Yep, It Was a Disaster

Nurse K had an interesting take on my blog post the other day about dealing with an over-crowded ED: it was a disaster, pure and simple:

In short [she writes] if, really truly, your hospital is using 25/27 beds for admits and there is no way to transfer them out or transferring would be significantly delayed and six critically-ill people are coming in via ambulance…I don’t care what’s going on or what country you’re in, that’s a disaster. Seriously.  If this is your hospital, and people are being shitmonkeys and refusing to assist you, start busting out the triage tags.  Page every administrator out there.  Say you have a disaster and are starting your Disaster Code.  Maybe someone will cancel a meeting if the media starts calling.

I’m not sure if she’s fisking me, engaging in some not-so-gentle mockery, or using my post to buttress her conceptions about the nature of Canadian health care: referring to the Canadian public system as commie-pinko-socialist is probably a clue. In any case the point is taken: it was a disaster. It’s an ongoing disaster. It’s funny how sometimes it takes someone outside the situation to point out the obvious.

I will say, however, that Nurse K’s suggestion to implement the disaster plan — in Ontario, known as a “Code Orange”” — isn’t feasible. In my hospital, at least, it’s a decision that needs to be made jointly amongst the charge, the manager and the ED physician, and  in any case tends to be reserved for external mass-casualty disasters, like busloads of HIV-positive haemophiliacs crashing on the 401, not for severe hospital-induced multi-system dysfunction. So what’s a harrassed, stressed-out charge nurse to do?

Nothing. Get all rowdy with equally harassed and stressed out bed flow managers. That’s about it.

The point is that at my hospital and at many others there is no plan.

Why? Because 1) we cope, and 2) hospital administrators see emergency department over-crowding as “normal”, intractable, and somehow not a serious hospital problem. Both are wrong. We do cope, but we carry on in way an over-heating engine run for a while before it finally seizes up and stops functioning. Sick time and turnover are increasing: not a sign of a well-functioning department. And the problem is fixable. I know the Ministry of Health is working, albeit slowly, on long-term solutions. But somehow, it isn’t better knowing various health officials, flaks and functionaries are busily at work introducing systemic reforms when the problems are much more immediate. If I can think of four or five ways to improve flow of admitted patients out of the ED without even opening new beds or breaking into a sweat, then surely it’s not beyond the grasp of hospital management. All it takes is will and prioritization — which sadly seems to be lacking.


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  1. #1 by Rob Fraser on Thursday 10 March 2011 - 1351

    Thank you for all your hard work, so glad our hospitals- as crazy as it gets- takes care of everyone that needs it.

  2. #2 by Cartoon Characters on Thursday 10 March 2011 - 1452

    “the Canadian public system as commie-pinko-socialist” …..why am I not surprised – consider the source. Having worked in both systems – American and Canadian – I prefer ours, even with its wrinkles. I consider the American system more “broken” than ours.

    Anyway, it’s interesting – the difference between hospitals. My mom took my dad to Emergency the other night, to an interior hospital, and from the time they hit the door, was looked at and discharged was 2 1/2 hours. My dad is elderly, …..and had breathing problems and was given an RX. I actually have worked in that hospital and they have a small ICU/CCU as well as a L&D and Emergency that has recently updated. The docs I worked with there were very good and it was my favorite hospital (apart from another one I worked in when I was just starting out in my career) I have ever worked in. I think the problem is being worked on, but problem is, with the aging population taking up beds…it’s going to get worse …

  3. #3 by Sarah on Thursday 10 March 2011 - 2301

    It doesn’t help that we’re full up right now with ‘spring’ patients. Like I said before, my hospital isn’t far from yours and I think our situations are very similar – except that I’m on the upstairs side. I work on a 26 bed unit, we haven’t had less than 30 patients in over a month. Every winter/spring we have a surge of patients (this year seems worse than previous years) and then it settles down towards May and through the summer. Last summer we actually had empty beds. This is how we cope – the summer reprieve. We get refreshed and ready to do it all over again. As strange as it seems, we never seem to plan for the surge that happens every year – we look at yearly averages and fail to see the imbalance. We spend half the year over capacity and half the year under. At least, that’s how it seems to me.

  4. #4 by TracyKM on Friday 11 March 2011 - 0952

    I lived for 12 years in a town of 25 000 with a brand new hospital. I could figure on 3 hours for any ER trip. Now, I live in a “town” of 124 000 and there is NO hospital at all. There was (a fire 2 years ago shut it down totally), but it was only long-term care and dialysis; there has never been a L&D unit depsite being one of the fastest growing towns in Ontario; the ER became day-only about 20 years ago, and then shut down entirely. It’s certainly not because of lack of users! I have heard that a trip to the ER in the neighbouring city means 6 hours. There is talk of a new hospital…in about 10 years. What I don’t understand is why there aren’t 24 urgent care clinics that can do some of the ER stuff–stitches, x-ray, simple fractures, ultrasound, fluids/flu assessment.
    You know how there’s “Take Your Kid to Work” day….maybe we need “Take Your MPP to Work” day, each one going to their local hospital….

  5. #5 by Nurse K on Friday 11 March 2011 - 2220

    No, dude, I was serious. That’s a disaster. For instance, at my hospital, we successfully implemented a disaster for “slippery roads” one night when there were something like 500+ car accidents in the area. Slippery roads really isn’t normally considered a “mass casualty incident”, however. There were car accident people plus all the regular people and every hospital in the area was overwhelmed and all trying to divert to each other, hours-long waits, etc… The point of the mass casualty disaster plan in such a circumstance should be to get additional staff, find additional areas to see patients, and reduce charting and quickly figure out who needs to go where.

    Yes, you can see lacs and bumps/bruises patients in the medical director’s office.

    • #6 by Nurse K on Friday 11 March 2011 - 2319

      Also, I’m sorry that you have to wait for a “ministry of health” to “fix” your problem. In the US, we just hold charity balls and build bigger ERs and add wings on to the hopsital. All four of our area hospitals all built on to their ERs in the last 5 years and expanded inpatient beds as well. Mine added 20 more ER beds and 150 more inpatient beds in addition to more surgical suites, etc.

      It’s okay to be in favor of capitalism. It works in these sorts of situations. At the very least, if patients are diverted or leave your department and surgeries are cancelled due to held beds in the ER, your hospital loses money. End of story.

      • #7 by torontoemerg on Monday 14 March 2011 - 0857

        We have the MoH (plus some alphabet soup local agencies because actual provision of services is regional, and hospitals are run by community boards) but you have all the glory of the Joint Commission. :) I’m not sure which would be more irritating, having worked in both the U.S. and Canada.

        As for capitalism — this commie-socialist-pinko isn’t actually afraid of uttering the ultimate heresy (for Canadian nurses) and saying the system after 40 years needs a serious overall. If this means going to a mixed system of public and private payers, like they have in Europe, where the costs are even lower than here for similar outcomes, so be it — I’m interested in results, not how we get there.

    • #8 by torontoemerg on Monday 14 March 2011 - 0855

      Hmm… any tips on getting a reluctant manager to take up the cause, when complacency seems to be the order of the day?

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