By: Kenyon Wallace, Health Reporter
Sunday, February 11, 2024
Read the full article here.
It's 6:37 p.m. at Toronto Western Hospital's emergency department and Dr. Tessa Ringer is about two hours into her eight-hour shift. She has just seen her seventh patient, a senior complaining of a severe earache, and is en route to fetch some gauze and ear drops.
As she makes her way along the bright corridor of the ED's ambulatory care section, a voice suddenly comes over the intercom calling out a “Code Resus," the most serious and urgent medical alarm signalling to staff to drop whatever it is they are doing and head to the resuscitation room. A Code Resus is reserved for patients who need fast, life-saving interventions for conditions such as heart attack, stroke or respiratory failure.
In an instant, Ringer spins on her heels and starts running to the ED's east side, where the resuscitation room sits next to the entrance doors to the department's acute-patient area.
In about 10 seconds, she arrives to find an elderly patient already on the resus room stretcher in obvious distress.
The patient is conscious but their breathing is laboured and abnormal; their stomach rises and falls stiffly with each breath, desperately trying to push air in and out of the lungs. Their skin is a pallid grey.
One nurse is already hooking the patient up to oxygen and heart monitors, while another looks for an arm vein in which to insert an IV line.
Ringer, along with her fellow emergency physician Dr. Boon Chang, quickly dons gloves and a gown and rushes into the room. Ringer calls for an ultrasound machine, which will show the condition of the patient's lungs and heart with a probe placed on the chest.
Dr. Tessa Ringer arrives in about 10 seconds to help a patient in distress after a "Code Resus."
Nitroglycerin is administered to lower the patient's blood pressure and reduce the workload of the heart.
Karen Chen, one of the nurses attending to the patient, calls out for an “RT" — a request for one of the hospital's respiratory therapists to be paged to help manage the patient's oxygen intake.
It is a scene of controlled chaos, punctuated by the electronic ringing of alarms and monitors, as health-care providers from across the ED and across disciplines come together for a singular purpose: save the patient's life.
“Emergency medicine is all about making decisions and thinking, what are the two or three things we think this could be?" Ringer explains as respiratory therapist Brianna Mortillaro arrives to hook up a BiPAP machine, which will deliver pressurized air into the patient's lungs through a mask.
“For me, it's either there is something seriously wrong with the aorta, which is the major blood vessel in the heart, or it's a heart attack. If it's a heart attack, time is muscle," Ringer says. “The longer the heart doesn't have blood supply, the more muscle dies and the worse the outcome."
So begins another night in this busy downtown Toronto emergency department, one of hundreds across the country striving to ensure patients have access to timely, safe and high-quality medical care at a time when increased patient demand, a lack of sufficient access to primary and specialty care physicians, and infrastructure built for a population half its current size are combining to push ED staff to their limits.
In short, it's a symptom of decades of shortsightedness on the part of successive provincial and federal governments, which have failed to make the necessary investments in hospital infrastructure despite an aging population that is living longer (and therefore requiring more complex and frequent medical care). Compounding the problem are too few in-patient beds downstream from EDs, resulting in many admitted patients waiting, in some cases days, to be transferred to other areas of the hospital such as surgical and medical wards, and the ICU.
As of 2023, Canada had one of the lowest hospital-bed-to-patient ratios in the OECD, with 2.6 beds per 1,000 people, less than the OECD average of 4.3. The Star recently spent 12 hours on the night shift at Toronto Western to document the inner workings of a downtown emergency department.
Situated on the northeast corner of Bathurst Street and Dundas Street West, and serving a diverse community of new Canadians, seniors, unhoused and unemployed Torontonians, the Toronto Western ED exemplifies what it means to be a community ED.
Against this backdrop, responsibility falls to the charge nurse for ensuring that every patient who comes into Toronto Western's ED — one of the busiest in the city — is in the right part of the department and seen by the appropriate health-care provider in the most efficient way possible.
It's 3:22 p.m. and Nicola Cameron is today's charge nurse, who, in addition to managing patient flow, is also responsible for patient and family safety and ensuring each shift has sufficient staff, equipment and beds ready to accommodate the sickest patients who either arrive on foot or by ambulance. It's a role sometimes referred to by staffers as the “hot seat."
Cameron is seated at a desk surrounded by several screens in the middle of the ED's sub-acute section, sandwiched between the acute section, reserved for the sickest and most vulnerable patients (those suffering from heart attacks, strokes and COPD, for example), and ambulatory, the area for less serious conditions where patients are able to walk and are not confined to a bed. Sub-acute refers to patients who still require intensive treatment for serious problems such as pneumonias, alcohol overdoses, gastrointestinal tract issues, and cancer, but not to the same extent as acute patients.
On one of her screens, Cameron can see where every patient in the ED is, their level of acuity, illness, whether they have been admitted or not, and where they are headed. Another screen shows her how many ambulances are out on calls, their expected ETAs at the ED and the patient's ranking on the Canadian Triage and Acuity Scale (CTAS), a five-level scale that helps staff determine a patient's need for care. CTAS Level 1 (Resuscitation), Level 2 (Emergent) and Level 3 (Urgent) are assigned to high-acuity patients who cannot wait long for medical care, while Level 4 (Less Urgent) and Level 5 (Non Urgent) are considered lower-acuity patients who are able to wait.
It's her job to make sure the ED, which sees about 200 patients a day, can accommodate every one of these patients. It's a job that can be a bit of a juggling act.
“For example, if we don't have any beds, I can talk to my physicians and say, 'Hey, we've seen these patients. Are any of them OK to move to a different part of the ED, like into chairs, because I need a bed,'" Cameron explains. “If none of that works, I would then look at which of our patients I can move to the front of my desk so I can monitor them, or move to another area safely in order to create that space."
At the moment, Cameron can see that there are two ambulances responding to 911 calls: one is on scene for a CTAS Level 2 patient, while another with a CTAS 3 patient is expected to arrive at the ED in about three minutes. From here, she can also see ambulances that have arrived with patients being registered and triaged.
“Sometimes we can't take them off the EMS stretcher because there's no bed available, so the patient will stay with the paramedics until we can bring them in," she says. “It can get stressful at times, especially when you have patients outside and we don't have beds."
Ambulance offload times — the amount of time it takes for a patient to be transferred from paramedics to the care of a hospital emergency department — have been steadily growing at Ontario hospitals in recent years, resulting in patients sometimes waiting hours before even being wheeled into the ED.
Ontario Health figures show that average ambulance offload times across the province have increased from 21 minutes in May 2019 to 37 minutes in May 2022. The province says ambulance offloads should take 30 minutes or less.
Countless EDs are doing their level best to squeeze every last ounce of efficiency out of a system stacked against them. That necessity is the mother of invention is perhaps no more on display than in the practical innovations — even little ones that may go unnoticed by visitors — that staff at Toronto Western have taken in recent months to lower the amount of time patients spend in the ED. The hospital recently converted a conference room near the front doors of the ED to an open space that can accommodate four EMS stretchers to augment the ED's 51 beds, so that paramedics can hand over care of lower acuity patients and get back on the road faster.
Read the full article here.