The Fixing Health Care series presents 10 common problems faced by patients in Canada, along with 10 solutions that the authors argue can be achieved within our existing publicly funded health system. While the ‘problem’ scenarios in the series are fictional, the authors offer these examples to echo the patient experiences they have encountered through their work in health care and social services.
The Problem: Patients spend countless hours in the emergency department, waiting to get treatment
Keisha’s husband was diagnosed with cancer and, unfortunately, they were given a poor prognosis. But the team at the cancer centre was terrific and promised they would do everything possible to keep the disease at bay for as long as possible.
During the three years Keisha and Jim had left together before he passed away, they had very good treatment from the cancer system. However, as Jim gradually became sicker, they had to visit the emergency department more and more frequently, at first for complications from his chemotherapy and then for problems resulting from the progression of the disease. These experiences were not good. Each ER visit was the same – a long wait for registration, followed by hours waiting to see a doctor, waiting for test results and then waiting for treatment decisions.
If Jim could receive treatment in the ER (like administration of fluids or antibiotics) before being discharged, the whole ordeal could take up to 18 hours from the time they entered the emergency department. However, what Keisha really dreaded was receiving the news that Jim needed to be admitted to hospital as an inpatient.
Waiting in the ER for admission to the hospital was the worst part of their cancer journey. Even though he was often feverish and in pain, staff sometimes had to leave Jim on a gurney in the ER corridor since there was no bed available on the ward in the hospital. Keisha spent countless hours and sometimes days with him just waiting in the emergency department for a spot to become available. Usually, they just felt forgotten.
The Fix: Canada must improve ER treatment and alleviate hospital overcrowding by prioritizing transitional-care facilities.
For years, Canadians have been confronted by the phenomenon of “hallway health care,” defined by the sight of patients lying on gurneys in overcrowded ERs or hospital corridors. These images offer a stark and disheartening commentary on the state of our medical system.
Canadian hospitals are chronically overcrowded, with far too many patients needing admission to a limited number of staffed beds available on inpatient units. This often results in patients waiting on gurneys or chairs in emergency departments, corridors and even conference rooms while dedicated staff constantly huddle to figure out where to put the next sick patient. Chaotic emergency departments are too often used as catch-all waiting spaces.
Those unfamiliar with the inner workings of a hospital might blame ER staff for being disorganized or suggest that we need bigger ERs to accommodate more people. However, the real problem is that Canadian emergency departments are simply overwhelmed by a combination of patients who are waiting for admission to the hospital (inpatients), as well as those who arrive with an urgent medical problem (a mix of people who will either be discharged from the ER or who will require admission).
In practice, this means that emergency department staff have to continue caring for inpatients who are waiting for a bed on the wards (for example, checking in on their response to initial treatment, pain levels and vital signs) while also dealing with other patients who come into the ER for urgent care (injuries, fevers, etc.). Often, the reason ER waits are so long for even minor problems is that there is simply no space available in the department because all the stretchers have been taken up by those waiting for inpatient admission.
During the pandemic, the issue of hallway medicine briefly receded into the background as hospitals cancelled surgeries to free up beds and staff to look after patients suffering from COVID-19. But as hospitals try to return to “normal” operations and clear the huge backlogs of patients whose operations have been delayed during the pandemic, capacity issues are again in the foreground.
So, is the answer that we need more hospitals, hospital staff and ER spaces? Or at least more wings built onto existing hospitals that can expand the number of beds available?
In fact, there may already be close to enough beds in Canadian hospitals, even though we have fewer acute-care beds than most countries in the Organisation for Economic Development and Co-operation. In our estimation, the reality is that at least 15 per cent of the patients in these beds simply no longer need to be there.
These patients might be well on their way to recovering from a condition such as pneumonia or heart failure, and no longer require round-the-clock, hospital-level care. These “alternate level of care” (or ALC) patients are stuck in limbo – no longer in need of hospital care but not yet ready to go home and care for themselves. In 2011, the Canadian Institute for Health Information reported that 7,500 of the 57,000 hospital beds in Canada were occupied by ALC patients “who could be safely discharged elsewhere.” In some cases, these patients may eventually require admission to a long-term care home, but are faced with long wait times for an LTC bed as well.
People admitted to hospital with acute illnesses, especially older people, undergo a process of “deconditioning” that reduces their strength, independence and capacity for self-care. During hospital treatment, they may have stayed in bed for several days, which can rapidly weaken their muscles and make it unsafe for them to walk independently. They may also suffer from delirium due to pain medication, the effects of illness, or simply being in a foreign environment.
These deconditioned patients need time and relatively simple rehabilitation to be able to return home, though in some instances they may eventually require a nursing-home bed. In any case, they do not need the 24-hour complex care that our hospitals are designed for. But without anywhere else to go, these patients remain in hospital rooms while other people wait in our ERs for these beds to be vacated. This is not in any way the patient’s fault, or the fault of emergency department staff – we have not designed our health system to deal with patient needs appropriately.
Those who no longer need hospital care but are not ready to return home can benefit from a model known as transitional care. This type of care is provided in “reactivation centres,” where patients are given time to recover from their acute illness while being offered straightforward rehabilitation, such as help building up muscle strength for walking. In the United States, private insurance providers’ wish to reduce the length of expensive hospital stays has led to the creation of skilled nursing facilities, where patients are usually transferred rapidly after initial treatment in hospital. These transitional-care facilities are more cost-effective than hospitals since patients do not require the same type of expensive investigations and treatment needed in hospital, nor the same staffing intensity. In the U.S., the daily cost of a skilled nursing facility bed is a fraction of the daily cost for a hospital bed.
In Canada, we have been late to recognize the advantage of transitional care. While more transitional-care beds have been made available in recent years in certain regions, this type of care must become the rule as opposed to the exception in Canadian health care. A study of the transitional-care unit at St. Joseph’s Hospital in Comox, B.C., has shown that the proportion of ALC patients returning home (as opposed to eventually moving to long-term care facilities) increased by about 20 per cent when patients were transferred to transitional care rather than remaining in hospital.
By creating transitional-care facilities to recondition patients following hospitalization, we can increase hospitals’ capacity and improve the patient experience. There is no question that Canada needs more health care staff to look after people in these transitional facilities, but the staffing mix is different than in hospitals. The capital costs for transitional care are lower, since the complex facilities found in hospitals – such as emergency rooms, operating rooms, labs and imaging – are not needed. The capital costs are also lower than in long-term care nursing homes, since the transitional-care facility does not need to be designed to look after long-term residents. In Canada, most transitional-care facilities have been opened in redeveloped hospitals initially scheduled for closure or in renovated, older retirement facilities. These facilities can be opened much faster than new hospitals.
Investing in transitional care should be a priority for every provincial government faced with hospital overcrowding. Some regions of Canada with rapid population growth undoubtedly require more acute-care hospital beds. All provinces need to expand the number of staff who will care for an aging population in a variety of different care facilities. But in order to urgently improve ER wait times and reduce hallway medicine, we need to start by developing facilities for patients who no longer need a hospital bed.
About the authors:
Dr. Robert Bell is professor emeritus in the Department of Surgery at the University of Toronto, former deputy minister of health for Ontario and former CEO of the University Health Network. Anne Golden is past president of the United Way of Greater Toronto and the Conference Board of Canada. Paul Alofs is former CEO of the Princess Margaret Cancer Foundation. Lionel Robins is past chair of the Princess Margaret Cancer Foundation, and a board member for the United Jewish Appeal Federation and the Betel Senior Centre.
More from the Fixing Health Care series:
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