After a death at a hospital emergency department in Fredericton, N.B., last summer, the health authority responsible for its standards and practices conducted a quality process review and made four recommendations, but it remains unclear what progress has been made.
A patient died in the ER waiting room at the Dr. Everett Chalmers Regional Hospital on July 12, 2022. A witness, John Staples, told Global News at the time he noticed a male in “physical discomfort” sitting in a wheelchair in the emergency department waiting area.
After an hour, a nurse emerged to check on patients in the waiting room. It was at that time Staples said he noticed the patient wasn’t breathing.
The quality process review (QPR) was done and discussed by the Quality Care and Safety of Patients Committee about two weeks after the death occurred.
It pointed to a few key issues facing the emergency department at the hospital in the aftermath of the death, including lack of bed availability, increased wait times for people arriving by Ambulance New Brunswick (ANB), and a lack of consistent patient monitoring.
Horizon Health Network never released its findings to the public.
The recommendations
The first recommendation in the report was that the regional health authority (RHA) should develop a regional policy to establish a standardized process for the triage of patients who arrive by Ambulance New Brunswick, including during times of hospital overcrowding.
It included:
- Standardizing triage assessment on arrival/announcement of incoming ANB patients.
- Developing criteria for patients awaiting triage that may be left in the waiting room.
- Providing the triage nurse with ANB documents that will be included in the emergency department (ED) patient chart.
“Create a standardized patient flow process to mitigate the risk of health decline and facilitate CTAS level 3 patients through the ED by enabling pre-investigation workup prior to seeing a health care provider,” the recommendation reads.
Ambulance New Brunswick said it is working to resolve the issues it’s facing, including offload delays.
“Finding ongoing, sustainable solutions to offload delays will require a multi-faceted approach, and it is difficult to attribute any increase or decrease in offload delays to any one initiative over a short period of time,” said a spokesperson for Medavie, who owns and operates ANB.
Horizon Health Network declined to provide anyone for an on-camera interview for this story.
Global News requested a specific update on the recommendations and clarification on whether they were made public, but Horizon’s administrative director Steve Savoie wrote in an email that “the findings were communicated directly with the family of the deceased” and Horizon “has nothing further to add regarding this specific matter.”
Horizon has implemented patient flow centres, but never said whether those were a direct result of the death in July.
“The implementation of patient flow centres at Horizon’s Dr. Everett Chalmers Regional Hospital and The Moncton Hospital have been ensuring Level 2-5 Canadian Triage and Acuity Scale (CTAS) patients do not need to be diverted and can receive care in the ED in a more timely, efficient manner,” Savoie said.
Documents obtained by Global News showed that 41 per cent of patients presenting to the emergency department are levels 4 and 5 CTAS, which means they require less urgent care or non-urgent care, but only 3.33 per cent had been diverted to the nurse practitioner clinics.
Reports contained within the Right to Information request, which were separate from the QPR, also pointed out that many major ERs were operating their triage at 50 per cent capacity, and “not knowing the reason why patients are waiting is a significant safety risk.”
The QPR also noted the lack of bed availability within the emergency department.
“The lack of ED bed availability due to high volume of boarded ED admissions increases the likelihood for a delay in a triaged patient transfer to an ED bed requiring further assessment/treatment,” it said.
It recommended the establishment of a regional policy that identifies the criteria and process to facilitate the transfer of non-urgent (inpatient) admissions during ED overcrowding.
A submission from the nurses union discussed this issue as well, saying “units should not refuse their patients.”
“It would be helpful to have updated guidelines on what floors can and cannot accommodate for patients,” the submission reads. “It’s very difficult to manage an ER when the department is overrun with admissions.”
Savoie said it is not uncommon to operate at overcapacity.
“A key reason for this is that 30 per cent of all acute care beds within Horizon are occupied by Alternate Level of Care (ALC) patients who do not require medical care,” he said.
Savoie added that Horizon was working with its partners to find appropriate placement for those patients. Savoie did not directly respond to questions about what progress has been made on this recommendation. The final recommendation was on patient monitoring.
“The lack of consistent patient monitoring and the inability to meet standards in the emergency department waiting room decreases the likelihood for early recognition in a patient’s health decline,” according to the QPR.
It recommended the RHA identify and implement a strategy to ensure all waiting room patients are reassessed according to the CTAS reassessment guidelines outlined in the Horizon Emergency Department Standards.
The report said it recommended a dedicated health-care personnel resource, like a licensed practical nurse or personal care attendant, for monitoring of the waiting room according to CTAS reassessment guidelines, including contingency for meal breaks.
“Adequate available equipment for real time assessment and documentation of vital signs” was also part of the recommendation.
In August 2022, Horizon Health Network did implement patient waiting room monitors in five of its major ERs, and when asked, CEO Margaret Melanson told reporters it was a direct result of the death in July. Documents revealed the program is primarily being implemented using LPNs and student nurses, who have limited availability during the eight-month school year.
Bernadette Landry, the director of the New Brunswick Health Coalition, said this is a good thing, but it’s too little, too late.
“This lack of staff has been going on for decades, it didn’t happen overnight,” she said. “Governments have done nothing to solve the problem until now that we’re in such a crisis that they have to do something.”
She believes there is also a lack of proper training required to properly evaluate people whose condition could decline while waiting to be seen.
“They could miss some serious symptoms,” she said.
Landry said patients shouldn’t be waiting hours to be triaged or seen, but that’s the situation New Brunswick is in.
How do we move forward?
Keith Brunt, a professor of translational medicine at Dalhousie University on its Saint John campus, said there are solutions that can be deployed to help move the system forward.
“We have been slow to digitally transform … to digital records and we have struggled to implement what are fundamentally enhanced automated care systems,” he said in an interview.
He said when you place heavy workloads on individuals, it creates an environment where things can get overlooked.
On the night the patient died in the waiting room, a nurse who was doing two jobs was responsible for nearly 30 patients who were registered and waiting.
“Just to do a basic vitals assessment … just to do that critical assessment can be five to seven minutes, so you take those minutes … and then you multiply it by 30, and if that LPN did nothing else but do vitals, then we may not be able to be compliant with guidelines,” Brunt said.
Brunt said there was plenty of warning the system was headed for a wave of retirement and burnout in health-care providers as a result of an aging population, high acuity in patients and a lack of investment in primary care.
It’s termed moral distress.
“People who knew what they needed to do but could not take action to take care of patients the way they needed to,” he said. “Moral distress is a major driver of burnout.”
Health-care workers, he explained, are taking on more and more responsibility with fewer resources.
“One of the ways I think we’ve failed to improve is to give direction and scale and scope to health-care workers to have professional autonomy,” he said. “An ability to adapt to the needs of the patient around them, to the situation, to make professionally licensed, scope-of-practice, informed decisions about scheduling, about technology adoption so we can tackle things like digitization and patient empowerment.”
Brunt believes primary care investment and technological tools to empower patients are critical in how we improve the overcrowding and conditions in the ER.
He said when patients are equipped with the right resources and qualified information, it helps them determine their level of risk and choose the best course of action.
“I believe there are actions being taken to prevent this from happening again, but if we fail to learn from our mistakes, if we fail to take action aggressively, where we have been slow to act historically, then yes, people are going to get hurt and lose their life because of that,” he said.
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