HALLWAY HEALTH CARE

This woman spent 47 hours waiting for surgery in the Sunnybrook ER, with shattered wrists, a broken elbow, cracked ribs and internal bleeding. An investigation into the overcrowding of Toronto ERs

The day Kelly Yerxa had her accident was mostly uneventful. It was a Friday in January 2016. After finishing work in Cambridge, where she is the city’s director of legal services, she drove to Haliburton to join her 19-year-old son, a competitive snowboarder, who had spent the day training there. Yerxa is tall and lean and, like her son, athletic. She went to university on a swimming scholarship and now, in her 50s, competes as a triathlete. She was scheduled to officiate during the weekend’s snowboard events, and she met up with her son and about a dozen other parents and athletes at a cottage they had all rented. It was late when she arrived, and since everyone would be getting up early, she and the others headed off to bed. Just before midnight, Yerxa made a trip to the bathroom, and on her way back along the pitch-dark hallway, she veered slightly to her left and took a wrong step. She plunged down seven wooden stairs, hit the landing, punctured the drywall there, and then continued down four more stairs before coming to a stop in the living room.

An athlete sleeping on the couch rushed over. Bones were sticking out of Yerxa’s right elbow, and her wrists were in the shape of the letter S, her hands dangling limply. But she was in shock, and she felt no pain. She told the young man not to worry, that he should go back to sleep since he had to compete in the morning. Then she passed out.

When she came to, two of the other parents were hovering over her, and she was soon being rushed to Haliburton Hospital by ambulance, sirens blaring. Doctors there told her that in addition to the two shattered wrists and broken elbow, she had a couple of broken ribs and a lacerated kidney, and she would require complicated surgery, which was beyond their capability as a small hospital. The pain was by that point intense, and doctors gave her strong painkillers. The next day, a snowstorm hit that made an airlift impossible, so Yerxa was transported by ambulance to Sunnybrook, and her husband, Trevor Clough, drove in from Cambridge to meet her there. He sat in the ER for nearly three hours, waiting for her arrival, and he couldn’t believe the pandemonium he witnessed. “I’d never seen a hospital that busy,” he says. “I was amazed at how many people were coming in.” He remembers ambulances arriving every 15 or 20 minutes, disgorging patient after patient. There had been a major accident on the 401, which he thought explained the deluge, but the nurses told him it was always that way on a Saturday night.

In the hallway, there was no curtain, no call button, and Yerxa was next to the bedpan dumping station. Illustration by Jeffrey Smith

When he finally got to see his wife later that evening, Clough discovered that her bed was in what Sunnybrook staff call the “orange zone”—essentially a holding area for patients when no rooms are available. Her bed was pushed up against a wall, with the IV pole and other paraphernalia wedged in beside her. Clough had nowhere to sit, so he stood awkwardly next to her until a nurse kindly brought him a chair. There was a curtain, but no switch to turn off the lights at night. That location would be Yerxa’s home for the next 19 hours—and her predicament would get worse from there.

Hallway health care is epidemic in Toronto right now. Hospital administrators typically strive for an occupancy level of about 85 per cent, a rate that balances the need for efficiency with the ability to accommodate sudden surges in patient numbers. In other words, even on really busy days, a hospital should be able to find a bed when your father has a stroke or your partner contracts pneumonia. However, for most of the past year and a half, Toronto hospitals have had average monthly occupancies well above that target.

Occupancy at the University Health Network, which includes Toronto General and Toronto Western, didn’t dip below 97 per cent between January and May last year, according to documents obtained by the NDP. The three Mississauga hospitals that make up the Trillium Health Partners went as high as 109 per cent in January last year and didn’t fall below 103 per cent all spring. Etobicoke General spiked to 122 per cent last January and stayed above 106 over the next few months. The pattern has continued this year. Throughout the first half of January 2018, Toronto East General hovered between 104 and 119 per cent occupancy, and Scarborough and Rouge Hospital’s Birchmount site reached 147 per cent. Toronto’s hospitals are, in a word, bursting.

When a hospital finds itself with 147 patients and only 100 places to put them, administrators have to be creative. The first place patients are typically stowed, after being admitted through the ER, is in the emergency department itself—a terrible place for admitted patients. It’s frenetic, loud and bright, making it impossible to rest, and elderly patients, who make up the majority of admissions, often develop delirium as a result, which can take days to clear. In addition to serious privacy and dignity concerns, the cramped conditions make it hard to do the job right.

To relieve the congestion in ERs, hospital administrators have been forced to use what they euphemistically call “unconventional spaces.” In Yerxa’s case, it would end up being a spot in the hallway. In other instances, it is an office, a sunroom, a conference room, a TV room or even a bathroom, with the bed placed between the toilet and bathtub. There’s often no door, no curtain, no call button, no space for loved ones. If a wound needs inspecting or a private detail has to be discussed, it happens out in the open. If you need a bedpan, you just do your business right there.

This is no way to practise medicine, says Paul Pageau, an emergency doctor in Ottawa and president of the Canadian Association of Emergency Physicians. But he has noticed that patients seem to be slowly resigning themselves to the inevitability of long waits and a war zone atmosphere. “I find it remarkable that the patients we see seem to a great degree to accept this,” he says. “Which in itself I find unacceptable.” He thinks if the public demanded more, things might change faster. “I don’t mean to blame the public. But I don’t want us to become too complacent.”

Keeping track of patients who are stashed in hallways, bathrooms and alcoves sometimes requires doctors to get creative. Illustration by Jeffrey Smith

Her first evening at Sunnybrook, Yerxa was heavily sedated, so after she was settled into her bed, Clough drove home to Cambridge for the night. The next morning, a friend drove him to Haliburton, where he picked up his son and collected Yerxa’s car. First thing Monday morning, father and son drove to Sunnybrook to visit Yerxa.

Thirty-eight hours had elapsed since Yerxa had arrived, so Clough was surprised to find that she hadn’t been moved into a room but was instead in a hallway. She had a dressing on her right arm that stretched from her bicep down to her fingers, and another on her left arm that went from elbow to fingers. There she was, lying in the hallway of one of Canada’s premier hospitals, still waiting for surgery.

The hall was noisy, with machines constantly beeping and people talking. There was nowhere for her husband and son to sit where they weren’t in the way. “It was like parking in a fire route,” Yerxa says. Worst of all, they were next to a bedpan dumping station, which stank to high heaven. Yerxa couldn’t eat or drink by herself, let alone get out of bed or go to the washroom. She was entirely dependent on the nurses, who, despite being clearly overloaded, she says, took excellent care of her. Rather than venting or getting snippy, they just kept apologizing.

After lying in the emergency department for almost two days, Yerxa finally had surgery to install plates in her wrists and to repair her elbow. Then she was moved into a room, where she stayed until her discharge, five days later. In retrospect, she is glad she was so subdued by the pain. Had she been more lucid, she says, she would have been angry.

Since her time at Sunnybrook, the hospital-bed crisis has only escalated. Typically, there’s respite in the summer, after the flu season is over, but last summer that didn’t happen. “The surge from last winter hasn’t gone away,” Anthony Dale, CEO of the Ontario Hospital Association, told me in December. “All across the GTA, you’ve seen hospitals spike as high as 140 per cent at any given moment.”

When numbers surge like this, hospitals have to care for the extra patients without extra resources. Nurses, cleaning staff, clerical staff, food workers—they are all being run off their feet, says Pam Parks, a registered practical nurse and CUPE union rep who has worked at Lakeridge Hospital in Oshawa for nearly 30 years. Whereas normally a nurse on day shift might have been assigned four patients, she says, now they’re routinely getting six; on night shift, they sometimes have more than 10. They forgo their breaks. People yell at them and even throw things. “We can’t do it anymore,” she says. “We’re tired, burnt out and getting sick.”

Administrators are also exhausted. Figuring out how to accommodate all the extra patients has become a major obsession. “I can’t put in words the amount of stress I’ve witnessed on the entire hospital,” says Ari Zaretsky, who between July and December last year stepped in as Sunnybrook’s interim chief medical executive. He described hospital officials regularly having to clear their schedules and “call a huddle”—code for an ad-hoc crisis meeting to come up with a plan for how to accommodate the excess of patients without cancelling key services. Overcrowding is especially serious for a hospital like Sunnybrook, which not only accepts regular patients through the emergency department but also, as a specialist trauma centre, takes in many of the province’s car accident, burn and gunshot victims.

Part of Zaretsky’s job was to oversee what’s known as “flow and occupancy,” and when I spoke to him in December, the winter’s flu season was just gearing up. Modern hospitals have teams of specialists who use computerized bed maps to track every patient—Zaretsky likens them to air traffic controllers. As new patients arrive, these specialists have to decide how to reconfigure them according to illness type, severity, infectious disease status and likely discharge date. If someone needs to be isolated because of infection, for instance, they might jump the queue. The same is true if their condition is life-threatening. In rare cases, an extremely sick person can even bump a less sick person, ideally someone for whom discharge is imminent, out of their room and into a hallway. “It’s very contentious,” says Zaretsky. “You can imagine. You’re still ill—you have to be in hospital—but you’re not ill enough, compared to the poor person who has just been admitted.”

B
y the standards of most developed countries, Canada doesn’t have a lot of acute care beds: just two for every 1,000 people, compared to 4.1 in France, 6.1 in Germany and 7.8 in Japan. In terms of total beds, Ontario is one of the most sparsely bedded provinces, with just 2.3 per 1,000. The average in the other provinces is 3.5. That said, some places have low bed numbers but aren’t in crisis. Denmark, for instance, has just 2.5 beds per 1,000. The difference is that Denmark also has an extensive and well-orchestrated system of alternative care for patients who need treatment but don’t necessarily need a hospital.

People with dementia, complex health issues that come with advanced age, debilitating illnesses like multiple sclerosis or even schizophrenia—they all need care, but most of them could be and should be attended to outside acute care hospitals. Some patients just need to recuperate. Some need active rehab. Some need moderate assistance with the business of living and will need it for the rest of their lives. And the most challenging patients need complex continuing medical care—which really means they need homes within what are essentially medical facilities. In Ontario, we do have a patchwork of such facilities, but supply falls well short of demand.

Right now, some 3,200 patients requiring what’s known as alternative level of care, or ALC, occupy acute care hospital beds in Ontario. On the second-last day of February this year, exactly 75 of those acute care beds were at Sunnybrook, a 313-bed hospital. According to Florina Weisenberg, who works on patient flow, 12 of those people have been there for more than a year, including three who’ve stayed more than three years. If you add up all the “bed days” that just these 12 alternative-level-of-care patients collectively account for, it comes to 9,969 days, says Weisenberg. Given that an average acute care patient stays in hospital for six days, those 12 long-term occupancies alone displace 1,661 acute care patients—people like Kelly Yerxa—at just one of the city’s hospitals.

At the heart of the tension is the fact that Ontario has a policy that allows patients to turn down an available bed in one ALC facility while they wait for an opening in a place of their choice. They can indicate as many as five choices, or just one. If a patient says she’s only willing to move to one place, and if, for instance, that one place is Baycrest, a popular geriatric hospital and residence in North York, she’ll be waiting for nearly six years. And she might be waiting in an acute care hospital. She might be waiting at Sunnybrook. And she has that right.

In many other provinces, it’s legal to move a patient out of a hospital and into the first available bed, even if it’s 50 kilometres away from the patient’s home. In Ontario, a patient has to consent, and many don’t, preferring to be as close as possible to loved ones and caregivers. Zaretsky and many others think the Ontario policy is problematic. He recognizes that it’s important to be compassionate. These patients, like all Ontarians, deserve care. The question is where. “We’re an acute care hospital, not a residence,” he says.

Howard Ovens, who for 30 years headed the emergency department at Mount Sinai Hospital and is now chief medical strategy officer for the Sinai Health System, believes patients waiting for other kinds of care should take the first available bed and wait there until their preferred location comes up. “I don’t understand why they have to wait in an acute care bed so that another person just admitted with pneumonia or a fractured pelvis has to sleep in a hallway,” he says. “That seems like we’re putting the rights of one person way ahead of the rights of another one who’s actually sicker.”

The majority of ALC patients are old people, who are sometimes disparaged as “bed blockers.” Jane Meadus, a lawyer at Toronto’s Advocacy Centre for the Elderly, says it’s unfair to point the finger at the elderly, when all they have done is what we all hope to do: live long lives. The province has known for years that over-65s are a growing share of our population. According to Ministry of Finance projections, by 2041, as boomers move through their golden years, 22.2 per cent of the GTA population will be made up of seniors, compared to just 14.4 per cent in 2016. “The blame should rest at the feet of government and hospitals and health officials for not having properly planned,” says Meadus. “The fact that we have an elderly population that is ill and needs care is not a surprise to anyone.”

However horrific the crisis in hospital hallways, it’s even worse at their exit doors, says Meadus. She says she doesn’t hear from many patients outraged about a day or two spent in a hallway. “But I get a lot of calls on the other end,” she says. These are often people reporting that their parent is being kicked out of hospital or that the hospital is threatening to charge $1,000 a day if they don’t leave. In fact, it’s illegal to charge fees like this—the maximum allowed per day is less than $60—but that doesn’t stop some hospitals from doing it.

Most years, she gets about 200 such complaints about hospital “discharge planners,” whose job is to clear out the beds for new patients. But last year, she had about 600. That was despite the fact that the Office of the Patient Ombudsman had its first full year of operation last year, offering disgruntled patients a new avenue to raise their concerns. According to the ombudsman’s first annual report, 11 per cent of complaints—the single biggest category—were from patients and their families who said they were inappropriately pressured to leave hospitals.

What might seem to a hospital administrator like excessive choice is merely the exercising of rights enshrined in law to others. A patient ought to expect a facility to be bright, well staffed, clean, reasonably spacious and close enough so that family can easily visit, says Meadus. “Just because you’re not doing what the hospital tells you doesn’t mean you’re being ‘difficult,’ ” she says. “Remember, this is where you’re going to live, probably for the rest of your life.”

In 1998, five-year-old Kyle Martyn died of strep-induced toxic shock after waiting three hours to see a doctor at Credit Valley Hospital in Mississauga. In 2000, 18-year-old Joshua Fluelling died from an asthma attack after his ambulance was diverted from the emergency department at the Scarborough Hospital to the one at Markham-Stouffville. In 2005, engineering student Patricia Vepari decided to go home after being told the wait time in the ER at Kitchener’s Grand River Hospital would be eight or nine hours; she died two days later of bacterial meningitis. These are stories that have shaped Ontario’s health care identity.

Overstuffed hospitals are not just short on comfort and long on bad optics—crowding actually leads to more deaths. One Australian study from 2006 looked at every adult patient admitted between July 2000 and June 2003 at three hospitals—a total of 62,495 people. The researchers scored the hospitals according to whether they had less than 90 per cent occupancy, 90 to 99 per cent occupancy, or occupancies of 100 per cent and higher. Then they checked to see how many people had died by the seventh day after admission. Day seven mortality, they found, was 18 per cent higher when hospitals were at 90 to 99 per cent capacity, and 46 per cent higher when they were at 100 per cent or over. This remained the case regardless of patient age, diagnosis or urgency. The researchers calculated that an extra 120 people died each year in those hospitals because of overcrowding. A study published in the U.S. in 2013, using 2007 data from California, found a five per cent increase in the odds of death due to overcrowding—amounting to 300 “excess” in-patient deaths.

These sorts of deaths probably won’t make the front page. Most are not as dramatic as succumbing to asthma in an ambulance that had been waved away from the nearest ER. Rather, they often result from numerous small deficiencies, according to three doctors from the U.S. and the Netherlands who wrote an article on the subject in 2014. Simple things, like delaying laboratory testing, not recording vital signs or not supervising an IV line can be consequential, and can add up.

Last June, Jeffrey Roberts, a 56-year-old director of web development at TVO, had such an experience when he went to Sunnybrook with extreme abdominal pain. Because there were no beds or even gurneys, he was forced to sit upright in a waiting room chair. He was sent home that day but had to return the following day, and ended up staying five days with a life-threatening bowel obstruction. A 2011 study using Ontario data found that people seen by doctors in overcrowded ERs and then discharged, like Roberts, are more likely to be readmitted within the next 30 days, and are more likely to die.

Just keeping track of where itinerant patients are within the hospital can sometimes be challenging. Hospital staff have to develop ways to label them, and sometimes they resort to just scrawling numbers on the wall, according to the authors of the 2014 article. Occasionally, patients fall through the cracks. That was what appeared to happen to Lisa Marion after she had a motorcycle accident and was taken by ambulance to Etobicoke General in 2015. She had severe bruising and road rash all over her body, and doctors worried she might have internal injuries as well, so they lined up some scans. While she waited for them, her gurney was parked in a hallway, and her fiancé managed to find her. When she was whisked off to be scanned, he waited there for her to return, but she never did. Instead, she was deposited somewhere else—in a big room with desks where people were typing. “I wasn’t keen on that,” she says, “because I didn’t have any pants on.”

Hours passed. No one checked on her. She says she was never offered food or water. She was not given any pain medication. She didn’t know if she was okay or seriously injured. And she was all on her own, because her fiancé could not figure out where she was, and the hospital staff seemed to have forgotten all about her. Marion finally struggled up off her gurney and went to look for her fiancé. “I was shuffling like a zombie, wandering around in circles,” she says. “Other patients looked at me knowingly.” By fluke, she ran into her fiancé. Marion told him she wanted to leave. Barefoot, wearing just a hospital gown and a blanket tied around her waist, she simply walked out. “No one batted an eye,” she says.

Ontario’s hospital-bed heyday was in the 1980s. It’s been pretty much downhill since then. Premiers Davis, Peterson and Rae kicked off the cuts, in what was partly an ideological attempt to deinstitutionalize medical care in the province. The bulk of the rest was the work of Mike Harris, who shut down 39 hospitals and forced the amalgamation of dozens of others. In 1990, Ontario had 33,403 acute care beds, and, even as the population kept growing and aging, by 2014, we had only 18,588.

Since 1997, a low point in spending, increases to hospital funding have been mostly very modest, and in recent years have often been eclipsed by inflation. The 2008 recession made that bleak scenario even bleaker: 2017 was the first year in five that hospital budgets weren’t outright frozen, even as patient volume, labour costs, energy costs and regulatory requirements all continued to go up. Out of necessity, our hospitals have become lean. Today, Ontario spends on average $389 per patient less than the other provinces. It shows.

A common refrain over the years, from governments of every political stripe, has been that cuts to hospitals would be offset by increased funding for home care. That is a mirage, conjured by governments who just want to save money, says Natalie Mehra, executive director of the Ontario Health Coalition. The government claims it’s offering the same services, only more efficiently, but, according to Mehra, that’s not true. Can it ever be cheaper to transport the same amount of health care, right to every patient’s door? No, she says: it’s only cheaper because patients receive much less care overall, and the workers who provide it get much less pay. Even with the five per cent annual funding increases to home and community care we’ve seen over the past decade, it doesn’t come close to making up for what we lost through hospital cuts. What’s worse is that hospitals are now being forced to scale back on things like cataract surgery and EEGs, which can’t be delivered through home care.

Similarly, many patients are simply too sick to be cared for in a few hours of home care, yet along with the cuts to acute care beds that we saw over the last three decades or so, there were also deep cuts to beds dedicated to people with serious chronic health problems—referred to these days as “complex continuing care” patients. In 1990, Ontario had 11,435 of these beds in the province, but by 2014 we had just 5,329—a loss of more than half. Again, that’s in the face of a growing aging population and advances in medical technology that keep us alive longer.

Long-term care beds are the new dumping ground for many of our most complex cases—people on ventilators, with dementia, with ALS—even though many long-term care homes have only one mandatory nurse on staff—or in the cases of some unlicensed nursing homes, none at all. There’s a reason people are holding out for reputable places, says Meadus. Those wondering why frail elderly patients are taking up space in acute care beds at our major hospitals need look no further: there aren’t enough places for them to go, and the places that exist often aren’t up to snuff.

Recently, hospitals have been embracing a new model: partnering with separate facilities that specialize in various types of non-acute care: rehab, long-term care and complex continuing care. Bridgepoint has merged with Mount Sinai, for instance, and Providence Healthcare with St. Michael’s and St. Joseph’s. In October last year, the government announced it would pay for refurbishments on a building that had been mothballed for about two years, at Humber River Hospital’s old Finch site. Newly christened as the Reactivation Care Centre, that facility opened in December, with five hospitals signed up—North York General, Humber River, Mackenzie Health, Southlake Regional and Markham Stouffville—each of which would transfer 30 ALC patients out of acute care beds and into the more appropriate ALC beds at the site, where the hospitals will continue to manage their own patients’ care. This can lower costs for hospitals because ALC typically costs less to provide than acute care and also because they can share administrative costs. Additionally, as Meadus notes, because these transfers are technically internal, the hospitals are able to avoid the requirement for patient consent.

According to Mehra, the last time the Ontario government built a long-term care facility was in 2003. Recently, Queen’s Park committed to opening 30,000 new long-term care beds across the province over the next decade, although only 5,000 of them are promised within the next four years. As part of their seniors strategy, the government has also mandated that half of the beds in Toronto be upgraded by 2025, to eliminate four-patient wards, for instance, and meet modern standards.

Yet our city may be on track to have fewer, not more, long-term care beds. With real estate fantastically expensive, it may not be feasible to build long-term care facilities here. As for the upgrading of existing beds, few facilities in the GTA have begun that process. In some cities, a new care home can be built on vacant land beside the existing facility, and then residents can move in while developers tear down the original site. In Toronto, where density is high, there often is no “other part” of the property, and residents have nowhere to go while facilities are being upgraded. “If you think it’s bad now in Toronto,” says Meadus, “I’m predicting it’s going to be way worse.”

The problem has evolved into a major provincial election campaign issue, and the three party leaders have integrated hallway health care into their stump speeches. In March, Kathleen Wynne announced $822 million in funding to Ontario hospitals, to be delivered by the end of 2019, plus $650 million earmarked for home and community care improvements, and an additional 30,000 long-term care beds over the next 10 years. Andrea Horwath has committed to funding hospitals at minimum to the rate of inflation and to implementing a moratorium on front-line health care provider layoffs. Doug Ford, who says his mother, Diane, was recently treated in a hospital hallway after a tumble, is focused on finding efficiencies. He has even applied a catchphrase from his late brother’s mayoral days to the health care system, making solemn promises to “stop the gravy train.”

In the more than two years since her accident, Kelly Yerxa has returned to Sunnybrook many times. At first, she had monthly follow-up X-rays, to see how the bones were mending. After four months, she was set free from her final splint. She had already resumed swimming and soon returned to running. But the bones in her right wrist weren’t growing well, so in July 2016, she went back in for another surgery: doctors took a piece of bone from her hip and grafted it onto her hand. Last summer, she took up biking again, but her grip was still weak—the strength in her right hand was only half that in her left—which made it hard to brake safely. So in March, Yerxa was back at Sunnybrook for surgery to remove scar tissue in her wrist, which she hopes will be her final operation. She can still cross her fingers, and so she does.