The Effects of System Restructuring on Emergency Room Overcrowding in Montreal-Centre

by Daniele Roberge | Jun 01, 2001

Key Implications for Decision Makers

The Montreal area has been coping with serious problems of emergency room overcrowding for several years. In 1995 the Regional Board launched a major reorganization of healthcare services in Montreal. This initiative called for closing several short-term care hospitals and for a major shift to ambulatory services.

The study shows the following effects in emergency rooms:

  • The organization of community services was unable to adapt to the changes in the healthcare system, and this contributed in part to a constantly increasing volume of patients in emergency rooms.
  • Despite a significant rise in hospital productivity, access to hospital beds became increasingly limited for emergency clients.
  • The sharp cuts to beds and staffing levels clearly are restricting access to hospital resources.
  • The average length of hospital stays, which had levelled off in hospitals that had begun the shift to ambulatory care at an earlier date, began to rise with the increase in hospital clientele.
  • Clinical and management practices in participating hospitals have become more standardized, as evidenced by the narrowing of differences between hospitals in length of stays and use of emergency rooms.
  • Differences in length of stays between general and highly specialized hospitals are mainly due to differences in the composition of their clientele.
  • Some hospitals have a safety margin of too few beds to respond to fluctuations in demand.

Executive Summary

Quebec, and the Montreal area in particular, has been coping with chronic overcrowding in emergency rooms for several years. In 1995 the Regional Board launched a major reorganization of healthcare services in Montreal. This initiative called for closing several short-term care hospitals and for a major shift to ambulatory services. This research was designed to understand the impact of the shift to ambulatory care on the changing situation in emergency rooms.

The issue was approached from two angles:

  • To what extent have measures been implemented to manage ambulatory care in hospitals?
  • What is the impact of the level of implementation of ambulatory

The consequences

The study highlights the major efforts made by participating hospitals in recent years to implement the shift to ambulatory care, as well as the benefits of this shift for improved hospital productivity. However, the effects of improved hospital productivity on changes in length of gurney patient stays are inconclusive.

The constantly increasing volume of patients appears to be partly the result of growing problems of access to community services, for which the organization was unable to adapt to the changes in the healthcare system. The implementation of measures upstream and downstream from emergency rooms -such as homecare services or integrated services for vulnerable clients-is likely to reduce reliance on emergency services.

The study implies that access to hospital beds is becoming increasingly limited for emergency room clients. In the context of budget cuts, it is important to examine the scope and consequences for patients of under-use of short-term care beds.

The average length of hospital stays, which had levelled off in hospitals that had begun the shift to ambulatory care at an earlier date, has begun to rise. This trend is partly attributable to the increase in hospital clientele. Similar changes are anticipated in hospitals that began the shift to ambulatory care more recently.

Finally, clinical and management practices in participating hospitals have become more standardized, as evidenced by the narrowing of differences between hospitals in length of stays and use of emergency rooms. The narrowing differences between hospitals in length of stays in hospital and in emergency rooms suggests the emergence of a measure of standardization of clinical and management practices in participating hospitals. Differences in length of stays between general and highly specialized hospitals are mainly due to differences in the composition of their clientele.

Findings

All participating hospitals have implemented the shift to ambulatory care. Some institutions, however, have made most of their efforts before or around the announcement of the reconfiguration plan. For all the hospitals studied, we found a reduction in length of stays and an increase in outpatient care. This situation has specifically resulted in an increase of clientele for care units and a rise in hospital productivity.

The study revealed the impact of additional budget constraints imposed on hospitals as part of government policy to eliminate the deficit. This policy resulted in a reduction of the pool of short-term care beds and affected some institutions more than others. Productivity rose in all hospitals, as more was done with fewer resources. However, assuming optimal use of beds available in the hospitals studied, some have little or no margin of safety to cope with fluctuations in demand.

We noted a continuous, steady growth in the volume of gurney patients in the emergency rooms of all hospitals throughout the observation period. Hospital closings had less impact on the observed trend in changing patient volumes. As a result, the hospitals that remained open had to absorb this growth in volume despite cutbacks in the number of gurneys and beds in the region. Hospitals that took over from or were near the closed hospitals were only temporarily affected by the closures.

The average length of stay for gurney patients in emergency rooms has declined but these gains were made before the reorganization was announced, regardless of the initial level of overcrowding. The research findings therefore do not identify a clear pattern in the links between hospital productivity and the changing length of stays by emergency room gurney patients. However, the reversal in the trend toward longer average stays by gurney patients in recent years is a concern. In fact, despite earlier progress on the length of stays, hospital emergency rooms have been experiencing growing difficulty absorbing the continuous, steady rise in the volume of gurney patients.

Approach

This is a multiple-case study with time series spread over a seven-year period. Six hospitals in the Montreal-Centre region were selected based on:

  • Their proximity to or designation to take over from a closed hospital
  • The extent of overcrowding in their emergency room between 1991 and 1994

Implementation was carried out through a survey and semi-structured interviews of managers at participating hospitals. Various sources of administrative data were also used to document changes in:

  • Use of beds and gurneys
  • Availability of beds in participating hospitals

All the information gathered was presented in monographs and a cross analysis was conducted to verify replication of explanations. ARIMA models were used to analyse the change in use of gurneys based on the information contained in emergency room registers.

Further research

The study stresses the importance of developing a standard method for counting beds that factors in real-time bed closures as well as a computerized bed management tool to support adequate management of available resources.

The findings show that emergency room clients have increasingly limited access to hospital beds. The scope of this merits study to improve our understanding of whether or not - and to what extent - emergency rooms are used as a substitute for hospitalization, and of the consequences for patients of under-utilization of hospital resources.

Finally, we propose to study those new methods of organizing services (for example, integrated service networks for chronic patients and elderly clients, groups of family physicians, methods for articulating services between emergency rooms and the community) that help reduce reliance on emergency rooms.