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 is that preparation through education is less costly than learning through tragedy.
For those of us who have spent many years in Emergency Departments (EDs) in this province, we have observed that each year, at roughly the same time (December 20 to 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 at 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 Nova Scotia Health Authority (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 because admitted patients had no place to go, but more significantly, primary health 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 ED surge. One reason is that health care staff and administrators scheduled holiday time so that regular services are adjusted accordingly, resulting in back-ups in clinics and even Operating Rooms.
Decision makers (especially in the hierarchical system we have created) are not anywhere near the front lines, while 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 fourth reason is the desire to delay seeking advice or intervention until the holidays are over. Then there is the predictable tsunami of sick people who present with the annual flu. The final reason is the lack of health human resource planning for the gray wave that has both increased the number of those seeking health care interventions and simultaneously reduced the number of workers to provide care.
On August 24, 2019, Hurricane Dorian struck the Bahamas a devastating blow. Immediately, Nova Scotia Emergency Management Office officials, private corporations like Nova Scotia Power, Bell Aliant, Telus, municipal and provincial governments, and private citizens started preparation for what was predicated to be 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 importantly, leadership was focused on the end game; restoring normal and timely services to their clients.
How is the annual ED over-crowding 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, Nova Scotia Power 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 is 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?
Returning to Kentville to illustrate a point, shows that “bed blocking” (patients ready for discharge but with no place to go) is one of the most critical factors to ED patient flow.
Researchers at the University of Waterloo and the Hamilton and Niagara Haldimand Brant Community Care Access Centre (2012) found that while patients with delayed discharge, who were waiting for nursing home admission accounted for only nine per cent of patients with delayed discharge, these 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 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 in-patient 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 from accelerated functional decline, social isolation and loss of independence. This has been known by health managers and governments 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 over-crowded emergency rooms. Is that enough time to prepare? A recent report to the NSHA board on ambulance off-load delays indicated that improving turn-around times (an 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 over-worked personnel? In May 2019, it was reported that nurses at the QE II in Halifax pleaded with management to call a Code Orange (ED is unsafe at current workloads) when the Halifax Infirmary emergency room 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 front-line 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 ED’s?
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. Robert Martel