Raise the Hammer
A reasonable approach to health care involves targeted injections of resources. This is a complex problem, best solved with a combination of methods.
By Ted Mitchell
Published January 16, 2013
The past month has seen the most severe flu season I've witnessed in 15 years. Visits and illness severity are both up, creating predictably large increases in wait times. The system is stressed beyond capacity, and when this happens, quality of care falls and errors increase.
Some of this is inevitable; there will always be outbreaks of infections and randomness that increase demand beyond capacity temporarily. But it might come as a surprise to readers that there is no plan in place at any level for dealing with these events. If the wait time gets long enough, people just take themselves out of the queue.
The simplest cure is overcapacity. More doctors, nurses, ambulances, beds and test capacity all the time would mean these demand spikes cause less damage. But overcapacity is expensive and inefficient, and we're already spending unsustainably on health with worse to come.
A reasonable approach involves targeted injections of resources. This is a complex problem, best solved with a combination of methods.
It amazes me how little information our institutions provide for dealing with common conditions. To find out anything about the common cold, bronchitis, stomach flu or sprained ankles, you have to wade through a quagmire of terminology and misinformation online to get some useful advice.
Many people deal effectively with these problems using home remedies and common sense, but a large number of others are 'frequent fliers' to the emergency department, and seem unable to deal with the most trivial things by themselves.
They are unable to do the math that if everyone came in as much as they did, we would need emergency rooms five times their present size!
Part of the cause is the mistaken idea that doctors can do something that significantly alters the natural course of these diseases. Often this involves a belief that antibiotics are useful, when they have been shown in large studies to be useless for the relevant condition.
Patients will swear that they 'need' an antibiotic based on past experience which was facilitated by ignorant or lazy doctors who found a prescription pad an easier (or more profitable) choice than time spent educating. Once we have created such a 'monster' patient, they are very difficult to set straight.
To reduce these unnecessary visits, we need a reliable source of information on self-diagnosis and treatment of common conditions that generally do not require prescription treatment. Governments should partner with universities and medical organizations and write or approve already published information.
Furthermore, generally healthy 'frequent fliers' need to be identified and given specific attention to address their excessive and unneeded visits which strain the system. This problem is being recognized but I am skeptical of how administrators might implement it.
Physicians and nurses should steer these patients to published info, and treatment plans need to be discussed and consistently applied between different practitioners, such as the family and emergency doctor.
Telehealth, or as we call it, 1-800-GOTOEMERG, is a next-to-useless waste of money in present form. It either needs to be scrapped or improved to give it some guts and offer actual advice which sometimes avoids the need to seek out a physician in person.
Patients need to know the consequences of their visit can be more than just taking time in the wait line. An emergency room is a dangerous place to visit during flu season, especially if you have pre-existing vulnerabilities.
You can also spread your germs to others. I will give some medical advice here, as an example of what should be medically approved online advice.
Please do not come to the emergency room with 24 hour 'stomach flu' (which has nothing to do with influenza) unless you are a type 1 diabetic or dying of pain or a small child at risk of severe dehydration.
This is the most contagious bug we see, and there is not much we can do about it. It is often contracted from children (perfect virus transmitters), and hand washing and not touching your face is somewhat preventive.
Chances are good that what you think is food poisoning is actually one of these self-limited enterovirus infections. You will get vomiting and/or diarrhea, quite severely for the first few hours. You will feel like crap, and be very tired the next day but start keeping fluids and then food down, and by day three you're close to normal.
Antihistamines such as Gravol do nothing for the course of the disease but may make you feel less nausea and help you sleep. You can easily transmit the virus to other patients or staff despite careful precautions, and hospital wards are commonly shut down due to these outbreaks, which doesn't help reduce wait times!
One more thing: Always carry a list of the medications you are on. Not just a receipt from the pharmacy, but a precise list of drug doses, recent drug or dose changes, drug allergies and the reaction produced.
It might save your life, and it will certainly give you better care and save time. And you'll earn the nurses' and doctors' respect for having a clue, which is worth more than you know.
Increasing system flexibility means integrated changes at many levels. For example, family doctors closing their offices during the week between Christmas and New Year's during a flu outbreak is how not to do it.
Extra staff at all levels need to be available at short notice, and increased sick time must be expected. Front line workers need much more input on these decisions, as top-down managers cannot deal with the issues quickly or effectively enough, and assume no personal risk for their decisions.
Beds need to be created temporarily so emergency rooms are not plugged up with admitted patients which can slow throughput to a crawl.
Inter hospital transfers also need to be increased. Paradoxically, when small facilities need to transfer out sick patients to definitive care the most, the larger centres are least capable of receiving them.
One of my pet peeves is the line given by specialists "I don't have a bed so I can't see your patient", when that specialist is the best and sometimes only one for the job.
This creates more calls to CritiCall, more wasted time, and either speaking to the same specialist again(!) who is then forced to see the patient, or a transfer out of the region, or to a less appropriate hospital or specialist.
The situation is lose/lose for everyone involved, becoming more common all the time, and it needs to be dealt with.
We all know the concept of triage, typically performed by the first nurse you see in emergency. Patients are assigned to be seen in order of priority based on the time-sensitivity of their illness.
But triage also needs to be exercised at other levels where it typically is not. A large influx of sick patients waiting for a bed applies pressure to change the threshold for discharging currently admitted patients of lower severity.
But that's not entirely safe, so extra home care capacity is needed. But home care requires one-on-one staffing, which is very cost inefficient for high use patients.
In my opinion, flexible hospital step-down facilities need to be created, such as what nursing homes have for respite care. Physicians could then efficiently monitor recovery to promote better outcomes and reduce readmission.
A necessary consequence of specializing hospitals into 'centres of excellence' means it is more important to get the right patient to the right place. Here in Hamilton, not enough attention and resources have been given to that inconvenient reality. The results are seen in increased offload delays and 'code zero' (no ambulance available) events.
This is no easy decision for EMS personnel to make. Let's say a patient has symptoms of a stroke: do you take them to the larger stroke centre farther away, knowing the delays are typically large and put your ambulance out of commission, or the closer small hospital which can't provide definitive care, but maybe your patient is not sick enough to need it?
Sometimes, the patient knows where they need to go, like a dialysis patient going to St. Joe's or a cardiac or stroke patient to HGH. But when they call an ambulance, they're taken to a smaller nearby hospital, only to require a second transfer in a few hours.
One way to help minimize wasted time, money and EMS kilometers would be to implement a base physician triage system such as that used by the air ambulance. Quality of care would improve, and is likely to pay for itself many times over.
It used to be that you could just pull up to the nearest ER and transfer to a larger facility could be arranged if appropriate. But it's different now; that system is broken.
There is inadequate capacity in larger specialty centres to deal with regional demand. This creates delay, time wasted by doctors trying to arrange appropriate care. CritiCall, the organization that facilitates urgent transfers, is increasingly overused and less effective, taking longer and making more phone calls to solve a given problem.
When a patient is transferred by ambulance between sites, this usually involves two EMS personnel and a nurse, and with sicker patients, a doctor as well: four people unable to do any other multitasking as they would in the ER.
The nurse and doctor have to be replaced at the originating hospital, often after multiple phone calls and delays. This is grossly inefficient and expensive, and it impacts wait times and quality of care for other patients.
The system needs to admit this is the case, and educate and encourage patients to triage themselves to the right facility to the best of their ability. Let's discuss a few examples.
If you have had recent surgery and have symptoms possibly related to a surgical complication, you should get as close to the surgeon who did the operation as sensibly possible.
Ideally this means calling the surgeon directly during office hours. If not, then it means going to the facility where you had surgery. They'll have your records, the appropriate specialists on call, and even primary care staff are more familiar with your problem.
If you show up at the nearest ER and can't even recall the name of the procedure you just had, you might as well call a dentist or veterinarian, because they will have the same clue as to your problem.
Recent surgery changes everything about your presenting complaint, and the doctor's experience is useless unless they are intimately familiar with your surgery. It's just impossible to be both a competent generalist and specialist in everything.
If you have a good idea that you need a CAT scan, such as having a serious head injury, don't show up at a one-horse emerg without a scanner.
If your child is very ill, we have a dedicated pediatric hospital for that. If you bring them to a small ER, they're going to be making a phone call for a transfer, or perhaps, if the doctor is a bit cocky, provide inferior care outside of their comfort zone.
To McMaster's credit, they have always been very helpful in seeing sick little ones with a minimum of complaint. You might as well use this service, because you've paid for it.
Showing up at 4 am with a minor problem might sound sensible, because it probably won't be busy. But what you get is an irritated and sleep deprived staff that might be going 20 hours or more without rest. At that point, no human is fully functional. The staff needs all their tired brain cells to safely treat patients who really need to be there.
You will not get the same quality of care as you will when the fresh staff comes in for day shift. If x-rays or labs are needed but not emergently, you're staying for a few hours anyway.
In a small emergency room, serious psychiatric problems are as disruptive as a tear gas grenade. Cops are everywhere, the waiting room becomes a real life reality TV audience to the most bizarre and personal details, it's just mayhem.
Then I have to deal with psychiatry on the phone, which for whatever reason gives me the most grief of any specialty except perhaps neurosurgery.
Hamilton does not yet have a dedicated psychiatric emergency where they can deal with mixed psychiatric and medical problems, for example drug induced psychosis. If this is not part of the St. Joe's mountain campus refurb, then CEO heads should roll. Until then, the most appropriate place for seriously suicidal or psychotic patients is St. Joseph's Hospital.
If you live in the city but have waited for hours to deal with your huge, red, nasty oozing leg that makes experienced doctors go OMG!, don't sign out and drive into the country to a small ER. You explode wait times, and since the appropriate specialists after several phone calls still won't see you, your life is at risk.
This case is, of course entirely made up ... I wish.
But not everything follows this pattern of more severe problems going to the appropriate centre. If you have chest pain, you actually should go to the nearest emergency room, small or large.
There are two reasons for this: time is of the essence, and interventional cardiology is well funded and capable of taking in outside demand quickly when necessary.
Unfortunately, this level of service stands out for its rarity.
I am just one guy with incomplete knowledge and bias. I merely have the initiative to speak out when others just don't want to rock the boat.
But the boat is sinking. If you ask around, you will get similar stories that all is not well in health care and the system needs help. Ask the questions, and don't fall for bullshit answers. This matters.
This is the first in a series of articles on fixing health care.
By Pxtl (registered) - website | Posted January 16, 2013 at 11:07:16
RTH has countless articles explaining how "train and blame" is ineffective. Expecting patients to make any appropriate decisions regarding their own care as a standard matter of course is a bad path to be on. To me, the sensible place to start would be fixing the utterly-worthless telehealth and getting better infrastructure for transferring patient information and records quickly. If a patient could call telehealth and get useful, reliably-good advice about where to go (if anywhere at all)
All that stuff you said about picking the right place to go? That's what Telehealth should be doing. That's what it's for.
But instead, we get grilled with a boilerplate questionnaire of a million epidemiological questions to make sure we're not Patient Zero, and then directed to the nearest available ER. Telehealth is obviously run by lawyers instead of triage nurses or doctors.
By SpaceMonkey (registered) | Posted January 16, 2013 at 19:10:28 in reply to Comment 85229
The Dr's advice about educating patients is exactly what needs to be done. To say that patients can't be expected to make any appropriate decisions is ridiculous.
By SCRAP (anonymous) | Posted January 16, 2013 at 11:19:36
The doctor has brought forward some good info. However, I wonder sometimes about the action from those in the medical profession.
They seem not to be aware of the many changes to social programs that find those living in low income not being able to get access to things they may need from the health care system. This is especially true for those on Ontario Works, since the discretionary benefits have been cut. Or how about thhose who are suspended from the system, who cannot even get a prescription, with no money or benefit card.
How do you get access to things like home care, when you have no money or benefits to cover such things?
Maybe those in the healthcare profession need to organize better, to fight for more frontline workers and less adminstrators and CEO's, who are paid big time dollars. Are they not a big drain on healthcare dollars?
Some food for thought!
By Joanne (registered) | Posted January 16, 2013 at 13:11:24
I am a frontline health care provider, a registered nurse to be exact. I work in one of Hamilton's 4 specialized hospitals (consider ourselves very lucky!) Hamiltonians and smaller cities and towns surrounding this city have accessibility to specialized doctors and services. This can also be straining for our hospitals, in that we also absorb acute (very sick) patient populations coming from areas such as Niagara, St. Catherine's, Brantford, Burlington, etc, who's hospitals are only equipped to deal with "predictable care". Other than Toronto and London, Hamilton is the only place these patients can go.
Now I agree with the fact that there needs to be more accountability on the part of family doctors. Clinics and family physicians need to run on a more flexible schedule. They need to spend more than 5 minutes on their patients and actually do a full assessment prior to just sending them off with a prescription and/or a letter to by-pass people in ER (yes this happens, ridiculous)
Nurse practitioners need to be better utilized alongside family physicians. Doctors need to be more accepting of nurse practitioners, the fact is we don't have enough doctors being hired in ontario. Perhaps, because of the aging population, we need to bring back the idea of doctors seeing patients in their homes? Perhaps a team: Nurse, Doctor, or Nurse practitioner.
Perhaps they should have joined Urgent care, ER, and family practice clinics side by side, so people can easily be directed? (lol)
And the most important point, the public in general...i'm talking about each and every individual needs to be the most responsible for their OWN health and the health of their children. This includes lifestyle, education, the responsibility of understanding our health care system and where our tax dollars go...
Instead of complaining how front line workers get "paid well" and we're perhaps a "drain on healthcare dollars"...Who the hell do you think is doing the brunt of the work?
Doctors, residents, nurses etc...work on 24 hours schedule..that means either working 12 hour shift work, 4 days straight..or for doctors working 48 hours straight, and doing surgery! We're expected to work under working environments that promote burnout...we can't just "leave our work" at work...we can't just leave on time. I have been a nurse for 7 years, and have never left on time.
Involving ourselves through education, learning about our health system, voting, questioning our government and the people who are suppose to represent the public are all important in changing this dilemma.
I'm fortunate enough to assist in the great things that universal healthcare has been able to provide for the vulnerable, sick population. It's humbled me as a person. Our system is strained..and well need to do something about it!
By Stent (anonymous) | Posted January 16, 2013 at 19:46:50 in reply to Comment 85234
Thanks for bringing up nurse practitioners. Long overdue.
By SpaceMonkey (registered) | Posted January 16, 2013 at 19:16:35
This is a great article that brings up many great points. It looks like it will spark some much needed discussion on Ontario's failing health care system.
Our system is a mountain of problems. Serious changes need to happen soon because it will get increasingly worse in it's present state.
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