Strain of balancing ER demand with capacity leads to ambulance offload delays

For all the talk about patient wait times in the health-care system, at least one group of medical professionals can also be prone to long delays.

When an ambulance arrives at one of the major hospitals in the Halifax area, there's a good chance the paramedics will be waiting a while before they can return to regular duty. That's because offload times at the Halifax Infirmary and the Dartmouth General Hospital fall well short of the standard established by the province's Health Department.

The standard calls for a patient to be transferred into the care of hospital staff within 20 minutes of arrival, 90 per cent of the time. The two largest hospitals, however, only meet the mark between 10 and 17 per cent of the time.

At Dartmouth General, 12 per cent of offloads take more than three hours, while nine per cent of offloads at the Halifax Infirmary stretch to that mark or longer.

'Pressure on the EHS system'

The information was included in briefing notes prepared for Health Minister Randy Delorey when he assumed the position in June. CBC News received a copy through a freedom-of-information request.

"Ambulances that are backed up at emergency departments, sometimes for hours, waiting to offload patients (particularly within HRM) results in pressure on the EHS system … and adverse events for patients," reads the notes, adding that as many as eight crews can be lined up at a time, waiting to offload patients.

For those within the system, it's not a new problem.

"This has been a problem, pretty much, in different stages, forever," said Terry Chapman, business manager of the Nova Scotia Paramedics Union.

One of the biggest concerns for the union is when crews from outside the Halifax area come into the city for a transfer and then have to wait — sometimes for hours — before being able to return to their coverage area.

While the system sees crews in neighbouring jurisdictions floated in for coverage in the meantime, Chapman said it can lead to a "thinning of available services," especially the farther you get from Halifax.

Near-daily struggle

When the problem is bad, it can mean patients in the hallway, waiting for rooms, said Dr. David Petrie, the senior medical director of Dalhousie's emergency medical program of care. 

"That's the hardest thing as providers, I think, is being in that tough situation of knowing there's a sick person in the hallway, but also knowing there's a sick person in our beds. And which one do we move? How do we get them in quicker?" he said.

"That's what our nurses, our paramedics and the docs struggle with almost every day."

Dr. Andrew Travers, the provincial medical director for Emergency Health Services, said about 50 per cent of all hospitals in the province meet the standard, but added that offload delays are a problem across Canada.

While he believes they can get everyone in line with the provincial standard, Travers said there's also a focus on reducing the need for people to take an ambulance to an emergency room in the first place by providing alternative care.

One example is the extended care program, which is a team-based model that essentially brings an emergency department to long-term care homes.

Travers also pointed to collaborative emergency centres and how they work. The nighttime model sees nurses and paramedics working together to treat patients in rural areas — with the nearest regional hospital and a doctor simply a phone call away.

(The former NDP government opened eight of the centres, however no new centres have been opened under the Liberal government.)

Balancing efficiency and capacity

Trying to solve the problem requires looking at two issues, Petrie said: system efficiency and capacity.

And while efforts are always being made to improve efficiency, he said that can only go so far when it comes to the bigger challenge of balancing demand with capacity in the emergency system.

"At some point, we have to recognize that no matter how efficient you are, if we simply do not have enough beds in the system, there will be backups in the system that will manifest as wait times and ambulance offload times."