Recently, while working a morning emergency shift in a major Toronto hospital, I realized how rare it is that I actually work in a hospital that functions at full capacity. I should be more clear—I’m not talking about patient capacity. Functioning at over-capacity is the norm in that regard. I’m talking about clinical, diagnostic, interventional, administrative, and pretty much anyone-who-is-not-a-patient capacity.
It’s not like this is news to anyone who works in hospitals, but most of us just get used to it. Sending people home at midnight to return for an ultrasound at 8 a.m. the next day for a potentially serious condition is something we do several times each night. What’s the alternative? The ultrasound tech is at home. We would also need to convince the radiologist, who needs to interpret the scan, that the interpretation cannot wait until the morning, which it usually can. And so it usually does.
But sometimes patients are so frail, or in so much pain, that it becomes unsafe to send them home at midnight. Thus they wait in the emergency department. And because the ED has used up its beds, chairs, and other uncomfortable surfaces, patients wait in hallways and in the waiting room.
Slowly, factors start to accumulate which contribute to an unsafe environment. Similar issues occur throughout the rest of the hospital in much of the province, such as with patients who cannot be discharged from a ward on weekends because the nursing homes or rehabilitation facilities or supportive housing they came from will not accept them.
So, what’s the alternative? Having the same number of people working overnight, on weekends, on holidays? Well yes, that would likely solve some of the problems. So why does it not happen? Presumably because that would be quite expensive, but also because we can get away with less, at least most of the time.
I once responded to a Code Stroke at 3 a.m. I was the junior resident on call in a rotation I had just started, in a hospital I had never worked in. The patient showed up to the ED without any heads up from EMS. My senior team members had just been alerted and were making their way to the hospital. While examining the patient, who could not communicate due to his new speech deficit, I was trying to find a clerk to register the patient into the hospital system. Without this, I could not enter the necessary orders for his CT scans. Unfortunately, there was only one clerk working overnight and he was nowhere to be found, possibly on a break. Meanwhile, the CT scanner in the ED was down and there were no porters immediately available to transport the patient to the other scanner on a different floor, since they were also short-staffed. To save time, the only available nurse and I decided to go ahead without a porter, while carrying all the necessary equipment and continuing our assessment of the patient. During the transport, the intervention team kept calling to ask what the CT scan showed, so they could prepare appropriately. Then the patient’s family arrived, clearly in a panic. There were no extra personnel available to speak with them, so the nurse and I took turns. Trying to find out the patient’s medical history, asking his family about his wishes, informing them of his diagnosis, and getting consent for possible interventions was not easy to do while rolling down a hallway with a cellphone in one ear and several pieces of equipment in my hands.
Somehow, this patient ended up getting what he needed in reasonable time. But that night, the system seemed ripe with opportunities for error and failure, especially for a condition where “time is brain.” The fact that a depleted health care roster was able to deliver prompt and effective care was not because of the system we found ourselves in, but in spite of it. This happens in Ontario, and in many other places, on a nightly basis, as well as on weekends and holidays. While the training, adaptability, and resilience of our health care providers should be recognized, this type of environment should not be encouraged, nor allowed.
“It should surprise no one that a system that provides a full solution five days a week cannot match a problem that occurs seven days a week,” says Peter Viccellio, professor at Stony Brook School of Medicine, New York, and renowned lecturer on the topic of hospital boarding and over-crowding.
According to Viccellio, the nine-to-five system initially worked quite well because, when it came about in the 1960s, most hospital admissions were for predictable, elective procedures and simple medical conditions. Having a skeleton crew on evening and weekends made sense. However, we now get many more unscheduled admissions through the ED and these are not limited to daytime or weekdays. Additionally, the patients are older and much more medically complex, requiring more investigations, more procedures, and longer stays. Yet our hospitals continue to be understaffed on nights, weekends, and holidays.
What’s even more disappointing is that we have known about “the weekend effect” for many years. Studies have shown that weekend admissions are associated with significantly higher mortality rates for many of the leading causes of death. The same has been found for off-hours admissions, including holidays. Although we are still unclear about the true causes of these phenomena, reduced staffing and supervision, increased workloads, and limited resources must surely be playing a role.
I sometimes wonder if patients know about these differences in staffing and resources, or about such things as “the weekend effect.” Perhaps they’ve suspected that the hospital is not functioning at full capacity after 5 p.m. or on weekends, but I wonder if they feel more at risk when they come in during these times. I also wonder if they overhear staff whispering phrases like “just survive until the morning” to each other. I wonder what this makes them think of us?
Sadly, as far back as 2013, researchers from Ontario wrote: “Whether reduced weekend capacity is the result of cost-saving strategies or hospital staffing preference, it is clearly problematic. Unfortunately, evidence of harm… is often the only way to force a culture change. At this point, the evidence seems sufficient to justify a change in how we deliver care at weekends.”
There are definitely no simple solutions here and a discussion of potential changes merits nuanced discussion with feedback from many parties. However, I think one thing is clear: Hospitals are not banks and they should stop working banker’s hours.
The comments section is closed.
Gerhard, everything you say is absolutely true. But you miss one significant problem with offering full 24/7 care. Society generally functions 9-5. Humans are circadian. The reason it is more expensive to keep things going evenings, nights and weekends is that most humans do not like working during those times. Especially if they have families and children that operate 9-5.
This is a problem with the human clock- and that is inherently difficult to overcome.
Much like years ago when bedside ultrasound was in its infancy, Dr Urbain Ip had a simple solution which was to have a 24/7 ultrasonography within the Emergency Department. Fast forward 20 years and most level 3 trauma centers don’t have 24 hour ultrasound, so we either learn the skill or “light ‘em up” with CT. It was a simple solution, just provide the resource but instead we have a mush mash of variable skill level docs providing this service without compensation nor the thousands of dollars it takes for training.
I’m sure something else will come along which others can do cheaper and better, but EM physicians will be asked to step up and take it on. Oh wait a minute, the Electronic Health Record and physician order entry …
Totally agree,health system can’t function by banking hours.
The same must apply to the specialties. How many time ER Doc.s doing job that should be done by another specialist? All the time. We hold admitted patients overnight till they seen by internal medicine or hospitalists.
Why after 16:00 suddenly ER docs become “everythyologist”, including crisis workers, social workers,geriatric and CCAC?24/7 – that’s the magic solution if not all for sure to many problems , including waiting times.
However ,let’s not to ignor an elephant in the room either. The patient. Let’s have a serious conversation as adult to adult in our society about “ what is ER for”, let’s tell the patients the truth: after 4 pm and on weekends and holidays services are cut by 70-80%. We need to stop a futile exercise “ shooting the messengers ( health workers” and get serious about real changes.Banking hours should be abolished in the health system and that includes the bureaucracy as well.If you work in health care – you are a frontline worker regardless your position.
Banks are open 7 days a week and extended hours. The many thousands who work for financial institutions would dispute your comparison. Trying to gain empathy for one profession while slagging another with dated and uninformed information does not look good on you.
great article not just for Canadians but also happens in US also
This is an article about tax policy. We don’t run hospitals at full capacity 24/7 for the same reason we don’t fund expensive therapies for rare diseases — we’ve prioritized universality of care in a single-payer health care system, and with our current tax structure we can’t afford optimal care in all cases. Do we do pretty well, prioritizing and triaging with the off-hours resources that we have? Certainly. Could we do better? Certainly — for a price. If you want things to change for the betterment of patient care, I hope you’re admonishing your colleagues when they complain about their highest-income-bracket tax bill.
Internal haemorrhaging at hospital at night , 22 units blood ,code blue ,have to hopefully hang on to life till the radiology team starts work at 8am . A long long night waiting for their arrival , outcome great due to their expertise in gluing up internal leaks Totally grateful for the expertise but still feel aghast years later of experiencing first hand the rigidity of the system ie shift starts at 8 without exception.
Logy
Hallelujah! Someone said it out loud! Thank you Dr.Dashi for writing about an issue that is incredibly ludicrous to the average individual. Whenever I question why an outpatient medical day unit closes at 3pm, I just get a shoulder shrug. It seems that taking short cuts with patient care is alright as long as overtime isn’t incurred!
….. and besides patient safety… if we ran full services in hospitals, even just 16/24 for 7/7 (more than doubling full services to 112 hours/week), wait times would become reasonable. Off course, it would drive up costs, but we should also remember that we get what we pay for.
How timely this article is…my husband recently underwent heart valve replacement & a single by-pass. We cannot say or appreciate enough the expertise, skill of the surgeon and post operative providers of hospital care. It is truly a privilege to have access to such skilled, caring professionals and providers.
Unfortunately, it is our SYSTEM’s co-ordination & integration of patients’ and their caregivers’ “total health care experience” which is causing our health care budget to expand uncontrollably, causes our caregivers to burn out, and our skilled health care providers to be so stretched, stressed, retire early and need care themselves. These costly, health/life-threatening “serious consequences” are a lack of co-ordination and integration.
Our open-heart “surgical/hospital care experience” was excellent. Our post-op experience was xtremely stress inducing and seriously risked patient-safety. It lacked appropriate, quality education/coaching of the patient/caregiver – (don’t think, entertain for a nano-second the patient retains this post-op care information). WHY? Being very weak, in pain and on many drugs are the major factors, barriers to listening, let alone retaining any information. The caregiver receives a “10” minute rushed conversation with information, the morning of discharge and is provided documents (hand-outs) which were insufficient & incomplete. It truly defies any logic this is the treatment of those who must carry out the “home care”(i.e. CAREGIVERS) that can jeopardizes a talented surgeon and hospital staff’s EXPENSIVE work. The rationale escapes me as to how this part of the “system” (DISCHARGE) demonstrates lack of “respect, appreciation, or high regard” for our “highly competent professionals’ expertise”, when their work is so compromised by this failure of the system.
Post op, a week later, at 10:30 at night, a bleed occurred at the leg site where my husband’s vein had been removed for the single by-pass. Absolutely nothing prepared us for this, either in conversation re post-op care or, anywhere in the documentation received. A call to Telehealth yielded a message saying it would be a “2 hour” wait before an RN would get back to us. We did not think the bleed required an ambulance (we are aware of the strain on the system), but we were filled with fear, anxiety. My husband has a pre-disposition to INFECTION and we’ve experienced many problems with acquisition of & healing in the past. Twelve-thirty (2 hours later) an RN returns the call….advises we go to nearest ER.
The night is dark, rainy, foggy, we live 35 minutes from the hospital ER. Assist my husband in dressing..from underwear to socks, shoes, winter coat. He cannot drive, must sit in the back seat as an accident & airbag encounter in the front would cause his sternum to crack open”again”. I get him into the car, seat belted and drive carefully, nervously, very worried, through the dark, fog and rain. At hospital, I park, get wheelchair, unpack husband & get him into ER. I return to car and head for parking lot & run in the rain in to the hospital ER. There the waiting room is full to overflowing with unfortunate hacking, coughing, wheezing, sick patients. I move my husband’s wheelchair close to a wall, so sick people are just on one side of him. He cannot afford to catch “anything”, just days home from open heart surgery an a weakened immune system. Getting to the head of the Triage line takes 35-40 minutes. Tell the RN my husband’s recent history, hand over all the medical paperwork detailing it, plus his current meds’ story. Advise RN am concerned about infection. We are dispatched to Registration and wait another 30 minutes where after we are told to wait in the waiting room. At 2 a.m. we are ushered into the inner sanctum where we wait at least now, in a private cubicle for another hour to see the ER MD….review with him husband’s history again, our concerns. Blood work is ordered, done… we wait for another hour for results. Fortunately this time I get my husband onto a bed where he can get much needed sleep and cover him with his coat for warmth. ER MD joins us and says, now husband needs an ultra sound, BUT that department doesn’t open until 8:30 or 9:00a.m. It is now 4:30 a.m., so we will have to come back then. Go home, still in the dark, rain, fog, and return to ER few hours later. Husband still wearing registration wrist band identifier, from few hours ago but still we must line up for Triage and Registration for a new wrist band. Spend most of the day waiting, waiting, waiting. Finally new ER MD arrives with results says, we should see our family GP. Husband did get cold as result of this experience.
A genuine thank you to those who’ve managed to read through this patient/caregiver experience. I cannot convey the level of mental/emotional fatigue that resulted for both of us as a result of just this experience, let alone the worry, anxiety of the 7 months pre-surgery experience, where we faced/dealt with how our lives might be forever altered post the surgery. I asked my GP (whom we’ve had for over 20 years), how do seniors, others who have no one, cope with the ordeal we experienced. He simply said “THEY DIE”.
I have much experience as a caregiver, since 1999 – for my dad, 14 years who lived with us, then a retirement home and finally LTC. My husband has chronic conditions. Have advocated, across many, many, many elements of the health system, given presentations, sat on committees, participated in workshops, written many letters ++++++ . At what point do caregivers get to lead improvement initiatives? If the people who manage, organize, co-ordinate & integrate the various silos of the health SYSTEM had the competencies to IMPROVE the system and really understood the issues, wouldn’t they have done by now – 2019?
Always seeking “Quality Improvements”
Part of the system issues you address are due to wide-spread systemic fragmentation of the Canadian health system at all levels. Because of the many professional, political, structural and cultural silos different groups that affect our health system are working in, efforts for building, innovating, and transforming the Canadian healthcare system are mostly disconnected. Like for the tower of Babel, all stakeholders have a vision and a common goal to build something, but clear communication is missing due to the lack of a common language.
The Canadian health system is fragmented on many levels. Constitutionally, there are at least 15 delivery systems, with provincial, territorial, regional, indigenous and military elements that remain disconnected due to the structure of the federation. There is geographical fragmentation due to the huge size of Canada, with communities ranging from highly urban to remote and rural locations. This is further aggravated by structural fragmentation due to different degrees of regionalization and provincialization. There are functional silos for patients who require continuity of care, like adolescents or the elderly who have to transition between age groups, or patients who move from hospital to community care. For the same lack of functional integration, navigating the health system is difficult for patients with multiple chronic ailments. This functional fragmentation goes hand in hand with professional fragmentation due to an increasing number of subspecialties and programs. The absence of essential elements like pharma- and dental care from the Canadian ‘universal’ healthcare system further adds to functional fragmentation for patients and providers. Finally, for physicians there is a stressful fragmentation of their attention as they are hectored about handling electronic systems and large flows of emails, ever-increasing expectations of patients and dwindling resources, while redefining their professional roles. In addition, the uniquely legislated and structural role of physicians makes most of them independent practitioners with a business based on fee-for-service payments, in contrast to many other care givers who are employees within the healthcare system.
It should come as no surprise then that patients become disoriented when they enter this non-system of fragmentation without a map or clarity on where the various services are located.
Great article. I also have wondered about the wisdom of keeping pts in hospital over the weekend without PT, OT or discharge planning. Pt progress is slowed, extra hospital nights cost more $$, pt outcomes at greater risk. Pts languish, beds are full, and costs are up. Makes no sense
don’t forget about the added dangers that accumulate each time a patient is handed over from one ER physician to the next, which often happens twice between 9pm and 8am when the techs arrive.