Dr. Grant Innes, Alberta Health Services Head of Emergency Medicine at Calgary hospitals talks to a waiting patient in the Emergency room of the Rockyview Gerneral Hospital on Wednesday, November 24, 2010.Chris Bolin/The Globe and Mail
THE QUESTION
I recently took my elderly father to a hospital emergency department because he was suffering from severe stomach pain. A doctor saw him fairly promptly and decided to admit him. But my father then had to wait more than a day in the emergency department before he was moved to a bed in a hospital room. Why did he have to wait so long?
THE ANSWER
What happened to your father can best be described as hospital "gridlock." And, unfortunately, it's not uncommon for people to wait a long time for a bed when a hospital is nearly full of patients.
All hospitals follow standard procedures for assessing patients when they arrive in the emergency department. Those with potentially life-threatening conditions – such as heart attacks and strokes – are normally treated right away.
But once the decision is made that a patient requires further care in the hospital – to be admitted – this individual may have to wait on a stretcher in the emergency department until a bed becomes available in one of the hospital wards.
If all hospital beds are full, the length of time that a patient lies on an emergency department stretcher is going to increase, says Dr. Jeffrey Tyberg, Chief of the Department of Emergency Services at Sunnybrook Health Sciences Centre.
As more and more patients wait for beds, the emergency department will become increasingly crowded, which can be uncomfortable for them, and may delay care for newly arriving patients because staff and stretchers are occupied with the admitted patients and their care needs.
In some ways, moving patients through a hospital can be compared with travellers checking into a hotel. "The process of registration at the hotel front desk may be very efficient, but if the customers haven't left their rooms, then people in the lobby can't go upstairs," explains Dr. Howard Ovens, chief of the department of emergency medicine at Mount Sinai Hospital in Toronto.
Once customers from the previous night finally do leave, then hotel staff can start cleaning the rooms for the new arrivals.
Similarly, hospitals rooms must be cleaned and disinfected before patients can be moved in. But the job of freeing up hospital beds is further complicated by the fact that some patients must be transferred to other health-care institutions. These patients no longer require the medical care of a hospital, but they are not well enough to go home. They may need to go into a rehab centre, long-term care facility or nursing home. If there are no free spots in these institutions, then the patients will remain longer than necessary in hospital.
Studies suggest that hospitals should be operating at 85-per-cent to 90-per-cent occupancy for an efficient turnover of beds. Higher occupancy levels tend to lead to gridlock. But faced with tight financial budgets, many Canadian hospitals frequently have more than 90 per cent of their beds filled, Ovens says. And, at times, occupancy can exceed 100 per cent – with patients lying on stretchers in the hallways.
Of course, different hospitals get a different mix of patients. In some communities, a relatively high proportion of patients may go to the local emergency department because they don't have a family doctor or can't get a timely medical appointment.
But the problem of limited access to family doctors doesn't actually put an onerous burden on hospitals, Dr. Tyberg says. "There has been a long-standing myth that wait times are long in emergency departments because they're crowded with people with minor problems who shouldn't be there. That's incorrect."
These patients tend to be in stable condition. They don't usually need a lot of tests and don't use up a lot of hospital resources, although it may take quite a while for them to be seen by a doctor.
Tyberg says the major reason for emergency department overcrowding really boils down to one key issue – the availability of acute-care beds.
In fact, Canada has relatively fewer hospital beds than many other industrialized countries. There were 2.7 beds for every 1,000 Canadians according to 2012 figures. By contrast, the average number of hospital beds was 4.8 for every 1,000 people in 2012 for countries in the Organization of Economic Co-operation and Development (OECD). Over all, Canada ranked 30th out of 34 OECD countries in the hospital bed category.
Many Canadian hospitals have adopted various measures to reduce the time that patients must wait for care. "Hospitals are working to become more efficient – which is a good thing," Ovens says. But, he adds, there are limits to what can be achieved through efficiencies alone.
As the Canadian population increases – and grows older – demand for medical services is expected to rise. Many provincial governments have been focused on providing more home care and long-term care. "I think, eventually, we are also going to need more acute-care beds," says Dr. Ovens.
Paul Taylor is a patient navigation adviser at Sunnybrook Health Sciences Centre. He is a former health editor of The Globe and Mail. You can find him on Twitter and online at Sunnybrook's Your Health Matters.