Strategic Thoughts

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April 29, 2006

No ER Data

"We have been unable to find any indication of accelerated morbidity, mortality as a consequence of conditions in ERs."
Minister of Health George Abbott, Hansard, April 27, 2006

Abbott could have shown concern over the letters he has received from emergency room physicians, but he chose to up the stakes on his credibility with an assertion about morbidity and mortality. Consequently, he should be able to produce the research he has had done on morbidity and mortality related to emergency room treatment. Abbott told the Legislature that he and his deputy have been reviewing the allegations, made by two Royal Columbian Hospital physicians and a nurse, with respect to increased morbidity and mortality, "with the Fraser Health Authority, with the Ministry of Health and with the Canadian Institute for Health Information." That suggests there might be some data that the Ministry is using for its review.

The reduction in autopsies causes a data quality problem for cause of death but the Ministry should have information on the number of deaths of patients who were admitted via emergency rooms. Data do not exist which would allow a researcher to link emergency room deaths with type of care received in the ER. Morbidity data are even more difficult; the Canadian Institute for Health Information maintains the Hospital Morbidity Database. The most recent report on data quality in the database is for 2003-2004; according to the report, in that year the database captured discharge data for 388,186 in-patients in British Columbia. The elements in the database are inadequate for any research that seeks to determine whether persons treated in an emergency room are made worse (increased morbidity) as a result of a lack of resources or delays in being seen. Of course, the Ministry or Health Authorities (the agents of the Ministry) might have data that could be of some use. A Freedom of Information Request has been submitted to identify the data elements and methodology of the Ministry's review.

It is highly likely that the anecdotal evidence from emergency room physicians, who were widely quoted in the news, is the best information that is available. It is also highly likely that the high-sounding statement from Abbott on morbidity and mortality is nothing but a smoke screen since the data to do the kind of research he suggests probably don't exist. It would be a good idea to try to put some hard data together, but in the meantime the warnings from emergency room physicians should be taken seriously, much more seriously than the good humoured Minister of Health seems to be doing.

April 26, 2006

Emergency Room Crisis, or Not

George Abbott, MLA for Shuswap, is quick witted and has thoroughly studied of his portfolio; however, his apparent inability to give ordinary people understandable answers may be his undoing.

Emergency Room doctors at New Westminster's Royal Columbian Hospital wrote: "The current setting of severe bed shortage and lack of resources means patients will continue to suffer from our inability to see them safely in a timely fashion." Abbott's response was to quote headlines from the 1990s before going on to say: "One of the challenges of debating with the members opposite, frequently, is that they either live in some mythical past where these problems didn't exist - because clearly they did - or else they are debating some socialist nirvana of the future that never will exist in this province." Could Abbott really believe that it is some kind of "socialist nirvana" to want adequate resources for BC's emergency rooms?

It has become standard practice for the Campbell Liberals to answer calls for accountability by citing their versions of events from the last decade. In response to the Hughes' Report, Premier Campbell said: "I accept that we took on a big load. I accept that we took on many challenges. I accept that we may have demanded too much of the people who were at work in trying to help us do that." Campbell refused to offer an apology, and when asked to account for his failures he simply said that: "I think it is important, as Mr. Hughes suggested, for us to start looking ahead …" That's strange for a Premier and government that answers questions about accountability by looking backwards.

BC's former Auditor General, George Morfitt, helped create a framework which had the potential to revolutionize politics and government accountability if only it were supported by the political parties, and most importantly, by the public. He wrote:

"Why the concern over accountability? Because, I believe, people no longer judge government simply on the basis of how much it spends on a problem. Rather, as taxpayers, they wonder if the promise of better, more efficient government has been realized. As consumers of government services, they want to know whether the policies and programs of government are effective, administratively efficient and of high quality. And as citizens, they wonder whose interests are being served, and whether the government has been able to strike the right balance among competing interests (such as protecting the environment while encouraging economic development)."
Morfitt went on to say that that "public reporting must be improved such that it:
  • focuses on intentions and results;
  • covers all key aspects of performance; and
  • is comprehensive and inclusive of all government organizations."

Those recommendations resulted in the Budget Transparency and Accountability Act, which requires a strategic plan, service plans for each ministry and annual reports which set out intentions and quantifiable results. Unfortunately, those reports seem to be considered as a legalistic or academic exercise; the focus of political parties and the media continues to concentrate on the daily thrust and jab of the most quotable one-liner. The second of three goals in the Ministry of Health's service plan is that: "Patients receive appropriate, effective, quality care at the right time in the right setting. Health services are planned, managed and delivered in concert with patient needs." One of the performance measurements for that goal is the: "Proportion of patients admitted from an emergency department to an inpatient bed within 10 hours of the decision to admit." The goal for this year is that 80% of patients in emergency departments be admitted to an inpatient bed within 10 hours, and reduced to 8 hours next year. Emergency room physicians and the government are arguing over whether patients are dying in emergency rooms. Of course, there are always patients who die in emergency rooms, so the question is how many are needlessly dying there. No one is going to identify specific cases since that would call into question the judgment of the physicians and staff who served, or failed, a particular patient. Instead of engaging in this no-win debate, the government should be measured by the standard it set for itself. If that standard is inadequate, emergency room physicians, and others with the knowledge to comment, should say so. If the goal is realistic, but not being met, that should be the focus of the debate. Don't hold your breath waiting for that kind of rational debate to start in health care or any other issue in BC. Debating measurable intentions and results is not as attention grabbing as headlines over deaths in emergency wards.


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