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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
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I read Paul’s comment about the abuse by specific categories of people and while difficult to read he is making a lot of sense. I work a 911 call center and we do see the abuse of the medical system and paramedics everyday. Some examples….my baby has a fever and is sleeping, I have a headache and it’s raining outside. I just jammed a splinter into my finger, I am constipated, I have diarrhea, I have a toothache, I sprained my ankle climbing a ladder……the list goes on without end and you can hear the frustration in the Ambulance dispatcher’s voices. On our end we deal with the ridiculous aspect of the pocket dial that sends over 500 false calls into the 911 system everyday. When we were asked how to fix this problem, we said, make the people pay $5 for every pocket dial they make, charge it onto their bell bill and they will learn. It was suggested that the hospital charge a $50 fee for anything that not deemed an emergency. Both ideas were presented to the politicians, I mean people in charge and it was unanimous…….no. Why?….because they did not want to offend people by making them pay for something they have a right to……do they have a right to abuse the system?…do they?….or are the people in charge so afraid of losing their jobs that they refuse to do anything that has been proven to make positive changes to a system that could use as many positive changes as it could get…..it’s time for the politicians and people in charge to ball up and protect something that is cherished by all of us and needed by the people who really need it. Personally as someone on the peripheral of the medical emergency system I am tired of morons wasting the time and money of the people in the medical system….take your toothache to the dentist, your constipation to the pharmacist and your splinter to mommy with tweezers because a pay as you go system is on the horizon just there are funds to finance what is left of out medical system.
What Canadians never seem to grasp is that when you give something away for free, you get incredible abuses. Has anyone ever been to an all you can eat buffet at the Mandarin?…….it’s like rush hour at the farm. Your emergency departments should be just that, emergency departments. Far too many times you walk into an emergency department in any hospital in Canada and it’s more like a walk in clinic……sniffles, coughs, rashes, no stitch required cuts, bumps, simple abrasions, simple sprains, fevers, the medical needy…….the list goes on and on and they have no need to be there other than this people cannot take care of themselves when dealing with even the simplest of things. You have an uneducated public who use and abuses the system simply because they can and physicians and medical staff who are playing CYA because litigation lawyers are seeding themselves in the justice system. You are also dealing with a federal government immigration policy that has no filters built in whatsoever and allows anyone and everyone into Canada without any exceptions or exclusions as to their health status, their criminal background or their financial ability to pay for anything. Suddenly the average Canadian fears a bad headache because encephalitis breaks out in one community or TB shows up in another and everyone gets paranoid at a simple cough. Accidental and tragic gunshot victims are increasing annually and illegal immigrants queue up at emergency departments because they have no other avenue of treatment and it’s free because nobody monitors or restricts access. Add to the mix the high risk, continually attending, never ceasing, never learning repeat patients like drunks, drug addicts, criminals and anyone who just cannot seem to grasp the common sense that their life style is costing us all. They show up day after day, so often that they are known by the staff on a first name basis. Also add to the list, people who have no regard for others with their driving habits, their sports participation and activity that cause injuries to themselves or others and your emergency departments are now just repair centers for the ignorant, stupid, uncaring, in most cases not working, illegal, addicted, criminal etc etc. You have to wake up and see that while being compassionate and caring is a wonderfully Canadian thing to be, it’s impossible to sustain simply because the abusers refuse to be educated and the system refuses to accept the truth. The objectors pound their chests and roar we are Canadian and no one slips through the cracks but we all know that is not true and we see it every day in the news, the work place, on the streets and where we live.
Before you condemn what I have written, try sitting in a 911 center in any major city in North America. You will learn very quickly that I am telling the truth. You simply don’t call 911 because you have a fever nor do you call if you have diarrhea or a headache without other symptoms yet every day millions of people across North America jam our emergency departments with non-emergency issues. I think you need to educate…….people need to take some responsibility for themselves and stop relying on an overburdened medical system that will be in the toilet if something isn’t done…….now!!!
Overcrowding in US hospitals is currently in a crisis and rising. They do not provide free healthcare and its not low income individuals who are causing the overcrowding. Its middle class with healthcare that can’t get in to see their primary physician (for many reasons, usually limited office hours). Over 50% of all ED visits in the US are avoidable (non-urgent) and over $38 billion wasted due to avoidable ED visits. Research relating to the problem in the US seems to lack of access to primary care physicians due to limited availability (after 5pm) and urgent care facilities. I wonder if this same issue is also influencing Canadian hospitals?
Kudos to Dr. Howard Ovens and Dr. Shawn Whatley for countering some of the mythology surrounding emerg crowding!
The statement
Basically, if all the beds in the hospital’s in-patient wards are occupied, there simply isn’t suitable space for additional patients
is rarely true.
First, patients don’t all require “suitable” space. If you have a broken hand, you’d rather be seen standing up in a hallway and have an XR ordered, than to have to sit for hours in a waiting room until a private room with walls and a door comes up so you can tell the doctor without being overheard about how your girlfriend left you and you punched a wall. You mostly want to know if your hand’s broken and move on.
Second, as Dr. Whatley points out, admitted patients can only occupy “suitable space”–stretchers in the ED. So if you get rid of stretchers and put in hard exam tables, presto–you will have “suitable space” because when patients are not with a care provider, they will not be occupying this space–they will be on some nearby chairs. So by removing “suitable space” for admitted patients, you will create suitable space for emergency patients.
On a different note, I am delighted that Dr. Ovens pointed the fallacy in the myth that ED care is always more expensive. In fact, emergency physicians and nurses have to be staffed in large numbers to take care of rare but regularly occurring multiple contemporaneous resuscitations. If you have to have 20 nurses and 4 doctors, so that if you can resuscitate 4 critically ill patients at the same time and still look after the others in the department (a situation that happens once or twice a year in a large ED), what else do you want these people to do when they’re not resuscitating multiple people? You have to pay to have them there anyway–so they might as well be looking after less seriously ill or injured people. Since the fixed cost is attributable to the resucitations, the low-acutiy patients only attract the variable cost. I.e., treating them in the ED costs us less than treating them in a purpose-built clinic like a walk-in clinic.
Thanks for your response Marko:
I agree that “suitable” space may not be the best choice of wording. In fact, I actually struggled with what word to use.
Some space can always be found in the hospital. For instance, a patient in the emergency department can be sent up to a ward and wait on a stretch in the hallway until a bed in an in-patient room becomes available. But who will care for that patient in the hallway? The doctors and nurses working in the in-patient wards will already be busy dealing with the existing in-patients.
So the patient will either be on a stretch in the ED or in a hallway in one of the wards. And, in either case, the hospital is operating at or above capacity. A higher staff level is needed to treat additional patients.
I would also like to clarify something else. You give the example of a patient with a broken hand. Unless that patient requires surgery or there are other complicating factors, he would not be admitted as an in-patient. I think it’s fair to say he would be treated in the emergency department and sent home. He would not need an inpatient bed for an overnight stay.
So the patient with the broken hand wouldn’t need the “suitable” space in an inpatient room that I was referring to.
Sorry if my choice of language led to any confusion.
Hi Paul,
I’m glad you agree that some space can always be found in the hospital–and that patients waiting in the ED hallways can be brought to inpatient hallways to be cared for there instead. You discount this solution, seemingly out of hand, saying that the doctors and nurses working in the in-patient wards will already be busy dealing with existing in-patients. So for this reason, most hospitals do not move inpatients to inpatient corridors. (This implies that emergency doctors and nurses have unlimited capacity to look after inpatients, while ward doctors and nurses are limited).
In the next paragraph, you make it sound as if it were equivalent whether the patient is waiting in an ED hallway, or an inpatient hallway. Either way, the hospital needs more staff.
Really?
Let’s say that your hospital has 20 inpatients in the ED (not uncommon) and let’s say you only had ONE inpatient ward. If you were one of the 20 PATIENTS, what would you rather: continue to wait in an overcrowded ED with 20 inpatients in a hallway (sharing the same bathroom(s); or having 10 of these moved to the inpatient ward? Clearly, you’ll want the latter. Whether you’re one of the lucky ones who get moved to the ward (and now get care from inpatient nurses who are stretched beyond their assignments by the 10 patients), or you’re one of the 10 patients left in the ED who can now count on a bit more nursing care and less bathroom pressure because the number of inpatients just went down by 10, you’ll vote for the hospital to move the patients, rather than keep them all in the ED.
But it’s more obvious than that, because your hospital has more than one inpatient ward. Let’s say it has 9 inpatient wards. So if you were one of the 20 inpatients in the ED, would you rather stay there with the other 19, or would you rather that TWO inpatients went to the hallway of each of the 9 wards, leaving 2 in the ED? Wow, that’s already quite a doable situation. Most wards have 5-6 nurses, to care for 30 or so patients, so the addition of two patients is not a huge burden when you share the burden across the hospital.
But WAIT, it gets even better! If you put the patients on the inpatient ward, studies (Vicellio et al) have shown that:
1/3 of the patients get a bed immediately
1/3 of the patients wait less than an hour for a bed
1/3 of the patients wait about 8 hours for a bed.
That’s what pressure on flow usually does. There’s no incentive for wards to demonstrate that they have empty beds on the computer system–in fact, every incentive not to, because then more work (a patient) arrives. But if the work is already there, then there’s no reason not to give the already-empty bed to the newly arriving patient.
As you know, there’s excellent literature to demonstrate that patients do badly (have a higher mortality) the longer they’re kept in overcrowded EDs. Hospitals that are not using a robust full capacity protocol (FCP–the distribution of inpatients from emergency hallways to inpatient hallways) expose their patients to higher risk by crowding them all into the ED.
Thanks, Paul, for helping crush the urban myth that low acuity patients block EDs.
I offer a gentle push back to the bed-blocking excuse for long wait times. Without question, EDs full of admitted patients make it almost impossible to see new patients.
But new patients continue to arrive. The crowds packing the waiting room belong to emergency providers, too. We think it’s OK to leave patients for hours in waiting rooms because they got triaged, and blame our lack of action on admitted patients in the ED.
This must stop. Triage does not excuse withholding a diagnosis, investigation and treatment. Just because we cannot provide an ideal place to see and treat patients, does not excuse letting them languish in waiting rooms for hours.
If patients can wait in chairs in the waiting room, then they can wait in chairs inside the ED. Bring them in, rotate them on and off of exam tables, and start their treatment and investigation. That’s what we would do for our friends and family. We would never make them wait in the waiting room because ‘there were no beds’ inside the ED.
Until we put patients first, and do everything possible to provide care, we cannot complain that admitted patients are abandoned in our EDs. We cannot complain about admitted patients left to wait in our EDs, when we do the same thing by making patients wait in the waiting rooms.
Put patients first. Get them inside your ED. Do whatever you can to diagnose and treat them. We cannot wait for solutions to lack of inpatient beds.
Thanks again for a great post!
Best Regards,
Shawn
http://www.shawnwhatley.com