The Northern Health Region (NHR) will implement dozens of recommendations in response to the death of a man in a Winnipeg emergency room.
A report into the 2008 death of Brian Sinclair has produced 63 recommendations, most of which apply not just to the Winnipeg Regional Health Authority, but to all health authorities in Manitoba.
“We work in a health system where human beings are the service providers and as a result we are fallible and can make mistakes,” said Helga Bryant, chief executive officer of the NHR. “This report provides a catalyst for change that health care staff will use to improve how we deliver service, how we construct our facilities and how we ensure the highest quality of care is provided day in and day out. We will rise to that challenge on behalf of all of our citizens.”
As a result of the report, the NHR will investigate the possibility of on-site diagnostic equipment in its three hospital emergency departments (EDs), located in Flin Flon, The Pas and Thompson.
Ensuring that patients in the ED waiting room are regularly awakened and that ED nurses are not fatigued are among the other recommendations.
Several of the recommendations relate specifically to First Nations people. Sinclair was an Aboriginal man whose death has been blamed by some on racism.
The NHR will look at recruiting and retaining an Indigenous Elder for the EDs, and work with First Nations to review the potential of Indigenous personal care homes.
Underway
Bryant said work is already underway to implement the recommendations across the NHR.
She announced the formation of an NHR implementation team that she will lead.
Additional members will be drawn from all parts of the region and begin work immediately. Their work is expected to continue well into next year.
“Brian Sinclair’s death is a tragedy that cannot be undone, but from this tragedy we have the opportunity to make important changes that will save lives and improve the way we deliver health care in the North,” said Bryant. “Mr. Sinclair’s legacy will be a health system that learned lessons from what went wrong and took decisive steps to make improvements so we will not repeat those mistakes in the future.”
Ingrid Olson, executive director of clinical services for The Pas and area and a member of the implementation team, said the recommendations “form a roadmap for change that will help us improve the quality of care and the safety of all patients who are seen in our facilities.
“We are committed to adopting all of the recommendations in our control and working with government and stakeholders to move forward on the balance of those recommendations to help us deliver quality, accessible and compassionate health services throughout the region.”
Sinclair, a double amputee suffering from kidney disease, wheeled himself into the emergency room at Winnipeg’s Health Sciences Centre. He was found dead 34 hours later, having never received the care he required.
It was determined that Sinclair, 45, died of a treatable bladder infection.
With files from a Northern Health Region news release
Among the nearly 50 recommendations the Northern Health Region will implement are:
• Review policies and procedures to ensure that when a patient is a client of the Public Trustee, his status as such is clearly flagged on his medical chart.
• Review the feasibility of electronic charting for all facilities.
• Review the feasibility of the creation of a single electronic health record accessible to all health care facilities.
• Maintain the protocol that requires primary care physicians sending patients to the emergency department (ED) to notify the ED in advance by phone, including verification of whether a letter has been given to a patient to present to ED staff.
• Examine the feasibility of primary care physicians sending letters to EDs electronically.
• Review the system to ensure staff assist vulnerable people, including those with mobility issues, with the triage process immediately upon arrival at the ED.
• Review the floor plan of the ED to ensure that no one in the waiting room requiring medical care faces away from the triage desk.
• Review the system to ensure people in the ED waiting room are awakened at regular intervals.
• Review the feasibility of secondary traumatic stress training for all ED staff.
• Review the system to ensure staff intervene when a person is vomiting in an ED.
• Review the system with respect to interview notes taken on behalf of hospital administration after the occurrence of critical incidents, with a view to having the notes dated and initialed or otherwise authenticated by the interviewee.
• Review handover policies in the ED to ensure the oncoming triage and reassessment nurses are fully briefed on the status of people present in the waiting room.
• Review the feasibility of a security presence at the entrance to the ED.
• Provide ED security staff with training in the areas of substance abuse and dealing with persons with physical or mental challenges.
• Review the feasibility of the presence of a Community Support Worker for the ED.
• Review, create and implement long-term strategies for the recruitment and retention of nurses.
• Review a rotation of roles and hours of work for ED nurses in an effort to reduce fatigue.
• Identify staffing demands in the ED and strategically plan to supply adequate staffing.
• Undertake an ongoing review of staffing ratios for the ED to match supply to demand.
• Join a process to review the feasibility of strategic planning to implement accountability structures, including measurement and reporting systems.
• Review the feasibility of providing on-site diagnostic equipment in the ED.
• Review the feasibility of incorporating more nurse practitioners into the ED.
• Review the feasibility of hiring and retaining physician assistants to work in the ED.
• Establish a Hospital Length-Of-Stay Reduction Committee to monitor and optimize patient flow in the hospitals.
• Review the feasibility of the installation of an electronic board to monitor the status of the patients in the ED.
• Review the feasibility of incorporating training in the area of emotional safety for health care professionals.
• Review the feasibility of recruiting and retaining an Indigenous Elder for the ED.
• Review the feasibility of the hiring and retention of Aboriginal Discharge planners.
• Strategically plan with First Nations to review the feasibility of the establishment of rural Indigenous personal care homes in Manitoba.
• Develop and initiate policies for the implementation of mandatory and ongoing cultural safety training for all health care workers, and ensure cultural safety training includes a component that has been designed and delivered with the assistance of Aboriginal people.
