It seems every time we watch the news these days, there is some item about ambulances being unable to unload patients at the emergency room, or about ER wait times increasing or failing to meet some arbitrary target.
We all remember Gary Doer’s promise to end “hallway medicine” in six months for $15 million dollars, but it is now 16 years and hundreds of millions of dollars later, and these problems not only persist, but in Manitoba’s case, they are getting worse. Why is this problem of “patient flow” in Manitoba hospitals seemingly so difficult to resolve?
We can begin by looking at some of the results of poor patient flow and some of the metrics hospitals use to measure it.
Delays in ambulance unloading are the result of a full ER, meaning all of its beds are occupied and there are patients on gurneys in hallways, hence ambulances are diverted to other hospitals, or they wait — sometimes for hours — to unload. This is not the same problem as an ER waiting room full of patients with minor issues who have been triaged: the ER is full of patients because there is a problem of flow through the ER.
Let us explain. In the case of the ER at St. Boniface Hospital, there are 35 spaces or beds, and at any given time 10 to 12 of them are occupied by patients whose ER treatment is finished and who are awaiting movement to a medical-ward bed. ER has done its job, and these folks should be on a medical ward, thus moving people out of the halls and freeing spaces so patients in ambulances can be unloaded, and patients in the waiting room can be treated. So, in this example, at St. Boniface Hospital at any given time, approximately 30 per cent of the spaces are occupied by patients who shouldn’t be there. This constant mis-utilization of beds creates unnecessary stress on staff who are already doing very stressful work, and worse yet, negatively affects the quality of care provided.
Why are these patients still in the ER? Why have they not been moved to other wards? Most patients move to the medical wards from ER and post-op (surgery), and when it is appropriate, they are discharged. However, many are not discharged from the medical wards in a timely fashion. Once again, if we look at St. Boniface Hospital, as many as 30 or more medical-ward beds are occupied by patients who should be ex-patients. They no longer require hospital medical care and should be at home, in assisted living or long-term care.
In his book Chronic Condition, Jeffery Simpson calls these patients “bed blockers;” patients who should not be in a hospital, but are. He goes on to describe how, if a hospital’s back end is filled up with bed blockers, the jam they cause works its way through to the front end.
The ER is the front end, and as in the case of St. Boniface, we know 30 per cent of the ER spaces are occupied by patients who should not be there. This forces patients into hallways and causes delays in ambulance unloading. The City of Winnipeg then bills the hospital for the costs of the delays.
Why are patients who no longer need hospital care not discharged in a timely manner? Of course, there can be many reasons. In the case of the frail elderly, it can be the lack of an assisted living or long-term care space, waiting to accommodate a patient’s choice, the time the panelling process takes or the time it takes to organize home care.
There can be delays in getting family support organized, and in some cases, addiction, mental health and other social issues play a role. The bottom line is these issues of discharging patients in a timely and expeditious manner wreak havoc with the flow of patients in a hospital, all the way back to the ambulances waiting to unload at the ER.
Certainly the problem of discharging patients in a timely manner is complex. We believe that too often, efforts have been focused on specific problems at the front end of the hospital. Reduce ambulance unload times, reduce ER wait times and eliminate patients on gurneys in ER halls. These challenges are symptoms of the problems and issues of discharging patients at the back end of the hospital. Solving these problems requires looking at patient flow at both ends of the hospital and developing systemic solutions, such as a patient-flow strategy. A system is established with a discharge plan and a target discharge date established at the time of admission, and all who are involved know the plan and date. Delays and failures need to be monitored, causes identified and corrective action taken.
Another program that can assist with timely discharge of patients is the use of awaiting placement units. They can be spaces outside the hospital to which patients are discharged from the medical wards and housed with nursing resources 24/7 until they can safely go home, or to assisted living or into long-term care. This avoids tying up a tertiary care bed and the high costs associated with it.
To say this is a serious problem is to vastly understate the case. First, any patient no longer in need of hospital care should not be in a hospital for reasons of their own health. This is especially true of the frail elderly, many of whom have compromised immune systems and who should be getting physiotherapy and mental and social stimulation. They are at risk of contracting an infection and will regress physically and mentally in hospital.
Second, all of this takes a massive financial toll on the health-care delivery system and particularly on the tertiary care hospitals. Simpson states that in 2012 it cost taxpayers about $1,100 per day to keep someone in a hospital, about $200 per day in a nursing home, and less when they are returned to their own home with support services.
How can this problem of patient flow be resolved? It is our opinion these issues of patient flow will not improve until hospital funding is activity-based and the problems will persist as long as hospitals continue to be funded using a global-funding model. Global funding and activity-based funding were discussed in an earlier part of this series. Global funding creates serious disincentives for administrators to improve patient flow.
For example, there are no funds to invest in things such as LEAN or systems analysis, or to spend on studying internal activities to improve patient outcomes or achieve operational efficiencies. Funding such initiatives only creates a budget deficit. Activity-based funding creates incentives to invest in the future and work smarter and more effectively, not only to improve patient flow, but also to improve patient outcomes. Incentives matter, and if we want to improve the system, we must create incentives that motivate administrators to focus on those issues which do so.
Originally published in the Winnipeg Free Press, March 30, 2016
Wayne Anderson is chair of the Frontier Centre for Public Policy. He is past chairman of the board of St. Boniface General Hospital. He wrote this in co-operation with Dal McCloy, past chairman of Riverview Health Centre, and Judith Scanlan, R.N., PhD, past secretary of St. Boniface hospital’s board.