BED LIMBO

Code Zero: Elderly stuck in bed 'limbo'
Bed blockers take up valuable space as the backlog grows

With a single devastating misstep, Wai Ching Wong is falling.

Down, down she goes, frail head over elderly heels. Down onto the hard basement floor of her son's Greenwood Ave. home.

The impact brutalizes her withered 91-year-old body: Multiple fractures to the left arm; multiple fractures to the left ribs, numbers three through six.

As she lies crumpled at the bottom, one would hope that the damage is done, that the healing can now begin. But Wai Ching Wong's descent has just begun. Now she will tumble through the cracks of Canadian health care.

At least Wong will have company. Across Canada, more than 54 per cent of the 197,002 hospital injury admissions in 1999/2000 were caused by falls. Well over half were seniors.

In Toronto last year, paramedics responded to a staggering 22,000 emergency calls for people who took a tumble.

The reasons the elderly fall are varied. Some injure themselves in unsafe, isolated living conditions; some succumb to dizziness brought on by conflicting prescriptions — drugs often ordered up by a variety of doctors, none of whom speak to each other; others just fall from frailty.

The bottom line: A whole population is falling over itself into a health-care system unable to cope with the downward spiral toward costly long-term care. And as the population ages, the system is in danger of going broke on broken hips alone.

But that's the last thing on the mind of John Ma, the son of Wai Ching Wong. In a panic, he rushes downstairs in answer to his mother's cries. But at age 74, he hasn't the strength to assist. So he telephones his son, Bill Ma, who is busy running the family's restaurant on Gerrard St. near Broadview Ave. He rushes home, and together three generations of the family creep gingerly up the stairs, out the door and into their car.

There will be no ambulance, because the Wong family does not trust the ambulance service. In fact, they do not trust the health-care system. But today there is no choice. They race through the cold, gray March afternoon to Toronto East General Hospital.

Their matriarch needs them, both for comfort and for communication. Like many of the wounded coming through the doors of East General, Wong speaks no English. In excruciating pain this Wednesday afternoon, she is parked in a cot in overflow — the brightly painted pediatrics corner of the harried emergency room — unable to comprehend the chaos around her, or the agonizing wait for a bed upstairs.

Wong does not lack for care. Nurses, a physiotherapist, a surgeon, an orthopedic specialist, a home care co-ordinator and others all make appearances. Still, it's not until Thursday evening, after 30 hours of waiting, that she finally gets a bed.

It will take only a few days for her to stabilize, then two weeks to make the applications for a nursing home bed — but another five weeks before she will leave Toronto East General.

Wai Ching Wong is about to become a bed blocker.

= = =

Put simply, a bed blocker is a patient with no medical reason for being in the hospital. Bed blockers are the in-betweens awaiting transfer elsewhere — all fixed up, nowhere to go.

On any given day, as many as 55 of the hospital's 498 beds are held by people playing the waiting game. Bed blockers squeeze out crucial resources at the average daily rate of $534 per bed at East General, even as the backlog at Emergency grows.

Each is there entirely by default, waiting to be transferred to another type of care — in most cases, less expensive care tailored to their needs — be it a rehabilitation facility, supportive housing or a nursing home. Each is in limbo, on a list somewhere, hoping for a better situation than lying in a bed they don't really need — a bed that costs almost five times more than the average cost of a long-term care bed in Ontario.

Such is the lot of Beverly Morrow, a retired machinist. By the time Wai Ching Wong is admitted to East General, Morrow has spent three months in the Adult and Elder Care Ward.

This is the ward Wong should be going to, but it is already jammed. It's always jammed.

So she waits.

One of eight siblings from a family known for its longevity, Morrow is a lifelong bachelor of 67. Far too young to be facing 20 years in a nursing home, say two of his four sisters, Shirley Tinker, 74, and Imogene Gregg, 63.

Like Wong, Morrow took a header in his east-end apartment in January. Although the injury was largely cosmetic — a bruised, blackened eye — he has been at East General ever since.

The sisters say Morrow's problems began two years ago, when he was hospitalized after his health declined suddenly, and later treated for a fluid build- up on his brain. The solution was a drainage shunt, surgically implanted in his skull at another Toronto hospital.

Back home, Morrow began to slide when his crucial home-care support was slashed from one hour each day to just two visits per week. Then one day, Gregg's 4-year-old grandson called attention to what no one else had noticed: "Why does Uncle Bev have that white thing in his head?" asked the boy.

It was the drainage shunt, protruding through his broken scalp.

Back at the hospital where his first shunt was inserted, more invasive surgery planted a second one on the opposite side of Morrow's head. He was sent home two days after the procedure.

Within a day of his release, Morrow begin having seizures. He was rushed to East General, where he spent a month. CAT scans were done, his diet was adjusted, and he was put on anti-seizure drugs, though doctors never managed to pinpoint the cause. He was sent home again just before Christmas.

In January, the fall brought him back to East General. First he was in the Adult and Elder unit, then he was shuffled over to another unit, where he lies today — too healthy to stay there, too frail to live at home.

Until now, the Morrow family had clung to the hope that Bev could move to a long-term rehabilitation facility, where he might rebuild the strength to go home. But after three months of trying, it appears he is ineligible. Such placements are hard to come by, and offered mostly to patients with excellent prospects for a strong recovery.

That leaves only a nursing home.

"It's a hard decision to make. It's a final decision," says Gregg. "You know he's going into that nursing home and he's never coming out. And he's only 67.

"But it can't be any worse than just sitting here when he doesn't have the medical need."

Angry over the home-care cuts and what they perceive as an utter lack of co-ordination and communication throughout his encounters with health care, Morrow's sisters say they feel helpless.

Morrow has been on the waiting list for a nursing home since Feb. 20. Through no fault of his own, Morrow will continue to block a bed and contribute to a backlog at East General for months to come, perhaps as much as a year. Such is the wait for those without the money to buy their way into long-term care.

There are 485 people waiting for long-term care beds in East York alone. In the old city of Toronto, the figure is 2,768.

Most of those waiting are at home, or with a relative, and some are in retirement homes. But in some municipalities, as many as 10 per cent are marking time in hospital.

"I want to get out of the hospital, that's for sure," says Morrow, his speech low and slow, his point loud and clear. "If I was a millionaire, I could probably live by myself."

But the former auto worker is no wealthy man. He knows he won't have much choice about his final home. A lifelong fan of Dixieland jazz and country music, he hopes whoever takes him next will allow that much.

"What I really want is a nice place where I can play my music."

= = = =

Ivor Ellis is at the same crossroads as Morrow, but he won't be blocking any beds on the way to a nursing home.

Ellis, 90, spent half his life working for Toronto Hydro. In the late 1940s, he built the family bungalow on a vacant lot near St. Clair and O'Connor. He built a single-storey house so he could stay there until his last breath.

But today, it appears that breath will come elsewhere. Ellis is living in a retirement lodge, a temporary home since he was discharged from hospital almost three months ago, and there's talk of moving him to a nursing home, with a higher level of care and more activities.

He is in the midst of a verbal jousting match with his wife Reta-May, 87, his son Michael, 54, and Kim Kurchinski, long-care placement co-ordinator for the East York Access Centre.

Ellis is interested in only one home: the one he built. But his body, still weak from a three-month battle with pneumonia, isn't going along with the plan.

Ellis has had falls. Twice in his garden. The first time he fell, he was able to press his Lifeline electronic alarm pendant and paramedics were at his side in 10 minutes. The second time, he wasn't wearing the Lifeline. He was left lying face down for an hour before the neighbours spotted him.

"Oh, the garbage men would have found me," Ellis quips. "But what if it wasn't garbage day?" Reta-May fires back.

Much as she wants to keep her husband at home, Reta-May can't care for Ivor on her own. She's already getting an array of nursing care and personal support for herself through the East York Access Centre, plus some extra homemaking services, for which she pays $35 a week.

The Ellis family has money on its side. OHIP covers the lion's share of nursing home costs for those without the means by providing a so-called "ward bed" in a room shared by two to four people. But the wait can be as long as several years. Unsubsidized rooms, offered at a rate of $1,900 a month, come up far more frequently. And the family is prepared to pay for it. They're already paying $2,100 a month for the retirement home.

Kurchinski leaves to place a call and returns minutes later announcing there is a private room available at Bendale Acres in Scarborough. But the family will have to decide in the next two days.

The Ellis family scouted a number of nursing homes last summer before Ivor's health failed. Bendale was among their favourites.

After a lengthy conversation, Kurchinski senses Ellis isn't ready to face his new reality.

"I'm not sure you are capable of making a decision for yourself," she says. "Do you understand when I talk about your judgment being off? It's okay to disagree with me."

Ellis says nothing. Kurchinski then asks if he minds her talking to the family about nursing homes.

"I don't mind if you talk to them," he says calmly, referring to his wife and son. "Just don't talk to me."

= = =

Back at East General, Seerojanie Nancoo, 34, has been stuck in Room B506 for a year now. It hasn't been good for her, it hasn't been good for the system.

Nancoo's problems began in the fall of 2000 with kidney failure, forcing her on to dialysis and out of her job as a children's nanny. Last spring, she lost both her legs to gangrene, due to complications from diabetes.

With no job and no money, Nancoo has nowhere to go. She has lived at East General since May, 2001. She dreams of the night she can turn off the lights and sleep, uninterrupted by the screams of patients and the clank of hospital equipment. Her mouth waters at the thought of once again cooking West Indian food in her own kitchen.

Where can she go? A nursing home filled with elderly ill more than twice her age makes no sense. Most younger people in long-term care have brain injuries, yet Nancoo has no cognitive problems.

What she needs is a government-subsidized supportive housing unit or an accessible apartment with counters and appliances at wheelchair level. But such accommodation is extremely rare.

So here she is, in limbo at East General, at a cost of $534 a day. The almost $200,000 that Ontario taxpayers invested in Nancoo's hospital care since last May alone could have built her the kind of place she needs.

Still reeling from the trauma of losing both legs, Nancoo nevertheless is trying hard to make herself placeable. Each day she takes her turn in the second-floor hospital gym, working the triceps press and overhead lift machine, developing upper body strength to maximize her mobility. She can dress, bathe, eat and administer her own dialysis and diabetic care.

And she can get around on the one prosthetic leg the hospital purchased for her, with the help of a walker. She's even ready to work, if work can be found.

For now, Nancoo spends most days in her wheelchair, watching the world go by in the hallway of hospital unit B-5.

"I don't want to be around sick people," says Nancoo. She's wearing an "I love Trinidad and Tobago" T-shirt. A white hospital blanket is draped over her thighs.

"I want to live a normal life. But I need to find some place I feel safe."

Penny Wolcott, administrative director of B-5, is confounded by Nancoo's plight.

"We've called everybody, we've tried everything. We have provided a prosthesis so that she could be placeable, but still nothing," says Wolcott.

"When you find that the other pieces aren't there, it's like stepping off into a void.

"The worst cost is the opportunity cost. That bed isn't available for emergency or surgical patients. Somebody is displaced for every day an individual is here when they don't have to be.

"The other cost: This is a young woman. This is no place for her to live. The system has enough cracks in it that individuals do fall through. She is one of them."

= = =

Dr. Jonathan Ruth knows all about bed blockers. As medical chief of the Adult and Elder unit, more than 100 of the 498 beds at East General fall under his purview, dozens of them filled with people waiting for nursing homes or rehab.

A specialist in geriatrics, he sees them all, and is passionate about their care. Bev Morrow's sisters, in fact, say Dr. Ruth was one of the few links in the health-care chain to really be there for their brother. But even Ruth concedes the system, like so many frail elderly, is falling down.

Without a trace of irony, Ruth offers this pill of wisdom: "The hospital is not the best place to be if you're not well."

He breaks solutions down along the lines of "macro" and "micro." The macro solution begins with pediatrics. Think in terms of 50-year plans for better public health. Ingrain the lessons of diet and exercise, wage total war on the scourges of tobacco and alcohol.

And among his micro, short-term solutions: Bring back the house call, to help keep the elderly out of hospital in the first place; computerize medical records, to ease communication and make room for the bed blockers.

"Who would want to be in a hospital if they're medically stable? It's not aesthetically pleasing, it's not catering to their needs, there's a high risk of infection," he says. "There's no question this is not the right place for anybody once they're medically stable, regardless of age but perhaps especially so for the elderly."

The Ontario government promised in 1998 to build 20,000 long-term care beds but so far, only about 3,700 have opened. A 2001 study commissioned by the province placed Ontario last out of 10 jurisdictions — including Mississippi and Manitoba — in funding care and activities for residents of nursing homes and other long-term care facilities.

All of that is for the end of the process, when people have nowhere left to go but into care. In other parts of health care, people are working hard to keep people out of care in the first place.

One of the most hands-on, heads-up initiatives can be found on the drawing board of Toronto Emergency Medical Service and a group of community agencies, including North York Public Health.

As the people who respond to the 911 calls, Toronto's paramedics are the distant early warning line for the feeble and frail. Statistics show that once a senior falls, it is often the beginning of a steady decline. Yet up to now, paramedics haven't been able to do much more than soothe and transport the injured.

In a pilot project planned for September, EMS staff will dispatch a public health nurse to the home within 48 hours of certain fall calls. The nurse will audit the person's medical and physical environment — the layout of the home, slickness of the floors, check for possible conflicting medications that might lead to dizziness — and direct changes to reduce the likelihood of another fall.

"If someone busts a hip, that's a huge cost to the system," says Dean Shaddock, a veteran paramedic in charge of the EMS community medicine program. "For a little bit of money up front in prevention, the returns in cost savings are huge. People stay healthier, are able to live longer and on their own."

= = =

Living on her own is no longer an option for Wai Ching Wong. It is not easy, her grandson Bill explains, for the family to consider a nursing home. But there is no other choice. The support available in her seniors apartment building is not enough, even with extra home care.

The wait begins on April 8, when the East York Access Centre helps the family do the paperwork for spots in three nursing homes. Their first choice is Heritage Nursing Home, with its Chinese-speaking staff and convenient location on Queen St. E.

At first, no one can tell them how long Wong will wait — "a long time" is all they hear from one nursing home. So her devoted children and grandchildren visit half a dozen times a day, translating her needs for staff and keeping her spirits up.

Then, on May 10, Wai Ching Wong gets a room at Heritage Nursing Home. She has a bed, a wardrobe and a night table in a room shared with three other seniors. She eats Chinese food, speaks to the staff in her dialect, and visits a nearby park every day. The average length of stay at East General is six days. Wai Ching Wong left the hospital almost five weeks after she was ready to leave.

Bev Morrow, the 67-year-old bachelor, is still waiting after 14 weeks on the list. So is double amputee Seerojanie Nancoo, who just passed the one-year anniversary of her arrival at East General.

But not Ivor Ellis. A week after a placement co-ordinator talked to the family about nursing homes, he was settling in at Bendale Acres — one of the homes Bev Morrow hopes to get into.

Ellis has made some friends and enjoys the weekly art class. He is still not thrilled to be in a nursing home, but he has a room of his own and the care he needs — a luxury his family can afford.