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“The better you are prepared, the better chance you will have of staying on top of everything that is coming your way” has been advice that most parents have tried to pass on to their children from time immemorial. Another well-worn phrase: “Preparation through education is less costly than learning through tragedy.”
For those of us who have spent many years in emergency departments in this province, we have observed that each year at roughly the same time (Dec. 20-April 15), the wheels barely stay on the bus. There is evidence that people suffer increased morbidity and mortality because of the system’s inability to cope with people presenting for care during this time.
Each year, health workers run around with their hair on fire trying to address the needs of their patients. This was well articulated by the emergency room physicians at Valley Regional Hospital in Kentville last winter when they were asked by their NSHA supervisors to see sick patients on stretchers in hallways, and then had to ask those same patients (many of whom were elderly and frail) to get off the warm stretcher to make room for someone presumably sicker than they were.
Why? Because the emergency room was at 110 per cent capacity and admitted patients had no place to go — but more significantly, primary heath care was simply not meeting the most basic demand of its constituents: access to timely care within their own communities.
We have also known, for the better part of two decades, that there are easily identified reasons for the emergency department surge:
- Health-care staff and administrators have scheduled holiday time so that regular services are adjusted accordingly, resulting in backups in clinics and even ORs;
- Decision-makers (especially in the hierarchical system we have created) are not anywhere near the front lines;
- Family physicians and other community-based health-care workers are not as available, resulting in people seeking other venues and personnel to address their problems, resulting in an increased demand on emergency department services;
- The desire to delay seeking advice or intervention until the holidays are over;
- The predictable tsunami of sick people who present with the annual flu;
- The lack of health human resource planning for the grey wave that has both increased the number of those seeking health-care interventions and simultaneously reduced the number of workers to provide care.
On Aug. 24, hurricane Dorian struck the Bahamas a devastating blow. Immediately, Nova Scotia EMO officials, private corporations like Nova Scotia Power, Bell Aliant, Telus, municipal and provincial governments and private citizens started preparation for a direct hit on Nova Scotia. Each of these groups would know what can happen with hurricanes and other natural disasters (Juan and White Juan). As a result, they asked their people to suspend their leaves, staff from other jurisdictions were marshalled (ahead of the event) to bolster home forces, budgets were adjusted to assure adequate resources were available and, most important, leadership was focused on the end game: restoring normal and timely services to clients.
How is the annual emergency room overcrowding phenomenon different from hurricane preparedness? The former has a longer lead time than most hurricanes, the outcomes are more predictable, the location is easily identifiable and the need to return to normalcy is a life-threatening imperative. Yet every year, we end up with the same wringing of hands and familiar phrases from managers of the health system, claiming that the surge is a blip that will soon pass. After hurricane Dorian, NSP was criticized for not being proactive enough with respect to tree-clearing under power lines, communication companies were admonished for their lack of preparedness and politicians and business leaders were quick to point fingers. Why isn’t the health system held to the same level of scrutiny or outcome metrics?
The annual flu will hospitalize approximately 12,000 people and kill approximately 3,500 across Canada. These data are irrefutable. Therefore, health managers know that, at the very least, 10,000 hospital beds will be required to address the surge that the flu will cause, to say nothing of increased health human resources to cope with the predictable load. Yet each year, we are told that we do not have enough resources, both capital and human, to address this recurring and predictable event.
Why do we accept this?
“Bed blocking” (patients ready for discharge but with no place to go) is one of the most critical factors affecting emergency department patient flow. Researchers at the University of Waterloo and the Hamilton Niagara Haldimand Brant Community Care Access Centre (2012) found that while patients who were waiting for nursing home admission accounted for only nine per cent of patients with delayed discharge, these same patients accounted for over 40 per cent of delayed discharge bed days. In other words, patients waiting for nursing home admission are a fairly small portion of bed blockers, but they block beds for much longer than average. In Nova Scotia, it has been estimated that about 20 per cent of the province's 3,554 inpatient hospital beds are occupied by people waiting to get into a nursing home.
Bed blocking generates problems throughout the health-care system, from longer wait times in emergency to poorer health outcomes for patients, due to accelerated functional decline, social isolation and loss of independence. Health managers and governments have known this for over two decades.
The researchers also found that patients with the longest discharge delays tended to have one of four characteristics: morbid obesity, a psychiatric diagnosis, abusive behaviours or stroke. This is important, because it means that a significant portion (23 per cent) of delayed-discharge bed days involve patients who cannot easily be cared for in many of Ontario’s existing nursing homes. There is no reason to believe things are different in Nova Scotia.
Within 12 weeks, we will begin the annual struggle with an increased number of sick people seeking care in our overcrowded emergency rooms. Is that enough time to prepare? A recent report to the NSHA board on ambulance offload delays indicated that improving turnaround times (ambulances’ ability to return to active duty) improved, but the consequence was to increase the burden on other parts of the system — another entirely predictable outcome.
How prepared is the NSHA for the recurring crisis that will face our emergency rooms and its overworked personnel? In May, it was reported that nurses at the QEII in Halifax pleaded with management to call a Code Orange (which means the ER is unsafe at current workloads) when the Halifax Infirmary ER was understaffed and overcrowded. But they were denied. How has the NSHA prepared for the upcoming predictable workload that will face these same nurses this winter?
Is there a plan to increase capacity within the nursing home environment, move patients to alternate venues like hotels, hire more heath workers to help, educate people on preventative strategies (akin to having bottled water, candles and food at the ready)? Will frontline managers be given decision-making powers and have discretionary spending authority? And, finally, will the NSHA share with Nova Scotians how the infrastructure will be modified to address the recurrent problem, akin to building better dikes and moving people away from threatening shorelines?
Who should be held accountable for the failure to recognize that repeated warnings about recurrent events have been ignored? Who will be held to account for the increase in morbidity and mortality that is associated with overcrowded ERs?
A wise man said: There are two primary choices in life — to accept conditions as they exist, or accept the responsibility for changing them.
Dr. Bob Martel practised palliative care in Arichat.