Our health-care system has unfairly stacked the cards against patients suffering from addictions and mental illness. This is evident in many areas but is prominently seen in our local emergency departments. This system-level bias is, in turn, a significant reason why emergency care is under severe strain and placing all Canadians at risk.
Even as the pandemic appears to be entering a more stable and manageable phase, the strains on emergency care, both in hospital and prehospital (EMS) settings are showing no signs of abating. Most emergency care providers would undoubtedly identify one issue as the most important cause of crowding, compromised care, stress and burnout – boarding, which refers to emergency department (ED) patients who require admission to hospital but who must stay in the ED for hours, or even multiple days, due to the unavailability of an inpatient bed.
In too many Canadian hospitals, boarding often makes up more than half of all beds in the ED, consuming resources, taking up nursing time and crowding out new patients. All too often, it causes EDs to grind to a halt, leaving our paramedic colleagues stranded in hallways, waiting to transfer their newly arrived patients, unable to respond to 911 calls. High levels of boarding invariably lead to prolonged waiting times for patients seeking emergency care. EDs serve as their communities’ safety nets, but they cannot also serve as the safety valve for a system with inadequate hospital beds.
So, who are these boarded patients?
Over the past several years – made worse during the pandemic – mental-health patients who require admission have accounted for a growing proportion of boarded patients and are often the largest group among boarded patients. That patients in mental-health crises make up a relatively small percentage of all hospitalizations but are overly represented among boarded patients confirms a systematic bias in our health-care system. Making matters worse, boarded mental-health patients can spend days in secured unlit rooms in the ED, suffering through cycles of agitation punctuated by the need for sedation either with medications or physical restraints.
Rather than getting better while in hospital, they often are getting sicker while in our EDs.
In what are often deplorable conditions, these patients do not benefit from the support and therapy that is provided to those fortunate enough to secure a hospital bed. Rather than getting better while in hospital, they often are getting sicker while in our EDs.
There is much discussion about the burnout among our health-care providers that can show up as a lack of compassion toward our patients. In part, it is fueled by violence in the workplace that is not an uncommon manifestation of mental health and addiction-related illnesses. When emergency staff witness mental-health patients spending days on emergency stretchers in substandard conditions while other patients acquire beds on much shorter timelines, the message that the health-care system doesn’t care about them inevitably begins to become the standard.
Most mental-health patients who seek ED care and do not require hospitalization receive care from nurses and physicians without even requiring an evaluation by a psychiatric nurse or physician. The same cannot be said for the patients who come to the emergency with addiction-related concerns – alcohol, opioids, and methamphetamine predominantly.
Nearly one in 10 Canadians who visit the ER for mental health concerns or addictions have greater than four visits per year. But while nearly all Canadian hospitals have access to a standard range of specialty services like cardiology, neurology and surgery, the same is largely untrue for specialty care in addictions. The lack of specialized resources to support addiction-related illness demonstrates again how our health-care system discriminates against particular groups of patients and explains their high reliance on EDs through repeat visits.
If our health-care system claims to be equitable and considerate of patients with addiction and mental-health concerns, it has to resolve the issue of boarded mental-health patients in EDs. While there are no easy fixes, the public should be made aware of how many mental-health patients are held in Canadian EDs and for what periods of time; this data will help us see which hospitals can actually walk the walk.