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.”