This is the second part of our Full House series on overcrowding at Abbotsford Regional Hospital. For part one, click here.
The quest to get patients out of hallways at Abbotsford Regional Hospital has been going on for nearly a decade.
Those efforts have been largely unsuccessful, with The News reporting in Part 1 of this series that ARH operated at 118 per cent capacity in 2017/18. Fraser Health has been warned that operating above 95 per cent increases risks to patients.
In recent years, efforts have focused almost exclusively on the idea that the overcrowding issues can be alleviated if fewer people need to go to the hospital, and if those in a bed are out more quickly.
That strategy – which experts repeatedly say is both cost-effective and backed by data – has met with success in some areas, but has yet to reduce crowding at ARH. The strategy has been unable to outpace a growing and greying population, along with a significant increase in hospital usage by younger people.
Not all of the challenges have been out of the health authority’s control. The figures suggest that patients could have seen some relief if Fraser Health hadn’t chopped dozens of beds from ARH in 2015, and if they have made good on efforts to build a residential care facility promised five years ago.
RELATED: Crowded ERs linked to patient deaths, doctor errors
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Despite being a complex issue, hospital congestion is not particularly hard to understand.
Patients come to a hospital, whether through an ER or by referral from another source, and are admitted as an in-patient if a doctor deems it necessary. They can be discharged when they no longer need hospital care. Some are sent home or into the care of a loved one. Others are sent to a residential, assisted-care, or rehabilitation facility.
In Abbotsford, though, there are always more patients than fully funded beds, so people end up being placed in “flex-beds” in hallways, next to nursing stations and in other places not designated for patient care.
There are two main factors at play when a hospital is operating at 118 per cent capacity. First, some patients are ready to be discharged, but are waiting for a bed in a residential care facility or health supports to be in place at home. These are called “alternate-care (ALC) patients.”
Second, a hospital can simply have too many patients who need hospital care.
ARH’s emergency room is a relatively small part of the equation. When acute-care hallways fill up, patients end up stuck in the ER.
In 2014, the situation was bad enough that, on at least two occasions, a high-ranking ARH official sent desperate-sounding emails to colleagues. In one of the emails, which were obtained by The News in a freedom of information request, the official asked subordinates “to take some liberties with patient placement,” in order to make room for ER patients.
In 2017/18, one of every 10 patients waited more than 60 hours in the emergency room – a figure worse than in 2014. The ER’s impending expansion will reduce crowding for patients waiting to be admitted, but it won’t fix the root problem.
Fraser Health has focused its efforts in three areas: increasing community care by building more residential care units and adding new home health supports; speeding up the pace of patient discharges; and initiatives that hope to keep people out of hospital.
These strategies make sense, according to Eric Cadesky, the president of Doctors of BC. Hospital care is the most expensive type of health care and studies have shown that unnecessary and prolonged hospital stays are bad for patients.
“We always want people to spend the shortest amount of time possible in the hospital,” he said.
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There have been successes. Several years ago, the health authority noticed that more seniors were being admitted to hospital. A range of initiatives reduced that number substantially, although it remains above where it had once been. Seniors are also not waiting as long for services, and “frail seniors” are using the ER 20 per cent less.
But Fraser Health has been unable to reduce the number of people in unfunded and uncomfortable “flex-beds” in ARH. And as time goes on, the challenge isn’t getting easier as the mix of patients changes.
In 2013, those “ALC” patients waiting for care elsewhere made up 12 per cent of all admitted patients at ARH and more than 20 per cent at Chilliwack General Hospital. If the hospitals could find spots for all of them, the two sites would have been operating under capacity.
Five years later, the number of ALC patients in Abbotsford had been halved. That’s a notable success, but it comes with a catch. In 2018, even if every remaining ALC patient had been removed from the system, ARH would still have operated at 111 per cent capacity last year.
Fraser Health also suggests that many patients in hallways are ready to be discharged. While that may once have been the case, the figures show that no more than 40 per cent of hallway patients could be ALC patients.
The figures also show that, even without accounting for an aging and growing population, Fraser Health needs to decrease hospital usage by more than 10 per cent if it does not choose to add more beds to the system.
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A couple of factors are to blame. As officials worked to lower the hospitalization rate of seniors, the number of younger people being admitted from the ER shot up. Fraser Health says they are working to find out why those numbers have increased; a spokesperson notes that many of those patients have mental health issues or drug addictions.
Meanwhile, the region is rapidly growing and greying.
Between 2013 and 2018, Abbotsford, Mission and Chilliwack added a combined 18,000 people to their populations. The number of people over the age of 60 rose by 17 per cent.
But the three cities’ hospitals had three fewer beds in 2018 than 2013, thanks in large part to the axing of two dozen beds across the region in 2015. (The News does not have newer bed count numbers for the hospitals, but Fraser Health says it added 10 new surgical care beds over the last year.)
And a plan to build new residential care homes on the site of the old MSA Hospital on McCallum Road has been stalled for five years, with the process now supposedly being held up by consultation with local First Nations over the sale of the land.
That has frustrated Abbotsford Mayor Henry Braun.
“I am not happy about that but I can only push so far,” Braun told The News last fall. “It’s holding up, I’m guessing, 400 care beds that should have been under construction three years ago.”
While the number of ALC patients in Abbotsford specifically have dropped, ARH still has upwards of two dozen patients who are just waiting for a bed elsewhere. A similar number is waiting for space in other hospitals around the central and eastern Fraser Valley.
Fraser Health officials have been loathe to discuss the impact of bed numbers on crowding at Abbotsford’s hospital.
But Health Minister Adrian Dix came to the city last month, and said the health authority should be looking at whether ARH and other sites have the appropriate number of beds to care for patients.
“That’s a question that Fraser Health should review constantly and consistently,” he said.
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