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Question: I was recently in a hospital emergency room with my boyfriend who broke his arm skiing. There seemed to be a lot of people crowding up the ER with pretty minor health problems. I thought people are supposed to go to their family doctors or walk-in clinics for non-emergencies. Shouldn’t there be an advertising campaign to tell people when to go to the ER? It might reduce overcrowding and save money!
Answer: It’s good that you’re thinking about possible solutions to overcrowding in our hospital emergency departments, or EDs as they are known among Canadian medical professionals. But the inappropriate use of emergency department services really isn’t the major contributor to overcrowding.
Unfortunately, it’s a much more complex problem related to a lack of acute-care beds within the hospital.
“ED overcrowding is not just an emergency department issue. It is a system issue,” says Ray Howald, a Clinical Nurse Educator in the Emergency Department at Sunnybrook Health Science.
Basically, if all the beds in the hospital’s in-patient wards are occupied, there simply isn’t suitable space for additional patients. So when more patients arrived in the emergency department – and they need to be admitted – they have to wait there until an in-patient bed becomes available. That wait can take several hours, or at times, even a few days.
In the meantime, the ED doctors and nurses are kept busy attending to the urgent medical needs of the newly-admitted patients who would normally be transferred to a ward.
Mr. Howald trains front-line ED nurses in the art of triage (assessing and prioritizing patients) and he’s very familiar with the challenges posed by a shortage of acute-care beds.
When the hospital is operating below its peak capacity, “things flow well down here [in the ED] because admitted patients get to go upstairs [to the hospital wards],” he says.
But there are many days when the hospital is operating at or above 100 per cent capacity. “That’s when we get a blockage.”
Sunnybrook has 55 stretchers in its emergency department. On a recent Monday morning, for instance, 20 of those stretchers were occupied by people waiting for in-patient beds. “So our 55-stretcher emergency department, technically, became a 35-stretcher department,” noted Mr. Howald.
Hospital overcrowding problems are sometimes made worse by a lack of resources in other health-care institutions.
And, in particular, some patients with complex medical problems may be well enough to leave the hospital but aren’t well enough to go home. What they often need is an alternative level of care that could be provided in a long-term care facility or nursing home.
“But because these resources can be limited in the community, patients are required to stay in the hospital to receive the care they require as they cannot be discharged home safely,” says Mr. Howald.
“That means the patients who are now admitted in the emergency department can’t go upstairs [to the ward] because there are limited beds for them,” he adds. “You can see how… this has a trickle back effect which impacts wait times.”
Of course, the problem of overcrowding really amounts to a funding issue – and where health-care dollars are spent.
“We have too few beds,” says Dr. Howard Ovens, director of the Schwartz/Reisman Emergency Centre at Mount Sinai Hospital in Toronto.
Dr. Ovens is co-author of a recent academic paper that looked at the underlying causes of emergency-department overcrowding.
The paper points out that Canada has comparatively fewer hospital beds than many other industrialized nations.
“In 2009, Canada had only 1.7 acute-care beds per 1,000 Canadians, ranking 33rd out of 34 Organization for Economic Co-operation and Development countries,” says the paper published in the Canadian Journal of Emergency Medicine. The OECD average is 3.4 beds for every 1,000 citizens.
With the current level of funding for acute-care beds, Canadian hospitals are frequently operating close to their maximum capacity. “Functioning at capacities above 95 per cent does not allow for flexibility in the system to accommodate the natural peaks in patient volumes and admissions that will periodically occur,” according to the paper.
“The inability for admitted patients to access in-patient beds from the ED is the most significant factor causing emergency department overcrowding in most busy Canadian hospitals,” the paper concludes.
In your question, you mention that some people seem to be using the emergency department when they should be going to a family doctor or a walk-in clinic.
It could be that they don’t have a family doctor, or can’t get an appointment that meets their needs. But even if they are using the emergency services inappropriately, they don’t really clog up the system, says Dr. Ovens.
“Patients who don’t need to be in the emergency department, by definition, require very few resources,” he explains.
“They don’t need to get a CT, or an MRI or an ultrasound.” In fact, they don’t even need to lie down on a stretcher. They can often be examined just sitting in a chair. These patients may have to wait a long while to be seen by a physician because they would be deemed to be non-urgent cases by the triage nurse. But when they do get examined, they don’t usually take up much of the doctor’s time. “We can see them in a few minutes and they are gone,” says Dr. Ovens.
You also make reference to walk-in clinics as being possibly cheaper alternatives to the local emergency department. That is not necessarily the case, says Dr. Ovens.
If a patient goes to one of these clinics because of an apparent sprain or an infection, that patient may still need an x-ray or some lab tests – and will likely be referred to another medical facility or even a hospital emergency department. So that’s not going to save the health-care system money because it amounts to two separate appointments.
“If you have a laceration, a sprain, a fever, then the emergency department is a very cost-effective way to deal with those acute episodic illnesses and injuries. We are open and staffed already and we’ve got it all in place,” says Dr. Ovens.
After all, “the emergency department is the front door of an entire hospital system,” he explains. “We have access to a broad range of knowledge and expertise of all the hospital’s [physician] consultants, as well as the high-tech labs and imaging facilities … We can provide care for those patients who require lab work, x-rays and [medical] consultations.”
But Dr. Ovens is also quick to point out the ED’s limitations. “The emergency department is not a place to provide continuing care,” he emphasizes. “If you have a chronic problem, such as high blood pressure, diabetes, [congestive] heart failure, and you need prescriptions refilled or you need something adjusted, it would be much better if your own doctor took care of that.”
Paul Taylor, Sunnybrook’s Patient Navigation Advisor, provides advice and answers questions from patients and their families, relying heavily on medical and health experts. His blog Personal Health Navigator is reprinted on Healthy Debate with the kind permission of Sunnybrook Health Sciences Centre. Email your questions to AskPaul@sunnybrook.ca and follow Paul on Twitter @epaultaylor