A Painful Truth

If one day soon you break your hip or have a stroke or simply have a bad case of food poisoning at two in the morning, how long will you wait in your hospital’s emergency room?

Hundreds of Albertans will today learn the answer to this question—and odds are it’ll be a painful revelation. A crisis is underway in Alberta’s healthcare system, with long wait times in the ER the most glaring symptom. The problem has been worsening for years, but it wasn’t until last fall that the issue finally exploded into the public’s consciousness.

In October 2010, local media published a leaked letter from the province’s chief emergency room doctor to Health & Wellness Minister Gene Zwozdesky and other government officials warning of “catastrophic collapse” if immediate action wasn’t taken. The letter was written by Dr. Paul Parks, president of the Alberta Medical Association Section of Emergency Medicine, and the media spotlight sparked the government to acknowledge the issue in a way that years of internal complaints and calls for action by ER doctors had failed to do.

One year after Dr. Parks’s letter was leaked, the government claims the ER wait times issue is under control. They’ve made announcement after announcement in an effort to reassure citizens. An Alberta Health Services website even claims: “People who need emergency surgery or treatment receive it without delay.” Should we believe the hype?

In the early 2000s Dr. Parks was working in the emergency ward of Edmonton’s University of Alberta Hospital. He and other ER doctors spoke to the health ministry and regional health boards about their rising concerns about overcrowding and wait times, especially at the busier urban hospitals across the province. Their concerns went unaddressed and conditions continued to decline. In 2006 the situation reached a critical point.

In an effort to spur action, Dr. Parks started to collect examples of substandard care and “adverse events” caused by overcrowding in the ER. He approached ER departments at other hospitals to do the same, but concern about reprisals deterred them from following suit.

Triage Liaison Physicians at University Hospital documented problems in the ER in reports they called “sub-optimal outcomes documents.” Dr. Parks began sending these reports to the government and the health region, along with letters appealing for action. When nothing happened, he continued to submit the reports and appeals every few months until a dialogue was initiated. Despite finally getting a response, nothing else changed. When the letters and reports were eventually leaked to the media in 2010, they launched a firestorm.

The reports were damning. They revealed multiple cases of people with appendicitis forced to sit in the waiting room for hours. Elderly stroke victims missed their window for treatment; even those who arrived by ambulance had been out of the therapeutic window for hours by the time they got a bed. Numerous mental- health suicide crises went untreated in the waiting room; some patients returned later via ambulance after a drug overdose. In one night, two intentional overdoses left the ER without having been seen. The reports say that delays even resulted in at least one death: a man “ultimately died… of his ventricular infection from a drain that would not have been necessary if he had been able to have timely surgery.”

Though the reports contain medical jargon, the horrific conditions are apparent even to the layperson—as in this report, dated February 16, 2008:

Patient arrived with a suicide note and suicidal ideation at 1200. Didn’t make a chart and due to significant overcrowding [patient] managed to leave unbeknownst to the triage staff. Returned later via EMS with a significant OD, ultimately required intubation and ICU.

30yo female with RLQ [abdominal] pain that was worse with any movement. Registered at 2053, still not in a room at 1140 the next day when she got back from an ultrasound that confirmed her appendicitis. No fluids, analgesia or antibiotics for >15 hours.

Elderly patient with CVA [stroke], within the window for potential thrombolytic therapy; no beds in department. Patient received CT and blood work in WR [waiting room] and missed opportunity for possible treatment.

It isn’t only patients that are impacted by long waits, of course: paramedics have to wait with them until they get an ER bed. Dr. Layton Burkart, an emergency physician working at two Edmonton hospitals and an executive member of the AMA, told media that the problem was endemic: “It’s common to have five-plus EMS units and their medics tied up for hours while they wait for an ER stretcher to be freed up so that they can download their patient and get back on the streets to do the job they are supposed to be doing—saving lives.” In the leaked reports, one triage shift noted that seven EMS crews were stuck in the waiting room for several hours. In another instance, nine crews were in the waiting room at once—one of them stuck there for more than six hours. According to Elizabeth Ballerman, president of the Health Sciences Association, “The situation has gotten so out of hand that we now have patients calling 9-1-1 from the ER because they’ve waited so long in hospital emergency departments.”

It’s not a matter of slow treatment, but simple numbers. Three excerpts from the “sub-optimal outcomes” reports clearly show the ER was overcrowded because hospitals were overcrowded—patients admitted to the hospital had nowhere to go.

The reports are damning. People in pain waited hours. Stoke victims were missed. Suicide crises went untreated.

Arrived at 0600 to 28 EIPs [emergency inpatients] and 4 more patients requiring definite admits. During my eight hour shift no EIPs moved out of the department, there were only 2 ED [emergency department] beds ever available for assessment and treatment of patients (there were 4 chair areas intermittently available). During this shift I had to treat a narcotic overdose with Narcan in the WR. Another patient had a seizure at home, came in with EMS, and had multiple seizures in the WR with EMS. No ICU beds in region. Over 8 hour shift, half of all A-pod beds were taken up with acutely ill ICU patients that required staff presence and intervention for the entire shift. The lack of critical care beds in the region significantly impacted ED’s ability to care for our own patients.

Recorded by 0600 shift doctor: arrived at 0600, multiple patients in WR with prolonged waits, NO FREE BEDS IN ENTIRE ED to see patients. Saw two complex elderly patients with significant pain who filled the two existing triage assess beds (so had no area to even do triage ECGs). Assessed five patients from a chair in the alcove beside E-pod (a non patient care area with no curtains or equipment). Saw my first patient in an ED bed at 0845. A patient with a drug overdose and seizure arrived with EMS at 0549, and finally got into an ED bed at 1100 for assessment and treatment. I saw three patients in a proper ED assessment area during my entire shift.

On the same day >20 patients LEFT WITHOUT BEING SEEN. When I left my shift at 2400, there were 28 patients in the WR, 2 triage level 2s, and 23 triage level 3s! From a physician and personal point of view I feel helpless in the Triage Liaison Physician role (when the overcrowding is this bad, even the TLP role becomes non-functional).

Long ER wait times are associated with worse health outcomes. A study in the British Medical Journal found that patients whose ER wait times were six hours or longer were more likely to suffer an “adverse event,” such as the need for hospital admission, or even death. For patients needing acute care, the risk of death was 79 per cent higher if they waited for six hours or more, compared to those with one-hour waits; their risk for needing hospital admission was also 95 per cent higher. Even among patients who were less sick, their risk of death was 71 per cent higher and they were 66 per cent more likely to need admission if they waited more than six hours for care.

“We know that ER crowding is not one of mere patient inconvenience,” wrote Dr. Alan Drummond, chair of public affairs for the Canadian Association of Emergency Physicians (CAEP), in a 2010 letter picked up by media across Canada. “It leads to poor clinical outcomes, adds expense to hospital expenditures, causes system gridlock with ambulances unable to offload patients and causes very real human misery.”

There’s no doubt the system was in crisis for a long time, and that little was done about it. But has there been any progress since Dr. Parks’s letter was made public? In a 2011 Alberta Prime Time interview, Donna Wilson, a professor of nursing at the University of Alberta, said, “We are definitely moving in the right direction, but, boy, do we have a long way to go yet.” This sentiment was echoed by AHS president and CEO Dr. Chris Eagle, who told an Edmonton Sun reporter in March, “When I am saying we are not meeting targets, I am saying we still have a lot of work to do.”

The only way Albertans can know whether the system is improving—and how far it’s come—is by demanding accountability. When it comes to ER wait times, that accountability comes in the form of tracking the number of patients admitted in emergency who are waiting for a hospital bed, monitoring wait times and comparing wait times to established benchmarks (or the amount of time the healthcare system deems an appropriate wait in the ER).

There’s been some progress on the number of ER patients admitted to hospital beds. The number of people requiring an overnight stay decreased between September 2010 and May 2011. For Edmonton the daily average number of ER inpatients fell from 84 to 42, while in Calgary it fell from 68 to 18. More recent figures on the daily number of admitted patients languishing in ER are hard to get, however. Dr. Parks estimates that Alberta’s large-volume hospitals are still hovering at around 30 per cent of beds occupied by patients waiting to be admitted—meaning that those hospitals are still operating at well over capacity.

Average waits in emergencies have shortened as well, but are still far from new benchmarks set by the province. The target for wait times set by AHS are 75 per cent of patients to be treated and discharged within four hours by March 2012 and 90 per cent by March 2015. At press time only one of Edmonton’s hospitals (Stollery Children’s) was at the March 2012 target, while three of them hovered between 45 per cent and 52 per cent of patients meeting the four-hour-wait goal.
The goal for admitted patients is for 60 per cent to be seen, assessed, treated and stabilized and admitted within eight hours of arrival by March 2012. The target is 90 per cent by March 2015. At press time none of the hospitals in Edmonton met the 2012 target, with most between 28 per cent and 38 per cent.

The crisis coincided with a shift from funding long-term care beds to promoting for-profit facilities.

On average, Alberta’s 16 busiest ERs now discharge 63 per cent of their patients within the four-hour target. The system-wide average—which includes the province’s less busy rural hospitals—is 80 per cent. For those patients needing admission, 38 per cent are treated and admitted within the target of eight hours at the 16 busiest hospitals, while the province-wide average is 49 per cent.

Alberta’s ideal average wait times are longer than the national benchmarks. The national Wait Time Alliance recommends shorter waits for admitted patients, with a range from four to eight hours depending on how acute the emergency. For further comparison, the UK has set and reached a target of 95 per cent of patients admitted within six hours. Australia has also moved to the six-hour benchmark. Many observers say Alberta’s targets were not overly ambitious. Dr. Parks says frontline doctors took what they could get.

The bottom line is that waits are still too long, and that untold numbers of Albertans who count on their healthcare system suffer needlessly. “The really sick people are being treated,” said Wilson. “But there’s still a sheer volume of people waiting too long.”

Dr. Parks warns that not only is Alberta failing to meet its own targets, but slippage is expected as short-term measures are exhausted. Indeed, much of the improvement to date has been due to over-capacity protocols and surge protocols in hospitals. This includes placing cots in full wards and temporary beds in ER. Some efficiencies have been created through new discharge procedures.

However, years before Alberta moved to “over-capacity protocols,” the province implemented “capacity protocols” to deal with overcrowding. Alberta’s experience with “capacity” protocols is that wait times initially improve but then worsen as temporary measures are exhausted. Dr. Parks is concerned that slippage is already happening, citing rising emergency inpatient rates due to the exhaustion of over-capacity options.

The cots sandwiched into already full wards are not a long-term solution. They increase the load on already overburdened nursing staff and create more stress for patients already in the overcrowded room. As one patient told me: “I was in a cot pre- and post-emergency surgery that was sandwiched between two beds in a room obviously [meant] only for two. It was horrible. We were on top of each other and the patient next to me had mental health issues. I took the cot mattress out to the lobby at night so that I could get some sleep and the custodial staff woke me to move back into the ward when visiting hours started.”

According to Dr. Parks, ER doctors were clear from the beginning of this crisis that the issue of overcrowding in emergency was due to downstream capacity problems, mostly a lack of long-term-care beds in nursing homes. For example, in September 2010, between 60 and 70 per cent of all emergency beds in the city of Edmonton were occupied by patients who no longer required emergency care but needed to be admitted to other parts of the hospital.

Indeed, the overcrowding crisis of the last few years coincided with two widely criticized government decisions: its change in policy on seniors care and its shift from funding traditional long-term-care beds to promoting lower levels of nursing care in for-profit continuing care facilities. In this sense, the ER crisis was inevitable. Under the guise of sustainability and cost controls, the government has been cutting corners in Alberta hospitals and long-term care to compensate for cost increases in other areas, such as pharmaceuticals and new technologies. Hospital spending in Alberta has plummeted from 44.7 per cent of health spending in 1975 to 27.8 per cent in 2009.

“ER crowding rarely occurs when hospital bed occupancy is at 85 per cent, occurs frequently when occupancy rates exceed 90 per cent and is a given at 95 per cent occupancy rates,” said Dr. Drummond of CAEP. “Most Canadian urban hospitals routinely operate at greater than 100 per cent bed occupancy.
“When hospitals are overcrowded, admitted patients languish on the stretchers of emergency departments for extended periods. For every admitted patient waiting in an ER bed, six emergency patients per hour are prevented from being treated.

“In the mid-1990s, many provinces cut the number of hospital beds by 30 per cent. With an aging population, about 20 per cent of hospital beds are occupied by patients who need to be in a nursing home or at home with home care. As a result, 50 per cent of hospital bed capacity has been reduced in the past 15 years despite increasing need as a result of an aging population… Restoring bed capacity is, in part, the correct approach to solving emergency department overcrowding.”

Canada operates its hospitals at the highest capacity of all developed countries. In fact, Canada has the highest hospital bed occupancy rates in the OECD. The trend is toward lower numbers of hospital beds across OECD countries. However, Canada had only 1.8 acute care beds per 1,000 population in 2008, the lowest number of all OECD countries except Mexico (the OECD average is 3.6 beds per 1,000 people). And despite our vast wealth, Alberta has fewer hospital beds than the Canadian average.

The same situation exists for long-term care, where Alberta’s number of beds per capita falls below the national average. But don’t think the province makes up for this by supporting those folks in their homes. Alberta also sits close to the bottom of provinces for home-care spending.

Alberta compares poorly on healthcare professionals, too. Alberta has amongst the lowest number of nurses and licensed practical nurses per capita in the country. We are again almost at the bottom of the OECD in terms of the numbers of medical school graduates per capita. And despite these alarming numbers, the provincial government cut funding to universities in the 2010 budget. Not long afterward, medical school tuitions increased in Alberta and the number of seats in medical schools were cut.

So where do we go from here? What has the government promised? In addition to introducing short-term “over-capacity protocols,” the government opened 360 new hospital beds in Edmonton and Calgary in 2011. It announced plans to open 5,300 new long-term care beds by 2015 (1,174 of them were ready by April 2011), to make additional investments in home care (800 new clients in Edmonton and Calgary) and to improve patient discharge planning. It also announced a five-year plan that includes a primary-care focus. In other words, the government aims to give Albertans better access to a primary-care team—doctors, nurses, pharmacists, dietitians and others.

Will this be enough to take the pressure off Alberta’s ERs? The United Nurses of Alberta is skeptical. “The plan says capacity must increase as our population ages,” says a UNA press release. “But there’s no plan to increase full long-term care, nursing homes and auxiliary hospitals. This is the category of care that is most needed to take pressure off our hospitals.” The UNA explains what we need: “Long-term care refers to a nursing home or an auxiliary hospital with on-site care by Registered Nurses and Licensed Practical Nurses. Supportive living is a different category and has no on-site RNs.”

According to an ER nurse quoted in a UNA news bulletin, “Ambulances bring us patients from the assisted living facility all the time. They fall or they get their meds confused. There is no nurse on-site, so the staff just call the ambulance. They come in and usually we do an assessment, which could just as easily have been done at their site by an RN. It’s a colossal waste and a terrible way to treat these people. So many of them must be terrified to go in the ambulance. They must think it’s their last ride. Having RNs on site could save so much grief and money.”

The more we try to save money by cutting corners and privatizing services, the more problems we create.

Though the government has committed to increasing the number of long-term care beds, this is within a framework of private, for-profit delivery in which Albertans will receive lower levels of nursing care at higher out-of-pocket expense. Dr. Parks says that there’s no real transparency about beds or numbers and thus no clear plan for how those would match with the needs of patients awaiting discharge from the hospitals. He also says that even if beds are created, they may not match the needs of hospitalized patients, because of the lower levels of nursing support and the high personal cost for the patient and his family. “Indications are that the private, for-profit care model may actually create barriers to moving patients out of hospital beds,” he says.

Overall, the Alberta government’s claim that “people who need emergency surgery or treatment receive it without delay” just isn’t true, at least in most cases and especially in the busiest ERs. Worst cases—car accident victims, those unconscious or in severe respiratory distress—will almost certainly be seen right away, as per the Canadian Triage & Acuity Scale. For anyone else, suffering anything from a stroke to acute psychosis, all bets are off.

Do we want better than this? At some point it simply comes down to resources: you cannot operate hospital beds and long-term-care beds without spending money. Ironically, Alberta’s experience seems to show that the more we try to save money on healthcare by cutting corners and offloading services to the private sector, the more problems we create, especially in the province’s ERs, and the more money we then need to throw at the problems.

“More than mere indignation, Canadians should be rightly outraged,” says CAEP’s Dr. Drummond. “Whether we like it or not, we are going to have to increase bed capacity, both in the hospital and in the community, to meet the needs of an aging population.” If Canadians should be “outraged,” it’s hard to find the right word for how Albertans should feel about their healthcare situation, given that this province already lags behind the rest of Canada in terms of acute and long-term care and numbers of doctors and medical graduates.

Alberta can afford to spend more and needs to spend a lot smarter—specifically, by properly funding a system of universal, public long-term care, including home care. This is especially true given that these investments would almost immediately lower other costs—think seven crews of paramedics twiddling their thumbs in an ER room. An intelligent reallocation of funds could fix what years of cutbacks and misspending broke. Poll after poll shows that Albertans are willing to pay more taxes for quality public healthcare. According to the OECD, Canada ranks in the bottom half of developed countries for the ratio of tax revenue to GDP. Alberta has the lowest ratio in Canada.

As Dr. Parks’s leaked letter finally made clear to the government and to the public, we’re all paying a steep price for neglecting our healthcare system. It’s time for Alberta to step up and enshrine a real plan for a properly funded, fully accessible and affordable continuum of public care. #

Diana Gibson is the research director for the Parkland Institute. She has an extensive background in social and fiscal policy research.