This is Part 2 of a three-part TVO.org series on emergency health care in Ontario. Click here to read Part 1.
I can’t think of any other place where people can have such radically different experiences as they do in a hospital emergency room. Someone with a throat infection could be receiving medical care 20 feet or less away from someone with multiple gunshot wounds. ERs are essential elements of our health-care system — but they are struggling.
In the first part of this series, I recapped two recent health-care experiences involving my young son. A few months ago, he was ill — potentially with a fast-moving, life-threatening illness. We took him immediately to the ER at Toronto’s Hospital for Sick Children, where staff provided spectacular and rapid care for what eventually turned out to be a minor virus. A few weeks ago, that same little boy fell down and broke his collarbone. The closest hospital, Lindsay’s Ross Memorial, was overwhelmed and unable to provide meaningful care for my son. We eventually left without treatment. We weren’t the only ones.
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In Part 1 of this series, I talked about a little-appreciated part of the ER — the paramedics who bring patients into hospitals and watch over them until nurses take over. These nurses are absolutely essential parts of the emergency room. They not only provide care; they also bring order to chaos, holding things together while doctors work their way through patients in priority sequence.
But Ontario does not have enough nurses.
Just a few weeks ago, the Ontario Nurses Association, citing information published by the Canadian Institute of Health Information, warned that the province was well behind the national average of nurses per capita, by as much as 20,000. Last year, the ONA released a joint statement with the Registered Nurses' Association of Ontario in which it noted that there were 10,000 unfilled nursing positions in Ontario hospitals.
What does that mean in practice? What does an ER nurse do?
Nurses are “the first line for assessment,” said Vicki McKenna, the president of the ONA. “They’re the ones that review the symptoms, the ones doing the initial assessment of someone’s situation when they come in. And, at the same time, they’ve got patients that you probably don’t see in other places in the ER that they’re also caring for at the same time.”
Larger hospitals, McKenna said, will usually dedicate a specific nurse to the triage process: “Nurses are not assigned triage unless they’ve been in [that ER] for a number of years. Most of them have advanced certificates and additional training for emergency care.” The most important thing for a triage nurse, she stressed, is “their eyes and experience,” adding that “the triage nurse will take their blood pressure and their temperature and their heart rate and ask them a whole bunch of questions. But the nurse is also watching the patient closely to judge their reactions and condition. That takes years of seasoning and experience, but it’s essential.”
The triage nurse doesn’t generally provide direct care; their assigned duty is to manage the flow of arrivals and assess their priority. McKenna explained with a chuckle that any nurse assigned to triage quickly learns the hard way that, no matter how quiet the ER may seem, the moment they step away from their post, a patient will arrive wanting to see someone. More seriously, McKenna noted that, when a patient arrives in critical condition but can’t be seen because the triage nurse has left their post, any delay could be disastrous.
Initial triage is just one part of the health care nurses provide. Once a patient has been admitted, nurses oversee their care. Larger ERs often segregate patients by the severity of need or even by the specific type of emergency. Smaller or older facilities may simply operate a single mixed ER ward. In any case, the patients are overseen by nurses. The nurses do their best to manage pain and keep patients comfortable, but, critically, they also look for signs that their patients’ condition may be worsening. The initial triaging process isn’t perfect, and circumstances can change. So nurses watch over their patients to see whether those changes make them a higher priority for care.
What’s happening while the nurses are watching?
I had a chance to speak with a nurse who works at a large emergency department in the Greater Toronto Area. (She was not cleared to speak with the media and so asked to remain anonymous.) Her hospital, she noted, is considered one of the better-organized ones in the region and has an effective ER, which she puts down to strong leadership and a good team. Even so, she readily admitted that some days are challenging — particularly when there’s a sudden spike in patient volume. I asked her what those days were like and what a nurse is actually doing when a patient is in their care.
It depends a bit on the severity of the case, she explained. At her hospital, patients, once triaged, are admitted into separate areas based on the severity of their need and on their specific complaint. The specific wards are staffed to ensure that the patients most in need are overseen by the most nurses. Some patients only need treatment for their sickness or injury. The nurse simply has to keep an eye on them until that treatment can be provided. But, she said, in other cases, the process of diagnosing the problem itself can take many hours and can involve CT scans, MRIs, blood work, and X-rays. The nurse then not only has to monitor the patient but also to coordinate the various tests and inform the doctor when results come in.
“A big part of the job is PR,” she confessed with a laugh. “I have to tell patients and family members that we’re doing the best we can and that we understand how stressful and uncomfortable it is. But sometimes the tests just take a long time, or there’s a series of them. All we can do is monitor and try to keep them calm and comfortable.”
The nurse quoted above works in a large, modern hospital in the GTA. I wanted to get a different perspective. Judy Christensen (disclosure: she’s the stepmother of a friend of mine) spent her nursing career at a tiny hospital in rural Ontario. Christensen’s hospital had only a few dozen beds and a very small staff. There was no specialized triage nurse, she explained. The staffing just didn’t allow for that — indeed, on the overnight shift, the ER would be staffed by a single nurse. Christensen, who worked that shift for three years, said she could call another nurse if she became overburdened. A doctor was also on call.
“I have stories,” she said when I interviewed her this week. On the overnight shifts, she was responsible for triage and cared for everyone who was admitted. She also acted as the security guard when things got out of hand. Christensen recalled an incident in which two rival criminal gangs had had a fight — and, since hers was the only local hospital, both gangs brought their wounded there. She put the members of one gang in one half of the room and their rivals in the other, with a police officer in between. (Everyone behaved, she noted.)
In her small hospital ER, workplace or agricultural injuries were common, as were heart attacks and childbirths. Car crashes on the nearby freeway were frequent. But, in general, the job of her small ER was either to provide relatively simple care or to stabilize and transfer patients to larger hospitals. She did, though, have to deliver one baby by herself. “The mother was calm and knew was she was doing,” Christensen assured me.
I shared with her some of the other things I’d been told thus far. She was particularly interested in hearing about how paramedics convey patients to hospitals in larger cities. She told me that, in her hospital, the paramedics would often stay as long as they could to help in the ER and act as assistant nurses — as long as no other calls came in for that ambulance. “But in the cities,” Judy agreed, “you’ve got to turn them around and get them back on the road as soon as possible.”
Nurses, clearly, are essential to an ER. But, as McKenna explained, they can be difficult to retain. The ONA’s data, she said, show that many nurses either quit or leave Ontario for work in other jurisdictions in five to seven years. It takes four years to train a nurse, so we’re not getting much value back. But the work is often precarious. Hospital budgets are set one year at a time, and hospital administrators view nurses as more easily replaceable than doctors (or, apparently, other administrators). Since hospitals cannot run operating deficits and must account for inflation, they budget conservatively. A hospital worried that it’s close to going into the red will often shed nurses in hopes of being able to hire them back later.
That leaves ERs understaffed, McKenna said, with fewer nurses than the hospital’s capacity warrants — and when you consider that hospitals often operate at over 100 per cent capacity, you can see why problems develop.
She’s right. But we’ll save that for Part 3.