A Sin of Omission: Sabotaging our Efforts to Improve ER Wait Times

September 28th 2011: Have you been to the Emergency Room and been forced to wait hours before being admitted?  Have you waited months for a surgery date only to have the hospital cancel the day before the set date?  Many provinces are now benchmarking and tracking ER wait times and making some progress but some are ignoring the systemic fix that could drastically improve the hospital’s ability to process patients.

The 2003 Health Accords identified the need to expand home care, supportive housing and integrated care options to deal with the challenges of an aging population and unsustainable health care budgets.   Consider the following passage from a Canadian Association of Emergency Physicians report published in 2005:

The principal cause of overcrowding is the lack of beds on hospital wards and in Intensive Care Units. With the shortage of hospital beds, overflow patients are often “warehoused” in Emergency Departments, creating a situation where the sickest patients are “blocked” from accessing timely care. Acute care bed capacity is also significantly affected by patients who require an “alternate level of care” (ALC), patients who could be served at home, shortages in home care resources as well as a lack of chronic and palliative care beds. These patients account for up to 20% of acute care hospital beds and act as “bed blockers”, thereby contributing to the problem of ED overcrowding by preventing the admission of emergency patients to hospital beds.“**

ALC patients have been called “bed blockers” but not usually in official briefings.  This official use of the term is disturbing.

“On average, one patient “warehoused” in the Emergency Department denies access to four patients per hour to the Emergency Department, directly contributing to prolonged wait times and patient suffering.”**

What these passages won’t tell you is that in the vast majority of cases, an ALC patient is synonymous with “senior”.  The median age of ALC patients is 80 years old.  The most common diagnosis is dementia.  Most of these patients are admitted via the emergency department and stay an average 26 days compared with four days for non-ALC patients.  At a time of changing demographics when all common sense indicates we need increased community support and assistive housing for people with chronic health conditions, we’re currently saddled with the costly and outdated model we know: acute episodic hospital-based care.

When reading about how the ALC patient directly contributes to prolonging the suffering of other ER patients, it’s easy to forget that these ALC patients are also victims. They themselves do not have access to the care they need.  No one wants to be forgotten and stuck in the ER, exposing their weakened immune systems to harsh conditions, overworked caregivers and the grizzliest of bacterial infections.   These are people who have no other options; they’re either waiting on a set up that will allow them to go home and get medical help and help so they can eat and go to the bathroom at least once a day or they are waiting for a transitional rehab bed where they recuperate until that kind of help is available or a bed in a long-term care facility.  The 12% of them who have died in the ER waiting on those things would surely have preferred to be somewhere they were not regarded as a drain and a burden.

We are talking about 92,000 hospitalizations and over 2.4 million hospital days a year.  They represent 5% of all hospitalizations and 13% of all hospital days.  Just this April, they filled 15% of Ontario’s acute care beds and in some regions they fill up to 20%.  This means that almost one in six people in hospital beds is occupied by a senior languishing away when they could and should be somewhere else.   It is estimated that this inappropriate care costs $1, 200 a day – considerably more than it would cost to get them the care they actually need.

For other patients, this means that in hospitals with occupancy rates greater than 85%, the high number of ALC patients in in-patient beds helps explain why wait times in emergency rooms are so much longer for seriously ill patients who need a bed than for patients who do not require admission and can be discharged home.  For every ALC patient who can be placed in proper care, the hospital will be able to admit four more patients per hour.  First responder and paramedic services will also improve because they will not have to wait as long while their patient is transferred.

Another and less discussed face of the ALC issue relates to how it affects the hospital’s ability to because it can create a shortage of Intensive Care Unit post-operative beds available. Many surgeries are cancelled on short notice when these spots are not available.  Consider the following example provided by the recent Wait Times Alliance Report:

The Ottawa Hospital (TOH) is 1, 000 bed, multi-site bilingual teaching hospital with an emphasis on tertiary-level and specialty care serving 1.5 million residents primarily of Eastern Ontario.  In 2009–2010, the hospital had over 47,000 patient admissions, over 134,000 ED visits and almost one million ambulatory care visits.  High occupancy levels are an ongoing issue for TOH. The hospital routinely has an occupancy rate of over 100%. On average, 15% of the hospital’s beds are occupied by ALC patients.

As these patients remain in hospital for prolonged periods of time, there is a heightened sense of urgency to get patients not designated ALC home as soon as possible. An indication of this factor is that 50% of patients are discharged within 3 days of admission. As a result, TOH performance has been impacted by prolongation of emergency wait times, surgical cancellations, patient dissatisfaction and staff stress.
The impact of the high rate of ALC patients on TOH:

·      Less than 25% of patients received their beds within the provincial standard of 8 hours.  Some of them waited more than 24 hours.

·      In one year, TOH cancelled 580 elective surgeries because of the absence of an available bed.

·      The situation creates tremendous pressure to discharge patients who do not require community support. There can lead to premature discharge and patients can encounter complications when they return home.

These factors place a large burden on patients and families. Prolonged wait times in the emergency department lead to physical discomfort and can lead to a loss of privacy and dignity. Hospital readmissions are very stressful for patients and their family. Cancelling an elective surgery can cause significant disruption in a patient’s life and can prolong the suffering caused by the underlying condition.

Luckily, the TOH is handling the problem.  Many strategies are underway to handle issue:  TOH and surrounding region will improve patient flow by:
·      Improving communications at patient documentation (particularly discharge)

·      Improving clinical and electronic documentation

·      The region will provide enhanced home care services under the Ontario Ministry of Health’s Home First Program (up to 60 days following acute care discharge) and increasing the number of transitional beds and assisted living spaces.

Other measures that should be taken to address the ALC crisis are:

·      Investments in home care and the creation of a National Healthcare Program

·      Using multi-disciplinary care teams and patient navigators who will provide case management, help families and individuals find care in their communities as well as assisting with/ ensuring the success of the discharge plan.

·      Investing in a broader range of residential care supports; and

·      Providing supports for family caregivers.   Given how much they contribute we are not investing nearly enough in our caregivers.  We must if we wish to keep leveraging their work.  To this end, CARP has crafted a National Caregiver Strategy.

** From: 15 Canadian Association of Emergency Physicians, Taking action on the issue of overcrowding in Canada’s emergency departments. June 16, 2005. http://www.waittimealliance.ca/waittimes/CAEP.pdf 16 Health Quality Ontario, 2010 Report on Ontario’s Health System. 2010. http://www.ohqc.ca/pdfs/2010_report_-_english.pdf