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Hospital discharge: Reaching a breaking point

There is a systemic issue that gets little attention in the media but is rapidly growing into one of the most significant problems in our Province: hospital discharge. At any given time in an Ontario hospital there are a number of patients who no longer require acute care services and are waiting for discharge to another setting, such as home or long term care. These patients are designated “ALC” for “alternate level of care”. In May 2016, 15 per cent of all Ontario acute care beds were occupied by ALC patients. On June 30, 2016, more than one-third (36 per cent) were waiting for placement in long-term care. An additional 18 per cent were waiting for discharge home, either with or without home care or community services. The statistics vary widely by LHIN. In the North West LHIN, 24 per cent of inpatient beds were occupied by ALC patients in May 2016. On June 30, 64 per cent of ALC patients in the South East LHIN were waiting for long-term care placement.

The implications of this data are readily apparent. If 15 per cent of Ontario hospital beds are occupied by people who don’t need them, that’s equivalent to removing 15 per cent of acute care beds from the system. That means 15 per cent fewer beds available for people who do need hospital care. Not only does that contribute to backlogs in emergency departments, but it also results in lower quality care for patients who end up stuck on emergency department stretchers for 36 hours or more. Then we have to factor in the cost to the system (which is paid by all of us as taxpayers): the cost of a hospital bed runs an average of $800/day, while the cost of a long-term care bed or home care is a fraction of that. Do the math: as of June 30, 2016, there were a total of 2765 ALC patients occupying acute care beds in Ontario at an average cost to the system of $800/day ($ 2.2 million dollars per day).

Why do ALC patients get stuck in acute care beds? There are many contributing factors: the rapidly aging population, the limited and stagnant supply of long-term care beds, the lack of affordable alternatives (such as assisted living facilities and retirement homes), and the increasingly scarce resources available in the acute care system. Another factor is the legislative framework, which requires consent to place someone in long-term care. Of course that requirement exists for good reason: to protect some of our most vulnerable citizens from being forced into facilities against their wishes or isolated from loved ones by being placed in facilities where their loved ones are unable to visit.

In some cases patients can be discharged into a home setting but family members don’t feel safe with the patient at home and/or can’t afford to hire the necessary private home care services to support the patient at home. In other cases the substitute decision makers (typically family members who have legal authority to provide consent on behalf of a mentally incapable patient) have specific preferences for long-term care homes, which can result in the patient being on very lengthy waitlists. Not infrequently this leads to a stalemate, with ALC patients occupying beds for weeks, months, and in extreme cases, even years.

The systemic factors listed above won’t change any time soon so we (hospital staff and families) need to figure out how to work collaboratively in the best interests of patients. As hospitals there are things we could do better to improve the process. We could do a better job of identifying and working to address the concerns of families and other potential barriers to discharge early in a patient’s hospitalization. We could also do a better job of providing meaningful information to family members to explain the complex system. We need to conduct more research on the impact of hospitalization on the frail elderly and do a better job of sharing the evidence that already exists – evidence showing that for the frail elderly, staying in hospital longer than absolutely necessary is actually the worst thing for their health and well-being.

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