Insights (Essays) January 2020

The Real Answer to ER Overcrowding Lies in Understanding What Lies Upstream and Downstream of the Hospital

Dan Florizone


For every complex problem there is an answer that is clear, simple, and wrong. - H. L. Mencken (1880 – 1956)

Our most vulnerable citizens are a heartbeat away from crisis. That crisis is likely to land them in hospital. That hospital admission is likely to result in a prolonged stay, swift functional decline and loss of what little independence they had, setting them on a pathway towards institutionalization.  

Our system of care, designed in the mid-1900s around episodic acute illness, is being overwhelmed by patients with a much different need: chronic and complex illness. While acute crisis brings the patient to hospital, it is most often chronic and complex illness that keeps them there.  

If patients who did not need to be seen in the emergency room (ER) could be seen at a more appropriate site, that would be a good thing. But, it would not solve hospital overcapacity issues and long waits for admission. Work undertaken by the Saskatchewan Health Quality Council estimates that even if 50% of patients in the province’s ERs were seen elsewhere, ER waits for the patients that remain would only be reduced by eight minutes. Not a bad improvement, but when waits are upwards of eight hours, or at times several days, it is not the kind of improvement that creates real change.  

Building more long-term care beds or acute care beds or increasing capacity in the ER only brings temporary improvement. As those beds fill, the system once again backs up, impeding patient flow. Likewise, aggressively discharging patients home will bring short-term, immediate relief of congestion, but pushing those patients out to unsupported living environments invites further crisis and harm. The whole cycle begins again.  

The real answer to ER overcrowding lies in understanding what lies upstream and downstream of the ER and the hospital itself. We should be asking patients as they arrive, “what was the crisis that brought you here?” and “what could we have done to avoid the crisis in the first place?” Similarly, we should ask those in care, “what impediments exist to you returning home or as close to home as possible?” It is from those responses that true gaps in care and support become known – and a clarity emerges on where and what to invest towards programs and services in the community.  

So who asks these questions? If these questions exist at all, my hope is that they become embedded in the communities and neighborhoods that we live. These questions need to be asked by the emerging primary healthcare teams that know and care for our most frail citizens, and that senior citizens trust. High functioning primary healthcare teams know their patients by name, by strength and by need. And the care team views every unanticipated admission to hospital as a gap in community care, as an opportunity to improve design to close that gap and eliminate the defect. These community-based care teams practice the best patient first care: to help you not become a patient in the first place. And, if you are admitted to hospital, they double down on the support you need to pull you back home.

What services and supports need to be provided by these teams? A configuration of services tailored to your current needs and adjusted for your evolving or changing needs. Services that expand and contract when and if needed. Daily services that are provided every morning, every evening and every night.  

Who is part of this primary care team? The team is configured and adjusted based upon who and what you need. The more complex your needs, the more diverse your team.  

Where is the team’s home base? It may be a place – if you need a place. It could be your home. Or it might be on the streets. They are where you are; that is where they provide care. And if they find you are not home, that you are in hospital, they are driven to prevent, and delay, you from becoming institutionalized; to get you back to living as independent as possible.   

About the Author

By Dan Florizone, Executive in Residence, Johnson-Shoyama School of Public Policy

Former President & CEO of Saskatoon Health Region, former Saskatchewan Deputy Minister of Health, former Saskatchewan Deputy Minister of Education, former Chairperson, Saskatchewan Health Quality Council.

Twitter @florizone_dan

Linkedin @Dan Florizone



DocBrad wrote:

Posted 2020/03/12 at 08:12 AM EDT

These questions need to be asked in the ED as well. The problem then becomes - what next? In Ontario - a referral can be sent to the CCAC to engage with patients urgently but the biggest gap is determining who the true coordinators are. Services can be sent into the home BUT this does not solve the problem. Ontario Health Teams have been created to coordinate the myriad of health care needs of individuals. These teams are in their infancy so there are no metrics to suggest they have been successful. As a first step, I would suggest an EMR that allows for complete access to a patient's medical history (medications, services, health care visits, lab and imaging results etc) and that a coordinator tracks visits and coordinates care for a set number of rostered patients. This would allow for a much better experience and potentially decrease some of the fragmentation and duplication of services.

I also agree that increasing bed capacity is not the solution - inefficiencies of the current system need to be addressed first.


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