Continuity of Care

Primary Care Physicians

The key link in the healthcare system is the primary care (family) physician. Primary medical care consists of first-contact assessment of a patient and the provision of continuing care for a wide range of health concerns. The scope of primary care includes diagnosis, treatment, management of health problems, prevention and health promotion, and ongoing support.

The doctor-patient relationship is of utmost importance in the delivery of primary care and is established by continuity of care which is delivered over a period of time at a variety of locations. The physician gathers and records accurate information, establishes rapport and trust with the patient, and assumes a professional responsibility for ensuring continuing, comprehensive care.

Under the present system the doctor-patient relationship is being eroded by programs which are site-oriented, program-oriented, disease-oriented, or problem-oriented. There is disruption of the primary care physicians' opportunity to provide coordinated care for their patients, which they accomplish through working closely with other physicians and health care professionals. For example, under the present system, the primary care physician often does not receive required feedback from specialists.

Continuity of care is an important factor in determining physician quality. Lack of hospital practice can lead to a significant deterioration in the skill base of the physician. A report by the College of Family Physicians of Canada (1993) states that "Family physicians' clinical participation in hospital care assists in the maintenance of specific clinical skills, and provides peer review and educational opportunities that do not exist in exclusively office-based practice."

Specialists

Specialists are by nature problem-oriented. At the same time, it is desirable for patients to return to the same specialist so that the specialist can become familiar with the patient's medical history and problems. With the demise of the community hospitals, specialists must move about from site to site. Inpatient care is more and more being given by whoever is available rather than by the physician who is most familiar with the patient.

Surgeons

Program development which encourages itinerant care by surgeons makes it extremely difficult to provide the quality of pre-operative and post-operative care which is professionally required. It leads, for example, to one physician operating and a different physician providing post-operative care, or to a surgeon discharging a patient over the phone because he is working at another site and is unable to visit the patient's hospital until late in the day. These practices contravene an important guiding principle of the College of Physicians and Surgeons, which is that the best post-operative care is provided by the surgeon who performed the operation.

Generic Physician Provider

Generic care is considered to exist when a patient and referring doctor must accept the physician on rotation rather than the physician of choice. While this is not a new phenomenon, it is becoming more widespread. The concept of generic provider fragments care and disrupts trusted patient-physician relationships and referral patterns which have developed over time. It increases the possibility of duplication of services, for example, the repetition of tests already done. It increases risk to the patient, for example, the patient may neglect to inform the physician on rotation what medicines he or she has been taking.

Multiple Sites

Physicians and surgeons who must provide care at more than one site are spending unacceptable amounts of time in travel between sites. The extra travel reduces time available for office bookings and as a result patients wait longer periods following referral from primary care before they receive care from these specialists. Time for teaching is also reduced. When more than one site is involved it is harder for physicians to return to a site, for example, to see patients post-operatively.

One surgeon's travel log documents an increase in travel time of about 8 1/2 hours per week. Another surgeon estimates that travel between sites increases the average surgeon's day by at least 90 to 120 minutes and most of this time is non-productive. Most surgeons feel that they waste 1 to 1 1/2 hours per day when servicing two sites.

Physicians are increasingly practising at more than one hospital. For example, the percentage of surgeons currently working at multiple sites in Region 10 are general surgery 73%, orthopedics 76%, and urology 100%. Overall, there has been a 250% increase in this phenomenon from 1993 to 1995.

Studies show that practicing in multiple hospitals has a negative effect on patient care. Dispersion across several hospitals is associated with longer length of stay and, in obstetrics, increases the likelihood of Caesarean sections (Burns et al, 1991; 1995). Many physicians rely more on diagnostic tests when working in multiple hospitals because they believe they have inadequate time to perform a careful history and physical examination. The inpatient resource use of physicians rises with the number of hospitals in which they work (Miller et al, 1996).

Fragmentation, Duplication, and Gaps

Fragmentation, duplication, and gaps in care can follow program development which fails to involve the primary care physician and community care providers, is disease or problem-based rather than patient-based, is site-specific, or lacks sufficient communication among care providers.

The criteria for admission to a variety of programs leave gaps in care where one individual fails to qualify for any program. There is no overall plan to ensure these programs are coordinated in a seamless fashion. Patients who have "nowhere else to go" often end up in general internal medicine; discharge is difficult when they have mental illness or do not meet criteria for sub-acute care (too long a stay), NARG (too young), homecare (no caregiver), or a continuing care facility (no space).

E.g., a middle-aged multiple sclerosis (MS) patient admitted with febrile illness and worsening condition needed prolonged rehabilitation when better, was not suitable for Northern Alberta Regional Geriatric Program (NARG) or subacute care, ended up in University of Alberta Hospital (UAH) in an acute care bed.

E.g., a man from Spruce Grove injured in a fall was checked at UAH neurosurgery and found okay but developed anginal symptoms and was admitted to general medicine, was recommended for intermediate care but refused at Stony Plain and Edmonton (out of region), spent days in a tertiary care bed then was finally taken by subacute care.

Access to Care and Resources

Collection Sites

Collection sites for laboratory samples were rapidly reduced in our communities from about 150 to 24, resulting in major disruptions in service. Patients must now travel from their physician's office to a different location. These patients are often frail, elderly, ill, or infectious. Extra travel is difficult and may be dangerous for them. They must often wait where there is no medical assistance should they experience problems while waiting to receive attention in the lab.

Waitlists

Specialist Referrals

There are long waits for specialist referrals. E.g., patients are waiting 2-3 months for neurology consults. E.g., patients must wait several months to see cardiologists. E.g., one woman waited 3 months to see an obstetrician/gynecologist. E.g., wait is 1 1/2 to 2 months for pulmonary specialists, except in urgent cases. E.g., rheumatologists are so backed up they are asking residents to see patients.

Pediatric Rehabilitation

There is a long waiting list for assessment of children with school-aged neurodevelopmental disorders such as mental retardation, autism, and severe language problems. 500 children are on the wait list, which has now been closed. The wait list for preschool assessment is an additional 300.

Medical expertise for pediatric rehabilitation is in short supply. Children with autism, behavioural problems, and seizure disorders are poorly served. There is an absolute shortage of a children's psychiatry program in Northern Alberta.

Audiology

There are long delays in audiology support services. Glenrose Rehabilitation Hospital (GRH) has 240 patients booked for Auditory Brainstem Response, which records brain reactions to sound, and Electronystagmogram, which diagnoses nerve damage that causes dizziness. Bookings are now being made for January 1997. There are 43 outstanding referrals. UAH Audiology Department has 355 outstanding new patients and 42 patients awaiting reviews. Waiting lists are growing.

Orthopedic Surgeons

The median waiting time for orthopedic surgeons is 8.5 weeks. 658 patients were waiting for joint replacement surgery in September. 40% of patients are waiting over three months. Lack of access can mean lost work and income, increased dependence on others, and a lower quality of life due to

disability. E.g., a forty-seven year old man who worked as a landsman waited six months for a hip replacement, with impaired ability to walk and work.

Other Admissions

Waiting lists are unacceptably long for various other admissions. E.g., patients with epilepsy wait 3 months for evaluation. E.g., people wait 6-8 months for the infertility clinic.

Programs

Obstetrics and Gynecology

There are inadequate obstetric/gynecology services. Facilities are insufficient for the number of patients and the care required. There are difficulties finding beds to accommodate patients. There has been a reduction in quality of care as well as a large increase in the number of babies delivered. Grey Nuns is especially overloaded with an increase in labour and delivery admissions averaging 43.5% for the first six months of 1996 compared with the first six months of 1995

E.g., pregnant women are sitting in chairs in hospital hallways. E.g., there are frequent delays when trying to book a pregnant patient for induction of labour, even with pressing obstetrical indications, because the ward is so busy with patients in spontaneous labour. E.g., obstetrics/gynecology services are not available at UAH so patients with potentially serious thrombotic and hemorrhagic problems must be managed elsewhere.

34% of women who experience a vaginal birth are going home in 24 hours or less; 70% are going home in 36 hours or less. Many patients with major gynecology surgery are being discharged after 3 days. 42% of women surveyed were dissatisfied with their length of stay. A New Zealand study by Mitchell et al (1993) of 4286 parents found that most mothers choose to stay in hospital for 4 to 7 days following childbirth. In September 1996 the president of the US passed a law making a two-day maternity stay mandatory for normal vaginal births.

There is an increased number of patients requiring special care. Royal Alexandra Hospital (RAH), the tertiary care centre, had an increase of 83.9% in high risk mothers and a 38.5% increase in low birth weight babies. E.g., Caesarean section rates in the Region have increased. E.g., there are rapidly increasing rate of hypoxic ischemic encephalopathy, from 3.6% to 8.9% over two years; meconium aspiration syndrome, from 4.4% to 8.2% over two years; and pneumothorax/mediastinum, from 3.0% to 10.9% over two years. E.g., there is a large increase in the number of newborns being transferred to the neonatal intensive care unit (NICU), from 270 in 93/94 to 408 in 95/96, a 51% increase.

Work load in labour and delivery wards has increased in the four sites and care is being provided by fewer, less experienced, more stressed nurses. Staff are overworked and demoralized. There are inadequate staff for proper labour supervision, diagnosing and managing risk problems, and responding to problems such as poor fetal heart rate tracings. There is less access to gynecologic consultation and pediatric coverage. Post partum nursing care on the ward is lacking. Patients state that they could not manage without a friend or relative at the bedside.

E.g., fetal monitor strips are being misinterpreted -- abnormal strips are misread as normal, abnormal results are not reported to the physician. E.g., Caesarean sections in the operating rooms are tying up the majority of available nurses. E.g., patients are labouring with no nurses visible in the unit. E.g., nurses are looking after two or three patients in active labour in "non-busy" times. E.g., delayed intraoperative gynecological consults are leading to longer open wounds and increased risk of infection. as well as delays in attending to unexpected problems.

Children's Health

A major reduction in beds has taken place at UAH. 108 beds are available and 120 are required. Beds are 80-85% occupied leaving no flexibility for peaks and valleys of need. There has been a remarkable rise in sepsis in patients with lines, probably due to overcrowding. Pediatric beds at the Misericordia are being reduced from 12 to 6.

At emergency there is poorer care, overcrowding, long waits, and turning away of admissions. E.g., an infant with bowel obstruction waited nine hours. E.g., 29 day old baby with possible sepsis could not be admitted at RAH for eight hours. Difficulties occur obtaining beds for sick patients at the UAH Walter McKenzie Centre (WMC); time is spent triaging beds. The closure of neonatal nurseries at WMC and transfer of babies to RAH NICU, which is overcrowded, has had a negative effect on children. Summer bed closures create an access problem. Continuous transfer and discharge of patients takes place, with pressure felt to discharge early.

Other problems at emergency include lack of medications, e.g., humulin (insulin) was not available for a patient with diabetic keto-acidosis (DKA), and continuing inappropriate placement of young children with acute illness beside adult patients.

Children have prolonged waits for surgery and long waits for subspecialities. E.g., ear-nose-throat (ENT) specialists are lacking. Under present conditions all elective surgery for the next six months will have to be cancelled.

Shifts in experienced nurse staffing have resulted from bumping. Fewer, less experienced Registered Nurses (RN's) are caring for sicker children. 3/4 of the parents surveyed said they felt they had to assist in the care of a child. There has been a loss of established, experienced part-time and casual pediatric nurses. Nursing staff are overtaxed and suffering from exhaustion and burnout. Support staff have been cut.

The rapid normal newborn discharge from hospital for most women is leading to increased hours of work for pediatricians, for example, telephoning and searching for test results. Pediatricians spend more time travelling between hospitals and obtaining support services for patients. Pediatricians are working on average 50-70 hours per week but are spending decreased time with patients.

Problems occur with laboratory results, such as long waits for results, duplication of reports, cancellation of tests, lost samples, errors in reporting, and inability to interface with the client response centre.

The early discharge of mothers has been correlated with incomplete rehabilitation for parents, incomplete ability to link up with community resources, and increased workload for general practitioners.

Northern Alberta Regional Geriatric Program (NARG)

There are tremendous increases in resource utilization for geriatrics across all hospital sites. Average length of stay (ALOS) has increased from 28.9 days in February 1996 to 38.2 days in May. Consults have greatly increased: at UAH from 65 in 1992 to 190 in 1996; at RAH from 164 in the first half of 1995 to 285 in the first half of 1996; at Grey Nuns from 15 in February 1996 to 56 in May 1996. Average days awaiting placement has increased from 9.4 days in October 1995 to 32.8 days in May 1996, an increase of over 200%. Admission have increased, for example, at the Misericordia from 173 in 1992/93 to 254 in 1995/96, an increase of over 40%.

One main problem is a pattern of slowdowns in the movement of elderly patients through the system. There was a striking delay in June in the transfer of patients into the NARG/Glenrose geriatric program. This created severe delays in the discharge of elderly individuals from the referral hospital system, which led to diminished access for emergency room patients to acute medical wards and delayed entry into hospital of community-based patients. Hasty discharge from acute care institutions meant frail patients who were discharged home soon returned to emergency. The flow problem in June was alleviated when long term care centres opened 40 temporary long term care beds (which should remain open).

Frail elderlies are struggling in the community. They are a hidden problem, often seen only by family practitioners. A large number of disabled, demented seniors in the community are waiting forever for the longterm care they require. They are not ill so there is a lengthy delay before they gain access to long term care institutions. Many are receiving care from exhausted, stressed caregivers. The absence of sufficient continuing care beds inevitably leads to the transfer to NARG of older patients who have no realistic hope of returning to the community.

Seniors with serious physical ailments visit emergency and receive rapid-fire treatment but do not gain access to hospital. Examples are patients with congestive heart failure, coronary obstructive pulmonary disease, gastrointestinal disease, or musculoskeletal difficulties.

There is a shortage of geriatric physicians, with only three internal geriatricians in northern Alberta. Providers have little time left for teaching.

Cardiology

There is a shortage of staff and resources. More nurses are needed, more cardiologists are needed, and there are not enough beds. Equipment is insufficient or outdated. E.g., the UAH angiography equipment needs replacing. E.g., funding has been discontinued for cardiac defibrillators. E.g., demand for pacemakers is rising. An information system network is required for increased efficiency of care. Funds for prevention are needed, which will improve patient quality of life and decrease costs to the system in the long run.

Cardiac patients cannot be assessed in a timely fashion from the community. E.g., a 56 year old man died of cardiac arrest waiting to be assessed by a cardiologist, despite making three trips to emergency. Access to care is unacceptable. 262 patients were waiting for cardiovascular surgery in August. Urgent inpatients are waiting 10-14 days and urgent outpatients up to 2 months. Planned outpatients are waiting up to 10 months. At the UAH, 13 patients have been waiting more than a year, 66 have been waiting more than 6 months, and 75 have been waiting more than 3 months. Outpatients wait 12 weeks for echocardiography, 4-6 weeks for exercise testing, and 8 weeks for nuclear cardiology.

An unpublished UAH study by Hamilton et al (1996) of over 100 Edmonton patients who had waited more than six weeks for bypass surgery concluded that nine of ten patients sharply reduced physical activity, more than half suffered significantly worse chest pains, many became housebound due to pain, and many stopped working. A three-year study by Kieser at al (1995) of 2325 southern Alberta patients waiting for open heart surgery found that events such as death, mental illness, and readmission were frequent and unpredictable, especially in outpatients. A study by Underwood et al (1993) concluded that there are associations between the time patients wait for coronary artery surgery (CABG) and levels of anxiety, depression, and social functioning.

Dialysis/Nephrology

The 5B1 renal dialysis unit at UAH is overloaded. For more than six months it has been asked to dialyze about 10 patients more per day than it can handle. This has meant patients already in hospital are being dialyzed in their rooms, requiring extra technician and nursing time. A two-bed active treatment room has also been used for dialysis, removing two beds from their real function.

There is a reduction in patient quality of life. There is no regular dialysis schedule because of disruptions due to the need for emergency dialysis. Some patients are sent unsuccessfully to several different sites before they are dialyzed. There is inadequate assisted self-care. Continuity of medical and nursing care is being lost. No action has been taken on repeated proposals for expansion of dialysis services.

Gastroenterology

The volume of work has increased with no increase in staffing. Urgent and emergent consults have increased by 260%. Inpatient occupancy has increased by 145%. Endoscopic volume has increased by 42%. Emergency after-hours endoscopy has increased by 1000%. Liver transplantation has increased by 25%. An excess of 30 to 40 consultations and 6 to 10 inpatients are presenting to the UAH site. Present clinical services are above and beyond the capacity of existing physician (3.0 FTE) and support resources.

Academic responsibilities and mission are no longer sustainable and teaching and research are being cancelled. Members of the division are not able to fulfil academic job descriptions. The Royal College Gastroenterology Fellowship Program is in jeopardy of being cancelled.

One of two Gastroenterology Fellows has resigned. There are several pending notices of physician resignation. Physicians and nurses are burnt out. Morale is low and stress is high. There are inadequate nursing staff to cover nights and weekends.

Shortages of equipment exist. UAH has one each of video colonoscope, pediatric colonoscope, and biopsy accessible fiberoptic scope, and no biopsy channel fiberoptic scope. RAH has one fiberoptic gastroscope, one videoscope, one videoscope on loan, and three fiberoptic scopes with frequent technical breakdowns.

Hematology

Deterioration has taken place in the quality of patient nursing care due to a shortage of qualified staff. E.g., lack of notification of significant changes in patient condition. E.g., non-reporting of adverse changes in vital signs. E.g., increased bacteremia rates due to poor care of broviac catheters.

So much bumping has occurred in nursing staff that expertise built up over several years in dealing with specialized patient problems has been lost. Nurses are highly stressed and very concerned about job loss. There is significant deterioration in housekeeping and dietary services.

There are problems relating to specialized testing which impact substantially on hematologic practice. Slow and variable reporting and lack of availability of appropriate tests is having a negative effect on patient care.

The quality of work life of physicians has diminished due to deterioration in patient care. E.g., one physician is working 80-90 hours a week to "ward off clinical disaster", has little time for teaching and research, is having problems with lab reports coming back, blinding of her study was jeopardized, her patients are being discharged inappropriately, and she has difficulty getting necessary drug approvals.

Pulmonary Medicine

There are inadequate beds with occupancy beyond the allotted 18 at UAH. Delays in getting written pathology reports and getting radiology support have lengthened the investigation of pneumonia, pulmonary fibrosis, and other pulmonary conditions. The number of patients in non-invasive ventilation has increased; the daily average is 2 patients on BiPAP. There are very few beds available for general pulmonary patients.

The bronchoscopy suite is too small. Equipment is outdated. The total number of bronchoscopies has increased from 484 in 1995 to 683 in 1996 or 41%. The number of bronchoscopies outside ICU has increased from 319 to 411 or a 29% increase. Pulmonary Function Laboratory activities have gone up from 4549 for a three month period beginning in July 11995 to 5975 for a three month period beginning in April 1996, a 31% increase. Resources available to both these areas have gone down, both at UAH and RAH.

There is a long waiting list for Sleep Diagnosis services. The wait for complete polysomnography is 11 months, up from 7-9 months before restructuring. 500 people are wait-listed and will face an 11 month wait despite the increased risk they carry for cardio-vascular disease, cerebro-vascular accidents, and motor vehicle accidents.

General Internal Medicine

There is a high level of acuity at the UAH site. Only 20% of hospital days were not required for acute care, meaning those patients might possibly have received more appropriate care in other venues, for example, a rehabilitation facility. In comparison, data from Manitoba and Saskatchewan suggests that upward of 40 to 50% of their hospital days might have been "avoidable".

Resources for care are inadequate. Front line staff have to work very hard to maintain quality care. Recording of daily weights, and intakes and outputs in patients such as those with congestive heart failure or renal failure is not occurring as ordered. Temperatures are not being recorded. There are more medication errors. Delays of up to six hours occur from the transcription of orders to the implementation of orders, including orders for medications. There are delays in receiving test results.

Rooms are at times unacceptably dirty which means increased risk for infection. E.g., a patient on orthopedics who had C. difficile and diarrhea could not be placed in a private room for two days due to lack of access. Quality of food is poor; diabetic patients frequently get their meals too late.

There is tension with Emergency when patients cannot be placed immediately. The ward is now an inadequate place to assess and stabilize an acutely ill patient. Patients do not smoothly enter and exit the system; there are problems with discharge and patients relentlessly present for admission. General Medicine has become a "sink" for patients that have nowhere else to go.

Psychiatry

There is decreasing access to the psychiatric day hospital at UAH -- 141 patients per annum were served in 1991, 115 per annum were served in 1995. Average daily census of patients treated dropped from 38.2 in 1991 to 31.8 in 1995. Staff has been reduced from 9.5 positions in 1992 to 6.4 in 1995.

There is decreased access to psychiatric services at the Grey Nuns. The hospital opened with a 70 bed psychiatric wing complete with ICU, the largest in the city. At present 40 beds remain open with only 28 open in the summer. Nursing staff is barebones and support services have been cut. There are long waiting lists and people are being turned away daily.

There is reduced access to the psychiatric walk-in clinic at UAH -- assessments have been reduced from 3896 per annum in 1992 to 3234 in 1995, a decrease of 17%. Staff have been reduced from 15.28 in 1992 to 9 in 1995.

At UAH, staff are treating a sicker population with fewer beds. The waiting time for acutely ill patients has increased. To admit new patients to UAH requires discharging others. Suicidal patients frequently cannot be admitted when necessary.

Psychiatric patients are sent to the end of the line at emergency departments. Mental health programs are underfunded. Psychiatric patients are shuffled from hospital to hospital. One patient was discharged in the middle of the night. At times, no beds are available in the entire city. Summer bed closures create more problems. A very long waiting list exists for the eating disorders program, which is the only such program in the province.

Information Systems

Referral Hospitals

Each hospital has its own information system and making systems interface, while providing some security, is difficult. Local systems which worked were destroyed before an improved system was put in to replace them.

Radiology and Diagnostic Imaging

There is no central dictation system at UAH. A new Radiology Information System is required. In computerized tomography (CT), a network is required which connects all sites with review stations at all sites, in ICU, Emergency, Diagnostic Imaging, and in some physicians' offices, e.g., neurosurgery.

Microbiology

The information system is not working properly. E.g., problems occur with improper or inadequate requisition, improper comment formatting, inadequate tracking of specimens, and inaccurate tracking of results including lost and misdirected reports.

Anesthesia

There is a need for a regional system for more effective booking of anesthesia for surgical cases. 5 sites and 8 different surgical suites need to be properly coordinated to use operating room (OR) time most effectively.

Continuing Care

Continuing care organizations have elementary systems that are directed to financial matters but have no way of facilitating the transfer of medical information to their 25 facilities and 4000 beds. Assessments are duplicated in physicians' offices and in hospital by social workers, home care, and CAPS (Central Assessment and Placement Services) workers before being repeated to some degree in the continuing care centre.

Surgery

Fractures

Patients with fractures are waiting too long for treatment. The result is increased pain, missed work, and difficulties with activities of daily living (ADL). E.g., a man waited 10 days for treatment of a fractured hand which needed to be re-fractured to set. E.g., a nine-year old boy waited two weeks for treatment of a fractured jaw.

Lumbar Disc Surgery

200 people are on the waiting list for lumbar disc surgery. It is virtually impossible for primary care physicians to get back patients assessed in a timely fashion.

Neurosurgery

The waiting list for neurosurgical patients has increased by 61.75%. Over 280 patients are waiting, including those with brain tumours, with cerebrovascular disease, and requiring spinal surgery.

Surgical Services

One surgeon notes that two of his patients died in emergency while awaiting transfer to an acute care centre. He feels that these patients would have survived prior to restructuring since urgent surgery would have been available on-site.

Notification of Surgery

Cancer patients are given only one or two days notice of surgery, leaving no time to prepare themselves. Also, this leaves no time for physicians to rearrange their schedules.

Cancellation, Delays of Surgery

Surgery is cancelled, often repeatedly, because there is a lack of inpatient beds for adequate pre-operative care or a lack of ICU beds for anticipated post-operative care. Elective surgery is cancelled on the day of surgery due to the priority of accidents and emergencies. E.g., a 42 year old man with colon cancer and lung cancer had surgery cancelled 4 times.

Semi-urgent surgery frequently experiences unacceptable delays with an adverse effect upon outcome and total cost. There is poor and delayed timing for emergency surgery because of pressure on OR time. Some patients are waiting months in pain for surgery. Surgeons are constantly dealing with the pressures of insufficient OR time and insufficient staff. There is difficulty staffing the emergency theatre on weekends. OR closures in the summer increase back-logs.

E.g., a breast cancer patient waited ten days for surgery, then was finally admitted as an emergency. E.g., a man waited for bypass surgery as an inpatient for 30 days. E.g., a man expectorating blood and mucous waited 3 weeks for surgery for lung cancer; he was told his wait would be six weeks. E.g., a woman waited 3 months for a D & C operation. E.g., a 46 year old man waited 7 months for heart surgery. E.g., a patient died awaiting bypass surgery. E.g., one general surgeon now operates in a hospital outside the region in order to provide timely access for his patients.

Waiting for Blood

Surgeons in OR are waiting 45 minutes for blood required for transfusions.

Patient Care

There are inadequate nursing staff levels in acute care hospitals and there is poor continuity of care for patients with surgical disease. Nursing staff in community health centres are losing the ability to assess serious complications of surgery because of lack of exposure.

Hospital Care

Patient Satisfaction

Satisfaction surveys show a decrease in satisfaction at all five hospitals surveyed since the last quarter of 1995. The decreases were 11% at RAH, 6% at UAH, 6% at Grey Nuns, 6% at the Sturgeon, and 1% at the Misericordia. The lowest level of satisfaction is at the RAH, now at 76%. This means that 1/4 of all patients admitted to RAH are dissatisfied with their care.

Community Health Centres

The Misericordia, Grey Nuns, and Sturgeon were formerly acute care hospitals with traditions of timely access, quality care, and cost effectiveness. The attempt is continuing to turn these into "community health centres" (CHC's), even though the emergency departments at the two referral hospitals, the RAH and UAH, are over-run and there are continuous bed shortages throughout the referral system.

Longstanding, quality programs at the CHC's have been closed due to the ill-defined high/low intensity split. This has meant the disenfranchisement of family practitioners, significant increases in unproductive travel time for physicians, fragmented care, and waste of valuable resources, as well as deprived the CHC's of the critical mass necessary to maintain both quality care and physician expertise.

Many people in the region are uncertain as to what services the CHC's deliver and about where to go to when they have medical problems. E.g., the Edmonton Health Working Group reported this as a major concern emerging from their public forums. E.g., the Consumer's Association of Alberta office has recorded numerous calls from people asking where to go for treatment. E.g., people from all over the city are lining up at emergency at RAH.

Use of Beds

Hospital beds are in short supply and are used inappropriately. There has been a reduction in acute care beds at six sites from 2551 beds in 1994 to 1650 beds in 1996, a reduction of 35.3%. Taking into account the very large out-or-region population which uses Region 10 health care services, the number of beds per 1000 population in Region 10 is now 1.8.

The insufficient availability of acute care beds keeps patients in the ICU for extra days. Insufficient access to rehabilitation beds, sub-acute beds, and continuing care beds keeps patients in acute care for excessive periods. Patients are kept in emergency wards because of bed shortages at all levels of care.

Emergency

The problems in Emergency (ER) are a "mirror of the system". There is a shortage of nurses and physicians. Support services are needed at each site. Staff must spend too much time on "hotel management", i.e., finding beds. The physical plant and capital equipment are aging.

Emergency departments at the UAH and RAH are over run and patients are frequently transferred. There is a shortage of beds. Emergency is being used as a longterm care facility because of lack of access to inpatient beds. This further blocks the use of emergency for its designated purpose, as well as deprives patients of needed inpatient care.

E.g., ambulances are too often diverted due to reduced access. E.g., emergency beds are used for inpatients at the Misericordia because no inpatient beds are available. E.g., a psychiatric patient at UAH who was knocked unconscious in a fall was sent to Grey Nuns emergency for treatment because UAH emergency was full.

Trauma Service

Consolidation of trauma services at the UAH site would place unacceptable pressure on the ER, OR, and ICU and other inpatient resources. There is a lack of rotary aircraft to transport patients. Patients from rural areas feel they would be more at risk with only one centre. Ground patients north of the river may be delayed getting to UAH, especially in bad weather. The majority of physicians recommend two trauma centres, one at UAH and one at RAH. This would require added resources for at least one site.

Admissions

Patients are being moved from hospital to hospital. E.g., a newborn with E coli meningitis at RAH was transferred to UAH, the doctor was told the child was stable and could be transferred back to RAH, the child had grand mal seizure. E.g., a child with multiple problems could not be admitted at

UAH, was sent to RAH and had breathing difficulties, was sent back to UAH ICU. E.g., a man was moved back and forth between Sturgeon and RAH three times to receive cardiac care and a pacemaker.

Patients are being turned away because of lack of beds. E.g., a breast patient with biopsy diagnosed cancer waited 10 days for admission. E.g., patients with non-emergent neurological conditions cannot be admitted to UAH. E.g., patients with gastric obstruction from ulcer disease and gangrenous cholecystitis are being turned away from the Misericordia.

The occupancy rate for medical beds at the Misericordia is running at nearly 100%. The high geriatric population in the west end cannot be admitted where the primary care physician can be involved in treatment. This is also creating difficulties for families. E.g., a family took a patient home when no bed was available at the Misericordia; the patient was subsequently diagnosed with bacterial endocarditis.

Critical Care Units

There are insufficient and inadequate critical care units, and an increase in the number of critical care transports. Admission to the units is delayed because there are not enough beds. E.g., high risk surgery must be cancelled due to lack of staffed beds. E.g., a patient with liver cancer was sent home. E.g., at times serious consideration is given to sending patients to Calgary or Vancouver.

Out of necessity a general nursing unit at UAH was converted to critical care. The beds were too close together, there were not enough wash basins, infection rates were high, and there was no privacy for families in mourning.

There are insufficient nursing staff in critical care. 38 new ICU nurses had to be trained and carried by trained people for 18 months, with no budget. 12 additional nurses have been obtained and more are needed. Staff overtime and sick leave have increased. Insufficient in-house medical coverage at night results in residents covering multiple ICU areas on different floors. Lack of continuity of care occurs with residents cross-covering patients in two units.

Flexibility is lost with only two large ICU units in the region; there is not enough capacity to cope with peak overloads or disasters. Critical care equipment needs replacing, for example, monitors.

There is insufficient ventilator equipment and the wait is too long for ventilation. At UAH, there are more critical care beds than working ventilators. Some ventilators, which were purchased in the 1960's, are obsolete.

The jump in level of care is too great from the ICU to the acute care wards. The result of this is more patient days in the ICU when patients are ready to be moved.

Burns Intensive Care Unit

The Firefighters' Burn Treatment Unit is a regional burn center that is the sole center for most of northern and central Alberta, northeastern BC, and the Northwest Territories. Staff has been reduced. Plastic surgeons have increased workload. Stress is on the residency program to cover all of the trauma and burn unit. Budgets have been removed for the Firefighters' Skin Bank and for teaching and education.

High Risk Patients

There is no safety net for patients with a clinical picture which may deteriorate within hours to days. These high risk patients were previously admitted for observation. They are now discharged home

with instructions to watch for deterioration, however, their lack of experience or clinical judgment causes many to suffer increased morbidity or even mortality when deterioration goes unrecognized.

Discharge to Home

Patients are being discharged to home before they are stabilized and able to take care of themselves. This increases stress, agony, and unnecessary infections.

E.g., a husband and wife who were in a motor vehicle accident where the husband received a cervical fracture were sent home after two days to care for themselves and their children. E.g., a child of 9 with diabetes, keto-acidosis, and dehydration was sent home. E.g., a 90 year old lady with diabetes out of control was sent home from emergency. E.g., an 80 year old man immobilized with sciatica was sent home to his wife who had just been discharged after surgery for gastric carcinoma. E.g., a woman was sent home after a breast reduction operation still suffering from a partially collapsed lung.

Community Care

Continuing Care

The wait list for continuing care is around 420. This includes 27 waiting in acute care and 318 waiting in the community. 38 of the latter are considered urgent placements, which is double the total number awaiting transfer from the referral hospitals and community health centres.

Aids to Living

Patients are experiencing long waits obtaining necessary Aids to Daily Living which will enable them to look after their own needs. E.g., one woman waited a month just to get an appointment about a walker.

Communicable Disease Prevention

A drastic reduction is contemplated in personnel in communicable disease prevention programs. The plan is to cut 24 of 57 communicable disease control jobs (about 40%) by March 1997. This will increase the danger of outbreaks of tuberculosis, sexually transmitted diseases (STD), and HIV in our communities. Such outbreaks will place a much heavier load on the healthcare system, costing more in the long run than taking adequate preventive measures. E.g., the STD clinic at UAH sees 1400 patients per month. This includes contact tracing, outreach, and follow-up contact.