CRITICALLY OVERCAPACITY
‘Code gridlock’ in effect at hospitals
Margaret Otto is lying on a stretcher, waiting for a hospital room.
The 94-year-old arrived at the Queensway Carleton Hospital by ambulance with fluid in her lungs. That was Sunday afternoon. It’s now Monday morning, and she’s struggling for breath. She lies with her head raised on a stretcher along the edge of a bustling emergency observation room. Patients are separated by pastel curtains and hooked up to machines that monitor their vital signs.
Nurses and physicians gather around a hub at the centre of the room where each patient’s vital signs are shown on a screen.
There is a persistent beeping in the background. It is noisy and busy and hard to sleep.
Otto looks apologetically at a reporter and faintly says “sorry” between coughs and gasps for breath. She has serious heart problems. Her daughter is upset that her mother has been waiting so long for a hospital bed.
“I am pissed. It is pretty sad that a woman of her age and in her condition can’t get a room,” says Patricia McGoldrick, a wary eye on her mother.
It’s March break, so the roads around Queensway Carleton Hospital, which sits on a small island of green in Ottawa’s west end, are quieter than usual on this Monday morning.
But inside, it’s already a traffic jam.
Otto is one of 15 patients who were admitted over the weekend for whom there is no bed.
That means Queensway Carleton Hospital is over capacity, again.
The available beds are filled, some of them with what are known as ALC — alternate level of care — patients, who are usually elderly and no longer need acute care but have no suitable place to go.
It is part of the cycle of home care, long-term care and hospital care that, when there is not enough capacity, usually lands on the doorsteps of hospitals.
The 15 patients in question are backed up in the emergency department, waiting — on stretchers in observation rooms and in other spaces — for beds to become available throughout the hospital.
In addition to Otto, there is a patient who injured a hip after a fall. The patient, who might need surgery, also needs a bed.
As of 9 a.m., the hospital is 105 per cent full, or escalation Level 3, in hospital lingo. By the end of the day, it will reach the highest escalation level — Level 4.
Hospital staff are sent pages during the day alerting them that the hospital is at full capacity and requesting that patient discharges be considered “if appropriate and safe.” The hospital’s full capacity protocol is activated when there are at least eight admitted patients in the emergency department who do not have beds. If possible, those patients are moved on stretchers to their assigned units to make room in the emergency department.
In some hospitals, this is known as “code gridlock” and is announced over loud speakers.
Queensway Carleton prefers a lower key approach, which is why the message is sent via pager.
But it means the same thing: “We are a full house,” says Jaclyn Drynan, the clinical care co-ordinator.
To make things worse, a stomach bug has been felling nurses, making staffing a challenge.
And so the day begins.
The Queensway Carleton Hospital, first opened in 1976 under the government of premier Bill Davis, is today facing an overcapacity crisis. Since the beginning of the year, it has repeatedly admitted more patients than it has available beds.
Officials with the regional health network, which oversees health care in this part of Ontario, say they have been watching overcrowding at local hospitals with concern.
Both the Queensway Carleton and The Ottawa Hospital, the city’s major health-care centre, have been over capacity in recent months. Outside of Ottawa, the Cornwall Community Hospital has been as high as an eye-popping 138 per cent.
The overcapacity crisis is partly due to the season — winter brings more cases of flu and respiratory illnesses, and this year has been a bad one. But the situation also reflects a growing demographic reality: The long-predicted grey tsunami, as baby boomers enter the later stages of life, has arrived at the shores of Ottawa’s hospitals.
And it’s only going to get worse, experts predict.
Queensway Carleton Hospital, with 264 beds, is significantly smaller than The Ottawa Hospital with 1,050 beds at two campuses, and it is facing increasing pressure. Its emergency department is among the busiest in the city and it is located close to long-term care and retirement homes, which means a high volume of elderly patients and increasing emergency room traffic. The combination creates a bottleneck of the kind in full view on this Monday morning.
Three years ago, the Queensway Carleton saw about 180 patients a day in emergency. Today that daily number is 220 and it has gone as high as 280. Those patients are generally older and sicker.
Some local hospitals have reached the point where they are seldom, if ever, at or below 100 per cent capacity.
As the bigger questions — the future of health care and how to sustain it — are debated by politicians, hospitals are left to perform the daily dance of treating more and sicker patients without compromising care.
It is a routine that requires creativity, skill, co-ordination and patience. And it can take a toll on patients, their families and staff.
The hospital’s manager of bed flow oversees a daily 9 a.m. conference call to get an accurate picture of bed availability and what demand will be like during the day.
About 20 people take part in the call, including clinical nurse managers, clinical directors from each unit, members of the hospital’s logistics team and care facilitators. On busy days, there will be a second call at 2 p.m.
Staff knew that Monday would be a tough day.
“It has been building since Friday,” Drynan says. “As of Saturday morning, we had eight admissions in the department. Historically, you don’t see as many discharges on the weekends. We are now up to 15 (admissions without beds).”
As clinical care leader of the emergency department, Drynan is one of the managers in the eye of the hospital’s overcapacity storm.
She conducts rounds with patients and families to learn about their experiences in the emergency department, to answer questions and look for areas of improvement. She meets with staff to promote improvement and leads initiatives in the department as well as daily huddles.
A week earlier, the hospital had 22 admitted patients waiting for beds, “the highest number I have seen,” Drynan says.
She changed from her business clothes into hospital scrubs to help with the overflow because additional staff weren’t available to come in.
On that day, elective, or nonurgent, surgeries — potentially anything from joint replacements to urology procedures — were cancelled to help make space for admitted patients waiting for beds.
It is something the hospital only does as a last resort.
But in recent months it has cancelled 36 surgeries, including 12 in March due to overcapacity.
On Monday morning, as the situation comes into focus, more cancellations seem likely.
“It is an environment where patients are unwell and things are changing quickly. You need to be able to think fast. There are many nurses working very hard and doing very well and patient safety is their first thought, but it is a lot more exhausting and taxing on the nurses,” Drynan says.
“I know there are days when they leave that they wish they could have done more (such as) spending more time with a patient to really make that connection. When you are just running from patient to patient, that is certainly a challenge.”
You need to be able to think fast. There are many nurses working very hard and doing very well and patient safety is their first thought ...
On this Monday, the hospital has been given a bit of a break.
The emergency department, in the midst of renovations to add more space, is relatively quiet first thing in the morning, despite the overcapacity crisis.
John Chaffey, 68, sits in the waiting room reading a book called: The Quantum Universe: (And Why Anything That Can Happen Does). He brought the book figuring he would be there a while. He injured his leg falling between floor joists in his attic almost a week ago.
Instead of getting better, the pain has been getting worse and disturbing his sleep, so he came to have it looked at. “I am sure there are many people that need help more urgently than I do. Still, I thought it might be potentially serious.” His wait is relatively short.
But staff expect the volume to build as the day progresses.
And it does. By mid-afternoon, there are paramedics waiting with patients in the hallways, growing numbers of anxious families in the waiting room and full stretchers throughout emergency.
Meegan Smith, a triage nurse, is one of the first to see patients as they come through the door to emergency.
From her desk behind a glass window in the corner of the emergency waiting room, the soft-spoken, bespectacled nurse will be the first person patients suffering from chest pains, broken limbs, mental health issues and more will see. “We see everything.” Triage nurses are responsible for patients in the emergency waiting room, and even those coming in the front door, until they are in the care of emergency staff. Some days, her job is a “constant bob and weave” she says, as she tries to keep an eye on everyone. On busy days, patients can be waiting eight hours or more and are frustrated.
Triage nurses rate patients on what is known as the Canadian Triage and Acuity Scale, to determine how quickly they will be seen.
The scale goes from one to five, with one being the most serious. Level 1 includes patients with lifethreatening conditions requiring immediate attention — cardiac arrest, for example. Level 4 might include an earache, simple fractures or back pain, while Level 5 could include anything from prescription refills to sore throats. Volume will determine how long patients with less urgent ailments wait.
Part of the triage nurse’s job is to try to maintain a sense of calm and order. “My philosophy is that we want to treat people like we would want our families to be treated,” Smith says.
But overcrowding challenges staff’s ability to do just that.
Overcapacity means the emergency department has admitted patients and emergency nurses are caring for them because there is no room on the units. That means less room and fewer staff to handle emergency patients, says emergency physician Dr. Gordon Kee, dressed in blue surgical scrubs, a stethoscope around his neck.
“We have been getting creative. We have been seeing people in hallways and pulling people into paramedic assessment rooms to try to see more people. We have been doing whatever we can, but it hasn’t been enough on those days when it has been really busy. People wait a long time,” Kee says.
“It is frustrating. You do your best, but it is not fair for somebody to be in the waiting room for 12 hours, potentially getting worse.”
Overcapacity creates a real safety concern, Kee says. “It is not just people’s hurt feelings. They are out there with pneumonia and they are getting worse because they are not on antibiotics, they are not getting treated. That is happening.
“We are all trying to work harder, be more creative, find ways to get things done without adequate resources, but you can only do what you can do.”
By Monday afternoon, as the hospital becomes busier, the noise level increases and observation rooms, cubicles and hallways become more crowded. Nurses and doctors move more quickly and conversations are more abrupt.
“It can get pretty hectic,” says ward aid Carol Davis, whose job it is to put patients in examination rooms and get their charts.
“It is extremely important to work as a team. When you work as a team, it flows.”
Karen Lemay, the care facilitator responsible for the everyday operations of the Queensway Carleton emergency department, says the morning went well.
“I have not yet overflowed into the corridor by a significant number of patients. We are progressing better than we usually do.”
Among other things, the hospital moves patients who have been seen by a doctor and deemed safe into a lounge while they wait for further testing, freeing up a cubicle or stretcher for another patient.
Many days, the emergency department doesn’t meet its standard of care — as spelled out in the Canadian Triage and Acuity Scale — because of overcrowding, she concedes.
Patients rated Level 2 on the scale — with chest pain, a dislocated limb or drug overdose, for example — should be seen by a physician within 15 minutes, according to the scale.
As the day progresses, it becomes clear the overflow situation will continue, and likely worsen, at least until the next day.
“We are going to be in a worse situation by tomorrow morning than we are now,” says Jo Anne Higgins, the bed flow manager who co-ordinates the daily calls.
During the afternoon conference call, Higgins asks for predictions about how many patients will be discharged and new ones will be coming in. She also goes over staffing levels, which were stretched thin between March break and the gastro bug afflicting nurses.
“It does look like we are running out of resources to staff anything extra,” she says. The call is business-like, but there is a hint of exasperation in Higgins’ voice as the full picture comes into view: Reduced staffing and more demand for beds than beds available.
“Are there any extra nursing resources anywhere for this evening? It sounds like all units are short,” she asks one last time near the end of the call.
By the end of the day, six of the 15 patients who started the day in emergency waiting for a bed are still there, and will remain that way for at least another day.
Those six remaining overflow patients, “plus whatever else comes through the door,” are enough to convince Higgins some elective surgeries should be cancelled on Tuesday. The hospital tries to notify patients the day before when this happens, but it is not always possible. Some might only learn the morning of the cancellation.
Drynan, satisfied that the staffing shortage means the department will need extra help in the morning, says she will come prepared.
And 94-year-old Margaret Otto, who has been waiting in the emergency department since Sunday afternoon, is expected to be moved to a bed by the end of the day.
Earlier in the day, Drynan spoke briefly to Otto’s daughter, McGoldrick.
“We want to get (your mother) into a patient bed. It is a noisy environment; it is not easy to sleep. I completely agree with you,” Drynan said.
“I know you are the ones taking all the flak for this,” replied McGoldrick, “but it is a sad state of affairs. Nobody can deny it.”
On Tuesday, a new day begins. The hospital is at 107 per cent capacity and in full capacity alert once again.