By: Annamarie Fuchs, Creator. Partners in Health | Conversations
“People are dying in waiting rooms, in their homes because ambulances can’t get there in time and dying in ambulances. What else should we call this other than what it is – a disaster!”
“Without a fully coordinated response informed by all stakeholders, ill informed funding decisions have the potential to negatively influence the system resulting in catastrophic outcomes.”
Dr. Paul Parks, President Elect of the Alberta Medical Association and
Past President, AMA Section of Emergency Medicine
In Alberta and across the country we are hearing from physicians and other health professionals who are raising the alarm about the implications of ‘access block’ on health outcomes. While fundamentally, the term is understood to mean that access to care is delayed or ‘blocked,’ the reasons access block exists and the risks it presents are not fully understood by the public or in many cases, by funders. In this article, we will attempt to unpack access block and consider what may be ahead if we don’t respond immediately to address the myriad of problems associated with it.
What is ‘Access Block’?
Access Block is a term most often applied to emergency departments when unreasonable waiting room times result in risk to patients who cannot gain access to the department to be seen, assessed, and treated by physicians and team members. In simple terms, there are no available spaces in the ED to treat patients because all spaces are ‘blocked’ with other patients. Today we routinely hear on the news that emergency department overcrowding (EDOC) is resulting in extraordinary wait times just to be seen. We hear about deteriorating ambulance response times largely because paramedics are lined up in hallways, watching over patients until they can be transferred to the care of emergency department staff. However, while access block creates barriers for safe and efficient emergency department care, it’s important to understand that it has its roots elsewhere. Access block is not a problem that can be solved in the emergency department.
So where does access block originate?
Let’s look at the inpatient hospital setting. Hospital occupancy rates vary for a whole host of reasons. When occupancy lies somewhere below 100%, emergency department staff can transfer admissions to the inpatient setting with relative ease. However, when occupancy rates increase to 100% and beyond which is most often the case across the country today, emergency department admissions cannot be moved as efficiently. That subsequent over-capacity in the inpatient setting eventually trickles down to the emergency department. Once emergency department beds are full and admitted patients can’t be transferred to inpatient units, ED waiting rooms fill up and the public begins to experience ‘access block.’ The emergency department by its very nature – open 24/7, always staffed and with diagnostics and treatment options available – has become our default mechanism where on any given day, ED staff are expected to address shortcomings across the entire system.
A Conversation with Dr. Paul Parks
To better convey the implications to the public when access block goes unaddressed, I spoke with Dr. Paul Parks, President Elect of the Alberta Medical Association and Past President of the AMA’s Section of Emergency Medicine. He is a practicing emergency physician in Medicine Hat, and a long-time health system advocate. Dr. Parks has been advocating for strategies to address emergency department overcrowding and raising awareness of the consequences of access block for nearly 20 years.
Paul, thank you for speaking with me about this important topic. First, how would you describe ‘access block’?
In simple terms, access block is the name we use for a situation where the right person cannot get access to the right care in the right place at the right time.
As you know Annamarie, access block is not a new phenomenon nor is it something that we haven’t been struggling to try to manage or even eliminate for a very long time. In 2009 I initiated an effort by physicians to galvanize the media and the public to appreciate the issues which we believed were catastrophic at the time. We collected approximately 300 cases of patients who experienced sub optimal outcomes associated with emergency department overcrowding including tragically, some who died while waiting in ED waiting rooms. In our effort to advocate for change, we began reaching out to the media with our stories. Those early attempts to strengthen awareness and to advocate for change prompted some initiatives that actually resulted in improvements for awhile. In 2012 the Health Quality Council of Alberta released their report entitled “Quality of Care and Safety of Patients Requiring Access to Emergency Department Care and Cancer Surgery and the Role and Process of Physician Advocacy.” (A link to that report is available in the footnote below.)
What’s even more tragic is that the situation is worse 10 years later. And sadly, Physician intimidation against efforts to advocate on behalf of the public has worsened as well.
I remember those days well. Across the province, in the former health authorities prior to the launch of AHS, we had initiatives underway to improve patient flow across the entire system. The crises in emergency departments certainly prompted the work but we understood that while the situation was dramatic at the emergency department level, the root causes lived largely elsewhere, in primary care, ambulatory care, public health, with surgical scheduling issues, and more. Let’s talk a bit about that.
I echo your comments 100%. A lot of the troubles we are experiencing today weren’t created by AHS. They were inherited over time and frankly, the system has evolved in such a way that we are getting results that are not unexpected. First, we have what is known as EDOC” or “emergency department overcrowding.” Strictly speaking, this refers to emergency department access block. But again, it’s a much bigger issue than just what we’re seeing in the ED. Anytime and anywhere in the system where barriers to accessing services exist, we will experience access block. It’s important to remember however, that any issue that develops in one area of the system will undoubtedly have an impact elsewhere.
For example, if someone can’t get to their family doctor, they may end up in an emergency department. When the sick and frail can’t access long-term care or home care, they often end up in emergency departments where in many cases, they are admitted to inpatient beds. Each of these examples will add capacity challenges in the inpatient setting and eventually back up the ED to the point where we can’t see new patients and waiting rooms fill up.
Pick any sector of the healthcare system. If something isn’t working somewhere, the default is always the emergency department. Pre and post surgical issues, mental health, palliative care, primary care, long-term care – take your pick. Everything culminates in the ED. In emergency departments across the province and the country, you’ll routinely see paramedics sitting with patients in hallways for 8 – 10 hours. That’s 8 – 10 hours where those people aren’t available to serve the community. So, when you call for an ambulance and experience a delay it’s likely due to access block. The term embodies everything that is wrong with our system. At the end of the day, emergency departments own the sins of the system. We have honestly become the canary in the coal mine.
So how did we get here and how can we agree on the root causes of access block so we can begin to repair the system together?
One of our highest priorities is to acknowledge the silos that continue to exist and work together to remove them. It’s fascinating to me that we have a fully integrated health care system in AB and yet we continue to struggle with almost insurmountable silos! We are so fortunate to have a system like AHS that encompasses the largest portion of healthcare delivery across the entire province. There is certainly some care delivered outside of AHS but for the most part, Albertans receive the lion’s share of their care in facilities and agencies that are part of this one integrated healthcare system.
Since AHS was formed, data has become more readily available and transparently shared. That’s a good thing. It has allowed us to identify and address priorities. And yet with good data that is rapidly and transparently reported we continue to find ourselves trying to work in a system that is as bad as it’s ever been and possibly worse.
Certainly, part of the problem can be attributed to COVID-19 and the tremendous challenges the pandemic has placed on the entire system and the people in it. We have staffing and capacity challenges that we’ve never seen before but to be perfectly frank, those challenges were beginning to mount well before COVID came on the scene.
My colleagues and I were working on several province wide initiatives in the 4-5 years before COVID-19. Those initiatives were centered around strengthening primary care and providing support to the entire physician and healthcare worker community. We knew back then that while Alberta had made tremendous strides by creating Alberta Health Services and developing our Primary Care Networks, silos and longstanding cultural disputes persisted and to this day in my opinion, they remain our Achilles heel.
Well, we are still asking for a coordinated high-level approach with short, medium, and long-term strategies designed to solve the problems you refer to, all of which contribute to access block. Instead, what we’ve seen in the last 20 years is a series of efforts by individual organizations in Alberta to reinvent the wheel. There has been little to no collaboration or coordination and as a result, not only are we not making any headway in solving these issues, we are losing ground.
Intersectoral coordination and collaboration should be a priority on the part of every single agency that supports healthcare in this province. I’m talking about the regulatory colleges, the university faculties of medicine, nursing, and health sciences, the AMA, the Primary Care Networks, and more. It’s also essential that we join forces with union leaders and ask them to tell us what the workforce issues are and where the hotspots lie. Without a fully coordinated response informed by all stakeholders, ill informed funding decisions have the potential to negatively influence the system resulting in catastrophic outcomes.
Primary care itself is siloed. We have walk in clinics that are not integrated with the Primary Care Networks. We have disparate electronic medical records and relationships with acute care, public health, and ambulatory care that are inefficient because of siloed decision making. It’s urgent that we focus our efforts right now on eliminating silos altogether.
Right now, we know that there are Albertans without access to Primary Care Physicians, but we can’t quantify that number so how do we ask the faculties of medicine to fund more spaces? This is an example of an undesirable outcome when there is a lack of willingness to work together in a coordinated fashion on finding common solutions. Instead of thinking pre-emptively and providing appropriate funding to university faculties of medicine to train more primary care physicians, we wait until a community is suddenly left without enough physicians to provide reasonable access to care. At that point, AHS is forced to spend money bringing in locum physicians, adding call stipends, and trying to manage a problem that could have been addressed further upstream if we had worked together as one system and distributed funds and resources more effectively in the first place.
Ill informed decision making has the potential to create situations where AHS may be unable to reallocate resources to address upstream thinking such as expanding primary care, long-term care, public health, and home care. This isn’t an issue of blame. It’s about the need to better recognize and communicate our shared priorities and work together to solve them in new and innovative ways. And again, it’s about focusing specifically on upstream strategies that will finally address the root causes of access block.
An example of decision making gone wrong was the Alberta Surgical Initiative where surgical scheduling was managed with a province-wide surgical wait list. It makes sense in theory. Unfortunately, the decision was made independently without stakeholder feedback and without careful consideration given to the workforce that would be needed to run the program. Primary Care Physicians for example were not included in those discussions. As a result, the effect that performing pre-and post-operative care would have on our already overwhelmed primary care physician community wasn’t considered. Furthermore, when the program ramped up, already strapped anesthesia services in places like the Red Deer Regional Hospital have struggled to offer emergency surgeries because when anesthesia is unavailable and call schedules can’t be filled, surgeries cannot be performed. As a result, the demands placed on the system by the Alberta Surgical Initiative only escalated the challenges faced in already struggling environments.
So, it sounds like ‘access block’ has become the catch phrase if you will for the absolute state of disarray that our health system is in and that well meaning efforts to improve the system, when not properly informed, can impair the situation even more.
Well, we need to start by collectively acknowledging the problem to each other and to the public. Unless we can all agree that the system is overstretched, over capacity, and frankly rapidly approaching disaster, we will never address the problems that exist or action the solutions we know can work to improve the system for everyone. As I’ve already said, we need a coordinated, big picture approach. Without that, we’ll continue to see independent groups trying to implement changes that will very possibly result in adverse outcomes elsewhere.
In a true disaster situation or any mass casualty event, we immediately launch a disaster management plan. We establish an incident command center. We bring in key stakeholders with the power to make rapid decisions and apply the appropriate funding to get the job done. We work together to set priorities. Instead, people are dying in waiting rooms, in their homes because ambulances can’t get there in time and dying in ambulances. What else should we call this other than what it is – a disaster!
We need stakeholders from every sector of the system to come together and identity the top three priorities that must be addressed. Then we need to take each of these priorities into consideration and arrive at a 6-month plan, a 12-month plan, and a long-term plan. Each of those plans must be funded and actioned. And we need our Premier and caucus to trust the experts, to participate by supporting the work, and to respond with better informed decisions. Frankly, if our politicians can provide the support necessary to fix this situation, it would be a political win. Is it difficult? Yes. Is it complex? Absolutely. Can it be done? It must be done because frankly, we are out of time.
I understand the optics of declaring this a disaster. But right now, there is no question that the issues around capacity, workforce gaps, and staffing issues are dire across the entire country. If we don’t create environments where we place top priority on repairing the health system in our own province without undermining the integrity of another province’s system, then we all lose. My message – let’s work together now to solve these problems.
As our conversation continued, Paul and I deliberated about what’s next in healing our broken healthcare system. The array of people each of us has spoken with over the last few years have all maintained that they have never seen healthcare in Alberta and across the country in the state that it’s in today where nothing short of disaster management approaches will get us back on course.
As a critical starting point for investment, we must strengthen team-based medical homes led by primary care physicians in a team-based model and ensure they are accessible by every Albertan. And until we do, we must stop blaming people for coming to emergency departments when that may indeed be their only available option. We must consolidate virtual care because virtual care staff are redirecting patients who are trying to avoid using emergency departments to the ED because they can’t be properly examined in the virtual setting.
Over time, the healthcare systems in Alberta and across Canada have become bureaucratic, heavily funded sickness systems where a mere fraction of available funding is allocated to addressing prevention and wellness initiatives which, over time will reduce demand on the entire acute care system, making it safer for everyone. Our healthcare cannot be treated any longer as a political football. Instead, it must be seen for what it is – a moral imperative.