A report on the state of hospital emergency departments in Flin Flon and The Pas has outlined concerns in areas affecting everything from patient care to workplace culture to safety.
The external review was requested by Northern Health Region chief executive officer Helga Bryant. It was conducted in November 2013 with the resulting report made available in July 2014.
“Patient safety is a top priority for all staff in the region and the recommendations coming from this review will help to improve the quality and safety of all patient visits to our emergency departments,” Bryant said.
The report arrived at 31 recommendations to improve service.
“A significant concern the reviewers heard numerous times, and from individuals of varying professional backgrounds, was the lack of up-to-date medical knowledge, clinical skills and acute care experience of some physicians contracted to work in Flin Flon and The Pas,” reads the report, prepared by Winnipeg-based health care professionals Dr. Ted Kesselman and Lori Ulrich.
Reviewers were also told that teamwork, collaboration, respect and trust were lacking in ERs in both Flin Flon and The Pas.
One troubling observation was that open conflict between physicians, nurses and physicians, and among other ER staff members had been publicly displayed.
The report pointed out a lack of performance indicators and definition of roles and goals in the ERs. It was also noted that many of the ER policies and procedures were old and did not support up-to-date evidence-based practice.
Experience issues
It was also noted that physicians did not always have someone leading, guiding, watching or mentoring them. This led to a sense that some physicians were “over their heads” at times, according to the report.
A contributing factor is scheduling in the Flin Flon ER, where a physician is available 24 hours a day. This creates a situation where there is no overlap between more and less experienced doctors.
New staff, new graduates, use of agency staff, recruitment and retention were also mentioned as issues of concern.
Although physicians had taken courses in advanced cardiac life support and pediatric advanced life support, some had little experience and guidance in applying this knowledge, according to the report.
The review found cases in which physicians would summon the ER anesthetist and leave him or her alone to assume total care of a critically ill patient rather than staying and learning.
Reviewers felt that although ER physicians “should be competent in the initial management and stabilization of critically ill patients,” handing care over to an EXPERIENCED anesthetist was probably “the safest for patients at that time.”
A working group is currently reviewing the training program for new rural and northern physicians in Manitoba, the reviewers noted.
Patient care
One concern noted was the problem of overcrowding in both the Flin Flon and The Pas emergency departments. This was found to affect patient care from arrival to discharge.
Time patients spent in the ERs was increased by such factors as limited treatment room spaces and ER beds occupied by patients awaiting air transport.
As well, the report noted times when there was insufficient nursing staff to meet demand. One example of this was when no health care aides or housekeeping staff were on the night shift, requiring nursing staff to perform these roles.
Discharging patients was also seen to be ineffective at times when inpatient beds were not available for admitted patients, when delays occurred in transferring patients to other facilities, or when there were challenges finding accommodation for discharged patients.
Issues surrounding triage procedures, which prioritize patients for care, were reviewed in detail.
In both Flin Flon and The Pas, patients were first seen by a registration clerk, who would notify a nurse if there was concern about a patient’s condition.
“It is not ideal however to have a non-medical person responsible for identifying clinical concerns upon patient arrival,” stated the report.
The review found that it was unclear whether patients were prioritized on a first-come, first-served basis, or if the patient’s complaint or nurse’s observations determined the order of care.
As well, the process of triage varied, in some cases based only on a subjective assessment and in others a complete nursing assessment.
“Triage is meant to be a rapid event,” stated the report. “Completing the entire head-to-toe assessment at triage runs the risk of lengthening the triage process (and not triaging other patients in a timely manner), or having an incomplete assessment (as patients are clothed at triage).”
A chart review also revealed that in both Flin Flon and The Pas, inaccurate triage acuity levels were at times assigned
Other areas of concern included lab requisitions that were not initialed or signed on patient charts; a lack of pain management standing orders or protocol; a lack of call bells in Flin Flon ER rooms; and procedural problems surrounding transfer of patients within the hospital and between the hospital and other medical facilities, including air transport.
Patient safety
NHR has a patient safety coordinator (PSC) who supports the Flin Flon and The Pas sites. The coordinator maintains an electronic database of all occurrence reports and critical incidents, and submits summary reports monthly to senior leadership and the board.
“Managers also receive monthly reports, with the hope that information will shared with staff and physicians,” stated the report.
Managers were expected to identify opportunities for improvement, document steps taken and report back to the PSC. However, it was found this did not always occur.
“The PSC noted that at times the manager had not investigated the occurrence, met with staff, or responded to the occurrence in a way meant to mitigate future occurrences,” noted the review.
In the case of a critical incident report stemming from a fall, a falls management program had been developed but not rolled out as there were “no resources and no buy-in.” The report noted that lack of compliance to the PSC’s recommendations in this case was a concern to both the coordinator and reviewers.
Other barriers to safety outlined in the report included nurses and some physicians not always working well together; nurses and community having a lack of confidence in the abilities of some physicians; some nurses being “set in their ways and not buying into patient safety initiatives;” outdated policies and procedures; and no formal chart audit process.
Facility limitations
The report noted that the physical environment of the Flin Flon ER was extremely small, with limited treatment room spaces. The one-bed special care unit (SCU) was located within the ER, “allowing for the best use of the highly trained [ER] staff,” noted the review.
“It was also concerning that in both [ERs] the waiting room was not visible to [ER] staff,” stated the report, which also noted that Flin Flon did not have a confidential area for patient triage.
Reviewers learned that plans had been approved to increase the size of the Flin Flon ER.
The lack of availability of certain diagnostic tests was noted by staff members. Ultrasound was not available in Flin Flon or The Pas on evenings and weekends, and there was no on-call option. As well, there was no CT scanner in Flin Flon, and patients requiring CT were transferred to The Pas, where CT was available only weekdays from 8 am to 4:15 pm, with no on-call option.
Moving forward
To prepare the report, reviewers interviewed emergency department doctors and nurses in Flin Flon and The Pas as well as consulting physicians, health professionals, managers and senior NHR staff.
Chart reviews, occurrence reports and critical incident summary reviews were also conducted in both locations. Care maps, guidelines, and policies and procedures were reviewed, along with results of an online public survey.
The reviewers offered 31 recommendations in seven areas to improve services at the Flin Flon and The Pas emergency departments.
The NHR has formed a committee to move forward with the implementation of the recommendations. Their work is expected to continue throughout the balance of the year.
Dr. Hussam Azzam, chief medical officer for the NHR, said the ultimate goal is to meet the needs of patients and their families by delivering “timely access to high quality, compassionate health services” in the ERs.
