No room at the hospital

ITIJ 209, June 2018
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The pervading issue of hospital bed shortages in Canada continues to affect the ability of assistance providers to bring patients back to the country for medical care. Milan Korcok explores how Canada’s overcrowded hospitals are blunting patient repatriations

Flight time from the Dominican Republic to Toronto is only four hours (1,847 miles). Yet for Bryan Sockett, a Canadian snowbird stricken with pneumonia while vacationing in the Caribbean, going home was a trip too far. In January, after two weeks of deteriorating health in a Dominican hospital (while his family and travel insurer fought to secure him a hospital bed in the Toronto area), Sockett died in a Florida hospital where he had finally been rushed to try to stave off the inevitable.
Expressing the frustration of the family’s efforts, Sockett’s daughter related via Facebook: “I’m extremely saddened and outraged at the state of our healthcare system today.” Well, she is not alone.
Shortly after the Socketts’ sad encounter, another Canadian snowbird, being treated in a Mexican hospital for a brain hemorrhage, was forced to wait five days for transfer to a hospital in Ontario’s Niagara peninsula while his condition worsened. He died shortly after his return. Of that encounter, provincial MPP Peggy Sattler admitted on her Facebook
 
finding and securing available acute care or rehab beds for injured or seriously ill travellers … has often been difficult and sometimes impossible
 
page that she had failed in her efforts to secure a bed for her constituent: “He had a right to expect that our healthcare system would be there when he needed it most.”
These horror stories don’t end there, as another Ontario man being treated for a shattered pelvis, broken arm and back in Costa Rica was forced to wait six painful days for a hospital bed to become free in the Hamilton area before he could be transferred home by air ambulance. Opposition party leader in the provincial legislature Andrea Horwath issued a news release condemning the governing Liberals for perpetuating a hospital bed shortage throughout the province.
There are more such stories that have now become a routine litany, and not only in Ontario, where according to the Ontario Hospital Association’s own report at the end of last year: “Hospital occupancy exceeded 100 per cent capacity at about half of the province’s hospitals, and in some cases, occupancy reached as high as 140 per cent. To put this into perspective, the international standard for safe hospital capacity is around 85 per cent. Wait times for patients admitted through the emergency department were the longest during the month of September over the last seven years with 10 per cent of patients waiting approximately 32 hours.”
In the province of Quebec, despite a recent $100-million government investment to ease emergency room crowding, ERs are still as crammed as ever – the Montreal General Hospital running at 129 per cent capacity at times, with patients being treated on stretchers in hallways, lounges, TV rooms, or any space large enough to accommodate them. In other provinces, the stories are similar.
To be clear, shortages of acute care or rehabilitation beds can’t be isolated from other segments of institutional healthcare. If patients in an overloaded emergency department can’t transition smoothly to acute care beds, which in turn are overcrowded with patients who should be in long-term or rehab beds, then hospital gridlock occurs. 
For at least two decades, provincial governments have been pledging more and more millions of dollars to alleviate seasonal hospital ER and acute care bed overcrowding, especially during Canada’s long flu seasons. But the overcrowding has continued beyond those seasons and has become the norm. 
Yet, according to the Fraser Institute, a think tank that advocates a more active private sector role in healthcare, data from the Canadian Institute on Health Information and the OECD show that despite Canada having one of the most expensive universal healthcare systems in the OECD, it rates only 25th out of 29 in the number of practising physicians (proportionate to population), and 27th out of 27 in number of available acute care beds in 2015. It also ranked last of all its OECD cohorts in measurements of wait times for specialist care and access to healthcare (Commonwealth Fund-CIHI).
Consequently, as many Canadian travel insurers and assistance professionals have been forced to explain to the media and anxious families over the past two decades: finding and securing available acute care or rehab beds for injured or seriously ill travellers seeking timely repatriation has often been difficult and sometimes impossible.  
 
Any bed will do?
Will McAleer, President of World Travel Protection (WTP) and President of the Travel Health Association of Canada (THIA), underscores the difficulty of negotiating the process: “Getting a Canadian home at time of emergency can be a difficult task to accomplish and it varies from province to province. While we generally have more success with acute care beds, there can be significant delays when looking for rehab beds in provinces where a singular point of contact and co-ordination does not exist. When working in these provinces (Ontario and Quebec, for example) assistance teams have to find availability in the local catchment area … near their home, and then find a physician willing to accept the
 
Hospital occupancy exceeded 100 per cent capacity at about half of the province’s hospitals
 
patient and then confirm back with the hospital that they do in fact have an available bed.” 
Given the logistics related to bringing a patient home by air ambulance, said McAleer, beds can disappear, or patients miss their ‘fit to travel’ window, leaving them in a foreign hospital longer than either the insurer or patients – and family – would prefer.
McAleer notes that THIA has been brought into discussions with Ontario’s health ministry to offer industry input but says it is unlikely they will be open to keeping such beds open ‘solely for repatriated patients’.
Gratia Derde, Director of Case Management at Global Excel, explains that ‘one of the most glaring issues’ with repatriation is that ‘if a patient needs to return home for rehabilitation in the current system, the patient must be admitted into an acute bed (first) when they could go into rehab instead’. She contends that Canadians should be guaranteed a right of return ‘without the stress and hurdle of a bed search and be admitted to an ER where they can be assessed and admitted into the right bed’.
Dr Ferial Ladak, Medical Director, Essential Care at Global Excel, adds that the requirement that patients must first be assessed in an acute care bed even if they have already been assessed at the treating facility abroad only prolongs their hospital stay and uses up acute care beds in Canada unnecessarily. She adds: “Patients needing emergency procedures should be able to come to the emergency room by air ambulance and be assessed like any other Canadian. This especially should be available when patients are coming from countries that do not have the standard of care we have in Canada.”
 
Bed database access
Canadian travellers have long complained that once they leave the country for vacations or other trips, the tax-financed, provincially administered health insurance coverage they have paid for all their lives deserts them – paying only minimal amounts (perhaps up to 10 per cent) of any emergency medical bills they generate abroad. Though the great majority of travellers are accustomed to buying insurance for trips they take out of the country, they feel they should not be discriminated against for accessing those services if they need them while travelling. After all, they have paid for them, first of all in their taxes, and again for their private travel insurance benefits, including air ambulance or repatriation.
Miranda Hanna, Manager of Case Management for Active Care Management, believes that ‘ultimately, Canadian health officials, hospitals, and providers must take responsibility for out-of-country patient access to healthcare’. She notes that though the Ontario Ministry of Health has stated that there are many beds available throughout the province, ‘assistance companies do not have ready access to beds outside the patient’s catchment area’. “Ideally, an assistance provider should be able to notify the catchment area hospital that a patient requires a particular bed,” she said, “without waiting for permission to deliver the patient. Repatriations will always take at least six to eight hours to co-ordinate and execute (typically 24 hours plus). This should give the catchment hospital sufficient time to either locate a bed internally or secure a bed at another hospital.”
Hanna also notes that Local Health Integration Networks and provincial health ministries should develop clear channels for assistance teams to access when a bed is unavailable and there is a narrow window for transfer. There should also be an upper limit for acceptable bed turnaround time for cases that are important but not emergent.
WTP’s McAleer contends that there is a need for greater co-ordination by the ministries of health in provinces where a dedicated repatriation service doesn’t exist. He notes that British Columbia’s (BCPTN—Patient Transfer Network) and Alberta’s (RAAPID - Referral, Access, Advice, Placement, Information & Destination) have shown positive results in assisting repatriations, ‘but other provinces need to create systems to support repatriations in a way that treats patients seeking admission from outside the country the same as if they arrived in an ER in a regular ambulance without wings’.
 
A problem deeper than repatriation?
For more than two decades, provincial governments have been assigning more and more public funding to overburdened emergency departments, acute care beds or long-term care or rehabilitation facilities. But a study by the Commonwealth Fund, in association with the Canadian Institute for Health Information, which compared Canada’s performance in accessing key health services with Australia, France, Germany, the Netherlands, New Zealand, Norway, Sweden, the UK and the US, found that Canada’s standing was rated the ‘worst’ in patients’ ability
to get an appointment on the same or the next day, to wait for treatment in an emergency department, to wait to see a specialist and to wait for elective surgery; 
and second ‘worst’ in ability to get after-hours care (without visiting an emergency room).
In another survey by the Commonwealth Fund of 11 economically developed countries, Canada showed the highest proportion of patients waiting four or more hours for attention in the emergency department – 29.5 per cent. That compared to just 1.5 per cent who waited four hours or more in France, 7.9 per cent in the UK, 3.3 per cent in Germany, and 11.2 per cent in the US.
The survey also showed that 90 per cent of all ED visits leading to inpatient admission were completed within 32.6 hours, meaning 10 per cent waited longer than that, a 3.3-hour increase in waiting time from 2015-2016.  
 
Room for private funding?
When provincially funded health insurance plans clapped strict lids on what they would pay for travellers’ emergency medical expenses generated abroad in the early 90s, private health insurers quickly and abundantly filled the void. They freed up provincial treasuries to concentrate on domestic priorities, while at the same time allowing Canadians to fulfill their unquenchable thirst for travel. It was a win-win.
In underscoring Canada’s relatively poor performance on healthcare access measurements in these various surveys, the Fraser Institute emphasises that of the nine countries in the survey already cited, Canada is the only country that disallows private financing for medically necessary services, and relies almost exclusively on prospective global budgets to fund its hospitals ‘in contrast to other countries that are increasingly moving towards payment based on some measure of activity’.
Global Excel’s Dr Ladak suggests that instead of focusing on bed shortages, provincial ministries should: work on improving availability of skilled nursing facilities and rehab beds and use private nursing homes to help move patients
 
Local Health Integration Networks and provincial health ministries should develop clear channels for assistance teams to access when a bed is unavailable
 
to the care they require fast; facilitate access to private clinics and freestanding facilities to do surgeries that are now being done in hospital – procedures such as gall bladders and arthroscopies; and shift more palliative care that is now done in hospitals to private nursing home settings.
ACM’s Hanna emphasises also that ‘regardless how patients are entering the system (via ER, elective admission, or inter-hospital transfer), funding must be tied to overall performance of bed allocation teams, catchment size and patient volume and seasonality’. In addition, she suggests the need for development of a system to track turn-around time for accepting patients via out-of-country transfers and incorporating these data with all other patient-flow metrics in accurately allocating funding.
It’s clear that smoothing out the flow and process of bringing Canada’s sick and injured back home to be cared for by the health system they have already paid for makes simple sense. Repatriating patients is a function with many moving parts and often not a lot of time to do it. But in an environment already critically stressed and overburdened with other priorities, it’s going to take more than a few scary headlines to fix it. ■

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