ER overload: Deadly chess game

If you were to find a magic lamp, the first wish you should ask the genie to grant is good health. Number two on your list? A request that you don’t get hurt — ever. If the genie finds this a bit puzzling, tell him about Ontario’s hospital emergency rooms.

Patient volumes in ERs traditionally increase during the months of January and February, but this year the demand for service produced headline making stories of patients lying on stretchers for days waiting for hospital beds. With unprecedented frequency, hospitals in large urban centres, notably Toronto, asked ambulance services to re direct (RDC) incoming patients to other hospitals. On some occasions, hospitals went on critical care bypass (CCB), redirecting even critically ill patients for at least 30 minutes. And for the first time, York Central Hospital in the Greater Toronto Area community of Richmond Hill reached that dubious status in late January twice in the same week.

“We’re trying to work with the Ministry of Health and the hospitals to try and develop a solution,” says Peter Rotolo, Operations Manager for the City of Toronto’s Ambulance Service. “It’s not an easy problem to solve.”

His 80 to 9vehicles (30 to 40 at night) travel throughout the city and into the GTA, but when too many hospitals are on redirect, Rotolo says “We advise them everybody’s in the same status and we’re coming in. It gets to the point where you just have to go to the one that’s closest.”

Rotolo’s staff is facing a lot of frustration, much of it directed at them. “Nurses are frustrated because we’re still coming in,” he says. And patients and their relatives are often shocked when the patient is not transported to the nearest and most familiar hospital. “We have to say ‘Sorry, it’s closed we’ve got to go to Mississauga.’ They have to understand it’s not the crews they’d like to take you to the hospital where you’ve always been treated, but they just can’t,” says Rotolo.

“While you’re under our care,” he adds reassuringly, “your medical condition is not going to be jeopardized. The paramedics are great and you’re getting excellent care while in our units.” But it’s taking longer to get those units back into service after a patient has been delivered to an overly busy emergency department. This leaves ambulance dispatchers caught in a deadly chess game, trying to ensure emergency calls are answered quickly, providing maximum coverage with the units that are available.

But what will happen if the majority of hospitals are on redirect or critical care bypass and a catastrophic accident occurs?

Province-wide problem

If you live in a smaller Ontario community, don’t imagine you can’t be affected by the problem of overloaded tertiary care referral centres in Toronto, Ottawa, Kingston, London, Thunder Bay and Hamilton. Anyone requiring the specialized diagnostic and care services only available in those centres could wait longer for an urgent placement. CritiCall, the agency that coordinates arrangements to get patients into an appropriate treatment centre, is experiencing a 30 per cent increase in the amount of time it takes to find a bed for a critically ill patient. One Eastern Ontario woman blames the delay for the paralysis a family member is now facing.

Hospitals are struggling to cope. Some have brought in extra nurses and opened beds to alleviate the situation; Joseph Brant Hospital, in Burlington, even created a treatment centre in its boardroom. But the cost of these short-term solutions comes out of hospital budgets under siege by funding cuts imposed before restructuring began.

People are arriving at emergency departments more acutely ill than in the past. Doctors worry some may delay too long with fatal consequences because they’re reluctant to become part of the problem. They don’t want to wait hours to be seen by a physician, and they definitely don’t want to be kept on a corridor stretcher until an acute care bed becomes available.

Doctors are finding it harder to get their seriously ill patients into hospital and just as difficult to keep them there under close medical supervision.

Bed blockage

But what’s the problem? And why now?

A nastier-than-normal flu season hit staff hard and brought a crush of flu victims, including nursing home residents, to ERs.

Ten years ago this may not have been a problem, but since 1988 hospitals in Ontario have closed almost one third of their beds (and more will disappear as healthcare restructuring continues). And as many as 30 to 40 per cent of the remaining acute care beds are occupied by people who would be best served by long term convalescent care, rehabilitation facilities, or adequate home care services.

Alarmingly, promised long term beds are not in place and current funding for home care doesn’t appear adequate enough to meet the rising demand for services.

The minister responsible for seniors and long term care, Cam Jackson, has announced a $3 million increase for the Ottawa Carleton Community Care Access Centre (CCAC), $312,120 for the Simcoe County CCAC and is studying the need for budget increases in 10 other CCACs. But in Ottawa Carleton, deleted home care hours are still not being restored. And, unfortunately, not every discharged but still-ailing patient has family or friends with the time, training or resources to provide interim care while their health improves. In such circumstances, vulnerable people, many of them elderly, might well become victims of ineptitude, neglect or abuse.

Reinvestment too slow

In December, 1997, the Ontario Hospital Association began a study of the overcrowding in Toronto area emergency rooms; by February, its working group was joined by officials from the Ministry of Health. It’s not clear whether this task force has been given the power to make changes. Although the Health Services Restructuring Commission (HSRC) has ordered the closure of hospitals, the chair of the commission, Dr. Duncan Sinclair, thinks the task force will substantiate the HSRC’s recommendation that major reinvestment must proceed in other sectors the remaining hospitals, nursing homes and community based services such as home care.

“The pace of the reinvestment decisions is slower than I would prefer,” notes Sinclair, “I think it’s slower than the Minister of Health would prefer. But I remain confident that the link between hospital restructuring and the development of community based services, particularly long term care and home care, is clearly understood and there is a commitment to do that,” he says. Although he’s gone on record as saying the commission would postpone hospital closings if reconfigured hospitals, community based services and long term care beds were not in place, he believes enough lead time has been allowed before hospitals close to make the necessary changes. However, in a September, 1997, report prepared for the Ontario Hospital Association (OHA), the Richard Ivey School of Business at the University of Western Ontario recommended slowing the pace of change to allow hospitals to better plan and deal with the transformation they’re expected to undergo.

A second report prepared for the OHA by the Canadian Imperial Bank of Commerce, concluded hospitals will need more funds to cover the costs of restructuring. As it now stands, they’re forced to absorb the interest on loans needed for changes imposed by the government because they’re not reimbursed until reconstruction is completed.

A new kind of healthcare

Dr. Sinclair, head of the HSRC, is anxiously awaiting what he considers a key piece in the overall reform of health services. Primary care is the front line of healthcare the way you first get into the system. If restructuring is to be successful, it’ll mean we’ll all have to get used to a new way of accessing medical care.

Hospitals will likely be left to do what they do best — treating disease, often with high tech methods. Emergency departments will handle traumas and life threatening crises that need immediate intervention. The rest of the system will be geared to keeping people well and in their homes.

At a national conference on home care held in Halifax in March, federal health minister, Allan Rock, pointed out the importance of home care as part of the healthcare system — but couldn’t promise federal financial backing. Many, including CARP, were disappointed the federal budget introduced by Finance Minister Paul Martin in February virtually ignored healthcare. CARP had hoped for a restoration of transfers to the provinces for healthcare. And although the issue of including Pharmacare and home care under the Canada Health Act has been raised, Cabinet doesn’t appear to be behind such a plan at this time.

While the debate over primary care begins to emerge, people still lie in hallways, others wait for long term care beds, still others struggle to cope with the desperate needs of a bed ridden parent or spouse suffering from dementia. It’s time for the government to slow the pace of hospital reformation, get on with primary care planning and begin providing the services ill and injured people need.

Finding solutions

Expanding ER services and staff in Toronto, a promise made by Health Minister Elizabeth Witmer, won’t solve today’s jammed corridors, according to Ontario Liberal health critic, Gerard Kennedy. “All she is saying is that help is two years away. Just like long term beds, it will not happen overnight.”

His party wants new funds from the province to allow hospitals to hire more nurses and re open enough beds to get people out of the hallways and into proper care. “Emergency is not where people are supposed to get healthcare,” says Kennedy.

The Liberals are also calling on the government to halt hospital and ER closures until they can show, bed by bed, that alternate services are in place.

Dr. Frank Bailli is medical director for CritiCall and Vice President of Clinical Affairs for Hamilton’s St. Peter’s Hospital, a chronic care hospital scheduled to close. Putting money into ERs is not his notion of where the money would do the most good either. “Improve funding,” he says, “but for front line staff.” He believes enough beds in hospitals and chronic care facilities could quickly be opened up, creating or freeing up acute care beds.

Bailli is concerned essential critical care beds may unintentionally be lost in the restructuring process, when two or more hospitals merge. As head of CritiCall, he sees a province wide problem staffing critical care units. Hospitals are having a harder time recruiting critical care nurses; they’re leaving hospitals scheduled for closure; those left behind are becoming stressed out, burned out, fed up and increasingly concerned over the quality of care patients are receiving. And American recruiters can offer them greater job satisfaction and more money south of the border.

Staying healthier — at home

Remember a time when doctors actually made house calls? In the future, that house call could be made by a nurse who will be your first contact with the healthcare system. Shirlee Sharkey is President and Chief Executive Officer of Saint Elizabeth Health Care, a not for profit provider of nursing services to patients in their homes. She sees nurses as an adjunct to the traditional family practitioner; people will develop a trusting relationship with the nurse who will guide them to appropriate healthcare services. It may include preventative advice nutritional information or the suggestion that a visit to a physician is needed. Early intervention from such a healthcare provider may allow people to access good health information, stay healthier longer, and save unnecessary trips to hospitals and ERs.

“Just think of the real time assessment that can happen very quickly in the home environment with the nurse going in to make a visit,” says Sharkey, “versus someone having to sit eight hours in emergency.”

But this scenario and other visions of primary health delivery will not come easily. Creating a model and the accompanying financial incentives to satisfy physicians will be one challenge. “If we all begin to look at this from a broader perspective,” says Sharkey, “I think there’s the creativity to come up with some good changes.”