Sunday, May 10, 2015

A System that Fails to Care, Will Fail When it Matters Most

Hospitals, doctors, nurses - the entirety of the health system is under incredible strain. Back when I started working as a health economist in 2004/05, an "ideal" occupancy rate for a hospital was seen to be 85 percent. This was a level that was thought to be the sweet spot of providing quality care, a level that allowed for surges in demand to happen and would minimize the number of elective procedures that might need to be cancelled due to a lack of capacity. Even back in 2004/05 occupancy rates often ran above 85 percent - but rarely did occupancy rates exceed 100 percent. Fast forward a decade, and the hospital occupancy statistics in British Columbia are nothing short of disturbing. For many hospitals in British Columbia an occupancy rate less than 100 percent would be a dream. Many hospitals are running over-capacity - and significantly so. Numbers well above a 100 percent in British Columbia are no longer rare.

What does an occupancy over 100 percent mean for patients? It means stays in the Emergency Room that do not last hours, but rather last days and might last the entirety of the care encounter. It means elective surgeries being cancelled or deferred as there is simply no bed to admit a patient to. It means discharging patients without adequately considering what will happen after the discharge. When care capacity is stretched too thin in hospitals - it means quality care, the care that patients deserve and trust that they will receive does not happen. When care capacity is stretched too thin - it means those who work in the system, the doctors, the nurses, the porters, the technicians, the care aides (really everyone), are also put under incredible strain and the risks of error and burn out dramatically increase. Ultimately, when a system tries to do too much with too little - it loses the humanity it needs to delivery quality care and to perform well.

It is heartbreaking to read Mrs. Brenan's tale of care in the Manitoba health system. Mrs. Brenan spent the entirety (4 days) of her care encounter in the Emergency Department of the Grace Hospital, she collapsed on her front doorstep and died of a blood clot that moved to her lungs. Others have been discharged to cabs, only to freeze to death on their porches.

Is the hand-off of care of patients to taxi drivers appropriate - is a taxi service adequately prepared, trained or compensated to handle what needs to be done? Is it the act of a "caring" system or is it what a system stretched beyond capacity does to save a few dollars?

It is easy to reduce the transportation from hospital to home as just being transportation. However, patients are not packages to be couriered from one place to another - and the mere reality of being a patient in an overburdened system is that what is adequate for "an average person, a non-patient" may be entirely inadequate for a patient who has been discharged. The reality is that many patients who are discharged from hospital, are not "non-patients" but rather are still patients who are merely going from one place of care (the hospital) to another place of care (home). As such, the standard of care for transportation from one place of care to another place of care is different from what should be expected from a taxi - the taxi standard of care is a failure, as demonstrated by the experience of Mrs. Brenen and others. I would argue that if "the system" is going to discharge people before they are "non-patients" and treat patient residences as extensions of the healthcare system, that transportation from one place of care to another place of care is also part of the system.

Quality care demands that the reality of patients is considered and that their needs are met. Discharge to taxi is a failure to provide quality care - a failure that needs to be remedied, and a failure that likely results from a system that is simply too lean to care.

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