Overcrowded hospitals must get creative
It’s been a rough few months for Ontario hospitals. Wait times for patients admitted through ERs have hit peak levels; more patients have been admitted than discharged; and a number of hospitals have simply run out of space.
Frazzled administrators, forced to get creative in accommodating the overflow, have coined the term “unconventional spaces” to describe their solution. They have converted into temporary accommodations patient lounges, staff classrooms, offices — and in some cases even storage rooms.
Overcrowded hospitals are nothing new to Ontario. They typically experience patient surges every January and February when flu season peaks and when there is a rebound effect after the Christmas lull.
Province doesn’t pay for beds put in lounges and offices to deal with patient surge
Hospitals struggle with overcrowded emergency rooms across Canada and in other countries, too.
But there has been something different about this year’s surge in Ontario, according to numerous hospital CEOs interviewed by the Star — a handful on the record, but most off.
It was bigger than in years past and caught many by surprise. Patient capacity at about half of Ontario’s 145 hospital corporations exceeded 100 per cent and reached as high as 130 per cent, according to figures requested by the Star from the Ontario Hospital Association (OHA).
Hardest hit have been large urban hospitals, regional facilities and some community hospitals. They include hospitals throughout the Greater Toronto Area, Hamilton, Ottawa, London, Kingston, Windsor, Sudbury and Cornwall. Even some rural hospitals have been overwhelmed.
Many facilities have been over capacity for weeks, even months. While the surge has somewhat abated in recent weeks, it appears that some of the intensified demand for hospital services won’t subside any time soon.
To accommodate the overflow, hospitals have been forced to open at least1,100 “unfunded beds,” more than 250 of them in unconventional spaces, according to the OHA. The organization said these are conservative estimates because not all hospitals participated in a survey on capacity.
An unfunded bed is one that a hospital did not budget for and therefore did not receive provincial funding to operate.
To cover the cost, a hospital must dip into funds raised for capital projects, equipment and research through, for example, fees on parking, private rooms and food vendors.
The OHA is still surveying hospitals to determine exactly how severe the overcrowding problem has become, how many unfunded beds remain open and what the total cost of operating them has been. The cost of operating one such bed for a single day is $450, at the low end.
Some hospitals have incurred deficits to accommodate the extra patients.
There are three main causes of the growing pressures, health-care leaders agree: a population that is growing, aging and showing up in the ER sicker than ever; a health system that is not robust enough outside of hospitals, such as in the long-term-care and home-care sectors; and five years of austerity funding with minimal increases to operating budgets from the province. When inflation is factored in, hospitals budgets have actually fallen in real dollars.
The OHA has told the province that hospitals cannot go on at this rate without significantly compromising front-line care, the Star has learned. The organization has asked the province to put an end to the austerity and come to the rescue with asignificant infusion of cash — $850 million — in the budget, to be tabled April 27.
A highly placed government source, who wasn’t authorized to speak publicly, said the province is well aware of pressures on the sector, though questions whether they are really as severe as are being made out.
The source said the province may announce in the budget that it will loosen the purse strings to free up more hospital beds and create more capacity throughout the entire health system. Improving health care outside of hospitals is the key to relieving pressures inside them, he said.
Since October, Hamilton Health Sciences has been struggling to care for more patients than it has beds. Its capacity peaked in February at 114 per cent, but remains high today.
Last Sunday, it was at 111 per cent capacity. There were 70 more patients in beds than the hospital had budgeted for.
Senior administrators and physicians meet daily to pore over “bed maps” to figure out where they can accommodate the overflow. When there is no more space for gurneys in ER hallways, they look to unconventional spaces, which can include patient sunrooms and recovery rooms normally dedicated to short-term stays for patients who have just had surgery.
“The whole system is under stress and Hamilton Health Sciences is no exception,” said president Rob MacIsaac. “We are constantly operating on the edge. There is no slack left in the system. Zero.”
Among the hospital’s 1,391 inpatients last Sunday were 168 who had completed their acute-care hospital treatment and no longer needed to be there. Mostly frail seniors, they are known as “alternate level of care” or ALC patients because what they really need is care outside an acute-care hospital.
Alternatives can include longterm-care homes, their own homes with home-care support, palliative care, rehabilitation facilities and complex continuing care facilities.
But there are shortages in these sectors too, especially for patients who are both physically and cognitively impaired. The hardest to place have multiple chronic physical ailments, dementia, behavioural problems and/or mental health problems.
When ALC patients can’t be discharged, there are fewer beds available for those admitted to hospital from the emergency department. That makes for a particularly bad combination when there is a big influx of patients on that end too. Last Sunday, there were 40 patients admitted through the ER at Hamilton Health Sciences, waiting for beds.
The hospital has seen a 3-per-cent increase in emergency department visits over the past year. The average acuity of patients — or intensity of nursing care they require — jumped 5 per cent over the same period.
“Circumstances overwhelm anything we can do internally. Fundamentally, there is no making up for lack of capacity with better processes,” MacIsaac said.
Staff are stressed, patient satisfaction is suffering and the facility’s budget is stretched thin, he noted.
The hospital was forced in February and March to cancel and reschedule 26 surgeries though it “moves heaven and earth” not to do that, MacIsaac said.
Cancelling surgeries compromises its regional role in providing treatment for cancer, trauma, burns, stroke, cardiac care and pediatrics. The hospital serves a population of 2.5 million and its catchment area stretches out to Burlington, Oakville, Milton Niagara, Branford, Haldimand-Norfork and Kitchener-Waterloo.
“We are waiting on tenterhooks to see what our funding is. We are beside ourselves trying to figure out how we are going to manage,” MacIsaac exclaimed.
People are often surprised to learn Ontario has very low numbers of hospital beds, compared to countries in the Organization for Economic Co-operation and Development. The province has 2.3 beds per 1,000 people, fewer than 31 OECD counties. Only Mexico, Chile and New Zealand have fewer.
But provincial policymakers don’t see that as a bad thing. On the contrary, it’s by design and it’s a point of pride, proof of a highly efficient system.
Ontario has purposely shrunk its hospital system. In 1990, there were 33,403 acute-care hospital beds, according to the OHA; today there are 18,571.
During that same period, the province’s population jumped 36 per cent to 14 million.
Additional figures from the OHA and Canadian Institute for Health Information requested by the Star show that:
The number of visits to Ontario emergency departments jumped by 5.6 per cent to 6.3 million from 201213 to 2015-16. These patients are older and sicker than ever before.
Ontario spends $1,427 per capita on hospitals. Of the 10 provinces, only Quebec spends less.
The average length of stay for Ontario hospital patients fell to 5.7 days in 2014-15 from 6.9 days in 1995-96. That is the lowest of all provinces.
Advances in technology have contributed to shorter patient stays. Surgeries are less invasive, allowing for faster recoveries. More procedures are done on an outpatient basis and more followup care is provided through home care.
Groups such as the Ontario Health Coalition argue that the province has gone too far in cutting hospital beds and want to see the sector built back up. But policy-makers and healthcare leaders see it differently. In their view, patients wouldn’t need to rely on hospitals as much if they were kept healthy in the first place and received more health-care services in the community, where it is less expensive.
This has long been the vision for Ontario’s publicly funded health system, the way to keep it affordable and sustainable. But getting there has not gone as smoothly as planned.
Said one GTA hospital president, who spoke on the condition of anonymity: “Hospitals have maximized their efficiencies, but things have not evolved as they should have over the last five years outside of acute care. We need more resources in the community.”
Said the government source: “So what part of the system is good and what part is disorganized? I would say our hospital systems are pretty good and we have the data to prove it. Outside hospitals, we are disorganized.”
The source said that the province’s ongoing measures to transform the health system, an effort known as Patients First, will take pressure off hospitals by improving health care outside of them.
“That is why Patients First is so important . . . to organize the prima- ry care, home and community and mental health care that are currently disorganized,” he said.
OHA president Anthony Dale had a feeling last year that hospitals were heading into a tough winter. He had been watching the provincial ALC rate, which the government has been trying for years to lower.
The proportion of acute-care hospital beds occupied by ALC patients had fallen from a high of 19.6 per cent in 2008 to a level hovering between 13 and 15 per cent between 2011 and 2015.
But in July 2015, the ALC rate started to rise again — sharply. It went from 13.9 per cent in July 2015 to 16.5 per cent in November 2016.
By January this year, there were 3,121 ALC patients waiting in acutecare beds. A third of them were waiting to get into long-term-care homes.
At the same time, pressure was building in ERs because of flu season. By February, ER waits hit their highest levels since the province began measuring wait times nine years ago. Nine out of 10 patients waiting to be admitted from the ER waited 32.4 hours or less. The target for admitting all complex patients is eight hours.
“What caught us by surprise was the intensity of the flu surge,” Dale said.
ER waits are a barometer of how well the health system is functioning, he explained. If there is a problem somewhere, it inevitably manifests in the ER.
“(ER waits) are often a warning sign of a system under stress and at the moment, the warning is flashing bright red,” he said.
In recognition of this, the provincial government last November provided an extra $140 million to the sector on top of the $345 million announced in last year’s budget. It was a much welcome “lifeline,” Dale said.
The sector has asked for and received very little in the way of extra funding over the last five years. Hospital base operating budgets were frozen for four of those years and last year increased by 1.5 per cent. When inflation is taken into account, hospitals have actually seen real-dollar budget cuts for nine years.
Hospitals agreed to take less funding so that other sectors with greater need — namely home, community and long-term care — could get more. At the same time the provincial government has been trying to cut its deficit.
But hospitals say they can no longer take a back seat to other health sectors. They are hoping the budget will include a 4.9 per cent increase in total operating and capital funding.
Perhaps the hardest hit hospital in Ontario has been the Cornwall Community Hospital, which has reported occupancy rates as high as 138 per cent. Since Christmas, it has been operating at more than 100 per cent capacity.
“Being overcapacity isn’t anything new for us. What is different this year is the extreme levels of occupancy and the length of time we have been in this state,” said president Jeanette Despatie.
The hospital is using not only ER hallways to accommodate the overflow, but hallways in the hospital’s medical and surgical units as well. Former clinical space that had been turned into offices has also been converted back into patient rooms.
“It is a very challenging environment to work in. It has compromised our ability to en- sure we are providing the quality and safety we want for our patients,” Despatie said.
She is particularly worried that there is no “surge capacity” to deal with a large-scale emergency such as a pileup on Hwy. 401: “We would be hard pressed to meet the needs of an immediate surge.”
ALC rates in Cornwall are up noticeably this year, at 19 per cent of total patient days compared with 15 per cent least year. Eight ALC patients have been waiting more than100 days to get into long-term care and one has been waiting more than a year.
“These patients are tougher to place in appropriate settings because they have mental health or behavioural challenges,” Despatie explained.
These ALC patients also include seniors who cannot afford to pay higher fees for private or semi-private rooms in long-term-care homes and are waiting for subsidized, wardstyle rooms to open up.
“We are constantly operating on the edge. There is no slack left in the system. Zero.” ROB MACISAAC PRESIDENT, HAMILTON HEALTH SCIENCES
The government source questions the accuracy of hospitals’ peak occupancy rates, noting they can vary widely depending on the time of day they are measured. For example, if measured during the middle of the day, it’s possible for one bed to show two patients — one that has just been discharged and another that has just been admitted.
The most accurate time to take a patient census is midnight, he said, adding that the sector and government are currently working out a mutually agreed-upon measurement protocol.
This source also pointed out that the province does not fund hospital beds, per se, but rather patient activity. In a well-managed hospital, there should be some spare beds, say in an older section, that could be put to use in flu season and closed again when ER activity slows.
“Some hospitals will occasionally use unconventional spaces and that is not good and needs to be fixed,” he said, acknowledging the sector is under pressure. Both the OHA and the government accept that the average annual occupancy rates for Ontario hospitals hovered between 91 and 93 per cent between 2012 and 2016. The oft-cited ideal capacity rate for hospitals is 85 per cent. Anything above that leads to long waits and increased risk of transmission of infectious disease. As well, it leaves little wiggle room in the event of a big emergency.
The government source said the budget may include money to relieve overcrowded hospitals. The funds would go to hospitals and to sectors such as home and community care, in an effort to lower ALC rates.
But the source also said that a lasting long-term solution rests with creating more forms of “congregate” living arrangements where personal support workers would be available to assist the growing senior population. In the past, cultural and religious organizations did more to support their seniors through the creation of assisted-living and supportive housing facilities, he explained. Society needs to return to those models with the encouragement of government subsidies, he said, adding that the budget may make some movement in that direction.
The time to beef up services outside hospitals is running short, health-care leaders agree. The oldest of the baby boomers turns 71this year. Age 75 is when people enter their high health-care consuming years. Theresa Boyle can be reached at tboyle@thestar.ca.