What happened to the hospital patients who had “nowhere else to go”?

The rush to clear Canadian hospital beds to make room for coronavirus disease 2019 (COVID-19) cases has meant finding places to send thousands of patients who no longer need acute care but previously had nowhere else to go.

Delays in discharging patients who need an alternate level of care, most of whom are older adults, has been a longstanding challenge in Canadian health care, contributing to long waits in emergency departments.

When the first Canadian cases of COVID-19 surfaced in January, more than 3000 such patients were occupying nearly one in five hospital beds in Ontario and were often unfairly blamed for blocking beds. About a third were waiting for long-term care, while the rest were waiting for home care (12.2%), rehabilitation (11.6%), assisted living (10.3%) and other services.

According to Ontario’s Ministry of Health and Long-Term Care, hospitals have since discharged 2116 patients to other settings, including back home, with or without supports, and to long-term care, retirement homes and palliative care. A ministry spokesperson cautioned that “not all” of these transfers were because of COVID-19.

The rapid discharge of patients who need alternate levels of care has drawn criticism from the Ontario Health Coalition, a nonpartisan advocacy group. The coalition has received “thousands of calls from people who were told they must get their loved ones out of hospitals,” according to executive director Natalie Mehra. She is concerned that many patients have landed in settings with inadequate care or a lack of oversight.

Early in the pandemic, there was a push in some provinces to discharge patients no longer requiring acute care to long-term care settings. New Brunswick, for example, placed 65 such patients in long-term care homes. Hospitals in British Columbia moved 1000 patients to other settings, including a new 320-bed long-term care facility called The Summit. And Quebec, which needed to clear 6000 beds, sent an undisclosed number of patients waiting for alternate levels of care to Centres d‘hébergement de soins de longue durée (CHSLD).

Advocates worry the pandemic has worsened the situation of patients previously unfairly blamed for blocking beds.

Image courtesy of iStock.com/JohnnyGreig

By mid-April, however, both Quebec and Ontario stopped admitting people to long-term care because the sector was grappling with deadly outbreaks of coronavirus. As of May 7, 82% of all COVID-19 deaths in Canada were linked to long-term care. Ontario has since resumed admissions to long-term care homes without active outbreaks. But according to the Ontario Health Coalition, the long-term care sector remains critically understaffed and unable to curb new infections.

The coalition recently documented a more than 200% increase in COVID-19 deaths among long-term care residents in Ontario between April 21 and May 6. Over those two weeks, deaths among residents rose from 339 to 1065 by the coalition’s count, which is slightly higher than Ontario’s official toll. By comparison, Ontario Public Health reported an increase of 13 to 40 COVID-19 deaths among hospital patients over the same period. The Ministry of Long-Term Care told CMAJ that capacity and staffing remain “tremendous challenges for the sector, resulting in high levels of ALC [alternate level of care] Ontarians on the wait list for appropriate care.”

Mehra is also concerned about the offloading of patients to assisted living or retirement facilities. Most are forprofit and self-regulating under Ontario’s Retirement Homes Act, which is not a medical act, Mehra says. The Ontario Health Coalition called for the act’s repeal in 2010, arguing it did not provide adequate safeguards for residents.

An alternative solution may be funding a level of care between acute and long-term care to receive patients who can’t be discharged elsewhere, says Dr. Brian Hodges, executive vice president of education and chief medical officer at the University Health Network in Toronto.

The Toronto Rehabilitation Institute’s post-acute program recently opened 24 beds in a repurposed space and 48 in a “reactivation” unit designed to serve patients caught in the limbo between acute care and other settings during the pandemic. The program accommodates about 70 of the University Health Network’s 120 patients needing an alternative level of care, using existing staff and no additional funding.

Other hospitals have set up temporary wards in hotels and other unused spaces. For example, Sudbury’s Ramsey Lake Health Centre freed 200 beds by transferring 95 patients to the Clarion Hotel.

In Quebec, patients have been moved from long-term care to the previously shuttered l’Hôtel-Dieu de Montréal hospital. According to Dr. Fabrice Brunet, president and CEO of the Centre Hospitalier de l’Université de Montréal, the transitional facility is being used to stabilize patients. He also noted that the Quebec Ministry of Health and Social Services is sending patients previously stuck in hospital and others to “containment sites in the community.”

Meanwhile, in Saskatchewan, some rural hospitals will be dedicated to patients requiring alternate levels of care.

“We’re seeing innovative solutions,” said Dr. Ben Kaasa, a hospitalist at Toronto Western Hospital. “Barriers that used to exist [to discharging patients] are vanishing.”