A Dalhousie University researcher says there’s been a dramatic rise in the number of vulnerable people with no acute medical issues being left at Halifax area emergency departments.
The phenomenon has been on the rise since the pandemic began and tends to increase over the holidays. These patients are largely older adults and also includes people with longstanding mental health issues.
Researcher and physician Dr. Jasmine Mah said the number of orphan patients — also referred to as social admissions — left at emergency departments in the Halifax area has increased “exponentially” since 2020.
In 2010, there were just three social admissions in the entire year. In 2020, Halifax hospitals were seeing on average one to two such admissions each week.
Last year, that number climbed to 109. It’s expected to break that record when 2022 draws to a close.
“It’s Christmas season, which means things will pick up, and we’re on track for 120, 130 (social admissions) this year,” Mah said in an interview Monday.
“That’s a lot of people who don’t need to be in hospital.”
These patients tend to have poor outcomes while in hospital despite not having any medical reason to be there.
“There is high in-hospital mortality for these patients who theoretically have no acute medical issues. They do get de-conditioned in hospital, they do fall in hospital, they receive medications that they probably shouldn’t,” Mah said.
“It is not safe for them and it’s not safe if you yourself need hospital care. That’s because we have these patients who are not supposed to be in hospital keeping beds for those who need to go for surgery.”
‘Our social systems are failing’
These patients are often taken to emergency departments by friends or family members who either can’t properly care for them at home or experience difficulty accessing services in their community.
More must be done, Mah said, to help socially vulnerable patients stay in their homes.
“It is happening because our social systems are failing. We want to keep older adults in the community. We know that older adults are overwhelmingly happier in the community,” Mah said.
“The majority of people do not want to live in hospital. But there are not enough resources, there is not enough help formally to actually sustain that. So we rely so heavily on informal care. Combine that with everything else that’s going on and those people are burning out as well.”
Mah, an internal medicine resident, has been interested in this patient population since 2017. She began studying the phenomena more in depth in 2019, and has already reviewed the charts of all orphan patients in Halifax dating back to 2010.
“I was prompted to look into this very vulnerable population because of how sad some of these stories were,” Mah said.
“When you care for some of these patients on the ward and realize that there is nobody else to advocate for them, you really do get a personal connection. As more of these patients tell similar stories, you realize that we are not taking care of them as a society.”
‘Happening to people just like us’
Mah has many stories of orphan patients that stick with her.
They include older adults with poor sight and hearing who rely on their spouses to cook and bathe. When those partners leave or pass away, there is no where for them to go except the emergency department.
She said some of these individuals are confused, but some are “very cognitively well.”
“They can still move around, but still need someone to help them with small daily tasks to live in the community,” Mah said.
“Think of an older gentleman who cannot see but needs cueing to bathe or cook or take medications safely, because they’ve never done it in their entire lives–but there is no family or friends to do this. That’s the only care we’re providing some patients in hospital.”
Mah points to another recent example where family members arrived at the emergency department in tears with their grandparent. A typical story is their dementia has progressed to the point where overnight behaviours become increasingly difficult for the family to manage.
“They’ve maxed out continuing care, they’ve maxed out VON support…They actually have private money that they can pay,” Mah said.
“But with our labour shortage, they just said ‘There’s nobody who has any further time to help us, who has any availability.’ And so they had to bring in their grandparent.”
Mah said as much as we might want to believe this would never happen to us, the reality is that it could.
“At the end of the day, this isn’t just people who are poor or on the street. This could be any one of us,” she said. “This is happening to people just like us.”
‘They’re people who are forgotten’
Mah said these socially vulnerable people also tend to remain in hospital for disproportionately longer periods of time than the average person.
In Halifax, their hospital stays range in length from one day to a maximum of 624 days.
“There is nobody else to advocate for this population on their behalf. That’s because often, if they are to the point where they are a social admission, it means that their social circle is so small, or they have maxed out, or there is nobody else,” Mah said.
“By the time they’re in hospital, these are patients who are rarely visited. They’re people who are forgotten. And if we as a medical system don’t care for them because, quote unquote, they don’t have acute medical issues, then there’s nobody else. And our job is to help those in need.”
‘A reflection of our values as a society’
Last year Mah received a grant to launch a series of interviews with these patients, their caregivers (if they have any), and health care professionals and administrators.
The research team has already completed half of those interviews and Mah expects results will likely be published in late 2023.
The project involves stakeholders ranging from primary care providers and researchers to pharmacists and hospital administrators. The goal is to find the best solutions to this growing problem.
“From a system level, I think we actually have to recognize that this phenomenon of the social admission that’s increasing is a reflection of our values as a society and ageism to a large degree,” Mah said.
“We say we care about aging in the community, but we’re not putting our resources there. We need to have more physiotherapists, occupational therapists.”
Avoid being a gateway to long term care
As an example, Mah points to someone who ends up in the hospital because there are too many steps in their home.
“That is something we can help with that would actually cost less than being in the hospital.”
Mah said they’re currently working on a model for transitioning between hospital care and non-hospital care. They already know many of those admitted as orphan patients can be helped within the community.
Her review of the charts of orphan patients showed that 38.1% had no formal supports before coming into hospital. She described this as an opportunity for intervention.
“With time, we want to show that there are individuals who are at risk of this to show which interventions have worked to keep them out of hospital,” Mah said.
“Once they are in hospital, there are models and other systems, such as intensive rehab programs, that are able to help them get out of hospital instead of the hospital being a gateway to long term care.”
‘We have failed in so many ways’
Mah said it’s also important for family members and friends to be aware of the resources available in their communities before a loved one runs into difficulty.
She said it’s also important for policymakers to invest in more than just hospitals.
“Some of these stories, your heart goes out for them…We have failed in so many ways, and there are solutions to make it better,’ Mah said.
“But we can’t do it on a one-off and one-off. It’s got to be available for everyone.”
The hope is to eventually expand the research beyond HRM and to explore the issue of social admissions across the province.
“Without good data we don’t even know what this population needs,” she said. “No service in hospital cares for them, no service outside of hospital takes responsibility.”