Some patients in Ontario are getting stuck in a health system under strain.
Patients who don’t need to be in hospital are occupying an increasing proportion of Ontario hospital beds as they wait to receive care elsewhere, such as in a long-term care home or assisted living. On any given day in the province in 2018/19, about 4,500 hospital beds were occupied by patients waiting to go elsewhere. That’s the equivalent of 11 large, 400-bed hospitals filled to capacity by patients who don’t need the high level of care their hospital bed provides, and was up from about 4,000 beds per day on average in 2012/13.
In terms of overall hospital capacity, 15.5% of all the days patients spent in Ontario hospitals in 2018/19 were spent waiting to receive care elsewhere. 1 During the data stabilization period, patients designated Alternate Level of Care (ALC) and transferred to Reactivated Care Centre (RCC) sites under Humber River Hospital, North York General Hospital, Southlake, Markham Stouffville, Mackenzie Health and Sunnybrook Hospital were reported separately. Therefore, the figures presented herein do not include the patient population designated ALC at RCC sites. Having patients in hospital waiting for care elsewhere is a symptom of broader issues across the health system, and leads to stress and uncertainty among patients and caregivers. 2 “It’s a waiting game” a qualitative study of the experience of carers of patients who require an alternate level of care. - PubMed - NCBI [Internet]. [cited 2019 Aug 9]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28464878
Among health systems around the world, the U.K.’s National Health Service (NHS) reports the percentage of days hospital beds were occupied by patients waiting for care elsewhere in a similar way to Ontario. 3 Note: Caution is required when comparing across countries for rates of hospital beds occupied by patients waiting for care elsewhere due to differences in the clinical coding. In the U.K., this designation requires a multidisciplinary team to determine that a patient is ready for transfer. In Ontario, this designation is determined by a physician or delegate, in collaboration with an interprofessional team, when available. In comparison, the NHS reported a rate of just over 5% for 2017/18, more than its target of 3.5%, but still substantially lower than Ontario’s rate of 15.5%.
In Ontario, many of the patients in hospital beds waiting for care elsewhere are waiting for a place in a long-term care home. In 2018/19, the median wait for patients who moved into a long-term care home directly from hospital was about three months, or 90 days.
If you count all the days Ontario patients waited in hospital beds for care elsewhere in 2018/19, 44% were days patients spent waiting to go to a long-term care home, while 13% were days patients spent waiting for supervised or assisted living, and 11% were days patients spent waiting for home care.4Daily Bed Census Summary, Wait Time Information System, provided by Cancer Care Ontario
In many Ontario hospitals, having many patients waiting for care elsewhere can lead to overcrowding, with patients receiving care in hallways because no regular beds are available. This overcrowding is often most visible in hospital emergency departments. Here, patients who need to be admitted to the hospital can get stuck waiting for a bed to become free. The average amount of time Ontario patients waited in emergency departments for an inpatient bed – calculated from the time the decision was made to admit them – increased to 9.7 hours in 2018/19, from 7.7 hours in 2015/16. The average time admitted patients spent in total in emergency departments increased over the same period to 16.2 hours from 13.8 hours.
For people not admitted to hospital, Ontario hospitals have managed to hold the line on the amount of time spent in emergency departments. Despite a 12.2% increase in visits to emergency between 2011/12 and 2018/19, time spent in emergency by patients who were not admitted remained essentially unchanged. In 2018/19, among patients who were not admitted, the provincial 8-hour target for maximum length of stay in emergency was met for 93.3% of those with more serious conditions, while the provincial 4-hour target was met for 85.3% of those with less serious conditions.
Like Ontario, New Zealand has had to deal with overcrowding in its hospital emergency departments – with patients often spending a long time in emergency receiving care and waiting for an inpatient hospital bed. Target-setting and increases in hospital capacity resulted in improved patient flow within hospitals and led in the short term to decreases in time spent in emergency. However, little was done to improve capacity in other parts of the health system to better enable the flow of patients out of hospitals, and improvements in emergency wait times have slowed. 5 Tenbensel T, Chalmers L, Jones P, Appleton-Dyer S, Walton L, Ameratunga S. 2017. New Zealand’s emergency department target – did it reduce ED length of stay, and if so, how and when?. BMC Health Services Research 17:678
Also contributing to crowding in Ontario’s hospital emergency departments are patients whose primary care provider is not available, or who don’t get the health care or supports they need outside the hospital.
Four out of 10 Ontarians (41.7%) who had visited the emergency department said in 2018 that their most recent visit was for a condition they thought their primary care provider could have managed, if that provider had been available.
Among adults who visited emergency for a mental illness or addiction in 2017, about a third (31.9%) had not received mental health care from a family doctor or psychiatrist during the preceding two years. However, there has been improvement in this indicator for children and youths up to 24 years old. In 2017, 40.4% had not received mental health care from a family doctor, pediatrician or psychiatrist during the two years preceding their visit to emergency, compared to 49.9% in 2006.
Among Ontarians who visited the emergency department in 2017/18 for a mental illness or addiction, 9.5% – or nearly 18,300 people – visited four or more times in one year. That was up from 8.2% – or about 13,200 people – in 2013/14. Frequent visits to emergency for mental health care may indicate a lack of services or support in the community to meet people’s level of need.
Total health spending in Ontario – which includes both public spending by government and private spending by insurers and individuals – increased to $6,239 per person in 2016, the most recent year for which final spending estimates are available, and was up 9.0% from 2006. 6The time trend controls for inflation and population growth when comparing growth across years. Public spending on health care in Ontario - $4,125 per person in 2016 – was the lowest among all provinces, with spending in Newfoundland and Labrador being highest at $5,502 per person.
Public health spending in Ontario was also lower than the Canadian average of $4,487 per person. Compared to countries with similar social and economic profiles in the Organisation for Economic Cooperation and Development (OECD), Canada was among the lowest-spending half when it came to public spending on health care per person in 2016. Forecasted health spending estimates suggest Canada will be in a similar position compared to its OECD peers in 2018.7 OECD Health expenditure and financing. Retrieved August 28, 2019, from https://stats.oecd.org/Index.aspx?DataSetCode=SHA
Learn more about what health care organizations are doing to address hallway health care. Read their quality improvement plans: https://qipnavigator.hqontario.ca
Stuck in the hospital
Read Mendal, Diane and Lisa’s Story
Mendal “presented well,” but his wife and seven kids knew something was very wrong. The 85-year-old retired dentist from Kingston was diagnosed with Alzheimer’s disease in 2015. “We as the kids were seeing problem after problem,” says his daughter Lisa. “We would kind of joke amongst ourselves that we have to defuse bombs each week.”
One night, the situation escalated when Mendal called his brother-in-law and left a message that caused him to believe that Mendal would harm his wife or himself. The family had to call the police, who escorted Mendal to the hospital in Kingston, where he was admitted to the psychiatric ward.
At the hospital, the family was told that Mendal did not qualify for long-term care and that he should go to a private retirement home or move back home with around-the-clock care. The family decided Mendal would stay in hospital.
After three months in hospital, Mendal was deemed eligible for long-term care, but there was only one long-term care home in the Kingston area that had a secure facility to accommodate his behavioural issues and flight risk. And once the Kingston long-term care home assessed Mendal, they determined that the home would not be an appropriate place for him.
The family decided to put Mendal’s name on the wait list for a long-term care home near Toronto. They were told the wait would be six months to two years for long-term care.
After another four months waiting in the Kingston hospital’s psychiatric ward – seven months in total – Mendal’s health had deteriorated. He had to stay in the psychiatric ward because he needed to be in a locked unit, which was not available in the regular hospital wards. This proved very difficult for Mendal and the family, says Lisa. Mendal’s wife, at home, was struggling with her own health issues, along with the stress of feeling like she had abandoned her husband. The seven siblings, who lived in different parts of the province, scrambled to help as well.
The family felt a lot of pressure for their dad to leave the hospital, and they finally decided to pay out of pocket for a private retirement home, spending more than $40,000 over six months. Eventually, a spot opened up in the long-term care home near Toronto, in Markham.
At the long-term care home, Mendal tried to get out of a locked unit, and in the process knocked down one of the staff. He was admitted to a psychiatric unit of the hospital nearby, where the chief psychiatrist correctly diagnosed him with frontal lobe dementia, which can cause drastic personality changes and impair cognitive reasoning.
“Mom moved to Toronto once he had calmed down,” his daughter Diane says. “The long-term care home is phenomenal, and the staff is wonderful. He’s very stabilized, his family is close by, and it’s as optimal as it can be. But it was a long, hard journey getting here.”
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