The Quebec health network must prepare to face a potential sixth wave of COVID-19. To get through this, it will be necessary to maximize the use of beds in hospitals. The DD Pascale Dubois, specialist in internal medicine, has been thinking about this question for years, notably within two ministerial committees. The doctor, who practices at the Verdun hospital, puts forward solutions.
The emergency room is overflowing. Patients on stretchers cannot be transferred to floors, for lack of beds. How to fix this problem ?
We need to give more holidays [aux patients déjà hospitalisés]. As an inpatient physician, you often have to ask yourself who needs a bed the most. Is it the patient who has been hospitalized for a few days, who is relatively stabilized and for whom the majority of the investigation has been done, or is it the patient who is on a stretcher in the emergency room who does not have a diagnosis established ?
The patient who is on a stretcher in the emergency room has a greater risk of complications and of going bad. Elderly people who can’t sleep in the emergency room because of the light in their face can go into delirium. Keeping them in the emergency room will ultimately prolong their average length of stay in hospital. It’s a vicious circle.
What do you mean by giving patients more time off on the floors?
It’s always tempting, when you’re the attending physician and you have 20 patients in your care, to give the best possible care to those 20 patients. It may seem that the best care is to keep a patient two or three days longer to have them reassessed in physiotherapy to be sure that the risk of falling has been reduced. But many of these things, which we often do at the end of hospitalization, could be done externally.
You know, sometimes we keep patients in the hospital for 15 minutes of physiotherapy a day because we don’t think they’re quite stable enough to go home. Is it the best use of an inpatient bed to hold a patient for 15 minutes of physiotherapy? Me, I think not.
Are these home physiotherapy services accessible?
Not a lot. We in the Verdun region have a few. But there are deadlines. It won’t necessarily happen the day after the patient is discharged. When we wait, the risk is that our patient loses the gains he made in the hospital and deconditions himself again. We really need to increase home care services.
Are there other ways to reduce hospital stays?
The patient’s discharge must be planned from day one. This is called early joint discharge planning. This is a strategy in which the interdisciplinary team is involved from the start: pharmacist, physiotherapist, occupational therapist, nutritionist, speech therapist, social work, etc.
There must also be a nurse case manager or liaison nurse, who coordinates all the assessments. His task is to ensure the link with the family or the CLSC.
So, in parallel, we carry out the medical investigation, the treatment and the interdisciplinary evaluation. At the time of medical discharge, the patient is ready to leave.
Interdisciplinarity in the hospital is essential for the quality of care and for fluidity. And that really decreases an average length of stay.
Should targets be set for average lengths of stay?
To maximize the use of beds, it is necessary to establish target average lengths of stay for certain common diagnoses and impose on hospitals the respect of these (e.g.: 4.9 days for a myocardial infarction and 7 days for an accident cerebrovascular). In hospitals that do not respect them, it is necessary to identify the brakes or obstacles to achieving these targets.
In Quebec, very few hospitals have emergency and hospitalization medical coordinators, whose mission is to ensure fluidity in episodes of care. These positions need to be established. The Department of Health recommends it and provides funding for it. When I am the coordinator, I can intervene to speed up the examination of a patient who is waiting, for example, for a scan and who is occupying a bed.
If the length of stay is reduced, isn’t the quality of care likely to be compromised?
The complication rate is directly proportional to the time spent in hospital. We are much better at home. The risks of deconditioning, delirium, opportunistic infections, such as diarrhea or Clostridium difficileare much lower when you do not stay long in the hospital.
What are the solutions other than traditional hospitalization?
The brief hospitalization unit is one of them. The patient gets all of his tests faster because he will be discharged quickly. He remains in the unit between 24 hours and 72 hours.
There are also rapid access clinics in specialized medicine. For example, a patient presenting with chest pain in the emergency room. His electrocardiogram is normal, his cardiac enzymes too. At that time, we are not very worried. But if the emergency doctor has a doubt, he sends the patient to the rapid access clinic in cardiology. He has an appointment the next day for a stress test (treadmill) and he sees the cardiologist. It prevents an overnight stay in the emergency room.