Access Block: A Public Health Emergency

The Ottawa Charter for Health Promotion names 5 action areas for health promotion one of them being Accessibility (The World Health Organization, n.d.). Emergency room overcrowding and access block is a public health emergency (Affleck et al, 2013). It can be described as the inability to provide appropriate care in a timely manner (Innes, et al, 2019). Access block is particularly prevalent in Newfoundland and Labrador (NL) which has the highest rates of chronic disease and one of the oldest populations in the country (Peachy, 2019). The causes of emergency room access block can be understood as difficulty with input, throughput and output in the ED, it is a multi-level problem and should be viewed as a hospital wide issue (Morley et al, 2018). Access block affects different populations to differing degrees as marginalized patients are often subject to longer wait times (McDonald, Quick & Oremus, 2020). Once admitted, boarded patients in the emergency room with delays to a hospital bed frequently suffer poorer outcomes than those that transfer in a timely manner (Morley et al, 2018). Solutions to this problem lie in involvement of key stakeholders, enhancing health promotion and development of new technologies to enhance primary health care.

Multi-Disciplinary Approach

The issue of access block does not rest solely on the heads of ED staff. Cause of access block include factors having to do with Input, throughput and output of the department (Affleck et al, 2013). With each factor of access block there is an opportunity for interdisciplinary action to help improve delays.

Input issues include poor access to primary care and issues that arise around an aging population including increased complexity and acuity of patients (Morley et al, 2018). Coordination with EMS can help decrease input (Affleck et al). Deployment of mobile resources, especially for those living in long-term care can assess patients in the community and decipher if hospital admission is necessary (Mazurik et al, 2020). More accessible primary care particularly for populations that are marginalized could decrease the patient volume seen in the ED and potentially decrease admissions to hospital (Peachy, 2019). It has been proposed that proper use of multidisciplinary resources including nurse practitioners could allow general practitioners to see 50% more patients (Peachy, 2019).

Throughput challenges involve waiting for test results and assessment by physicians and consultants and then a plan for definitive care (Affleck et al, 2013). Throughput delays could be improved by working with lab and radiology to have dedicated ED satellite sites to prevent delay of test results and to organize urgent out-patient tests (Affleck et al, 2013). Nurse initiated protocols have also decreased wait times as the client does not have to wait to see a doctor for certain test processes to begin (Morley et al, 2018). Increasing discussions about treatment escalation with family, palliative care and the medical team including goals for the patient and end of life care can ensure that unnecessary admissions don’t occur and that patients may be allowed to die with dignity if they wish (Mazurik et al, 2020).

Output refers to the disposition of the client whether it is discharge to home or transferred to an inpatient bed (Affleck et al, 2013). Delays due to output occur when hospitals are over capacity and an admitted patient must wait for an inpatient bed (Innes et al, 2019). The inability to transfer the patient to an inpatient bed means the patient spends many hours or days in the emergency room, these patients face delays to treatment, are subject to more medication errors and worse outcomes than admitted patients that are transferred in a timely manner (Innes et al, 2019). Once admitted, discharge planning should begin. This is a multidisciplinary process that should include case management to individualize the approach (Malia & Mitre, 2020). The discharge team includes occupational therapists, physiotherapists, speech therapy and pharmacy for safe and effective discharge planning. Some discharges from the emergency room are challenged when the patient does not have a reason for admission to the hospital but cannot return home due to increased need for home supports or need for placement in long-term care. It is important to have social work involved early in these cases to expedite either the return to home or placement in long term care (Peachy, 2019).

Determinants of Health and Vulnerable Populations

The healthcare system and an individual’s access to it, is a determinant of health (Raphael, 2009). Access block does not affect every population to the same degree. Those at a material and social disadvantage use the ED more frequently and are marginalized and often subject to longer wait times (McDonald, Quick & Oremus, 2020). The NL health accord (2019) acknowledged key elements that must be addressed to improve access to healthcare in the province, these include its response to the aging population, geographical challenges and the social determinants of health.

Populations that have lower average socio-economic status and older populations tend to experience greater amounts of emergency room crowding (Dinh & Russell, 2021). Race and ethnicity is also over represented among those affected by emergency room overcrowding, Indigenous people for example, tend to have higher rates of chronic disease, less access to primary health care and tend to require more ER services (McDonald, Quick & Oremus, 2020). Essentially anybody that requires hospitalization becomes a member of a vulnerable population when access block is present.

Multi-Level Health Model

The socio ecological model (SEM) is a multi-level health model that explains how health is affected by the interaction between the characteristics of an individual, the community and the environment including physical, social and political components (Kilanowski, 2017). The SEM can be employed to understand some of the effects of access block and to address barriers to discharge. Understanding the individual, community and political environment to which the client is returning can help healthcare teams work to enhance and facilitate the clients safe return.

The Socio-Ecological model, retrieved from https://images.app.goo.gl/Axt9TuDQCsB544v18

On the individual level patient education is imperative to ensuring a timely discharge. The patient should understand with respect being paid to their education level how to manage their disease and their goals. Those with insufficient resources, financial or otherwise may find it particularly difficult to manage their health conditions (Jason et al, 2017).

On the community level, there should be accessible support and follow up in the community. Discharge planning may include incorporating family and friends that are available to support the client’s safe return home (Malia & Mitre, 2020). The location of the community and the resources available may predict an accurate estimated length of stay. Many rural sites have limited quality healthcare personnel and may not be able to monitor an individual that needs ongoing assessment in the community thus delaying discharge(Regan & Wong, 2009). The effects of access block are felt in rural sites as referring hospitals and ambulances are often unable to access secondary and tertiary care facilities in an appropriate amount of time when urban facilities are full (Newfoundland and Labrador Medical association, n.d.). This is an issue that greatly affects the province of NL which is geographically challenged to provide definitive tertiary care to a population that is segregated by urban rural lines. Half of NL’s populations live in the urban St. John’s region and the other half live rurally, some only able to access lifesaving procedures like cardiac catheterization if flown to the St. John’s site.

Patient flow policies can ensure timely discharges, these policies would require all team members to work together to facilitate appropriate discharge. (Affleck et al, 2013). Changing the way access block is viewed so that it becomes a whole hospital problem instead of an ED problem will help change the thinking for solutions that address the actual cause, that of admitted patients boarded in the ED (Innes et al, 2019). Formalized hospital flow policies, monitoring and improving consultation times and initiating length of stay committees are contextual changes within healthcare that can lead to better outcomes for patients affected by access block.

Future Directions

Future solutions must aim to make our health care system more sustainable both in the short term and in the long term. Because much of the difficulty with patient flow is caused by older patients with complicated medical problems and inpatient beds requiring alternate levels of care it stands to reason strategies aimed at healthy aging and management or prevention of chronic diseases would help alleviate some of this pressure (Dinh & Russell, 2021). Remote monitoring programs are available for patients with chronic diseases like congestive heart failure and COPD. These programs keep patients from being admitted to hospital and allow their diseases to be managed from home (Walker, Tong, Howard & Palmer, 2019).

Solutions to access block have advanced during the COVID-19 pandemic out of necessity (Mazurik et al, 2020). Call centers were used more readily and telemedicine became common place (Whiteside et al, 2020). General Practitioner and specialist appointments by phone translates to savings in human resources and financial costs and allows for more timely assessment and greater patient satisfaction (Mazurik, 2020). If a patient has greater accessibility to their family physician there is a better chance of catching an illness early and preventing hospitalization (Morley et al, 2018). Many EMS calls can be triaged over the phone and some clients can be directed to self-care (Af Ugglas et al, 2020).

As healthcare authorities seek solutions to hospital overcrowding trends toward self care and virtual care at home will likely become the norm. Support for health promotion initiatives could be very beneficial in preventing frailty in the population and delaying or preventing hospital admissions.

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