It's 10:20 a.m. The hospital-wide overhead announcement indicates the Halifax Infirmary emergency department is calling a Code Census, again. A combination of too many admitted patients occupying stretchers, plus illness severity, plus paramedics waiting to deliver patients indicates the need for some relief, like a pressure valve.
The code indicates to other hospital staff that extra effort and collaboration are required to create some additional in-patient capacity.
As the only adult specialist hospital in the province, the facility has many demands placed on it. It needs to provide unique specialist services to the province, but at the same time provide basic emergency services to its local citizens. Until this summer, the Code Census call has become all too predictable, occurring almost daily and some days, several times.
It has been called "Code Senseless" by some.
Solutions over the last few years have all helped divert some patients from going to or spending time in the ER. Two excellent patient flow managers, with newly expanded hours, negotiate space for patients on in-patient floors.
A Rapid Assessment Unit (RAU) down the hall from the ER is used for patients waiting to see surgical specialists. Some specialty clinics help prevent visits to emergency.
The Halifax Infirmary Offload Team, a nurse and EHS paramedic, enable some ambulance crews to return to service sooner than before, but it also means sick patients are being treated in hallways.
The real problem, however, is not entry into the emergency department, but exit. Most patients seen in ER — about 85 per cent — are treated and discharged home. The remaining 15 per cent require advanced care in the hospital. Many are elderly, with complicated problems.
Patients in limbo
Over the course of a year 4,000 to 5,000 of these patients wait for many hours, sometimes days, for actual admission to a hospital floor. They are caught in limbo between the end of the emergency treatment and the full services they require in hospital.
They occupy stretchers and consume emergency department staff time that should be used by newly arriving patients who wait, for many hours, in the waiting room, or maybe never seek help when they should.
Moving patients smoothly involves linking many hospital departments together, having ready access to home care, short and long-term care seven days per week for hospital discharges and being able to respond to predictable and unpredictable demands.
It is a complicated, urban system problem. It requires a "can do" and "must do" culture change that some other hospitals and provinces in Canada are achieving. A new culture of shifting away from institution-based (hospital and long-term care) to home and community-based care; changing physician funding and practices; changing traditional expectations.
Nova Scotia is not there yet.
Nova Scotia has a professional, fully integrated emergency system that manages all out of hospital and between hospital routine, urgent and emergency ground and air patient assessments and care. It relies on evidence-based protocols to minimize treatment times for trauma, stroke, on-scene delivery of clot-busting treatment for heart attacks and other medical problems.
Better Care Sooner, the government's policy on improving emergency care — championed by Finance Minister Maureen MacDonald and Deputy Minister Kevin McNamara — appears to be having a positive impact, although we need to wait for the results of some objective research studies that are currently underway.
No other province or U.S. state is doing this as well as Nova Scotia. In addition, paramedics, leveraging their immediate access to a telephone or radio on-line physician, are working with specially trained nurses in rural Collaborative Emergency Centres, assessing and treating patients who require care during the evening and night.
Mixing politics and common sense
Community paramedics are treating patients in some nursing homes, when safe to do so, preventing transfers to congested emergency departments. Some are working within emergency departments, doing triage or working in interprofessional teams to provide minor and critical care to a wide spectrum of patients.
In summary, when I visit other provinces, I frequently hear that Nova Scotia’s paramedic and Emergency Health Services system is more advanced than others in Canada. This can be traced back to a clear vision by former minister Dr. Ron Stewart in the 1990s and a lot of hard work by many since then.
Overall, I think we have made advances in health care in the last four years. This is a leading concern for people in the province, where everyone has a strong opinion and stories to tell of both good and bad health care.
Rural improvements were started first, and now a real focus on the urban patient journey and flow problems needs to occur. We are not unique in mixing politics, fiscal restraint, passion and common sense when choosing priorities and making, or not making decisions.
I would like to see increasing engagement and involvement of the residents of Nova Scotia and health-care providers by taking more responsibility for their own disease and injury prevention and self care.
We also need to hold physicians, district health authorities and political leaders accountable for answers to some difficult questions.
We spend a lot of money on health care. We should not be accepting mediocre results.
During this election campaign, here are some questions that voters can consider asking political candidates:
- Why is this province lagging behind in addressing emergency department crowding?
- What additional measures are you going to take to provide more community-based, not hospital-based care?
- What are you going to do to help seniors stay healthy and in their own homes longer?
- How is accessible primary health care being provided to communities, including on evenings, weekends and holidays
- What steps will you take to improve safety systems and processes to ensure that patients and health-care staff are not harmed or get sick when they are staying or working in hospitals?
- When will Nova Scotia have an integrated health record that collects patient information in one place that is accessible by health-care providers and patients themselves to improve safety and reduce wasted time?
- Should we divert attention by merging our 10 district health authorities (administrative busy work) or focus on developing functional provincial programs across the authorities that provide high quality, accessible care?
- How will you prove to taxpayers that we are getting improved health outcomes for our investment?
Dr. John Ross is a professor, consultant and practising emergency department physician. He's also author of the 2010 report, The Patient Journey through Emergency Care in Nova Scotia.