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Hospital overcrowding is an accountability problem, say emergency doctors

Dr. Sam Campbell stressed the emergency department at the Halifax Infirmary is overcrowded, but 'it’s not overcrowded with emergency patients, it’s overcrowded with people who have been admitted to hospital and don’t leave the emergency. There’s nowhere to put the emergency patients.'
Patients were crammed into the hallways at the Halifax Infirmary this week, putting their safety at risk, the Nova Scotia Government & General Employees Union said earlier this week.

Overcrowded hospitals have more to do with accountability than any particular seasonal virus outbreak, says the chief emergency doctor at the Halifax Infirmary.

Patients were crammed into hallways this week and sometimes triple-bunked in rooms, putting their safety at risk, according to a statement issued Tuesday by the Nova Scotia Government & General Employees Union. It blames the problem on what’s dubbed Code Census, a practice where non-emergency patients are moved out of the emergency department to other units.

“They’re sitting in hallways downstairs without seeing a doctor to try and get the people that have seen a doctor and have been admitted to hospital to go into a hallway upstairs,” Dr. Sam Campbell told Local Xpress.

Trouble is, people responsible for treating patients can say, “‘Sorry, we’re full, and basically close the door,” said Campbell, who works at the Queen Elizabeth II Health Sciences Centre’s Summer Street site.

“They have no reason to improve their efficiency or anything because they’ve removed any pressure that tells them how far behind they are,” he said.

The Infirmary’s emergency department isn't backed up worse than normal for this time of year, Campbell said.

“Every January or February everyone gets so excited and says, ‘Who would have believed it? We had a flu epidemic?’ This time of year, people get sick. But we’re chronically overwhelmed. There’s either a shortage of capacity or a shortage of efficiency. I’m not sure which it is.”

Campbell stressed his department is overcrowded.

“But it’s not overcrowded with emergency patients, it’s overcrowded with people who have been admitted to hospital and don’t leave the emergency. There’s nowhere to put the emergency patients.”

The NSGEU plans to strike a working group Friday “to address concerns from nurses about the Nova Scotia health authority’s decision to strictly enforce a directive that requires patients be admitted to floors where there is no space for them when the hospital is in ‘Code Census.’ ”

“Our hospitals are overcrowded, and as a result, the safety of patients and front-line staff is being put at risk,” union vice-president Sandra Mullen said in a news release.

Campbell points to an article about patient blocking that appeared last March in the Canadian Journal of Emergency Medicine.

“Emergency department overcrowding is the number 1 operational and safety concern in (emergency departments) across North America, Australia and western Europe,” Dr. Grant Innes, of the department of emergency medicine at the University of Calgary, writes in the paper titled Sorry — we’re full! Access block and accountability failure in the health care system.

“Overcrowding is increasing, often reaching crisis proportions in urban hospitals. Although ‘emergency overcrowding’ is the usual descriptor, the problem is not overcrowding, and it does not originate in (emergency departments). A more appropriate term is access block, the inability of patients to access care in a reasonable time frame.”

Our hospitals suffer from widespread access block, Innes argues, with many patients waiting in the wrong place for too long.

“Patients referred for long-term care placement wait in acute care hospital beds, compromising access for newly admitted patients. Patients waiting for hospital beds are blocked in (emergency department) stretchers, compromising emergency access. In domino fashion, emergency patients are left in hallways or waiting rooms without care.”

The latter leads to prolonged hospital stays, “inadequate pain management and increased patient mortality,” Innes writes. “Whereas related ambulance offload delays and diversions compromise our pre-hospital and disaster response systems.”

The root cause of this is “a system-level failure to define accountability for patient care and lack of planning to address care gaps,” he writes. “In our system, accountability is vague. When patients cannot access the care they need, there is rarely a backup plan, and it is not clear where to look for solutions.”

The problem persists “because the rewards for blocking access are profound,” Innes writes.

“Workload is controlled; waiting patients are out of sight and out of mind; staff stress is reduced; budgetary challenges are mitigated; and the program is protected from evolutionary stressors that would otherwise mandate innovation and system change. Without an accountability framework, there is little hope for a high-functioning system.”

Nurses and doctors focus too much on the patients in front of them, rather than the system as a whole, he argues.

“We focus on perfect care for the single patient and offer all treatment options, regardless of cost, and no matter how small the chance of benefit,” Innes writes. “In a system with infinite resources, this may be feasible. When beds, tests, and provider time are constrained, such an approach conflicts with the needs of the many.”

Ineffective patient care is “pervasive,” he writes.

“Hospital days that do not improve outcomes, imaging procedures that do not drive beneficial management changes, physician and nurse activities that do not reduce patient disability, ‘routine’ laboratory testing, expensive drug selection, wasted supplies, avoidable interventions, cardiac monitors for stable patients and stretchers for people who do not need them are all examples of ineffective care.”

Gaps to emergency care “could be eliminated by flow adjustments, efficiency improvements or thoughtful reallocation of care,” Innes writes.

“If we accept that our accountability is to all patients, not merely those already in care, we might reconsider how we deliver services, what services we provide to whom, and how we match care capacity with collective patient need.”

Doctors and nurses tend to share a common belief that more care is better, he writes.

But there’s a “sweet spot” for health care, beyond which that often isn’t true.

“Simple measures provide substantial benefit at low cost, whereas complex and invasive measures generally provide incrementally less benefit at higher cost,” Innes writes. “In our attempts to provide ideal care, it is easy to push through the zone of diminishing returns into an area of ineffective or even harmful care.”

The aim should be matching care to what’s required, he writes.

“By blocking access, we can preserve preferred care practices (sometimes under the guise of ‘quality’) and focus resources on the subset of patients we have accepted. Rather than matching care delivered to care required, this often leads to perverse allocation where acutely ill patients who have not yet been assessed, diagnosed, or stabilized are left without care in waiting rooms or ambulance stretchers.”

Hospitals need an “accountability framework,” he writes.

“Accountabilities must be established for all programs because failures in any one area will have a domino effect, compromising other components of a highly interdependent system,” Innes writes.

“Care delays will not be solved until someone is accountable to solve them, and people who are unaware of their accountabilities are unlikely to fulfill them. Physicians, nurses, and other care providers must understand who is in their waiting room (accountability zone) and recognize that accepting accountability for the many may require modifying the allocation of health resources. They should critically evaluate their practices and eliminate ineffective care wherever possible.”


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Chris Lambie

About the Author: Chris Lambie

Chris Lambie is a journalist based in Halifax, Nova Scotia. He has worked at newspapers from Newfoundland to the Northwest Territories.
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