Article

Gridlock in Ontario’s hospitals

About one in six beds in Ontario’s hospitals are occupied by patients who no longer need hospital care.

These beds are called Alternate Level of Care (ALC) beds.

Because ALC beds are not available for sick patients in the emergency department, ALC beds are an important cause of emergency department overcrowding.

The term ‘gridlock’, used to describe heavy traffic on roads or highways, is being applied to our hospitals and health care system. Gridlock occurs when patients are unable to flow effectively and efficiently through the health care system. One of the biggest causes of gridlock is the inability to discharge patients who no longer need hospital care – patients who cannot go home because there are insufficient supports at home, or are waiting for a bed in a rehabilitation hospital, nursing home or other assisted living facility. These patients are described as needing alternate level of care (ALC). An inability to discharge ALC patients is one of the root causes of long emergency department wait times.

How many acute care beds are occupied by ALC patients?

Overall, about 16% of acute care beds in Ontario are occupied by ALC patients. ALC rates are influenced by the age of the population, as well as the availability and integration of health care services.  Across Ontario there is significant variation in ALC rates. For example, in Northeastern Ontario 31% of acute care beds are filled by ALC patients, while in Toronto the ALC rate is 10.5%. Differences across regions may be related to a great concentration of community-based health care services in the urban Toronto area.

Who are ALC patients?

The frail elderly, people with cognitive and behavioral problems and neurology/stroke patients account for the greatest proportion of ALC patients. ALC patients are twice as likely as non-ALC patients to have multiple medical problems.

Why are ALC patients still in hospital?

ALC patients tend to need help with activities of daily living, which can range from house cleaning or cooking, to people who need round the clock care. ALC patients who remain in hospital do so because the supports they require outside of the hospital are not available. The shortage of diverse options that meet the needs of ALC patients outside the hospital (ranging from enhanced home care to supportive housing to rehabilitation to a nursing home) is the main reason ALC patients are not discharged from hospital as soon as they no longer need acute care. Interestingly, a study from Montreal found that elderly patients who do not have children stayed in hospital twice as long as those who do have children.

ALC and emergency departments

ALC has gained prominence in Ontario as an issue that affects the whole health care system, including the emergency department. If fewer hospital beds were occupied by ALC patients, those beds could be used to immediately admit patients from the emergency department, thus potentially decreasing emergency department overcrowding. There is thus considerable pressure on hospitals to discharge ALC patients.

Of course, ALC beds are not the only cause of emergency department overcrowding – please click to expand the below infographic for more causes. Please note that this diagram is provided by Alberta Health Services (AHS), not to be cited or distributed without permission from AHS.

Decreasing emergency department crowding versus patient choice

Newspapers have reported on patients who were forced to vacate a hospital bed for a long-term care home they didn’t choose. These hospitals are often dealing with gridlock and severe patient flow issues. Hospitals can receive a special Category A1 Crisis designation when the hospital is experiencing overcapacity and there are many patients in the emergency department waiting for acute care beds. Under these circumstances hospitals attempt to discharge ALC patients more quickly. Patients who are in hospital waiting for a bed in a specific chronic care institution may be asked to go to another institution in the region.

There have been cases in Ontario where patients have refused to go to a facility that was not on their list of top 3 choices, and indicated that they wished to remain in hospital.  Some hospitals have policies where they begin to charge patients for the costs associated with their stay if they refuse to be discharged.

16 Comments
  • Joe Canadian says:

    Personally I have no problem with true ALC patients staying put in hospital. Why, till a place to receive them is in place they will not get the care needed or require! The fact is we aren’t looking at the root of the problem. A lack of LTC beds ,these other locations are not set up for it. But nice if you want a billiards room and 24 hour snack bar.

    If we keep going why not build a small chilled warehouse or rent a meat locker. There is no gridlock, just hospital social workers and the CCAC doing what little they can as they hurry some out the door into a place they know can’t care for them properly. They are not assisted living.candidates!
    My point is Ontario needs to get on point and find the money somewhere, lord knows it’s being spent in the wrong places.
    If I was premier, I’d start work on 3 new LTC buildings, each with 250 beds in every mayor city. I’m sure we would still have the same problem again in time as it would be tucked away and forgot again when this gridlock feeling went away for the first time. While the family’s behind the scenes deal with the stress & worry of a loved one!

    Hippocratic Oath be dammed as soon as your given a ALC status

  • Golfer says:

    One contributing factor to the inability of discharging patients to home is the absence of the network of family, extended relatives, and friends to support the discharged patient. The multi-generational home and historical nuclear family unit are no longer the norm. The alternative after the acuity improvement is to reclassify the patient to ALC status and wait for institutional and often government-supported care. Economic demands and the need for a second wage-earner take women from the home where they filled that traditional role. Furthermore, our society has educated women and empowered them to leave their homemaker role and participate in industry and the general workplace. We now look to public health to fulfill their responsibilities of elder care and palliative care while we participate during “visiting hours”.

  • Jenny says:

    I often read in newspapers anecdotes of frustration and chaos when an elderly person, our parents, grand parents or great parents enter a hospital. What happened to planning? Parents pick the neighbourhoods to move into based on the ranking of the elementary and high schools. Then together a year or so before graduation, take a tour of universities and deciding on different majors. After that there’s an application to the top choices of universities.

    How is this different than picking a long-term care home? Is it the taboo topic of death? I think not, since so many people even in their 20s have a will and funeral arrangements (thanks to the HST for hurrying that one!). Can there be change in perspective and processes just like graduating from highschool meant applying to university, that reaching retirement meant applying to a long-term care home?

  • Grace says:

    Another thought is that if the patient doesn’t get placed into one of the three places of choice, then the patient could end up in a place that is too far from home. It would make it harder for family to stay with the patient during his/her time period of palliative care or convalescent. This is the compassionate side of the situation.

    I know that a family member, who did not have to leave because he was in ICU, had to be operated on in the nearest available hospital. That was on the other lower side of town and we had to commute twice a day to ensure that my mother could be with him during the day and again during the evening. This was quite taxing on an elderly person over a four week period.

  • Linda Murphy says:

    Congratulations to all involved in establishing this site.

    I believe that Ottawa has several pilot sites where retirement homes are receiving funding to provide care for this type of transition patient care – Embassy West and the Valley Stream Manor amongst others and others are offering progression in levels of support/care available – without government funding so it is strictly at the patient’s/families cost which is a significant barrier for many.

    It looks as if the lines are blurring between the different traditonal levels of care residents. I hope that options like these have the potential to change the status quo – if properly regulated and funded. I also hope they will make the LTC care industry more competitive and patient centered as it was pretty bleak when my in-laws ended up in nursing homes in the past.

    Would love to see more on this in future.

  • Ann Marie McKenna says:

    A recent piece on ALC problem at Sunnybrook Health Sciences Center in Toronto – relevant to your poll above.
    http://www.thestar.com/iphone/news/article/941693–pay-1-800-a-day-or-get-out-hospital

    At the rate of $1800 a day, we ought to consider chartering a cruiseship for ALC patients – the food and entertainment would certainly be a spot better!

  • David Walker says:

    Very useful forum, congratulations. Significant transformation across our system is needed to sustain the principle of maintaining our older generation at home, and when all else fails, in another venue appropriate for their needs, with an integrated approach to meeting their social, physical, medical and other needs. When acute care is needed, it should be provided with speed and efficiency and rapid return to the home or other setting, once again meeting the patient’s requirements – there should be no “ALC”s, nor should our EDs, acute care and CCC beds be so clogged that they cannot function as required. If we don’t fix this now, add the boomer demographic to the vision!

  • Paula says:

    First, let me say that this is a fantastic and innovate site that brings thoughtful debate to the issues that cover the front pages of our newspapers. Outstanding job St. Mike’s/Li Ka Shing!!

    I agree with Steve’s comments above. People need to understand that health system is stretched because people are living longer with multiple long-term illnesses. We have become very good at saving lives and extending lives. The result is huge demand and limited supply. Patients need to be moved to the most appropriate location for their needs at a given time, and this goes beyond acute care hospitals. The same issue exists in complex care and rehabilitation hospitals, where many patients are waiting for their preferred choice of long-term care facilities. The result is that acute care cannot move patients that need complex care and rehab because beds in these types of hospitals are full. The health system is clogged further downstream than acute care. Patients, and their families, should not be in a position of making choices that impact the lives of other patients and their families. Acute care, as well as rehab and complex care, are for people that need ‘hospital-level’ care. Patients who do not, should be moved to a level of care that meets, rather than exceeds their care needs.

  • andreas says:

    interesting article in today’s windsor star about the controversy of charging patients and thier families if patients don’t agree to be discharged to a chronic care facility that isn’t of their choice – http://www.windsorstar.com (sorry about the multiple negatives – it is 6:30am and only one cup of coffee)

  • Andrew Beck says:

    I forgot to mention. Great work and awesome site!

  • Andrew Beck says:

    I think we need to look at the definition first. How are these patients who no longer need hospital care defined and who justifies that they do not need hospital care anymore? Is it the doctor, nurse, patient, a family member, or a mix? Another issue is what happens when patients are discharged too early? You will most likely see them in the hospital again!

    It is a complex issue; we have individuals holding limited spots that others need. What is the purpose of a hospital? Are they an institution that specialises in treatment? If so, their view may more likely be to move these sitting ducks out and bring in the sick! Or are they an institution that supports a health society? It seems that the former is increasingly more common. Once ‘fixed’ you are passed onto your family or a privatized institution.

    There are no affordable alternatives. Why are LTCs the only option? Research has shown over and over, that these institutions are not very supportive of health. They tend to have profits and cost-cuts in mind. They are not uncommon to have a small staff of part-time employees with a large supply of patients. We see countries with successful LTCs, that are much smaller, designed like neighbourhoods (not warehouses), and are fully staffed with an almost 1:1 staff-to-client ratio!

    I understand we do have CCAC, but aren’t they over burdened as well? From anecdotes of clients, they are understaffed, poorly organized, have limited hours of availability, and have long waiting times to receive support after you have placed an order.

    I must agree with Tom, it is reassuring that some hospitals do care enough not to throw people out. But we are making others wait longer.

  • Steve Shumak says:

    Great work! Thanks for letting us know about the site!

    Regarding the forced discharge of ALC patients to an institution that is not one of their top choices, it is important to note that they are not condemned to stay at that facility forever. Indeed, the patient can wait for a spot in one of their top choice institutions while they’re admitted to that non-preferred site.

    At the end of the day the question becomes: where is the best place for a patient to wait for his/her preferred LTC institution – in the acute care hospital or, temporarily, in an institution they do not wish to be at? Given the current status of the acute care hospital system, I submit it is preferable to dissatisfy one patient (for a limited amount of time) rather than further overloading the acute care system. Doing so may engender unhappiness for one person (and family) but the alternative may be to cause unacceptable outcomes for a different person, e.g. development of delirium in older patient compelled to stay in ER for an extended period (rather than being admitted to a proper hospital inpatient unit) because of inpatient bed unavailability.

  • Tom Auger says:

    Right on, Karen. Keep up the great work. the site looks great by the way!

  • Tom Auger says:

    I’m not really sure how I ought to vote – it’s a complex question. On the one hand, ER gridlock affects us all; on the other, it’s nice to know that the hospital system cares enough not to throw people out if they feel that it will do them more harm to be outside the system than in it.

    Perhaps this issue can be resolved downstream – perhaps it’s the lack of appropriate, cost-effective outpatient services and support institutions into which these ALC patients can be funded that is forcing hospitals to make an ethical decision. It may be an unfair burden to place on hospitals as they have to balance such a complex topology of conflicting directives.

    What options are available to an elderly person with no immediate family and who can’t afford homecare or a private home for the elderly? In a scenario where the person has been living alone, in frail, but relatively good health, and suddenly is beset with illness, is treated in a hospital and is now recovering but likely to suffer additional conditions – what options are there? And how are they funded?

    • Karen Born says:

      Hi Tom – This is definitely a systems issue that relates to many different players outside of hospitals.

      In Ontario, Community Care Access Centres provide support and case management to those who want to stay in their homes, but need support, those that need help finding care in the community and those who can no longer stay at home. There are 14 Community Access Centre’s in Ontario. To learn more visit: http://www.ccac-ont.ca/

      Also watch for a story coming up in a few weeks on http://www.healthydebate.ca on wait lists for long-term care that will discuss some of the challenges in accessing community-based care.

Authors

Karen Born

Contributor

Karen is a PhD candidate at the University of Toronto and is currently on maternity leave from her role as a researcher/writer with healthydebate.ca.

Andreas Laupacis

Editor-in-chief Emeritus

Andreas founded Healthy Debate in 2011. He is currently the editor-in-chief of the Canadian Medical Association Journal (CMAJ)

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