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Hospital crowding: despite strains, Ontario hospitals aren’t lobbying for more beds


Patients languishing on stretchers in hospital hallways, hospitals issuing capacity alerts when they can’t take more patients, tension in emergency departments as patients wait hours and even days to be admitted.

That’s too often the reality in our hospitals. And, given the statistics, you’d think that hospital executives—especially in Ontario—would be pushing hard for more beds. Here’s a snapshot of the situation:

  • Canada has 1.7 acute care beds per 1,000 residents, which is only half of the average per capita rate of hospital beds among the 34 countries of the OECD.
  • The average occupancy rate for acute care beds in Canada in 2009 was 93%, the second highest in the OECD, surpassed only by Israel’s rate of 96%, according to OECD figures.
  • Between 1998 and 2011, the number of all types of hospital beds in Ontario remained “virtually constant at approximately 31,000” while the population increased by 16%, according to a 2011 Ontario Hospital Association document.
  • In 2012, Ontario’s per capita funding for public hospitals was the lowest of the provinces, according to the Canadian Institute for Health Information. This makes Ontario’s hospitals both very efficient and very pressed for beds at the same time.
  • As Ontario struggles with a provincial deficit, hospitals in the province are facing flat-lined budgets for the next several years. Zero increases effectively mean funding cuts, given inflation and salary pressures.

It may come as a surprise that despite these statistics, Ontario Hospital Association president Pat Campbell is not advocating for more hospital beds.

Instead the OHA wants to see much more attention devoted to the capacity of the entire health care system and to improving the integration of care with sectors including primary care, home care, rehabilitation and long-term care.

“This is a roadmap that we don’t have,” Campbell said in an interview.

The United Kingdom and Australia consider an 85% acute care bed occupancy rate to be the safe upper limit, according to the OECD. But Campbell, who says the OECD’s figures on Canadian occupancy rates are probably accurate, is not interested in debating appropriate overall rates.

Occupancy has to be looked at on a service-by-service basis in individual hospitals, she says.

It’s a perspective shared by Keith Rose, the executive vice-president at Sunnybrook Health Sciences Centre in Toronto who is in charge of capacity planning. “On a day-by-day basis, we do juggle,” he says. “It is hard to get the numbers right, to balance fiscal reality with the demand for beds, with flu and seasonal variations.”

Rose says, for example, that occupancy rates in surgical critical care units, characterized by rapid turnover and short stays, should be about 75% to be efficient.

Improving integration

When Rose came to Sunnybrook (having previously worked at North York General and St. Michael’s Hospital), he says that lack of capacity meant some neurosurgery patients were being sent to the United States.

A creative solution, allowing patients to stay in Canada, came in the form of co-operation with the University Health Network and St. Michael’s Hospital. The Ministry of Health and Long-Term Care also boosted funding for neurosurgery.

This kind of cooperation could also work when hospital crowding becomes excessive, for example when flu season hits, says Mike Tierney, vice-president for clinical programs at The Ottawa Hospital and one of the editors of Healthy Debate. What is needed is “an ability to look at hospital occupancy and bed availability across a region in real time, rather than each hospital trying their best to manage on their own. This exists for critical care but not for medical/surgical beds.”

“It would be a mistake to add beds to a dysfunctional system”

Occupancy rates matter if you accept the premise that high rates lead to poor access for patients who need to be admitted from emergency departments, notes Michael Schull, an emergency room doctor at Sunnybrook who has published on wait times in emergency and overcrowding risks.

While wait times for patients who come to emergency departments have improved overall in Ontario after this was made a priority, there has been much less success in meeting target wait times for those patients waiting to be admitted from emergency departments.

Still, Schull does not advocate for more hospital beds. “It would be a mistake to add beds to a dysfunctional system,” he says.

Instead, focus has to be placed on improving patient flow through the system, says Schull. That will require defining measures of quality care, and creating incentives and processes to support primary care providers and community based-services in better managing patients where they live. This would avoid hospitalization or if they have to be admitted, help to get them to appropriate post-hospital care in a timely fashion.

Investment needed in Alternative Levels of Care

The sobering reality is that Ontario hospitals are tight for capacity largely because of the number of beds occupied by patients, most of them elderly, waiting for admission to another facility (such as rehabilitation or long-term care) or for support to return home.

These alternate level of care (ALC) patients typically occupy between about 12% and 20% of acute care beds in Ontario, and several recent reports have focused on trying to find ways to deal with the situation (see for example the OHA roundtable report).

David Walker’s 2011 report for the Ontario Ministry of Health and Long-Term Care, Caring for our Elderly Population and Addressing Alternate Level of Care, stressed the need for community level support, and for assessing and restoring the health of the elderly, so they can remain at home and so the hospital emergency ward “does not become the default” place to access care.

In the absence of early intervention in the community, too many elderly patients are admitted through the emergency to acute care, where their condition then takes a “downward spiral,” he says.

Administrators at Health Sciences North in Ontario have discovered the benefit of very active cooperation between the 459 bed Ramsey Lake Health Centre (formerly the Sudbury Regional Hospital) and the local Community Care Access Centre (CCAC). Working together, the result has been a reduction of ALC patients at the health centre from 133 to 78 in the period between September and December 2012, says David McNeil, vice president of clinical services and chief of nursing.

The challenge for the CCAC was to expand its capacity for community-based care, and some funding was received from the province for new programs including behavioural support and mobility programs. For its part, the hospital recruited a new geriatrician, gradually closed beds at the former Memorial Hospital site that had been used for ALC patients, and redirected money towards chronic disease management.

As well, community groups have been engaged “to help them understand that the hospital is no longer the centre of the universe,” McNeil says, adding that in the absence of concerted action being taken to boost preventive and convalescent care in the community, there will continue to be a “bottleneck” in the most expensive part of the system—that of hospitals and doctors. On the other hand specialists must work closely  with primary care and community providers to provide optimal care.

“We need to get the continuum of care right.”

What’s your view—do you think Ontario needs more hospital beds?

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9 comments

  1. David

    I voted that investments should go to other parts of the system, although I don’t agree that should necessarily be to LTC. Home Care, assisted living, clustered approaches to community based care, multi-disciplinary approaches to patients with chronic multiple conditions and preventative and restorative rehab should be priorities. A big LTC issue is the need to provide services for those with complex needs; these are the folk who languish in acute care for weeks, months, sometimes years – a location that does not meet their needs but for whom LTC generally cannot either. We need LTC incentives and resources to address this critical subset of people who often have a complex mix of behavioural/dementing/continence and mobility issues for whom LTC is necessary but not available.

  2. Rick Janson

    This is the old saw we’ve been hearing for years — cut hospital services and wait for services to emerge within the community. At the end of the 1990s the Health Restructuring Commission set a specific target for reduction of pyschiatric hospital beds under the proviso that new services be established in the community first. Some services were, but not nearly in the proportion necessary to offset cuts to the larger institutional providers. As a result our mental health system is a mess, where patients are now finding the lost beds in our corrections system at an incredible cost to society and the families involved. The Canadian hospital occupancy average is 93 per cent, Ontario is closer to 98 per cent. We’re repeating the story all over again. Government has already realized a premium from bed cuts, but again wait times would tell us that we never saw the alternative. Think about it — home care is getting a 4 per cent increase this year. Inflation is at 1.2 per cent, population growth usually adds another 1 per cent pressure, and aging another one per cent. That means while we are seeing yet another round of cuts to hospital beds, the government is adding only 0.8 per cent in new funding to home care. The situation is worse among other alternatives. We’ve taken all the bed cuts we should from hospitals. It’s time for Deb Matthews to put our money where her mouth is and create these alternatives to offset the beds that have already been lost. If not, put the beds back.

  3. Brian Orr

    Hospital inpatient beds are an expensive and scarce resource. They are critical for the delivery of complex care that can only be provided within a hospital. From personal experience, having a hospital operate with an average inpatient bed capacity significantly above 85% creates operational waste, and degrades the ability to provide timely care to patients most in need of admission to a hospital.

    The article is correct that the cost-effective approach is to reduce the occurrence of ALC patients staying in hospitals by expanding the capacity to care for these patients either at homes, supportive care facilities or in long-term care homes. The ideal goal is to have zero ALC patients in hospitals.

  4. dr merrilee fullerton

    %featured%I believe there is a level of fear that exists amongst health care administrators to suggest there is need for more hospital beds when government does not want to hear this because of associated costs.%featured%

    If ALC patients were all moved out of acute care institutions tomorrow, three things would happen:

    1. Government costs of long term care and home care services (plus additional costs of readmissions when pts in the community with co-morbidities succumb to acute events) would rise as more providers and more services would be necessary to provide the community care that is promised.

    2. Gov’t costs of acute care in hospitals would rise as more patients waiting in queues for expensive treatments would finally get their care in the vacated beds (unless those same vacated beds are closed)

    3. Gov’t costs of caring for elderly, debilitated patients would rise as more ALC patients fill the hospital beds vacated by previous ALC patients who are now cared for in the community at additional government cost.

    In each of these scenarios, costs to government health care and social services will rise and no savings or cost-control will be achieved…..UNLESS the vacated beds are really closed and not made available to all the Canadians waiting in queues for care.

    This begs the question:

    If we are already at HALF the number of beds per capita compared to other OECD nations, can beds really be cut further to control costs?

    I suggest that the answer is NO.

    And a note on readmission rates:

    The real problem with readmission rate overall may be that patients are being discharged too soon from acute care hospital beds because of the efforts to control bed usage that is already in short supply.

  5. Sassy

    %featured%Alot of the ALC problems would be helped, if LTC facilities weren’t able to pick and choose the patients they are willing to accept into their facility%featured%…LTC facilities are staffed, with RPNs, RNs,PSWs and doctors and even sometimes a Nurse practitioner….all have the same base knowledge and skill set of a nurse working in an acute setting. So why are nursing homes sending a patient to the ER for simple manageable scenarios… like a urinary tract infection… oh they need IV antibiotics, so they get admitted to an acute care bed, why can’t the resident return to the nursing home and provided the NURSING care of IV antibiotics at the nursing home… IV therapy is a BASIC NURSING SKILL.

    Another scenario…. a patient deemed ALC in a hospital, who has tube feeds, a bed sore, and a permanent tracheotomy would be deemed “too much care” and refused by the nursing home….why is that even allowed to happen!!!! When a patients care needs are more then say an average residents needs, the LTC facility applies for HIGH INTENSITY FUNDING, which sees the ministry giving extras funding to the the LTC facility to provide the extra care for that patient. NO excuses there in my opinion.

    And last but certainly not least on the list….. is the family/patient who has occupied an acute care bed for over 470 days while awaiting placement because they have refused THREE nursing homes beds…. this should NOT be allowed to happen at all…. and if the public, or patients who have been on an ER stretcher for a week waiting for a bed, knew how often this happens, there would be public uprising!!!! These issues all need to be ironed out….i think the saying goes, it takes a village …..

  6. Dan Davis

    %featured%You can add beds, look at services outside of hospitals or lobby for new hospitals, but the reality of our health care situation now points directly at abuse by accountants, lawyers, politicans, administrators and doctors who have replaced their hippocratic oath with an oath to make money.%featured%

    According to the latest figures, Ontario’s doctors earn, on average, $385,000 per year and are the best paid in the country.

    Many specialists now earn twice that amount or more.

    Since 2003, doctors’ pay has increased by an average of $164,000

  7. Colleen Smith

    After caring for my mother for 12 years at our home, we are now asking for a long term placement as my husband and I are no longer able to give her the care she requires. Some staff are fantastic but the system is in crisis! No beds, overworked staff, and my 90 year old mother in emergency for three days waiting for bed. We are a family that has never misused services, always sensitive to the needs of others and now when we require assistance we get nothing but pushed and hassled. It is absolutely disgusting and heart breaking. We are getting different answers from people working in the same building!

  8. Pasty

    Enough talk. It’s all we ever get. I am currently experiencing the bed emergency first hand. My 84 year-old father was transferred from one hospital because a NO BEDS. He then stayed in the ICU longer than necessary for the same reason. Enough. Contact the Health Minister and scream.

  9. Elaine Lowe

    Baby boomers are aging quickly. We don’t need more hospital beds. We need to develop less expensive and more innovative ways of living and of caring for this huge segment of the population.

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