Our Health Care System Needs More Aggressive Treatment
Posted May 17, 2019
The health care system in Nova Scotia is staffed by skilled health professionals who give timely care to patients, most of the time. Most of the time is of course not good enough.
There are occasional articles and letters to newspapers expressing warm appreciation for care received. But most of the media coverage has been a disaster for the government and the Nova Scotia Health Authority (NSHA).
Recently a poignant and widely reported video by Inez Rudderham told of a cancer diagnosis seriously delayed because of her inability to access primary care.
An article in this space on February 2nd examined the problem of ambulances spending long hours at emergency departments because the hospitals are too crowded and could not offload the patients. The present protocol is that the ambulance and paramedics must stay until the hospital is able to take responsibility for the patient.
At that time, NSHA advised that a plan of action was scheduled for release in mid-February. It didn’t happen.
At the beginning of March, the Department of Health and Wellness issued a directive to fix the ambulance back-up problem. In mid-May, a policy document was released. The intention is to follow that with a plan that would be implemented in five initial sites starting early in June.
NSHA estimates that 50% of inpatients occupying some 3,500 rooms should receive care in another environment—home care, long term care, social housing–to better meet their needs and unclog the patient flow in hospitals. The strategies within the hospitals include:
- Communicating an expected discharge date to patient and family at time of admission so they will be prepared. Strive for discharges in the morning so a new patient can occupy that bed on the same day.
- Improving processes to complete patient assessments for home care supports and long-term care and communicate the Home First philosophy.
- Review allocations of beds to various programs of care.
- More efficient processing within emergency departments.
- Implement technology that would better manage bed availability data in hospitals and out-of-hospital facilities.
These are all sensible ideas and no doubt have occurred to many of the site managers around the province. The implementation feels plodding, overly prescriptive, and badly communicated.
The policy document referenced above begins includes a statement that “ED Team Members must offload ambulance patients within 30 minutes of the patient’s arrival to the ED.”
This sounds like a change in protocol, but it isn’t. The 30-minute standard is still an aspirational goal. If the hospital can’t take the patient from the EHS ambulance the paramedics will still have to wait until they can.
The policy document continues for a further 14 pages, including academic references supporting the policy. It does not provide much room for front line managers to adapt to their circumstances.
There are very capable people running the Emergency Departments around Nova Scotia, each of which has its own particular issues and challenges.
Why does the NSHA need a 14-page document incomprehensible to anyone but a policy wonk? Far better for the central office to identify the strategies listed above and then provide support (not direction) to site managers as they implement them in their distinctive environments.
Mary Barra took over as CEO of General Motors in 2014. One of her first moves was to replace GM’s 10-page dress code treatise with a two-word appeal: “Dress appropriately.” Trusting people’s judgment works just fine there and in many other large organizations.
It is instructive to note that the Minister’s directive to accelerate ambulance handoffs was inspired by a visit to Dartmouth General. The team there had achieved remarkable improvements on their own initiative without the benefit of a 14-page policy document from head office.
The essence of the strategies is to move patients along the continuum of care as efficiently as possible. The potential for these strategies to succeed will be limited by the available capacity in potential destinations for inpatients no longer needing treatment in general hospitals: home care, long term care, social housing, and specialized mental health facilities.
There are about 6,900 long term care beds and another 900 beds in residential care facilities. There are 1,200 patients on the waiting list for long term care of which about 1,000 are at home. On a given day about 200-250 long term care beds are empty but available beds refill quickly.
Having more long term care beds will be useful but represents only a small part of any viable solution. The government has committed to more beds in Cape Breton but beyond that wants more studies about the number and nature of the further resources that might be required for this and other non-hospital destinations for patients who don’t need to be in the hospital.
To extend that capacity requires more than new facilities. It will also need more staff, particularly nurses who are already in short supply in some regions. There are plans for this and for the continuing shortage of family physicians.
The studious approach to these issues does not provide the needed sense of urgency. More on this next week.
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