View full article and comments: http://thetyee.ca/Views/2006/12/26/ER/

In early December, the minister of health reached a deal with False Creek urgent care clinic owner Mark Godley to publicly fund services offered there. Clinic owners claimed the clinic would help solve the problem of crowding of our hospital emergency departments by seeing patients who might otherwise go to the hospital. So will it?

The Godley clinic has clearly said they will only see the "walking wounded" -- or "low complexity" patients -- not those coming in by ambulance or needing admission to hospital. Offloading the lighter patients is unlikely to lessen emergency department crowding according to a recent study from Ontario in the Annals of Emergency Medicine.

Dr. Michael Schull and colleagues examined the impact of "low-complexity" patients on the timeliness of care for other patients in the emergency department. They studied more than four million patient visits at 110 emergency departments and found that each patient who came to the emergency department for a minor ailment increased the overall stay for patients with true emergencies by 32 seconds and the treatment time by 13 seconds. Challenging conventional wisdom, the authors concluded that diverting these patients away was unlikely to reduce waiting times for the other patients.

The authors explain this study result is based on the fact that most emergency room departments do not place low-complexity patients in the spaces used for sicker clients. There is often staff dedicated to the "walking wounded" patients so that "off-loading" them has little effect on the real problem of emergency departments crowded with sicker patients.

Real cause of crowding

A recent BCMA policy backgrounder identified the real cause of emergency department crowding as prolonged boarding of in-patients. These are patients who are sick and need to stay in hospital for treatment. However, due to the lack of available acute beds and staffing shortages, they have no place to go. They therefore lie in emergency departments -- sometimes for days -- until a bed opens up.

The policy backgrounder emphasized that B.C. now has only 1.8 beds per 1,000 of the population -- 55 per cent below the 2.75 recommended by the B.C. Royal Commission in 1991, and substantially less than the rest of Canada, which has 3 beds per 1,000 of the population.

In the same policy backgrounder, the BCMA calls for immediate implementation of overcapacity protocols to redistribute admitted patients throughout the hospital. This makes good sense. We cannot expect our emergency departments to transform themselves into in-patient wards every time there are no beds upstairs, while at the same time continuing to provide good emergency care.

Better bed management and discharge planning, more availability of step-down beds (beds for those recuperating from illness and not yet ready to return home because of difficulty with mobility or other daily activities), and improved co-ordination of care between the hospitals and community to reduce the number of "bed-blockers" (patients who are medically stable but unable to be discharged due to functional decline) are also short-term solutions. More long-term care beds and more accessible home care and home support would also take pressure off the emergency and acute care system, both by delaying and avoiding acute care admissions at the front door, and giving people a place to return to once their acute illness has been resolved.

Ultimately, an expansion in the number of acute care beds, to accommodate the "surges" of sick patients when they come, will make the biggest difference to the problem of hospital crowding.

Real solutions to crowding

So if the Godley clinic won't solve the problem, what will it do?

For starters, it will allow clinic owners to get taxpayer-financed returns for their 10 million dollar investment. One potential downside of this is "over-servicing" -- where clinic providers who are remunerated based on the number of services provided (essentially "piece-work"), and need to bring in returns on their investment, are motivated to do unnecessary things or "over-service" their patients, in this case at the expense of the public purse. The clinic will also have to attract health professionals, technicians and nurses from the hospital setting, most likely by offering higher salaries to work there. This will worsen the shortages of these professionals in our hospitals.

It is true that the clinic will provide another place to go for "low complexity" patients needing urgent care. However, two of our smaller hospitals -- UBC and Mount Saint Joseph -- already provide excellent urgent care services and may well be under-utilized. If there were a need to expand such services, then encouraging the "walking wounded" to attend these facilities, and expanding their hours, is likely to be a more accountable and sustainable option.

It is ironic that the BCMA, which authored the policy backgrounder on emergency department crowding, also brokered the deal between the Godley clinic and government -- a deal that ultimately skews public funding in favour of a few physicians' commercial interests and does nothing to solve the crowding so eloquently analyzed in their report.