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In the Fall of 2005, after years of effort by emergency physicians at Vancouver General Hospital (VGH) to address the crisis of admitted patients in our ED, the Senior Medical Director at VGH introduced the topic at a medical staff meeting by saying we were “behaving like junkyard dogs.” On Apr. 3, 2006, the junkyard dogs bit back, when a majority of VGH emergency physicians began giving selected patients a one-page statement declaring “non confidence in the ability of the VGH Emergency Department to provide safe, timely and appropriate emergency medical care.” The statement explained that “despite initiatives to improve the situation, the approach to hospital overcrowding continues to involve an excessive, inappropriate, and unsafe use of the ED to house admitted patients.” It went on to outline a recommendation to temporarily address this problem using existing hospital resources, by sharing the excess workload equally throughout the hospital rather than placing a disproportionate share of the burden in the ED. This was a recommendation we had been unsuccessfully lobbying administration to implement for years. The statement ended by informing patients we were “outraged with the deplorable situation” they were likely to find themselves in, and urged them to help us in our efforts to improve things by contacting the Chief Operating Officer and Chief Executive Officer of the hospital and the Provincial Minister of Health. The decision to declare non-confidence in our ED was not taken lightly, nor was it easily or unanimously reached. It arose after years of seeing our patient care deteriorate despite huge efforts and advocacy on our part. Of course this situation at VGH is not unique. The identical problem exists to varying degrees in most major Canadian EDs, and has caused many emergency groups and ED leaders to engage in increasingly acrimonious interactions. However, a public declaration of non-confidence at a flagship teaching hospital, and the magnitude of events that followed, are to my knowledge unprecedented in the history of Canadian emergency medicine. Reflecting on these events, and on the systemic issues that led to the VGH action, may provide insight into how to address the crisis of admitted patients in Canadian EDs. As awareness of the VGH action spread, reaction was swift. Within 48 hours the government’s official opposition, quoting directly from our patient statement in the provincial legislature, launched a verbal assault on the BC government; an event that led the evening TV news. Meanwhile, VGH administration took particular issue with our use of the word “unsafe,” and reassuringly declared to a skeptical public and media that if the ED were indeed unsafe they would have closed it. Our administration also demanded we “cease and desist” the action, which they deemed to be “unprofessional.” Over the next week circulation of the statement was suspended while members of our group communicated with the BC Medical Association, the BC College of Physicians and Surgeons, the Canadian Medical Protective Association, the Canadian

The junkyard dogs find their teeth: addressing the crisis of admitted patients in Canadian emergency departments