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Dr. Alan Forster, chief quality and performance officer at the hospital, said readmission rates have generally been "trending up" for complex reasons that include an aging population and the fact that medicine can now keep more people alive than in the past, which means "we have more sick people going home and it is likely some of them will come back." Age, he said, is the biggest risk factor for readmission to hospital. Forster said connecting readmission rates to hospital cuts is "not correct." The hospital, which has faced a funding freeze over the past four years, has not made cuts in areas that would affect the patients being readmitted, he added.

Forster said he believes the numbers should promote some action but that should go beyond the hospital and involve improving supports and care for the elderly, largely, in the community. "We need to think about how we look after people." Michael Hurley, president of the Ontario Council of Hospital Unions, said CUPE looked at readmission numbers from the Canadian Institute of Health Information after it began hearing reports from hospital workers about patients they believed were being discharged too soon.

The CIHI numbers back up that anecdotal evidence, he said, and point to a problem at The Ottawa Hospital, whose readmission rates are higher than national and provincial averages, higher than the average within the Champlain Local Health Integration Network and higher than other teaching hospitals (a category The Ottawa Hospitals says includes some facilities less complex and therefore not directly comparable). Hurley said being readmitted to hospital after discharge represents a huge setback for individuals as well as a significant additional cost to the health care system.

Hurley warned a decision to discharge most new mothers 24 hours after giving birth, which began last year and is not reflected in current statistics, could result in a higher readmission rates at The Ottawa Hospital and admission of more newborns to the Children's Hospital of Eastern Ontario. The Society of Obstetricians and Gynecologists of Canada released a policy statement in 2007 citing studies that have found that early discharge increases the risk to newborns. epayne@ottawacitizen.com

According to CIHI, Ontario government per capita funding for hospitals is $1,395.73. The rest of Canada, excluding Ontario, spends $1,749.69 per capita on hospitals. In other words, provincial and territorial governments outside of Ontario spend $353.96 more per person on hospitals than Ontario does, or roughly 25 per cent more. According to the findings, these numbers have increased steadily over the years and in 2005-2006 the gap between Canada and Ontario was at just 4.3 per cent.

"With working in the hospital you see reductions and they may seem small at first, but year-to-year you really see their growing impact," said Rodrigues. "Our front line workers hear the frustrations. They also hear about being sent home too early and see the readmissions." According to the report, Ontario has the fewest number of hospital beds in

any province and the length of hospital stays continue to be reduced for this reason. This decrease leads to an increase in readmissions. "We have a drop in admissions and an increase in readmissions," explained Hurley. "In terms of readmissions, Ontario is higher than the rest of Canada and Kingston is actually higher than the rest of Ontario. From our point of view, readmissions represent failures of the system to actually repair people properly."

The report also looked at funding for homecare and long-term care, an area the government has claimed they are expanding to meet growing needs. "We have been told that investments are being made in those areas," said Hurley. "But long-term care is 7.2 per cent behind the rest of the country and for homecare and community care we spend 14.3 per cent less. We have the fewest number of hospital beds, so you think we would have the most vibrant homecare system, but in fact we underspend."

Overall, Hurley emphasized that while hospitals require about a three per cent increase year to year to keep up with inflationary needs, hospitals in Ontario and in Kingston are only receiving about one per cent. "The increase should actually be around five per cent when you take into account additional pressures like population growth and aging and we are nowhere near that," he said. "Because of that we see nursing and staff cuts as a result and that is not acceptable." In terms of staffing, the reports conclude that in Kingston, across all hospitals, approximately 137 registered nurses and about 407 other staff would need to be added to equal comparable staffing in other provinces like Manitoba or New Brunswick.

That is a lot of people," said Hurley. "This lack of staffing means there is less care in the hospital for mothers who have just given birth, or people recovering from surgery and than again leads to readmissions and complications." So what can be done about these issues?

"People can talk to their Member of Provincial Parliament about these issues. That would be really appreciated," said Hurley. "We are doing these reports in every major community in the province and we are hoping to get some traction with the government to increase the funding." Illustration:

Mandy Marciniak / Michael Hurley, president of the OCHU (left) and Mike Rodrigues, president of CUPE 1974 (Kingston General Hospital).

Rodrigues will be joined at the media conference at Kingston City Hall (216 Ontario St.) in the Memorial Room, by Ontario Council of Hospital Unions (OCHU) president Michael Hurley. According to the data, Ontario hospital inpatient days have fallen 13.4 per cent over the last four years. In the rest of Canada (excluding Quebec) inpatient days, per-capita have actually increased 8.4 per cent over the last four years.

Real funding cuts for hospitals, shortened inpatient stays, keeping patients out of hospitals altogether and downsizing hospital capacity are the focus of the Liberals’ health reforms, says Hurley. “There is a direct correlation, we believe, between the provincial budget cuts to the hospital and these readmission rates.” 

Readmissions also represent a huge cost to the healthcare system, Hurley says, because these cases typically require much longer stays. “The Liberals have cut hospital budgets by 20 per cent over the last four years in real terms and now the hospital system, with the fewest beds available in the developed world is failing to properly heal an increasing number of people. The province needs to fund its hospitals properly.”

Godin will be joined at the media conference at the Royal Canadian Legion, (Boardroom) 180 Park Street, Brockville, by Ontario Council of Hospital Unions (OCHU) president Michael Hurley. According to the data, Ontario hospital inpatient days have fallen 13.4 per cent over the last four years. In the rest of Canada (excluding Quebec) inpatient days, per-capita have actually increased 8.4 per cent over the last four years.

Real funding cuts for hospitals, shortened inpatient stays, keeping patients out of hospitals altogether and downsizing hospital capacity are the focus of the Liberals’ health reforms, says Hurley. “There is a direct correlation, we believe, between the provincial budget cuts to the hospital and these readmission rates.” 

Readmissions also represent a huge cost to the healthcare system, Hurley says, because these cases typically require much longer stays. “The Liberals have cut hospital budgets by 20 per cent over the last four years in real terms and now the hospital system, with the fewest beds available in the developed world is failing to properly heal an increasing number of people. The province needs to fund its hospitals properly.”

Forster said the increased rate reflects recent changes including demographic changes and better technology and treatment, which means the hospitals can keep more people alive than before. He also said the Ottawa Hospital is a "teaching hospital," which means they deal with more specialized treatments. "The focus on the hospital and ongoing spending in the hospital isn't the right question," he said. "The question should be ... how do we improve care for people with complex diseases when they're not in the hospital?"

While the cuts have affected the hospitals, there have been improvements in monitoring people after their discharge, Forster said. He added the "slight increase" in readmission rate is not enough to be called a "spike." Ontario's Minister of Health and Long-Term Care Eric Hoskins said in an email correspondence the province will be increasing funding for home and community care by 5% every year, adding up to a total increase of $750 million, which would help reducing readmissions. Since 2003, the province has increased funding for the Ottawa Hospital by 45%, to nearly $700 million this year, he wrote.

Kira Leeb, CIHI’s director of health system performance, said the data show Ontario is “going in the wrong direction” in a number of other statistically significant areas.

Ontario hospitals lagging behind other provinces, report finds

Ontario hospitals lagging behind other provinces, report finds

Pat Campbell, president of the Ontario Hospital Association, noted that patients in this province tend to be sicker, making cross-country comparisons difficult. “It is generally not an apples-to-apples when you look at these statistics,” she said. Ontario hospitals are “more efficient” than those in other provinces because lengths of stay are shorter and admission rates are lower, Campbell added. More patients are cared for outside of hospital, in their own homes, by primary care providers and community health-care workers.

Hurley is travelling throughout the province, to explain how over the last decade Ontario's acute hospital funding has been on the slide compared to other provinces. In 2005-06, Ontario was "in the ballpark," with per capita funding of $1,112 compared to $1,159 for the rest of Canada, Hurley said, citing figures from the Canadian Institute for Health Information. Ten years later, Ontario's funding was $1,396 compared to $1,750 for the rest of Canada. He said the numbers extrapolated for Windsor are conservative, taking into account only the City of Windsor's 211,000 population, even though Windsor Regional's patients come from all over the Windsor-Essex region (population 389,000) and beyond.

Hurley said while Ontario did increase its funding for hospitals during the last decade, it did not come close to accounting for inflation, population growth and the aging population. This year, hospitals received a one per cent increase, but their actual costs rose 4.5 per cent, he said. "So their budgets have been cut again." Windsor Regional declined to comment on Hurley's assertions. In a statement, Health Minister Eric Hoskins said his government is doing what citizens want - continuing to invest in a health-care system that "puts patients first," asserting that 94 per cent of Ontarians now have a family doctor, and that wait times for some procedures are among the shortest in the country.

This year, it's increasing health funding by $1 billion, a 2.1 per cent increase, and it's increasing funding to hospitals by $345 million this year. "In Windsor, (since 2003) we've increased funding for local hospitals by more than $126 million - an increase of almost 50 per cent," said Hoskins. He also said Ontario is investing additional millions into home care, community health centres and home-based hospice and palliative care, because people prefer to receive their health care at home instead of a hospital. Hurley said the province argues that while it has been actively downsizing the acute care system, at the same time it's increasing investments in home care and longterm care, to "pick up the slack." But he said Ontario is actually spending less on long-term care and home care than the rest of the provinces. He said Ontario's high readmission rates are a sign the system is suffering. "So we have fewer beds, there's tremendous pressure to get people out of those beds and send them home, and often when they're sent home they haven't been made well actually and they return to hospital for a more lengthy and expensive readmission." Hurley said his council is calling on the government to fund hospitals "at least" at a level that reflects their rising costs, to stop reducing the number of beds and staffing, and to increase access to the people who need it.

The people being hardest hit by this are elderly, he said, who often have lived a long time without serious health problems, until they're hit with a health crisis that lands them at a hospital doorstep. "First they queue up in an ER for hours, and if they're going to be admitted it's likely a stretcher in a hallway," he said. And once admitted, there's likely pressure to get them discharged before they're fully well, he added. "For the elderly in particular they feel the brunt because there's rationing going on, the beds are so scarce." bcross@postmedia.com

Michael Hurley, president of the Ontario Council of Hospital Unions, discussed health-care funding in the province Thursday during a news conference at the Royal Canadian Legion Branch 255.

Sudbury's hospital is short-staffed and has a high patient readmission rate because of under-funding from the provincial government, according to a report released by the Ontario Council of Hospital Unions.  "There's incredible pressure to clear the beds because there's another person who needs that bed," council president Michael Hurley said. "That's the reality. We don't have enough capacity here in Sudbury."

178 more nurses, 529 more staff needed at Sudbury hospital 

Ontario's choice where to spend health dollars

Ontario's Ministry of Health countered the OCHU's claim by referencing another union's report — the Service Employees International Union  — that said Ontario and Quebec lead the country in spending health dollars "wisely and efficiently."

Sudbury hospital working on reducing patient readmissions

In 2009, under the Maryland Hospital Acquired Conditions Initiative, hospitals in the state stood to lose 0.5% of total inpatient revenue if they didn’t collectively reduce rates of specified postadmission complications such as urinary tract infection. Within a year, preventable complications dropped by almost 12%.

adjusting risk for severity of illness and comorbid conditions so hospitals that treat more seriously ill patients aren’t unfairly penalized for higher rates of negative outcomes.

Though the pay-for-outcomes payment model sounds good on paper, making it work in the health care system is another story, says Walter Wodchis, a professor of health care finance at the University of Toronto in Ontario. Linking negative outcomes to specific hospital procedures is difficult as there are many factors that affect how an individual reacts to a medical treatment: genetics, medical history, diet, fitness level and lifestyle, to name but a few.

The payment model would also be difficult to implement in hospitals with low patient volumes.

There have been many attempts to create risk-adjustment models, notes Wodchis, and the results haven’t been great.

Only 8.3 per cent of patients from cities were readmitted, compared to 9.5 of rural residents.

a shortage of home-care services like palliative care and physiotherapy outside major centres could be to blame

nearly one in 10 of those discharged from a hospital end up in an ER within a week.

Unfortunately, that's how many hospitals operate. Inadequate staffing is a nationwide problem, and with the exception of California, not a single state sets a minimum standard for hospital-wide nurse-to-patient ratios. Dozens of studies have found that the more patients assigned to a nurse, the higher the patients' risk of death, infections, complications, falls, failure-to-rescue rates and readmission to the hospital -- and the longer their hospital stay. According to one study, for every 100 surgical patients who die in hospitals where nurses are assigned four patients, 131 would die if they were assigned eight.

In pediatrics, adding even one extra surgical patient to a nurse's ratio increases a child's likelihood of readmission to the hospital by nearly 50 percent. The Center for Health Outcomes and Policy Research found that if every hospital improved its nurses' working conditions to the levels of the top quarter of hospitals, more than 40,000 lives would be saved nationwide every year.

Nurses are well aware of the problem. In a survey of nurses in Massachusetts released this month, 25 percent said that understaffing was directly responsible for patient deaths, 50 percent blamed understaffing for harm or injury to patients and 85 percent said that patient care is suffering because of the high numbers of patients assigned to each nurse. (The Massachusetts Nurses Association, a labor union, sponsored the study; it was conducted by an independent research firm and the majority of respondents were not members of the association.)

And yet too often, nurses are punished for speaking out. According to the New York State Nurses Association, this month Jack D. Weiler Hospital of the Albert Einstein College of Medicine in New York threatened nurses with arrest, and even escorted seven nurses out of the building, because, during a breakfast to celebrate National Nurses Week, the nurses discussed staffing shortages. (A spokesman for the hospital disputed this characterization of the events.)

It's not unusual for hospitals to intimidate nurses who speak up about understaffing, said Deborah Burger, co-president of National Nurses United, a union. "It happens all the time, and nurses are harassed into taking what they know are not safe assignments," she said. "The pressure has gotten even greater to keep your mouth shut. Nurses have gotten blackballed for speaking up."

The landscape hasn't always been so alarming. But as the push for hospital profits has increased, important matters like personnel count, most notably nurses, have suffered. "The biggest change in the last five to 10 years is the unrelenting emphasis on boosting their profit margins at the expense of patient safety," said David Schildmeier, a spokesman for the Massachusetts Nurses Association. "Absolutely every decision is made on the basis of cost savings."

Experts said that many hospital administrators assume the studies don't apply to them and fault individuals, not the system, for negative outcomes. "They mistakenly believe their staffing is adequate," said Judy Smetzer, the vice president of the Institute for Safe Medication Practices, a consumer group. "It's a vicious cycle. When they're understaffed, nurses are required to cut corners to get the work done the best they can. Then when there's a bad outcome, hospitals fire the nurse for cutting corners."

Nursing advocates continue to push for change. In April, National Nurses United filed a grievance against the James A. Haley Veterans' Hospital in Tampa, which it said is 100 registered nurses short of the minimum staffing levels mandated by the Department of Veterans Affairs (the hospital said it intends to hire more nurses, but disputes the union's reading of the mandate).

Nurses are the key to improving American health care; research has proved repeatedly that nurse staffing is directly tied to patient outcomes. Nurses are unsung and underestimated heroes who are needlessly overstretched and overdue for the kind of recognition befitting champions. For their sake and ours, we must insist that hospitals treat them right. ☐