Even before Covid-19, Canadian travellers stricken by medical emergencies abroad were forced into long waits for repatriation to hospitals at home, despite the best efforts and frustrations of frontline emergency assistance professionals trying to get them there.

In an ITIJ report on Canada’s overcrowded hospitals published in 2018, Dr Ferial Ladak, then a Medical Director for Global Excel, asserted: “Patients needing emergency procedures should be able to come to the emergency room (ER) by air ambulance and be assessed like any other Canadian.”

Six years later, Dr Ladak, now Global Medical Director of Global Excel, could only reflect disappointment and sadness that (patient) repatriations have worsened: wait times for acute beds have lengthened; staffing levels have lessened; and medically repatriated patients are reluctant to go through a repeat ER admission (which they have already undergone in their primary treatment facility). “In days gone by, we were able to get an ER doctor (in Canada) to accept a patient and then bring them home without a bed, especially if they were low acuity but still needing institutional care. This is impossible now: the (hospital) staff are so overwhelmed they cannot fathom another patient at their doorstep just because they want to come back to Canada or their travel insurance doesn’t cover rehabilitation,” she said.

How did it come to this?

In December 2023, the Fraser Institute released Waiting Your Turn, a report documenting how long Canadians had spent on waiting lists for non-urgent medically necessary services over the previous 12 months. The think tank has been issuing similar reports annually and the current version was a stunner, revealing that waiting times were 198% longer in 2023 than in 1993 when the report was first published.

Waiting Your Turn found that more than 1.2 million (3% of) Canadians were on official waiting lists for medically necessary (non-urgent) services in 2023; and 1.8% left the country to be treated abroad. Bottom line: Canadians waited a median 27.7 weeks for medically necessary services (compared with 9.3 weeks in the base year of 1993).

Waiting times for acute beds have lengthened; staffing levels have lessened; and medically repatriated patients are reluctant to go through a repeat ER admission

The province of Ontario had the shortest median waiting time at 21.6 weeks; Nova Scotia the longest at 56.7 weeks. The waiting time metric is of two parts: 1. from referral by a general practitioner/family physician to consultation with a specialist; 2. from consultation with a specialist to the patient’s receipt of treatment. Not included in these calculations are urgent care procedures demanding immediate lifesaving measures. (In Canada, specialists are usually accessible only after referral by general practitioners/family physicians).

Waiting lists do not occur in a vacuum, and in Canada’s case they are greatly exacerbated by historic emergency department (ED) congestion running well over 100% capacity, even at the best of times. Example: in Montreal, at the time of writing (midweek, midday), the Montreal General Hospital emergency department was running at 151% capacity, with 23 patients on stretchers for 24 hours, and 23 patients for over 40 hours. Meanwhile, at the venerable Royal Victoria Hospital (dating back to 1887), ED capacity was running at 181%. A stretcher count for the ‘Royal Vic’ was not available. At the same time, the Children’s Hospital of Eastern Ontario in Ottawa had 17 triaged patients waiting to be seen within an estimated 4.5 hours, and at St Boniface Hospital in Winnipeg, 46 pre-registered ER patients were assured they would be seen by a doctor within 9.5 hours. Then, of course, comes the wait for beds.

No wonder that, in 2023, according to the Canadian Institute for Health Information, 1.3 million frustrated Canadian patients walked out of emergency rooms untreated.

Travellers are rich, aren’t they?

In this kind of setting, ER staff, worn down by Covid-19 burnout and personnel shortages, tend to look cynically at making room for patients flown in from vacations in Italy, Paris, Miami, Mexico or Barbados. (Though they may also be flying in after visiting Grandma in Ohio.)

Brad Dance, Past President of the Travel Health Insurance Association of Canada (THIA) and Chief Customer Officer at travel insurance provider TuGo, reflected that British Columbia (BC) is “the most difficult province in which to acquire receiving beds” as even the province’s Patient Transfer Network “is quite vocal about how a receiving bed isn’t a priority for our patients since they are already receiving adequate treatment where they are”.

Dance was asked if provincial health ministries should be held accountable for the costs of delaying or diverting Canadian medical repats who have been denied hospital accommodation in Canada. He concurred that that would be a good thing, but added that any health ministry official would say this was the responsibility “and the point” of travel insurance. But “it’s unrealistic to think they will”, he suggested, adding that other western provinces – Alberta, Saskatchewan and Manitoba – were doing “a bit better than BC”. He estimated the average waiting time for a bed in BC to be about four days.

Traditionally, Canada’s patient repatriation system has relied on getting the patient home as safely and quickly as possible – back under the umbrella of their tax-supported health insurance system.

Normally, emergency assistance personnel connect with intake and treatment staff at the treating facility abroad, monitor the patient’s care, and, if and when transfer is considered safe, arrange for air ambulance transfer to a hospital in the patient’s home or ‘catchment’ area. (Ontario, the most populous province, has an interlocking system of 16 catchment areas.)

Occasionally, they may transfer the patient to an intermediate third country location if treatment urgency is a factor (to the US usually if Caribbean cruise travel is involved). But ultimately, assistance service specialists will try to bring that patient ‘home’ or to a hospital in their catchment area.

And there’s the rub: when the receiving hospital is already under siege by patients waiting hours just to see a doctor (and then waiting a few more or two or three days on stretchers), the arrival of a patient from a beach resort in Cancun is more than an annoyance to harried ER staff.

In 2023, according to the Canadian Institute for Health Information, 1.3 million frustrated Canadian patients walked out of emergency rooms untreated

Staffing, fuel costs, and provincial health ministries

Mike Vallee, Vice President of Business Development at Air Ambulance Worldwide, emphasised that “most of the heavy lifting related to bed finding is borne by our clients (assistance companies), but our operations team agrees that the wait time from (price) quotation to activation seems to be a couple of days longer than it was a few years ago”.

He also attributed the growing delays not only to bed shortages but also to hospital staffing. “The health ministries are dealing with the knock-on effect of a health system that was overburdened and underfunded even before Covid-19. I don’t think there is a quick or easy answer to the problem other than attracting and training more nurses to rebuild the public health service after so many left nursing.”

Vallee noted that repatriations are easier to complete to low population- density areas rather than metropolitan centres like Montreal, Toronto or Vancouver. But whatever the destination, “fuel costs are, and likely always will be, a major contributing factor in the price of a repat”. And while they certainly spiked to historic levels after Covid-19, they have largely subsided to “only moderately insane levels” now.

In addition, a shortage of pilots continues to be a cost factor difficult to deal with.

Fuel costs are, and likely always will be, a major contributing factor in the price of a repat

Will McAleer, Executive Director of THIA and Vice President of travel insurance brokerage CanAm, concurred that, although some provinces have made small improvements to bed-access processes, it has not resulted in better access for travellers requiring medical repatriation and “since urgent care often involves initial treatment while abroad, every moment counts”.

He added: “When combined with the fact that provincial hospitals are reluctant to develop processes for access to rehabilitation beds, the situation is not good, and Canadians will likely see delays in returning home and accessing the care they deserve in a system that is supposed to deliver universal healthcare to residents. Denying a returning traveller access to a hospital bed, simply because they had their emergency while out of the country, is neither fair, nor equitable.”

McAleer added that hospitals and assistance companies have agreed that beds need to be secured in advance, as opposed to simply having the patient arrive at the ER unannounced. “This is not in a hospital’s or patient’s better interest.”

As a bottom line in developing a more accessible repatriation system, McAleer insisted “the provinces, particularly Ontario, need to engage with the industry to develop an effective solution to the problem”.

But do provincial health ministries agree? Do they see that as a priority? Dr Ladak is skeptical. She asserted: “I have not seen any evidence of health ministries protecting the rights of out-of-country patients.” And though she cites Ontario’s CritiCall (a hospital bed-placement agency) as having the power to make necessary changes, “they will only work with the critically ill … and they have restricted their working schedule to regular business hours”. That’s hardly compatible with the round-the-clock working format of international emergency assistance professionals.

ITIJ reached out to CritiCall Ontario administrative staff requesting an interview regarding the concerns raised in this story, but no follow-up response was received.

Dr Ladak added: “There is a lack of trust that a patient returning from another country has been assessed properly, and that is driving the demand that they be reassessed in a Canadian hospital. If we could get around this, it would be revolutionary.”