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April 4, 2011
Ontario medics wait hours for ER to receive patients
By Johanna Weidner
ONTARIO, Canada — Paramedics waiting for hours in local emergency departments to hand over their patient to hospital staff commonly need to call a Hamilton doctor for medical advice.
Most of those waiting patients are suffering from serious health conditions rated as urgent, although not critical, because they could progress to a serious problem requiring immediate intervention.
"They're the more acute patients," said John Prno, director of Waterloo Region's emergency medical services.
Paramedics remain responsible for a patient - even while standing in an emergency department — until hospital staff can assume responsibility.
"They're not patients of the hospital yet," Prno said.
Ambulance off-load delays are a growing problem in the region's hospitals as they struggle with busy emergency departments and not enough beds.
Patients left waiting
That means patients are commonly left waiting on ambulance stretchers in emergency department halls, and ambulances must be called in from neighbouring municipalities when local paramedics are stuck waiting for hospitals to take patients.
In February, there were 522 off-load delays (counted when the wait is longer than half an hour) totalling 855 hours.
The average off-load delay is about 1.5 hours, with waits on average longer at Grand River Hospital, followed by St. Mary's General and then Cambridge Memorial hospitals.
The longest waits in February were about 8.5 hours at Grand River, just under six hours at St. Mary's and just under five hours in Cambridge. Last year's delays added up to 5,790 lost ambulance hours.
Prno looked into recent cases and was surprised by the serious condition of those patients waiting with paramedics. A few years ago when the off-load problem first emerged in the region, he said, "they were always the least acute patients."
Emergency patients are scored on the Canadian Triage and Acuity Scale, from one being critical to five being the least urgent. Now the majority of cases are in the middle, Prno said.
While these patients aren't critically ill requiring immediate intervention, their condition often causes considerable discomfort and potentially could worsen dramatically.
Paramedics watching these patients may need to administer more drugs, such as cardiac, pain or antiseizure medication, or help with personal care, including using the bathroom. Before going beyond the basic treatment protocol, paramedics must call the base hospital in Hamilton for advice and authorization from the on-call doctor.
"The system works well when you're out in the field," Prno said.
(Cambridge Memorial served that role locally until the Ministry of Health consolidated to just seven centres across the province.)
Patients brought into hospital by ambulance are triaged by a nurse shortly after arriving. Those critically ill go immediately into resuscitation and patients with non-urgent problems can go out to the waiting room.
"We don't have a problem with two extremes," Prno said. "The problem is in the middle."
Local emergency rooms are busy
"We recognize how important it is to get that patient off the ambulance stretcher," said Susan Harris-Howe, manager of Cambridge Memorial's emergency department. "Our ideal is to not have any off-load ambulances."
But local emergency rooms are busy. Cambridge, in particular, is getting upwards of 30 more patients a day over the past year, following the closure of the city's popular walk-in clinic last spring.
More ER visits are compounded by the problem of alternate level of care patients waiting for services in the community and taking up hospital beds needed for patients admitted in emergency.
"Our biggest problem is when we cannot access in-patient beds," said Sandra Hett, vice-president of patient services and chief nursing executive at St. Mary's.
When there are no beds, ambulances are stuck as paramedics need to continue caring for a patient. However, all the hospital officials stressed, room can always be found if a patient's condition worsens while waiting.
"If there is a change in condition, the whole team can move very quickly," Hett said.
Both Kitchener hospitals have provincial funding for a nurse designated to help with off-load delays.
Although that has eased the situation, hospitals are still working out how best to take advantage of the nursing position. Predicting off-load delays is difficult and sometimes the nurse will be occupied with other things when an ambulance comes in.
"It's very hard with someone waiting, not doing anything," said Sue Robertson, Grand River's vice-president of clinical programs and chief nursing officer. "That's part of the challenge, having that nurse available when we need her."
Now Grand River has added the nurse to the acute care area, making four available to take ambulance patients to begin tests and care ahead of the doctor.
The trouble is not so much the first ambulance but when a second and then a third arrive, Robertson said. About half the region's ambulances end up at Grand River's emergency department.
And, she said, "when one hospital is busy, all of them are busy."
'We've got to fix the system'
"We do everything we can to get the ambulance back on the road," Hett said.
Hospitals are working with emergency services and community partners to come up with solutions, in particular right now what to do when the region reaches a crisis with minimal or no ambulances available for calls.
"It takes all of us working on it," Prno said.
Adding more ambulances likely wouldn't help the situation, at least not for long.
"We've got to fix the system," he said.
More community services would help with the ER crunch, including primary care and support for people who have chronic illness and often rely on hospital visits for care.
Putting walk-in clinics in hospitals staffed by a nurse practitioner could also help deal with less acute patients.
"They're all great ideas, but they're not ideas that can be done overnight," Prno said.
Also educating the public is important, he said. Many people think calling an ambulance will get them seen by a doctor faster.
"The hospital sees the patients in order of acuity," Prno said. "Sick people don't always arrive by ambulance."
A regional approach is needed, care providers agree.
"We are trying to get a process in place that is going to work for all of us," Harris-Howe said.
The off-loads delays are difficult for everyone, Prno said, from the patient and paramedics stuck waiting to the overwhelmed emergency room staff trying to make room.
"It's a tough situation."
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