The crisis gripping Canada's emergency departments is taking on fresh urgency with the arrival of a new look at overcrowding and its root causes.
Ontario's Auditor-General has reviewed a trio of hospital emergency rooms and The Globe and Mail has learned that his findings, to be released Monday, will strike at the system from top to bottom. At least one regional hospital faces criticism, but the auditor's report will also take on the province over how it manages the system.
The findings will likely prompt sharper questions about the need for leadership and innovation in managing and funding Canada's health-are system, of which hospitals take up the largest portion of spending.
Emergency departments are the entry point for most patients, making them the most visible example of the problem all provinces are struggling with - rising health-care costs that already eat up about 40 cents of every dollar spent on social programs.
At the root of the problem, according to experts and those familiar with parts of the auditor's report, is an acute shortage of community-based care for aging Canadians. This bottleneck, which has been building for more than a decade, leaves too many patients occupying beds long after they should be discharged.
At Scarborough General, Canada's largest urban community hospital, 16 of the 35 stretchers in emergency were occupied on Sunday afternoon by patients waiting to be admitted, said Thomas Chan, chief of emergency medicine.
It's not just inefficient, it's expensive. "When we have patients boarded in emergency, it consumes not only bed resources but nurse resources," Dr. Chan said.
Scarborough General is one of the three emergency departments probed by Ontario Auditor-General Jim McCarter, along with Hamilton General and Southlake Regional Health Centre in Newmarket, according to sources familiar with the report. Mr. McCarter is expected to highlight problems at Hamilton General, which are said to flow from its status as a hub serving people from Burlington to Brantford and Niagara Falls to Guelph in Southwestern Ontario. Hamilton General has become the "overflow valve" for Niagara Health System, a complex of seven hospitals that closed two of its emergency departments.
"Everybody knows Niagara Health is struggling," said one hospital executive on Sunday.
Brenda Flaherty, executive vice-president of clinical operations at Hamilton General, declined to comment, beyond saying the hospital plays a regional role and serves 2.3 million people.
The auditor will criticize the government of Ontario Premier Dalton McGuinty for waiting until the 11th hour to tell hospital executives how much funding they will receive each year, sources say. But his report will also attack the broader, long-standing systemic problems that force doctors to use the expensive resources of emergency departments to board patients who need beds elsewhere in a hospital.
The problem dates back to the early 1990s, when cash-strapped provinces cut back on hospital beds. Now provinces are struggling once again with declining tax revenues and rising costs and that quick fix is coming back to hurt them. An aging population is putting government leaders under mounting pressure to fund alternative arrangements, including more long-term-care beds and strategies that allow elderly patients to remain in their homes.
In Ontario alone, one in six hospital beds is occupied by patients awaiting nursing-home placement. That causes a domino effect, leaving many emergency patients waiting for hours to be moved to a room. And it's not afflicting just urban centres, medical experts say. It's also spreading to rural Canada.
"We're an aging and growing population, so we know that demands on the health-care system are only going to get stronger," Ontario Health Minister Deb Matthews said.
The province invested about $270-million in community-care programs in fiscal 2009-10, to help more seniors live independently and receive appropriate care. But the provincial auditor's report says those measures fall short, according to sources. If hospitals could move patients out of acute-care beds and into more appropriate settings faster, the auditor concludes, that would go a long way toward reducing overcrowding in emergency departments.
Meanwhile, some health-care leaders are looking for ways to make better use of existing resources.
At Sunnybrook Health Sciences Centre, doctors launched a pilot project last week with Cleveland Clinic, a private, not-for-profit hospital based in Ohio, in an effort to improve the flow of patients through its emergency department. The so-called road map project is looking at every stage patients go through in emergency, from the time they arrive to when they are diagnosed and discharged or admitted, said Dr. Keith Rose, chief medical executive.
And St. Michael's Hospital is working on a research study with other major hospitals in Toronto to identify patients who are at higher risk of being readmitted after they've been discharged. A group of patients has been put into a "virtual ward," where a team of doctors and nurses monitors their health. The goal is to increase the patients' chances of not getting readmitted, said Robert Howard, chief executive officer of St. Michael's Hospital.
"We're looking for new ways to do things," he said. "Obviously, the same old, same old isn't going to get us to a better place."