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.