“I try to tell people: 'I think it's terrible too, you should not be waiting 16 hours, but there's only one of me and I can only really see one person at a time.”'

One child recently spent 36 hours in the waiting room, Litwin says.

“It was really awful,” she says. “But we're just working as hard as we can, doing as much as we can with the resources that we have.”

The Canadian Press recently spent hours inside SickKids to better understand the immense challenges faced by pediatric hospitals and the ways in which they are tackling them.

On this day, at 3:40 p.m., the emergency department is in a lull.

A screen at the entrance shows the longest wait time is nearly three hours with 31 patients yet to be seen. The department has seen 66 patients thus far. Thirty minutes later, the wait time jumps to 3.5 hours. The department gets packed in the evenings and will likely end the day having seen more than 200 patients.

Dr. Jason Fischer, the division head of emergency medicine, says the slightly slower pace recently has helped staff regroup.

“These two weeks have been a nice reprieve for people to kind of catch their breath,” he says.

Staff began worrying earlier this year about a difficult winter after seeing hospitals in Australia struggle with respiratory illnesses during their typical cold-and-flu season.

In September, SickKids noticed an uptick in respiratory illnesses.

In October, it began to see volumes usually experienced on Boxing Day - typically the hospital's busiest day annually, where about 320 patients are treated since most family and walk-in clinics are closed.

“We don't expect those numbers on a Wednesday in October,” Fischer says. “Boxing Day is one day, not six weeks.”

He remembers one night when 75 children were in the waiting room.

“Every child looked the same, every child was under four, they all had a fever and all had a high heart rate,” Fischer says. “But chances are some of those kids are going to have something more sinister going on and that was a real concern for us.”

Patient volumes got so high that the hospital built a new waiting room for the department in the cafeteria, where more than 60 more families could wait and even receive treatment if necessary. Plexiglas separates patients from diners.

A countrywide shortage of children's acetaminophen and ibuprofen compounded the problem. Families went to the emergency department to get medications to treat fevers of children who otherwise wouldn't have needed to go to the hospital, Fischer says.

Staffing was also a “real challenge,” Fischer says. A significant number of nurses left during the pandemic while others fell sick as respiratory viruses circulated.

“We were calling in backup continually,” he says. “There was a high risk of burnout and there was a real concern around the wellness and retention of our staff.”

The emergency department has beds for about 39 patients, says Fischer, although that's pushing it. Patients often spill over into beds in the nearby orthopedic clinic by 4 p.m. most days. The department is funded and staffed to see 65,000 patients annually but is on track to see more than 90,000 children this year, about 8,000 more patients than it has ever seen before.

The hospital has tried a few things to ease the intense pressure on the emergency department.

SickKids promoted use of its virtual urgent care program, which jumped from seeing about 40 patients per day to more than 200 in October and November.

It also diverted some patients by using a digital screening tool launched on phones with a QR code. If children didn't need urgent care, they were siphoned off with an appointment for primary care at the hospital's rapid access pediatric clinic.

SickKids also put directions on its website on how to use adult acetaminophen and ibuprofen for children while staff at the hospital gave parents hands-on instructions on how to cut, crush and mix the tablets with apple sauce or yogurt.

The department, like the intensive care unit, also benefited from the hospital's difficult decision to cancel some surgeries, which freed up four nurses from surgical units who were redeployed.

The hospital is trying new roles like a “greeter” who helps communicate with families and assists with patient flow. Emergency medicine technicians are also being trained to take blood to further alleviate pressure on nurses, Fischer says.

Staff also have apps on their phones that send alerts when patient flow slows down in one area so resources can be adjusted.

All the steps have helped to make the situation better, but Fischer worries about the coming months.

“We can't keep this up in the long term,” he says. “We were really pushed to our brink and we were having some trouble making sure every patient was safe.”

SickKids internal testing shows a hard-hitting influenza A strain is on a marked upswing while respiratory syncytial virus, or RSV, abates. The hospital believes the surge in respiratory illnesses could last until March.

The entire situation has led to a noticeable drop in staff morale, says Elise Gabriele,a physician assistant who's been at the hospital for four years and often does initial assessments for patients.

It comes back to lengthy wait times and frustrated parents, she says.

“It makes communication more difficult,” Gabriele says.

“Trying to spend time helping defuse that frustration while still trying to provide the best care possible has made the job a bit more difficult. We're not happy with the wait times either.”

The public can help, health-care workers say.

“If you're able to get your COVID booster and influenza shot, I would heartily recommend it,” Litwin, the emergency department doctor, says. “It will make a big difference.”

Now the hospital waits, hoping the next wave is not as crushing as the first.

This report by The Canadian Press was first published Dec. 13, 2022.