The right patient in the right bed
Ontario hospitals need technology to better manage patient flow and doctors to ensure their sickest patients get the care they need, reports Tanya Talaga THIRD PART IN A SERIES
Intensive care units across Ontario must be overhauled, computerized and better organized or patient wait times for surgeries will never fall and an event like a dreaded flu pandemic could swamp the system, the province’s top doctors suggest in a new report.
In order to handle the aging population and sudden surges in demand — possible with a flu pandemic — the report recommends new information technology be put in place in the units to better manage patient flow and teams of doctors be set up to ensure every critically ill patient who needs an intensive care bed gets one. The SARS crisis two years ago taught Ontario health providers that critical care — where the sickest patients fight for life — must be linked in a provincial system so doctors can easily identify the empty spots.
“ When you ask a simple question ( such as), how many critical beds do you have in the province? It wasn’t easy to figure it out,” said Dr. William Sibbald, physician-in-chief at Sunnybrook hospital.
Critical care is central to the correct functioning of the operating room, the emergency department and the whole hospital, said Dr. Alan Hudson, head of the advisory group examining critical care in Ontario and the lead in charge of the drive to reduce provincial wait times.
“ And it’s absolutely central to major surges in demand such as Asian flu,” Hudson said. “ That is why it’s very important the critical care doctors . . . be part of the discussion. They are on the front lines.”
Dr. Robert Bell, president of the University Health Network, has worked with Hudson on improving the system. “ This is too precious a resource to not have hospitals accountable for the patients that are there,” Bell said. He also co- authored the report for the health ministry. There are 1,788 critical care beds in 129 hospitals, the report found. As the population ages and if current patterns of critical care practice are maintained, another 40 to 50 critical care beds will be needed annu-
ally across the province, at a projected cost of $28 million to $35 million each year.
“ If we simply do a linear calculation of the number of critical care beds in the province today and what we need for the future, then it’s going to be a really big problem for the system,” said Bell. “ How do we sustain and open all those beds?”
Figuring out who needs to be in a critical care bed and who doesn’t is also key, Bell said. Not everyone occupying an intensive care bed needs to be there. “ The goal here is to have the right patient in the right bed with the right resource. Hospital flow is one of the biggest obstructions to that.”
Ontario hospitals generally run at 95 per cent capacity. Flow is always a concern. Ethical issues as to who should stay and go in these precious beds need to be tackled by society, Bell said. “ If somebody has terminal cancer and has a period of time to live there is an ethical issue of whether or not that patient should be in that bed.”
It’s impossible to put a price tag on an intensive or critical care bed because costs are fluid — from the latest drugs to the price of life- support equipment, the need varies for each patient. But it’s estimated critical care beds — occupied by those injured in traumatic accidents, violent incidents or as a result of serious illness — are the most expensive to run in any hospital, eating up about 35 per cent of the budget yet accounting for only 5 to 10 per cent of the beds. Key recommendations in the report are:
Hospitals must be accountable for who gets into an intensive care bed, ensuring the right patient gets into the right bed. To that end, the report calls for a hospital point person to decide who should be in critical care and to organize patient flow.
Development of medical outreach teams — already in place at the University Health Network — where any hospital staffer or family member of a patient can seek a consult if the patient appears to be deteriorating. The team consists of doctors and nurses who work in critical care but who can do consults anywhere in the hospital.
Investing in a critical care information technology system and increasing beds in facilities where needed.
Bell said Ontario is moving on installing information systems to ensure the right patient goes to the right bed at the right time.
If critical care units are not beefed up and better organized, the government’s proposed wait times agenda — the effort to reduce surgical waiting times in five key areas — could be hampered, the report suggests.
“ Indeed, the limitations of the current system have the potential to sabotage efforts to reduce surgical wait times within the government’s transformation agenda,” it said.
Critical care centres must also be tied to the new local health integration networks, which carve Ontario into 14 regions, said Hudson. Linking centres would improve their management, he said, adding “ if there is a pandemic, we have to have some method of managing critical care across the province.” Sunnybrook hospital has 120 intensive care beds — including neonatal, burn unit, cardiovascular and critical care beds — making it the largest critical care centre in the country.
Three types of patients usually require a critical care bed, said Sibbald. Those who come into the ER who are unexpectedly critically ill or who’ve suffered trauma, those from the operating room who require intense care and those from other parts of the hospital whose health suddenly deteriorates.
It’s impossible to know what will come at you and when, he said. Because of this, what gets put off are the complicated surgeries on the elderly, particularly cancer, vascular and heart surgeries that require greater time in critical care.
It’s like critical care is the top of the pyramid. If everything at the top stalls — patients stay for months because beds can’t be found for them elsewhere in the system — the rest of the hospital system backs up, Sibbald said.
That is how critical care relates to wait times, he said.
Trying to get a handle on how much a critical care bed costs a hospital is also difficult. When Sibbald starting quizzing colleagues in America and Australia, he found they couldn’t answer that question, either. Trying to figure out how much one bed costs to run is another enigma as each patient requires different medicine, technologies and supports to keep them alive. The “ guesstimate” is around $ 2,000 to $ 3,000 a day, including staff and drug costs, Sibbald said. But other expenses such as having an MRI available on standby 24/ 7 or a social worker are not reflected in that number. “How much does the army cost?” he said. “ Nobody knows until you go to war.” Nurse Robin Horodyski, the critical care unit’s patient care manager, looks at the care provided by the almost 400 staff members — including nurses, physiotherapists, respiratory therapists and support staff — reporting to her and she doesn’t know where to find savings. Cut staff and you skimp on giving the best care available to society’s sickest people. As patient care manager, the daunting task of actually running the unit is Horodyski’s responsibility. She staffs it with nurses, assistants and therapists. She administers the budgets, orders supplies, holds staff meetings and ensures there is cake to mark staff birthdays.
Throughout the month of July, the unit’s occupancy rate was 97.6 per cent, but Horodyski feels the number is probably higher. “ How many times did you see empty beds in July? How many times did we overflow?” she said. If no beds are available in the critical care unit, they often overflow patients into the adjacent cardiac unit. “ Demand exceeds supply.”
Yet the pressure is on to be cost- conscious.
In the critical care unit, 21 nurses work a 12- hour shift, 20 at the bedsides and one charge nurse. Support staff answer phones, clean and help turn patients. If Horodyski takes away support staff, nurses might not turn a patient, resulting in more bedsores and longer hospital stays. And more staff means better infection control.
“ It’s frustrating. Can’t you see what the ramifications are?” Horodyski asks. “ These are taxpaying people, they should get the safest care possible.”
Salaries are the number one expense, followed by medicine.
“ Drug costs are big but they decrease length of stay,” she said. Some drugs needed by critical care patients are very costly.
Sibbald is known as Ontario’s grandfather of critical care, a relatively new specialty of medicine born out of the battlefields of Vietnam and from the polio epidemic in the late 1950s.
Polio patients were corralled in one area by anesthesiologists treating their respiratory failure — the first kind of intensive care unit. Early resuscitation lessons were learned during the Vietnam and Korean wars: slamming in the fluids, getting patients on the ventilator and quickly inserting central lines.
Intensive care medicine still takes lessons from the military experience. Training and team building have been shown to improve patient safety, Sibbald said, adding Ontario hospitals get training ideas from the airline industry and U. S. Marines.
Sibbald also believes doctors, nurses and therapists must spend time away from the critical care unit to keep a healthy perspective. “ One week in four or three is about as much as you can put a doc through an ICU full- time.” Tanya Talaga can be contacted at ttalaga@thestar.ca