101 recommendations to fix safety and staffing concerns at Brantford’s ER
Report reveals millions of dollars paid to temp agencies, inadequate monitoring of mental-health patients and overwhelmed triage nurses
The emergency department at Brantford General Hospital was so understaffed that more than $4.3 million was paid to private agencies to supply temporary nurses over the last three years.
The hospital’s overloaded triage nurses were failing to assess patients within the standard 10 minutes of arrival because they were often doing the job alone while also answering ambulance calls and monitoring the condition of everyone in the waiting room.
Mental-health patients were left without adequate supervision in the emergency department for up to an hour — sometimes in a secluded room with no video monitoring.
Serious concerns raised by Brantford nurses about staff shortages, overwhelming workloads and lack of equipment have come to light in an independent assessment of the hospital’s emergency department that resulted in 101 recommendations. The Independent Assessment Committee (IAC) report dated May 5 described:
■ A revolving door of senior leadership with the clinical managers both starting in 2023 and the clinical director starting in 2024. The vice-president of clinical services and chief nursing executive position is vacant with interim leaders taking over while recruitment is underway.
■ High staff turnover to the point that in 2021 almost half of new nurses left within months of being hired. As a result, more than twothirds of the nurses working in the department have been in the specialty for five years or less.
■ The emergency department had a vacancy rate of more than 21 per cent — the average for Ontario hospitals was 15.5 per cent, which is already considered high.
The assessment was initiated by the Ontario Nurses’ Association (ONA) just over one year ago after Brantford nurses filed more than
300 reports since 2020 documenting their inability to meet the standards set by their regulatory college and other associations because of the work environment in the emergency room.
ONA president Erin Ariss described the move as a “last-ditch” measure in the collective agreement that was rarely used up until two years ago when the union had to start bringing in the IAC more frequently because of the increasing staffing crisis in Ontario hospitals.
The union has used the mechanism three times so far in 2024, including at Brantford General.
“Emergency departments broadly across Ontario are in a very bad position right now,” said Ariss. “It is not right. It is avoidable. There’s been warning signs for a very long time.”
Ariss said the situation in Brantford was “particularly awful” and the union has worked for years with hospital leadership to find resolutions. They agreed on 32 ways to mitigate the workload, improve staffing, support nurses and increase safety. But it didn’t go far enough, resulting in the assessment by three independent registered nurses, including a three-day hearing in March.
“There’s 101 recommendations — it’s what the nurses have been saying all along,” said Ariss. “This emergency department is chronically understaffed, both for the number of patients they see, but also how sick the patients are in this emergency department.”
Brantford General had 54,606 emergency department visits in 2023, averaging 149 per day. The patients coming to the department have been sicker over the past four years. More arrive by ambulance and off-load times have gone up by 23 minutes compared to before the pandemic, stated the report.
“We know that the staff who work in our emergency department face incredible pressures, are required to make timely and critical decisions, and deal with traumatic situations on a daily basis,” Beth Morris, interim chief nursing officer at Brant Community Healthcare System (BCHS), said in a statement.
The hospital network said it has implemented 62 of the 101 recommendations already. The rest will be “discussed and reviewed in detail.”
There is nothing to force the hospital to put the rest in place as the IAC is not an adjudicative panel and its recommendations are not binding.
“The BCHS leadership team remains committed to navigating these challenges and working collaboratively with our nursing staff to provide high-quality care to our patients,” said Morris.
One of the most troubling and high-priority issues for the union has been violence in the workplace as nurses have raised concern about their personal safety in the emergency department.
“They have an extremely violent environment there,” said Ariss. “One member had spoken to us … about the fact that they had had their life and their families’ lives threatened on multiple occasions. They’ve been physically assaulted, kicked in the face, spat on, all while trying to provide care in the waiting room or in hallways. Threats of violence and actual violence are happening daily. It is incredulous that this has been allowed to go on.”
The hospital has implemented 24-7 security in the emergency room as recommended by the IAC along with other measures.
The report also recommended security monitor the video feeds in two rooms used for mental-health patients — up until now the already-overloaded triage nurse had been watching the feed in one room while the other room had no camera at all.
It meant patients in distress were not being adequately monitored while their median wait to see the emergency room mental-health team had gone up to 27 minutes last fiscal year compared to eight minutes before the pandemic. The report stated patients waited up to an hour to see the team.
It’s a significant gap in an emergency department where 30 per cent of the visits have a mental health or substance use documented in their health record.
The video camera in the mentalhealth room was not the only equipment missing from the emergency department. The report listed the need to get more cardiac monitors, portable vital signs machines and ECG machines. BCHS said in the statement that it has spent more than $1 million in the past five years on required “vital equipment.”
Nurses also described spending an “extraordinary amount of time finding supplies,” which has resulted in a number of measures to ensure the emergency room is properly stocked.
However, the most urgent need that came up repeatedly in the report was staff as nurses described having difficulty keeping up with the workload even when the full complement was there.
At the time the report was submitted, the emergency room had 18 unfilled jobs — 16 of them were for nurses while the others were clerks.
Those vacancies do not include the extra positions that the report recommends such as a nurse practitioner.
To fill the gap, the hospital has had to turn to private agencies to supply temporary nurses to work more than 33,700 hours in the emergency room over the last three years.
Another difficulty has been getting the right mix of staff as just 18 per cent of the nurses have worked in an emergency room for 10 years or more. Nearly one-third have been in the specialty for one year or less.
“Understaffing contributes to the shortage because eventually nurses leave the profession and we’re seeing that,” said Ariss.
The ONA submission to the IAC described how the nurses have “experienced distress that they cannot meet the standards of care due to being short staffed and report being fatigued and experiencing burnout.”
“Most described traumatic experiences that had occurred caring for patients in life-threatening circumstances, while knowing that other patients were also in need of care,” stated the report. “The nurses also identified how they could not take the time to access the available mental health care supports offered by BCHS, as they didn’t want to leave their colleagues with one less nurse as they took care of their own mental health needs. They also described how they often went home worrying about what care they may have missed or reliving the traumatic events they had witnessed.”
Ariss said the union shouldn’t have to go to an extreme measure like turning to the IAC to have these issues resolved and hopes other Ontario hospitals are taking note of the 101 recommendations in Brantford.
“These are the barriers to receiving the best care and that’s why the panel has made these recommendations to improve care,” said Arris. “The right thing to do would be to implement them.”