FormalPara Clinician’s capsule

What is already known on this subject?

Health human resources are at an all-time low, resulting in unprecedented closures of local emergency departments (EDs)

What did the study ask?

How have the recent closures of EDs influenced potential access to emergency medical care in Ontario?

What did this study find?

14 ED closures during the study period resulted in 15,018 people losing potential access to an ED within a 45-min timeframe

What does this study matter to clinicians?

ED closures likely cause patient harm. Healthcare workers, hospital leadership, and government must work together to prevent further closures particularly in areas without overlapping coverage

Introduction

Access to healthcare is more complex than merely having a hospital. There must be adequate supply of services or resources and they must meet the needs patients to obtain satisfactory health outcomes [1]. But what happens when those resources are not available? During the COVID-19 pandemic, healthcare workers have faced unprecedented levels of distress, fatigue, and difficult clinical practices, leading to burnout [2,3,4]. Recently in Ontario, several hospitals have simply not had the human resources to keep certain patient care areas of the hospital open. Most notable, emergency departments (ED) have been forced to close. Closures can lead to worsening capacity issues at nearby hospitals [5] as well as longer out-of-hospital transport times for patients which increases mortality for life-threatening illnesses [5, 12] [6,7,8,9,10,11]. We examined how the recent or planned closures of ED’s have influenced potential access to emergency medical care in Ontario.

Methods

We performed population-level geographic information systems (GIS)-based analysis of potential access to ED hospitals in Ontario. We obtained the addresses of all hospitals with an ED (n = 164) from local health integration network websites. Location of all hospitals with an ED were geocoded to their exact address with 100% accuracy. Hospitals were used as the starting point for all travel times.

To understand which hospitals had ED closures, we searched all relevant news articles on ED closures since December 2021 due to a lack of publically available reporting of closures by governmental sources. We followed a previously used approach on media analysis [12] and continued to monitor other closures and updated the dataset as of August 8, 2022. We identified 14 hospitals with either partial (nightly), complete, or planned closures and are confident that our search identified all closures to date (Supplementary Table).

Potential access was measured using a 2020 road network analysis, which examined travel times based on land catchment areas from each hospital. We created separate land catchment areas for 30, 45, and 60 min travel times using non-overlapping polygons (meaning access is only given to one hospital)[13] Travel times were selected based on previous usage within the literature [13, 14], but they also represent a reasonable travel time to emergency care. Catchment areas account for data on speed limits and driving restrictions. The impedance applied for calculation was travel time, meaning the fastest route (not necessarily the shortest) would be selected.

The 2016 census block level population dataset was utilized to assess population with access. This is the smallest spatial unit where population-level data are released in Canada. First, the block polygon file was converted to points at the geographic centroid of the block and represents the population living within each block [14]. Once all the network catchment areas were calculated, the sum of all population block centroids were calculated and summed for each CSD. This process was completed with all ED’s open, as baseline data, then all steps were repeated for the 150 hospitals where ED’s remained open to account for the 14 closures. Analysis was then repeated by each month from March 2022 until August 2022. Monthly analysis only accounts for closures during the month, to account for not all closures happening at once.

To examine how potential access has changed in each CSD, we took the baseline population with access in each CSD, then subtracted the number of people in each CSD with potential access after the ED closures. This assumes that all hospitals were closed at the same time or same month, which was not always the case, but findings will identify areas where closures may be more problematic. The total number of people in each CSD was also compiled and used to calculate the percentage of population within the CSD that lost potential access.

Results

If all 14 ED’s had closed simultaneously, there would be 35,808 people who potentially lose access to ED care at 30 min, 15,018 at 45 min, and 12,131 at 60 min travel times. While the overall numbers at the provincial level are quite low, the percentage of people in some CSD’s who lose access to ED care was more significant (Table 1). Overall, the number of people who lose potential access is most striking at 30 min travel times, with rural areas most impacted. Nearly 60% of the population in North Huron and North Glengarry would not have potential access within 30 min. While at 45 min travel times, which may be more representative, Central Frontenac reported that nearly 2000 people or 44% of the population lost potential access to ED care. In Cochrane (North Part) 7,298 people or nearly 20% of their population lost potential access to ED care.

Table 1 Changes in access to care by CSD in Ontario using all three travel times
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Figure 1 illustrates the percentage of the population in Ontario by CSD that loses potential access based on 45-min travel times. As displayed, there are several closures in Southwestern Ontario, but few people lose potential access due to overlapping hospital catchment areas. In Northern Ontario, or Eastern Ontario there were fewer closures, but there was a much larger influence on the population who lost potential access which was attributed to one hospital closure. In the monthly analysis, it become evident that certain hospital closures may influence overall access more so than others and inequalities in access exist with certain hospital closures (Table 2–supplemental). The month of July reported the largest number of people who would lose access to emergency care.

Fig. 1
figure 1

Percentage of people who lost access to an emergency department by census subdivision in Ontario based on 45 min travel times as of August 8, 2022

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Discussion

Previous studies: inequitable impact of ED closures

The fact that rural residents had lower access to care is not new in Canada or the United States and has been reported in previous work [14, 15]. What was interesting here was that rural areas had more ED closures, and no overlap in health care access, so the impact of these closures is not equitably spread across the province. Closures to hospitals in Eastern and Northern Ontario led to much larger decreases in the proportion of people with potential access, which is highlighted in both the overall and monthly analysis. This is further complicated as much of Northern Ontario relies on air ambulance to provide transport to the closest ED with transport times of multiple hours for some communities [16, 17].

Interpretation

The Ontario Ministry of Health previously created a Provincial Framework and Plan to support improved access to health care in rural communities [18]. This Panel recognized the “golden hour” principle of emergency care, understanding that timely clinical interventions associate with better outcomes. Part of this plan was to ensure 90% of residents in a community could receive emergency services within 30 min travel time from their place of residence [18]. The justification of this shorter 30-min travel time was in anticipation that an additional 30 min would be required for patients to call for an ambulance and paramedics to arrive, assess, begin treatment and load the patient into the ambulance. ED closures in these rural communities significantly impair or even make it impossible to meet these Ministry targets.

Even though there were more hospitals with closures in Southwestern Ontario, the region still had the ability to provide potential access due to overlapping hospital catchment areas. Furthermore, it is important to note that the closure in Eastern Ontario (Perth) was a long closure that lasted several weeks. Since the Perth closure, several others in Eastern Ontario have been forced to close, further limiting access in this area. In the month of July when this hospital was closed, over 3,000 people in the area lost access.

Research implications: future research

While the focus here was to examine closures to ED’s, which mainly affected rural communities, this does not mean healthcare in urban areas was unharmed. To date there has only been one ED closure in a larger city (Ottawa), but many other larger cities have had to close urgent care centres or reduce hours to keep ED’s open. This was beyond the scope of this research, but it is important to highlight the challenges that all communities in Ontario have been facing.

Clinical implications: potential patient impact of ED closures

Short delays have been associated with increased mortality for severely injured patients [19] or effect patient eligibility for specialized stroke and cardiac interventions [20]. Therefore, although not examined in this study, our results suggest these ED closures may result in patient harm. Additionally, extended transport times for both land and air ambulances increases time to definitive care for patients and reduces the paramedic crew’s ability to respond to further emergent transports in that community [17]. Not surprisingly, when one ED closes, the nearest ED then sees an increase in their patient volume [21], putting further strain on that hospital.

Strengths and limitations

This paper highlights the number of people who may lose access to emergency care with recent ED closures in Ontario. We analyzed the closures as if all EDs were closed simultaneously, but also examined a monthly breakdown. While a limitation, as the monthly results illustrated this did not influence the major findings of this study, as the decreases in potential access were typically related to only one ED being closed in each region. In areas where multiple EDs were closed at once, many residents still had access to other hospitals, but other issues such as hospital capacity may become an issue. Another limitation relates to the fact that we had to rely on media reporting ED closures as this data is not publicly available. The Ministry of Health should create a standardized reporting system to identify and track closures throughout the healthcare system.

Conclusion

There were inequities with rural areas of Northern and Eastern Ontario seeing the greatest impacts of these closures and potentially greater patient harm. These closures also put additional stresses, capacity issues, and longer wait times for nearby ED’s. Health human resource recovery strategies must focus on areas where lack of overlap exists, while governments and hospitals must work together to address staffing issues and prevent further closures.