Overflowing emergency departments are a consistent, concerning story. Often, it hits the newspapers around flu season, but in many hospitals, it’s a year-round problem. This year the Toronto Star ran a piece describing more than 250 patients put in “unconventional spaces” such as sun rooms, offices, and storage rooms, some of whom would have otherwise been in emergency department halls. Healthy Debate’s own profile of Karen, an emergency physician frustrated with her perennially full emergency department, was one of our most popular ever. “Overcrowding causes real morbidity and mortality, and there’s an incredible toll on the staff trying to deal with it,” she said.
The problem is pervasive, year-round and across many hospitals. While most emergency department visits are completed in under eight hours, it takes far longer for patients who are admitted to hospital – many spend up to 30 hours in the emergency department, two-thirds of which is spent simply waiting for a bed.
It is these sicker, admitted patients who create much of the significant congestion. In 2007, Michael Schull, an emergency room physician at Sunnybrook Hospital who also conducts research on emergency department performance showed that low-acuity patients – the ones who are often vilified in conversation about overcrowding – had a negligible effect on ED wait times.
Seniors on stretchers in emergency department hallways have become almost a cliché. And despite the fact that only 10 percent of people who visit the emergency department will be admitted, that has a bottleneck effect for others who won’t be admitted, but need to be examined or treated on those emergency room stretchers. Even low-acuity people – those who don’t need much medical care – are affected.
The problems of emergency department overcrowding go well beyond the inconvenience of spending hours – or days – in a waiting room. Studies show that emergency department overcrowding leads to an increased risk of medical errors, delayed access to treatments, and increased gridlock in the broader health-care system. “Arriving at a crowded emergency department increases your risk of bad outcomes. It increases the risk you’ll bounce back to the emergency room, and increases the risk you’ll die if you’re admitted,” says Howard Ovens, emergency department chief at Toronto’s Mount Sinai Hospital.
Most agree that overcrowding in the emergency department congestion is a symptom of larger system issues, including fewer hospital beds; limited home and community care; long waits for long term care homes; and a growing, aging population.
Budget cuts and beds
Many feel ED overcrowding began to be a problem in the early 1990s, when budget cuts led to the number of available hospital beds being cut by about a third across the country. Canada has dropped from having four acute care beds per 1,000 people in 1990 to 2.1 per 1,000 people in 2013. That’s makes us third last out of 34 OECD countries.
Keeping a hospital bed open requires paying nurses and others to staff it, and costs upwards of $1,000 a day. So when hospital budgets are limited, one way to save costs is to not pay to keep those unused beds open. That means hospitals might operate at 95 percent capacity or higher. Ten hospitals in Ontario regularly operate at close to or over 100 percent capacity, according to a recent investigation from the Globe and Mail. More than half have an average occupancy rate of more than 85 percent.
That saves money, but it clogs up the flow of patients from the emergency department to those needed beds. “We know that emergency department crowding rarely occurs when hospitals run at bed occupancy rates of 85 percent, and it’s almost routine at 90 percent to 95 percent,” says Alan Drummond, co-chair of public affairs for the Canadian Association of Emergency Physicians. A position statement from the Canadian Association of Emergency Physicians about emergency department crowding suggests a maximum acute care capacity rate of below 95 percent.
“The problem isn’t one of emergency department crowding, it’s a matter of hospital crowding,” Drummond explains.
But that doesn’t mean that simply increasing available beds will solve the problem. “I do not believe that the answer is just more beds. That would just exacerbate a dysfunctional system,” Schull says.
An example of that is the rising number of patients who are in hospital despite not needing hospital level of medical care. Rather, they’re waiting for long-term care, respite beds, rehabilitation beds, or other supports before being sent home. These patients are formally designated as “alternative level of care,” or ALCs. ALCs make up about 13 percent of patients in acute care beds across Canada.
Some of those people only stay for a few days. But a smaller group are there for a long period of time, like six months; the CAEP position statement recommends that ALC numbers be a no more than five percent of acute care beds.
“We have older adults in the health care system, and they’re not ambulatory, and they’re not independent, and there isn’t a family structure or community care system that’s able to take them back home safely,” says Andrew Costa, the Schlegel Chair at McMaster and emergency care researcher.
Encouraging creative solutions
There’s also evidence that improving emergency department efficiency can help reduce overcrowding. “This is a hospital problem, first of all, but part of the solution does lie in the emergency department,” says Schull.
The Ontario government created an Emergency Department Wait Times Strategy in 2008, which included expanding ED alternatives, increasing staffing, and a pay-for-performance aspect that changed how hospitals look at the problem of emergency departments. A 2015 report from the Institute for Clinical Evaluative Sciences found that the voluntary pay for performance program resulted in a “modest overall benefits” in reducing average wait times, including waits for patients who were admitted.
As part of that, hospitals have started looking seriously at flow. Every hospital does things differently, but common approaches, says Ovens, include hiring a flow director and creating a flow committee to help identify high-volume times in the emergency department and bringing on more staff to match them. Adding more physician assistants and nurse practitioners can also help doctors see more patients per hour. Overcapacity protocols, or surge plans, can also be implemented. They might include having doctors on call or bringing nurses in from other parts of the hospital. Some hospitals also move patients who are waiting to be admitted from emergency department halls to the halls of wards.
Another common solution is rapid assessment zones. In those, patients rotate through stretchers instead of “owning” them until they’re admitted. Those who are capable lie down to be assessed, but then return to a chair in the waiting room to be monitored, freeing up the stretchers for more assessments.
Schull also believes that part of the answer is providing increased access to diagnostics and specialists. Some other community-based solutions that have been tried – including improving primary care, nurse hotlines, and increasing access to walk-in clinics – have not yielded significant improvements in ED wait times and congestion.
“For many years we and other jurisdictions have faced false promises of fixing ED crowding by fixing primary care, universal flu vaccines, phone advice lines,” says Ovens. “All of those things can be assessed on their own merits, but none of them would be predicted to help emergency departments.” Again this stems from the base issue that the patients who are waiting longest are those who are very sick and need to be admitted to the hospital. Drummond agrees. “It’s not so much an inflow problem as an outflow problem,” he says.
In some ways, emergency departments are actually doing a good job of keeping chaos at bay despite having increasing numbers of patients coming in with increasingly complex medical issues. “The system is actually coping well with increased volumes, and wait times have not been skyrocketing,” says Schull. “But it’s definitely an issue.”