No Patient Left Behind

Why do we need No Patient Left Behind?

During 40 years as an emergency physician, I dealt with many waiting room disasters and met many families who lost their loved ones because of emergency department (ED) care delays. These people are the inspiration for No Patient Left Behind.

This story began 25 years ago when I was working in a Vancouver emergency waiting room. Every chair was full. People were moaning. Someone was on the floor vomiting in a wastebasket. Two cops were restraining a psychotic patient in the corner. People were milling about in obvious pain and someone was yelling obscenities at the triage nurse. Six or seven paramedic crews were lined up down the hallway, unable to offload their patients, which meant they couldn’t respond to emergencies in the community. It was chaos. No one could move to a care space because all of the stretchers were blocked by admitted patients waiting to be moved upstairs to hospital beds. I had the closest thing I ever had to a panic attack. I decided I had to quit my job or do something about this absurd situation. I had never been interested in administration or leadership but the next week I applied to be department head.

Six hour waits for emergent patients should never happen, but now they are the norm. Worse are the waiting room tragedies, and there are many: The 45-year-old man who died of a heart attack after eight hours in an ED waiting room. The three month old who died in his mother‘s arms, in the waiting room, from a severe infection. The 51-year-old woman with breathing trouble who was sent to the waiting room and died hours later from a blood clot in her lung. The woman with an unrecognized stroke who was triaged to an ambulance waiting area for hours, where she suffered massive brain damage and died six days later. The young man who went into shock and required ICU care after hours in an ambulance hallway with pancreas inflammation. The 67-year-old who died with a blocked bowel after being left in a waiting room. The asthmatic teenager, unable to breathe, who had to be moved out of the waiting area into a parked ambulance to have a breathing tube inserted, because there were no available care spaces or resuscitation rooms in the ED. And the wheelchair-bound man who died in an ED waiting room after a 36 hour wait.

These stories are true, they are the tip of the iceberg, there are hundreds more like them, and they share a common factor. All of these patients had serious complaints and all were sent to waiting rooms because no ED care spaces were available. The cause of the emergency crisis is hugely misunderstood. Many healthcare leaders will tell you that too many low acuity patients are using emergency departments, but the problem is not low acuity patients. The problem is high acuity patients who can’t get the emergency care they need. It’s called access block. Emergency access blocks and care disasters happen mostly because of care delays elsewhere in the system (we’ll explain why). No Patient Left Behind has many innovative ideas to solve care delays throughout the system, and we think we can make a difference.

Grant Innes

Emergency access block: The crisis is best described as emergency access block—the inability to get emergency care when you need it. Emergency departments send too many sick patients to waiting rooms, dangerous unmonitored locations, because we have nowhere else to put them. Does this mean emergency departments are too small? Or don’t have enough staff? No! We have more than enough staff and stretchers to look after urgent and emergent patients. The problem is that most of our stretchers and nurses are unavailable because they are blocked by admitted patients who have already completed their emergency care and are waiting in an ED stretcher until a hospital bed becomes available upstairs (waiting in an ED stretcher is called “boarding”). When you look at root causes, emergency access block and waiting room disasters are mostly but not entirely caused by care delays elsewhere in the system. Until hospital medical programs can move boarding inpatients up to the ward beds they are supposed to go to, emergency care delays and waiting room tragedies will continue.

Hospital access block: When you go to the emergency department and are too sick to send home, you will be admitted to the hospital—perhaps to a medical specialist, a surgeon, a psychiatrist or an intensive care doctor. When you are admitted, you are supposed to move off of your hard ED stretcher out of the noisy ED environment into a quiet hospital room on an upstairs medical ward where you have an actual bed and bathroom. Sadly, this is unlikely to happen because there are usually no available hospital beds. Instead you will remain in a crowded chaotic ED for many hours or days, often in a hallway where the lights never go out, maybe sleepless. You will be looked after by emergency nurses rather than the ICU or mental health nurses you need. Research shows that the suboptimal care you get will compromise your recovery and you will require a longer hospital stay as a result.

Hospital access block, the inability to access necessary hospital care, happens when there are no available beds on medical wards for patients who need care. So does hospital access block mean our hospitals are too small? The answer is . . . Yes . . . No . . . Maybe. Canada has a low supply of hospital beds compared to other First World countries, but we could manage if we used our hospital beds more effectively. In addition to a relatively low supply of hospital beds, we have rising demand for those beds. Rising demand means we have an aging population that needs more hospital-based care. Because of better medical treatments, more people now survive with chronic diseases that need complex ongoing management. When patients can’t get that management because of failures in the primary care system or difficulty seeing specialists, they end up in emergency departments and get admitted to hospitals.

We could also improve our use of hospital beds, although our efficiency is not bad. Canada’s average length of stay (LOS) for hospitalized patients is 6.1 days, similar to other countries but longer than some comparators like the United Kingdom (5 days) and Nordic countries (5.3 days). These countries have more community and homecare resources and payment systems that encourage rapid hospital discharge. Striving for a half- or one-day reduction in hospital LOS seems insignificant, but even a few hours can make a huge difference in the ability to provide emergency care. To illustrate, a 4-hour LOS reduction in an average hospital with 30,000 admissions per year would free up 120,000 care hours—enough to treat about 30,000 more emergency patients rapidly.

Community Access Block: A low number of hospital beds, primary care failures, rising demand and imperfect hospital efficiency are important reasons why you can’t get a hospital bed when you need one, but the elephant in the room is the massive impact of alternate level of care (ALC) patients who occupy Canadian hospitals. ALC patients are frail, usually elderly, patients who have completed a course of hospital treatment, who are medically stable and ready for discharge, but who cannot manage independently in the community and have no place to go. They need homecare support, social contact, help with daily living, rehabilitation, palliative care, or just accommodation. With no place to send them (community care access block), they now occupy 15 to 20% of Canadian hospital beds. It’s not their fault, but it creates a large and critical bed loss that prevents the flow of patients out of emergency departments, and leaves hospitals and EDs in continuous crisis mode. Worse than their detrimental effects on emergency and hospital care is the fact these fragile patients are left on medical wards where they do not receive mental stimulation or rehabilitation. Many become weak, lose mental function and even develop delirium. An ALC stay can mean the difference between going home with home support or being institutionalized in a long-term care facility.

Like dominos falling, community access blocks cause hospital access blocks, which cause emergency access blocks, which cause ED waiting room tragedies. If we could solve one problem, it would be the ALC problem.

System-wide dysfunction leaves Canadian patients facing prolonged waits for all types of care, but there are many ways health programs can innovate and improve (these will be discussed). New accountability frameworks will be required to motivate system change (we’ll discuss these as well), and we can say based on research evidence that small improvements throughout the system will make a huge difference to emergency care. Patients should not have to suffer for correctable system shortfalls. Instead, the system must adapt to the needs of patients.

How big is the care gap? A national study of 25 Canadian emergency departments analyzed 1.8 million ED arrivals and determined that, on average, emergent and urgent patients (those at high risk) were left in waiting rooms for an average of 46,000 hours per year per hospital. This provides a large opportunity for waiting room disasters, and indeed many occurred. However, the same study determined that the 46,000 hour emergency care gap represented only 1.14% of the corresponding hospital’s bed capacity hours, meaning that very small hospital efficiency improvements in the range of 2 to 4% could eliminate the need to send sick arriving patients to waiting rooms. Experts in patient care and hospital management believe that improvements many times this large are possible without significantly stressing hospitals.

Our mission is to support the introduction of health system innovations that improve patient access to appropriate care (right care, right place) in emergency departments, hospitals or communities. No Patient Left Behind believes that by inspiring and training health leaders, by teaching and promoting better care processes, by rewarding high performers, and by lobbying for the introduction of accountability frameworks (care expectations) that will force changes in how things are done, that we can make the health system better and reduce care delays for Canadians.