Juggling Patients and Priorities: Life In The Emergency Department
The rapid growth in population means in the northwest quadrant of Mississauga means we've seen a dramatic increase in the number of patients at Credit Valley. More and more of those patients are being admitted to hospital as a result of their visit to the emergency department.
When the beds on the inpatient units are full, which is very often the case, patients being admitted through the ER must remain there until a bed on the unit becomes available. The CVH ER sees about 70,000 patients a year and is one of the busiest emergency departments in the country.
About one third of those patients are children. The hospital is the regional site for paediatric care, which impacts the number of neonatal and paediatric patients we see in the ER and on the nursing units. Many of these patients are admitted through the emergency department.
There are two triage nurses on duty 24 hours a day. A third triage nurse is on duty for an additional twelve hours. This helps to speed up the triage process.
Normally the triage nurse will see the new patients in order of their arrival. However, there are always exceptions when an obviously seriously ill patient requires the triage nurse's immediate attention. The triage nurse will ask you why you came to the emergency room and the symptoms you are experiencing. She will record the information on a patient flow sheet. This is part one of the triage process. If there are no other patients waiting to be seen, the nurse will continue with part two, but usually she will ask you to have a seat for a few minutes.
Part two is when the triage nurse takes your detailed medical history and vital signs (pulse, blood pressure, temperature etc.). It's at this point that the triage nurse determines the level of severity of the your condition and prioritizes you according to a five-level triage system. So it really doesn't matter when you arrived in the emergency room, the sickest patients will always be seen first (see also the article entitled, Triage Process). However, it's important to remember that if your condition changes while you're waiting, you should tell the triage nurse. The nurse will reassess you and document the information on your chart.
Once your triage has been completed, you'll be asked to register at the desk adjacent to the triage desk. The clerk will ask for the patient's address and OHIP information. This information is recorded on computer and so begins your patient chart. All health professionals who see you during your ER visit, will document information on your chart. After you've registered, you'll be asked to take a seat in the waiting room.
You can't always tell how busy the emergency department is when you're sitting in the waiting room. We may be completely full with several full-blown emergencies in progress. The ambulance entrance, which is where trauma and many seriously ill patients enter the ER, is adjacent to the resuscitation room, completely out of eyeshot of the ER waiting room. This allows for speedier transport into the ER and protects the patient's privacy.
The 39-stretcher department is often "gridlocked" with acutely ill patients who are too sick to be treated and released. They need to be hospitalized, on a nursing unit, in an "inpatient" bed. But as we hear and read daily in the media, those inpatient beds are at a premium. So the patients remain in the emergency department where they can be safely monitored and their treatments initiated until an inpatient bed becomes available. We have created a ten-stretcher holding area in order to expedite care of the emergency room admissions (ERAs).
Patients who have been triaged and who have been placed inside the ER either in Care Centre One, Two or RAZ area, have no trouble understanding how busy it is. The care centres are open-concept design. This means patients and nurses can see one another at all times. There are 14 RNs on duty who are assigned to the three care centres at all times. During peak hours there are three physicians on duty.
The staff in the ER work as a team with the other health professionals who are called in as required such as the physician specialists, respiratory therapists and social workers. Other health professionals that provide important diagnostic services to the ER (and other areas of the hospital) are the lab technologists, diagnostic imaging technicians and radiologists.
The ER is designed so that staff can care for the patients as efficiently as possible. Caregivers can order tests or prescribe medications on computer within the care centre. When blood tests and x-rays are completed, the patient is reassessed by the physician. There's a cart beside every bed which contains supplies and equipment so there are no delays in delivering treatment. Each cart is identical so no matter what room a physician or nurse is in, the supplies are in the same place. The patient service representatives (PSRs) keep the carts stocked as well as transporting patients to and from the ER for tests, or to the nursing units
Credit Valley's ER has a "fast track" area for patients with less urgent ailments, called RAZ – Rapid Assessment Zone. A nurse and a physician are dedicated to this area 12 hours a day but it is staffed by nurses 24 hours a day.
The Credit Valley Hospital has established several other programs to assist patients and caregivers. The Quick Response Team, a team of specially trained nurses, works with the patient, the family, the physician and nurse to determine any special requirements the patient may have once they return home. Contacts may be made with community service agencies such as homemaker or VON services so the patient, who doesn't require admission to hospital, will be able to function safely at home.
There is also a Crisis Intervention Team made up of social workers who assist patients with psychiatric illnesses or stress-related illnesses. Following their assessment of the patient, they develop a plan of care in consultation with the ER physician and psychiatrist on call.