Fixing Ambulance Congestion: It’s Complicated
Posted February 1, 2019
At one point on Monday, January 20th, there were seven Emergency Health Services (EHS) ambulances parked outside of the emergency department at the Halifax Infirmary (HI) site.
One or both of the two paramedics that go with each ambulance are required to stay with the patient in the emergency area until the hospital is willing and able to assume responsibility.
The clinical standard is that this should happen within 20 minutes. That is frequently missed. On that Monday, some of the patients waited for three hours or more.
Patient transfers and non-urgent EHS services suffer when too many ambulances are tied up at the emergency department.
A Nova Scotian patient is charged $146.55 for an ambulance call. When they arrive, the paramedics may conclude that the patient’s symptoms do not require a visit to the emergency department. If so, they can suggest alternatives such as a call to the 811 service, which allows patients to be advised by a registered nurse.
They cannot refuse to take the patient. At the hospital a patient showing no emergency symptoms is likely to have a long stay before seeing a doctor. Meanwhile, the paramedics wait.
In October, some relief was provided. A protocol was developed which allows such patients to be transferred to the general waiting area, often occupied by many others looking for access to care.
On an average day, the HI emergency department sees more than 200 patients. Over three quarters of them arrive without using an ambulance. Contrary to a common perception, few of them are looking for primary care.
Dr. David Petrie provides leadership to emergency departments in Nova Scotia. He estimates that 90%-95% of arrivals at emergency departments are at the right place for their condition.
That does not necessarily mean that they have a life-threatening illness. It is the right place to go if you broke your ankle, or have chest pain that might turn out to be from indigestion but could be a heart attack, or if you are having post-surgical problems with a prosthetic device.
The department has 36 beds and some extra spaces can be improvised when things get hectic. So why the backup?
Many of the hospital’s inpatients arrive through the emergency department, but a patient can only be placed if there is an available bed. Often there is not.
There are about 1,700 surgical/medical beds in Nova Scotia’s hospitals. On an average day, more than one in five of them are occupied by individuals not needing acute care.
Half have no substantial medical issue, but have family, home, or financial issues, or environmental barriers. It is both expensive for taxpayers and poor care for patients to keep them in an acute care facility.
Some need care that could be delivered in the community if the resources were there—strengthening and mobility training, dressing changes, intravenous antibiotics.
Some are awaiting assessment and placement in home care, long term care, or rehabilitation.
A variation on this story occurs in emergency departments all over the province. What is to be done?
The rate of arrivals at emergency departments is neither even nor predictable. It is not practical to staff for maximum loads, but even if capacity is for loads somewhat above the average, there will be days when things start to back up. Better to not expect or pretend otherwise.
Nova Scotians pay among the highest taxes in Canada. Health care represents 45% of departmental expenses. There is not much room for big increases in spending.
Patients awaiting transfer to long term care are only a small fraction of the problem, so increasing the number of long-term care beds, while useful, is only a small part of any solution.
A more comprehensive response is needed for patients who can be supported in their communities. This will need added resourcing for social housing, home care, and residential care facilities (which provide less comprehensive support than long term care) but will cost much less than occupying a hospital bed.
The policies around ambulance transport, scope, resource allocation, and transfers of responsibility from the EHS paramedics to hospital staff are all being reviewed. There is plenty of opportunity for improvement. A plan of action is scheduled for release in mid-February.
The log-jams in emergency departments are frustrating for patients and their families, frustrating for EHS paramedics, and stressful for the care-givers in the departments. For seriously ill patients, delayed care can be life-threatening.
There are opportunities to make the emergency departments work better. But an effective response will require much broader efforts within the hospitals, in other parts of the health care system, and in social services. It’s complicated.
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