By Annamarie Fuchs, Creator. Partners in Health | Conversations
March 24, 2022
Running an emergency department is like a battle: It takes an army. We must each be able to articulate the problem and our personal role in the solution. Without it the fight seems pointless. We are not inspired. We become defeated. And if we become defeated, we leave. And if we leave, we leave behind the very people who are the purpose of our existence – our patients. Who suffers? We all do.”[1]
I worked as a front-line nurse many years ago and only briefly in a rural emergency department. My clinical years were spent working as a Registered Nurse on inpatient units and in the intensive care unit. When I became an operational leader, much of my focus centered around finding efficiencies in inpatient settings to enable emergency departments, long believed to be healthcare’s ‘canary in the coal mine’ to be more safely and efficiently run. Over time, strategies around effective patient flow and access management have evolved into both science and policy, particularly since Peter Viccelio[2] and others began to develop ‘full capacity protocols’ in response to chronic overcrowding and as a means to distribute patients more safely across hospitals.
I left that environment years ago to become a consultant and writer but my respect and admiration for all healthcare providers, particularly our front-line providers has only grown. I’ve been blessed to have been able to continue learning from front line clinicians in my capacity as a consultant, a strategist, and a writer. In my capacity as a writer and while I’ve interviewed physicians, regulators, and researchers, I haven’t yet had the opportunity to speak with registered nurses who work directly on the front lines. In this article, we’ll hear from someone who has worked in the emergency department of Red Deer Regional Hospital Centre (RDRHC), a large regional referral centre for more than 10 years. RDRHC is a 345-bed acute care hospital and level 3 trauma centre that originally opened in 1904 as the ‘Red Deer Memorial Hospital.’ Today, it serves more than 450,000 people across Central Alberta.
That hospital has recently been in the news. In January of this year, a triaged patient died while waiting treatment. For those readers who do not work in the healthcare system, triage protocols assign a scale (numbered from 1 – 5) to each patient when they arrive at the emergency department. That triage scale allows clinicians to be more aware of who needs care most urgently. For example, a level 1 patient is emergent and won’t wait in the waiting room. A level 5 patient is non urgent and can wait while other more seriously ill or injured patients are seen in priority order. On this particular day, a patient had been triaged and was waiting to be seen by a physician while wait times in the emergency department were reported to be averaging 14 hours.
When Alberta’s health minister was interviewed later about the tragedy, he explained that there is an “infrastructure deficit”[3] in healthcare in Central Alberta but didn’t elaborate further with regard to cause or next steps being considered to address that deficit. The public didn’t have long to wait. On February 23 the premier announced that $1.8 Billion was being set aside to invest in infrastructure expansion with an anticipated completion date for those expansions set at 2030.[4] This announcement is the third in a series of budget announcements that have been made in context to RDRHC since 2020.
I’ve been in healthcare for 35 years and have seen political maneuvers many times. But I am continually astounded each time I hear about long-term solutions being announced for problems that are impacting lives today. I’m not suggesting that long-term solutions aren’t needed. They are. Good strategy requires it. But emergency department staff across this country are engaged in in a battle for survival right now. I point out in the quote at the top of this article that running an emergency department is often likened to that of an army engaging in war. Retired General Rick Hillier recently emphasized the following:
“What we say in battle is that we must focus first on the 25-meter target. What I mean by that is that we must first worry about the enemy standing right in front of us at this moment and worry about what else may be coming down the road later. You don’t start your defense when the enemy is at the front door. You start much earlier.”[5]
The 25-meter target. That comment resonated with me instantly as I thought about the chronic issues facing virtually every emergency department in the country and the plight of the incredibly brave staff who fight their own battles every single day. They fight to preserve life. They fight to preserve the environment for the next day. And they continually struggle to deliver excellence so that at the end of the day they know they’ve done heroic work in their effort to serve our communities.
Because my writing is intended to offer outreach to the public and to the healthcare community, the one question that is top of mind for me is whether the public or funders fully understand the work that our front-line providers do every day in these highly charged and chaotic settings. I reached out to a Registered Nurse I’ve known for nearly 20 years and asked her if we could talk about working in an emergency department and about burnout among health professionals. Our 90-minute scheduled conversation stretched into nearly three hours, and I came away with renewed insight, compassion, and heartbreak. What follows is our conversation and a caution that some passages in this interview may trigger past trauma.
Debbie (pseudonym), thanks so much for taking the time to speak with me. While I often work with physicians who work in emergency departments, we don’t often have a chance to talk in detail about what it’s really like day-in and day-out, year-in and year-out. And I think it’s time we heard from registered nurses at ‘Partners in Health | Conversations.’ Let’s talk about what it’s like to be an emergency department nurse. And can we talk about whether you think health professionals feel heard, understood, and appreciated, or whether there is even a sense of the day-to-day workflow and chaos that is endemic to all large emergency departments? But first I will ask you; where would you like to start?
I was on duty when Walter Reynolds came into our department.
Before we continue, let me offer a brief history about what Debbie is talking about. On August 10, 2020, about 6 months into the COVID-19 pandemic and while working at his clinic in Red Deer one morning, a beloved family physician was attacked and murdered. Dr. Walter Reynolds was 45 years old. I was silent for a minute. I leaned back in my chair and whispered, “I am so sorry Debbie.” Do you feel comfortable talking a bit more about it?
Well, I do if we can keep it in context to your questions about whether what we do is appreciated, understood, or more importantly, whether there’s even a sense of ‘what we do’ in the emergency department. That experience was devasting for everyone and as a way of respecting Walter’s family, friends, and my colleagues, I’d like to leave it there. I will say however that few if any people fully understand what we see, what we do, or what we take home with us at the end of a shift. Decision makers certainly don’t, and I believe that while the public understands we are there for them, they have no immediate sense about what may be happening behind the scenes while they wait in the waiting room. I have huge respect for first responders – the EMTs and Paramedics who are out in the field. But what the public should remember is that those victims are then brought to us. While we react to try to save an individual’s life, we are supporting the family and, in most cases, a completely full (and often over capacity) department and waiting room where every single person has expectations that we will care for them. Nobody likes to wait. I get that. But as the shift unfolds and particularly in a situation like that, we have no time to grieve or to process what has just happened to a respected colleague and friend. That day changed our lives forever. I’d like to leave it there.
Thank you, Debbie. Can you tell me what supports are in place to help emergency department staff deal with traumas and tragedies?
Well, I’ve been here for several years now, and I have to say that we do a lot more debriefing as a team than we used to. For example, after a patient with a recent critical injury was transferred out to a tertiary center, the trauma team met to discuss how the event had unfolded, how everyone was feeling, and what could be improved upon. This is an area of communication and support that we’ve been committed to improving in our department for awhile and it’s nice to see the culture changing as a result. Nowadays, when we are in the middle of a shift, we’ll often check in with each other. I honestly see that sort of support – when we can directly support each other – as far more effective than having someone who doesn’t work here and who rarely stops by, suddenly dropping in to offer assistance in coping with difficult situations. Learning about how to support each other every day is far more effective in my opinion.
So, tell me how your emergency department is designed to function.
We have three trauma suites – two for adults and one for pediatric patients. We also have a lean track, a critical track, and a minor treatment track. One nurse is assigned to float on either side of the emergency department and if a trauma comes in, the float nurse immediately becomes part of the trauma team which generally has three responders. Depending on the time of day, the third responder is either someone from minor treatment, the ‘flow tech’ which is an RN who figures out where to put all patients who are in the waiting room, or the charge nurse deploys to the trauma team between the hours of 11:30 at night to 7:30 the next morning. Regardless, when a trauma comes in, the emergency department is immediately short staffed for the period the individual is receiving care.
When there is more than one trauma, you cross your fingers that the first patient doesn’t need those three nurses in the room and then you start pulling people from other assignments in the emergency department. When we are really short staffed, the Intensive Care Unit may offer back up but that’s relatively uncommon. They have challenges of their own. However, when there’s more than one trauma or a trauma in a fully loaded emergency department, there are literally no breaks. You are critically thinking on the fly and praying that you don’t miss something. Labs results are coming in from multiple other patients. Diagnostics are being completed and the results of those investigations determine how we respond. There’s no time to be tired or hungry. There’s no time to take enough time to respond with adequate compassion or empathy when a patient or a family member is frustrated and angry or frightened. You do your best to respond to that person, but you absolutely have to keep moving. It can mean the difference between life and death. The burden of meeting the expectations of your patients, of the other people you work with, or other members of the healthcare team in the hospital can be overwhelming.
Things have become so unmanageable that we now have waiting room protocols to manage wait times. For example, certain patient complaints can be addressed in the waiting room by getting some things started – like blood work and so on. So those early answers help us to decide whether the patient is safe to continue waiting or needs to have their triage status changed. We can also do some pain management at triage now, treat mild fevers, that sort of thing. I’m sure this helps those who are waiting to understand and cope with the waits that we all know are not optimal.
I started thinking about what Debbie said about the expectations of meeting clinical demands, relying on high quality critical thinking and team-based communications, and changing priorities on a moments notice. Debbie had already given me a small sense of the distress and the moral harm experienced by the terrible loss of a colleague and friend and the traumas that are commonplace in all emergency departments. I asked Debbie to talk about the physical harm inflicted on staff which is something that is rarely spoken about and not well understood by anyone outside of that environment.
Oh, it’s common! I’ve personally seen someone attacked by a psychotic patient. His leg was badly broken in that incident. Another individual was stabbed by a pen and a few of us have had weapons like machetes waved at us. You have to understand that emergency departments by definition have gaps in security. They have to be rapidly available to the public and I get that, but we have no metal detectors for example. We have secure doors, but some people will come in for treatment from environments that are so unsafe that they routinely carry weapons. So, they arrive at a highly chaotic environment with bright lights and noise where they can become panicked very quickly. When that happens, a weapon might be brandished. I am just grateful that in this hospital, we have our security team physically located right at the ED.
Debbie’s insights offer valuable context. Emergency departments are available to the public 24/7. They provide the optimal setting to evaluate and treat serious, unscheduled, acute, and decompensated conditions. Despite enormous risk and mounting stress, the emergency department staff adapt and respond quickly. Efficiency and excellence are always the goal, but both can be disturbed by the lack of available qualified staff, a crowded department, or frustrated patients, but also on factors that are often far outside their control. Enter, COVID-19.
Prior to COVID-19 and in the previous 10-15 years, ED visits at the RDRHC had been steadily on the rise. Like many hospitals across Alberta and across Canada, the Red Deer ED was over capacity most of the time with wait times that were unreasonable and unmanageable for everyone. Over time, that overcrowding has become considered in my opinion as “tolerable dysfunction”[6] where decision makers across the country appear to have become less and less inclined to respond to these issues as being the critical and life-threatening events that they are. More likely, ED overcrowding seems to be seen as an issue of inconvenience and one that nobody has been willing to adequately address. As overcrowding continues to rise, patients leave without being seen, patient acuity increases, violence toward staff increases, and ultimately burnout and turnover of staff is the result. In a 2021 article, Kelen et al explained that emergency department crowding is a “sentinel indicator of health system function and while often dismissed as a mere inconvenience for patients, the impact of ED crowding on avoidable patient morbidity and mortality remains underappreciated. Further, the physical and moral harm experienced by staff is considerable.”[7] When COVID-19 arrived on the scene, the donning of personal protective equipment alone created added workload, time, and burden for exhausted staff working in environments that were already relentlessly overcrowded.
Tell me what it’s been like for you during COVID-19 over these last two years.
When COVID first came on the scene, as an ED nurse and a parent I was petrified. I wondered if I’d have to sleep in my garage just to keep my family safe. I wondered if I would die and leave my children and my spouse. Every day I asked myself “is this the day I will get COVID and bring it home to my family? I would sit in my car before and after every shift, breathing in and out and trying to screw up my courage to go in and work and then to go home and trust that I had been as careful as I could possibly be.
One of my physician colleagues was tested for COVID-19 just before getting vaccinated to see if the personal protective equipment (PPE) works. It does! He has not had COVID either before or since being vaccinated nor have I. But it’s a burden. It’s a burden to put on and remove the PPE. It’s a burden to add that extra step of caution multiple times a day. But it’s an essential step to protect our patients and ourselves. And it’s been a huge worry.
We’ve seen great numbers of COVID-19 patients over the last two years but what people might not realize is that we’ve also seen huge increases in domestic violence victims, drug abuse and overdose victims, sexual abuse, child abuse victims, mental health exacerbations, and the list goes on. And generally speaking, the people we see are just sicker. They hold off coming to the ED because they worry about COVID. By the time we see them their symptoms have escalated.
Through it all, when people have come to the ED for care and told us they weren’t vaccinated, we continue to provide care and that won’t change. But I wish I could tell people to just get vaccinated. I want to remind people that they eat microwaved dinners, consume mystery meat and all sorts of horrible, processed food without a second thought. They have had flu shots, shingles vaccines, and polio shots. They don’t think twice when vaccinations are required before they travel overseas. And yet this vaccine, this disease that has killed so many people… somehow this has become a rights issue? I’ll stop there. I honestly don’t understand. So, you can see that at the end of the day, COVID-19 has had far reaching effects on all of us.
So just recently you were told that the RDRHC was going to receive $1.8 billion in infrastructure funding. How do you and your colleagues feel about that?
First, I’ll believe it when I see it. We’ve been down this road before. Second, even if the funds are allocated and we get the expansion, which by the way is badly needed, where on earth are we going to find qualified staff and how are we going to cope in the meantime? We are short staffed on every single shift right now. To cope, we try to bring in different levels of staff. For example, when we can’t fill an RN shift, we bring in an LPN. That’s okay but when that happens, we have to adapt the environment to the skill mix. Patient assignments need to be changed so that the right skill mix is assigned to the right type of patient. We do everything we can to staff the ED so that it is available to serve the public. I work a regular schedule and pick up shifts to help my colleagues, so I work far more than full time. Most of us do. And I can show you that every day, all day, there are texts on my phone asking me to pick up more shifts. To achieve some sort of work life balance, I need to turn off notifications. But I have a family. I can’t turn my phone off completely. The reminders are there every day, all day, reminding me when I don’t go into work that my colleagues are working short. Then to add insult to injury, we hear through the media that the public believes we are being paid too much. Seriously?
Debbie, you’ve given us such a very ‘real’ and ‘raw’ look into the experience working in an emergency department. I know that despite our efforts in sharing this article, people including decision makers still won’t fully understand the challenges of working in today’s emergency departments. So, tell me, what worries you the most? Even if the $1.8 billion results in a wonderful, appropriately sized and fully staffed facility in Red Deer one day that can better respond to the needs of the public, what else should we be thinking about?
We have a crumbling healthcare system. We can’t staff this beautiful hospital the way it is now. We can’t respond to patients today the way we would like, and we have to try to live with that. And we can’t get through to decision makers about what we need in the short term and medium term or get the public to understand that emergency departments and hospitals were never meant to be used for convenience. When we are forced to provide the type of care that could readily be delivered in any of our wonderful primary care clinics across the region, it’s clear to me that the public simply do not understand what might be happening in the background, inside the emergency department, or what an emergency department is actually designed to do for the community.
Debbie, thank you so much for taking the time to speak with me today! Please know you and your colleagues have my respect and admiration for the work you do. I want to leave the last word to you. Any final thoughts?
Final thoughts? Well, while I appreciate seeing yet another promise of big money for expansion, I am begging for the help that is needed right NOW. We desperately need qualified staff. We need metal detectors. We need more secure mental health assessment rooms. We need training about how to best support each other every day so we don’t burn out. And we need the public to understand that we are doing our best to care for them under extremely difficult circumstances. Come to the ED if you need help. We’ll be there. But if you have to wait it is only because we are providing care to critically ill or injured people who need our help more urgently. Please help us to help you. Thanks Annamarie.
Thank you, Debbie!
References
[1] Ashoo, S. Running an emergency department is like a battle: It takes an army. March 5, 2018. KevinMD.com. https://www.bbc.com/news/world-us-canada-56324047
[2] https://www.researchgate.net/scientific-contributions/Peter-Viccellio-39261632#:~:text=Background%3A%20Full%20capacity%20protocol%20(FCP,ones%2C%20have%20not%20implemented%20FCP.
[3] https://edmonton.ctvnews.ca/triaged-patient-dies-while-awaiting-treatment-inside-red-deer-emergency-room-1.5754160
[4] https://rdnewsnow.com/2022/02/23/1-8-billion-announced-for-red-deer-hospital-expansion/
[5] March 2, 2022. “Power and Politics” with Ret’d General Rick Hillier. https://www.cbc.ca/player/play/2008385091882
[6] Ibid
[7] Kelen, G.D. Wolfe, R., D’Onofrio, G., Mills, A.M., Diercks, D., Stern, S.A., Wadman, M.C., and Sokolove, P.E. Emergency Department Crowding: The Canary in the Health Care System. New England Journal of Medicine Catalyst, Innovations in Care Delivery. September 28, 2021. https://catalyst.nejm.org/doi/full/10.1056/CAT.21.0217
