I Visit a Foreign Emergency Department

Okay, foreign, as in to a hospital I was not familiar with, which is sort of like (but not really) travelling overseas. Me and my wrecked ankle. Not my Emergency, mostly because some little bird told me a (figurative) bomb had exploded at Acme Regional’s Emerg, and I didn’t want adding to the clots of patients in the hallways. Going to strange Emergency Departments is always entertaining and informative, and so it was.

Arrived at 1034. (I kept notes in the margins of the most recent issue of Harper’s, where, incidentally there’s an excellent article on autism. And also, you might observe, became one of those freaky people who keeps notes about their Emergency Department visits. Emerg nurses will know what I’m talking about.)

Triaged at 1036.

Registered at 1041. Triage Nurse: “Tell the registration clerk to send you directly to xray.”

Taken by wheelchair to radiology from registration by what looked to be a 90 year-old volunteer (who wheezed as she pushed) at 1044.

BTW, this is NOT my ankle

Four views of the ankle at 1054.

Returned to waiting room at 1101.

Brought in by the doc himself at 1124.

Discharged at 1131. No fracture, by the way.*

I thought: Hot dog, this is how Emergency Departments are supposed to work. Patients shouldn’t be sitting in waiting rooms for hours on end, being tortured by Dr. Phil on the tube and tattered issues National Geographic twenty years out of date?

But most EDs don’t work like this. You see, it was dead quiet, as in bereft of patients, empty, unpopulated, shoot-a-cannon-down-the-corridor-and-hit-nothing, uninhabited, vacant, barren, and void. There were no admitted patients lolling about, taking up space and beds. Actual lumps-and-bumps patients, like myself, flew in and flew out. More acutely sick patients could be seen expeditiously.

We’re told constantly by the Ministry of Health that the issue of Emergency Department waits is complex and layered, which I take is Ministrese for There is No Real Political Will to Fix the Problem.

Actually it isn’t that complex or layered. This is how it works: long term care beds are in short supply, which means that patients waiting for placement are blocking acute care beds in hospitals, which means admitted patients spend days rotting the Emergency Department.

There are fixes around the edges of the problem, such the standard preventative care approach (i.e. healthy people use less services), but also such ideas as facilitating supports for in the community through Home Care, so the  frail elderly can stay out of nursing homes and live at home longer — and which has been shown to have better outcomes anyway. But in the end, what’s really required are more long-term care beds, lots more, because the demographics are not on our side. Unfortunately, the provincial government doesn’t seem too keen on providing them.


*And thanks for all the messages of concern and support. Yesterday was a wretch. I’m being told I was a little bitchy yesterday. (Narcs help.) Nurses are the worst patients, aren’t they?

, , , , , , , ,

  1. #1 by paedsnurse on Thursday 25 March 2010 - 1229

    Wouldn’t it be nice if all EDs worked that way? Or better yet, wouldn’t it have been amazing if they worked like that during H1N1?

  2. #2 by Maha on Thursday 25 March 2010 - 2150

    Surely this place exists solely in your imagination no?

    In any case, hope you feel better soon and glad to hear it’s not broken!

    • #3 by torontoemerg on Friday 26 March 2010 - 0637

      I swear, in and out in less than an hour.

  3. #4 by Zoe on Friday 26 March 2010 - 1402

    Actually, we re-vamped how our ER works about a year ago, and slashed wait times for patients with injuries such as yours. Despite nursing for years suggesting these changes, it wasn’t until the government dangled $$ in front of administration did these changes actually occur.

    Previously, the dept was divided into 2 sections: Acute and Fastrack. Over the years, as I’m sure we are are painfully aware, the less acute abdo pains got pushed to fastrack (young, hemodynamically stable abdo pains, usually just gastros) to make room for the elderly, less stable stuff.

    Now, we have 3 sections: Acute, RAZ (rapid assessment zone) and Supertrack.

    Supertrack is for the true walking wounded. Simple, straightforward, uncomplicated injuries. Also, all the outpatient IVT’s go to Supertrack, where we book appointments. Any short-term daily dressing changes go there too, also with booked appts. Triage can send pt’s directly to x-ray, with notes on the chart to go to supertrack following imaging. Average door-to-door time for this dept is around 90mins, and that’s a busy day. Less busy days are much quicker. It is staffed by 1 RN, 1 LPN, 1 unit clerk, and 1 EP. Also (since I usually work triage) the ability to book appts for these things allows me to filter people out of the general waiting room and book an appt for the next day to be seen in supertrack. Simple stuff like minor cast problems, or suture removal requests, or general follow up stuff.

    RAZ is where hemodynamically stable pts go, usually younger, or stuff that’s too complicated for supertrack. We have started nurse-initiated orders at triage (bloodwork, xrays, urine samples, ECGs) and by the time patients get called in, all tests are back. Dr. examines, diagnosis, sometimes adds more tests (most Add-on bw can be done on samples already drawn), and if the pt is stable, is booked for outpatient imaging, and discharged. Otherwise, they get admitted to get imaging done on the same day. They get IV’s fluids, meds etc. Most people triaged to this dept. are discharged within 4 hrs.

    I won’t describe the Acute side, we’re all familiar with this area.

    Anyway, long story short, it was a lot of work to initiate the changes, but overall people (most importantly the staff) are really happy with these changes. Our work environment has improved dramatically, as patients are less angry. 80% of our patients are in and out within 4hrs or less. And (in case you’re wondering) we’re the 2nd busiest ER in our part of Canada, so it’s not like we’re in some backwater town with low patient flow. We actually see more patients per year than any of the tertiary care centers.

    It can be done!

  4. #5 by torontoemerg on Friday 26 March 2010 - 1648

    Thanks Zoe for your great response. It’s good to know we all have similar problems. The Ont. MoH is also doing the carrot and stick thing, specifically targetting CTAS 2 wait times, but also looking at wait times in general and tying outcomes to funding. We try to make a similar system work. We get stuck, though when our admits get to the point where they are overflowing to our Treatment room beds. I was in charge last week when all I had to work with were 4 RAZ chairs and a suture room bed. I guess my question you would be, what strategies do you use for your admitted patients to get them upstairs?

  5. #6 by Zoe on Saturday 27 March 2010 - 0123

    We have similar issues with admits…what ER doesn’t? The last time I was in charge, I managed to keep admits out of RAZ, but the only bed I had to work with was the isolation room. Thankfully, I had a fantastic team at triage, and I credit any success of that day to them.

    One idea we came up with was a “discharge lounge” — when patient on the ward is discharged, they are sent to a lounge area, with reclining chairs and volunteers serving tea etc, to await their ride home. This clears the bed sooner. To ER staff, this is not a new idea…if you are discharged in our dept, you get dressed and wait in the waiting room for your ride home. Up on wards, however, people tend to get d/c’d in the morning, and family doesn’t arrive until after work, sometime in the evening. However, pushing them to the waiting room seemed a bit harsh, so the lounge idea was floated around.

    When the ministry began the “Pay for Performance” initiatives (the “carrot and stick” stuff) it was quickly realized that the moneymaker would be in clearing the CTAS 4 and 5’s. From registration to discharge, if we get them in and out within 2 hrs, the hospital gets an extra $100. This money is used to increase staffing and keep beds open on the wards. A previously closed wing of the hospital was re-opened, and turned into a “Transitional Care Unit” which moved the “awaiting placement” elderly out of acute care beds. We hired an emergency geriatric clinician nurse to assess elderly patients who are in ER, but not expected to be admitted. Her job is to get them hooked up with resources in the community, and prevent future admissions. She’s actually *very* good at her job.

    These are some of the things we’ve done. I’m not in any way saying that our ER is perfect and idyliic, but I will say that waits over 4 hrs are now generally unheard of. I’ve been working with the CNE on the data collection for this project (dry and boring work, but I can do it at my convenience, and it pads the paycheck a bit!) and it’s been over a year since anyone waited 6hrs or more. Complaints are fewer. Staff are happier. Staff were, in fact, highly motivated to make these changes and put in monumental efforts to make them work.

    BC’s ministry of health did not target any specific CTAS level. CTAS 4 and 5’s are given 2 hrs from registration to discharge; for all other CTAS levels we are given 4 hrs from registration to disposition. So if they are admitted within 4hrs, we still get the $$. As a unit, our ER has decided to target CTAS 2’s, and try to get them seen sooner, and have had many ideas put forward by staff, some that are workable, some not. One idea that has worked is to flag them differently, so the physician notices, and goes to assess them sooner. Our doc’s have been very receptive to this idea, and so far it seems to be working.

    One last thing (I’m coming off nights, and I’m tired…need sleep!)…one of the biggest struggles we had was not from within the ER itself. Imho, despite the question of “what’s wrong with emergency” being raised repeatedly over the years, I am of the opinion that there is NOTHING wrong with emergency. We actually function quite well, and quite efficiently. Think of a shift you worked when there happened to be ample beds available, and there were few admits in the dept. Think hard, I know it was probably a long time ago… What were wait times like? I’m guessing wait times were minimal. That’s because (and it bears repeating) THERE IS NOTHING WRONG WITH THE EMERGENCY DEPARTMENT! We are accustomed to dealing with volume, and we know how to get things to flow smoothly. The problem is getting the rest of the hospital to play along. The struggle and fight is from imaging, x-ray, lab, cardiology, the wards, and physicians not from the ER. There, I said it.

  6. #7 by Zoe on Saturday 27 March 2010 - 0123

    Good lord, I can really be long winded! Sorry…

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: