Imagine coming to work every day – and not knowing what awaits you, other than that it will involve emergencies and a variety of urgent situations.
Imagine coming to work every day and knowing that you will face people who are scared, sick, and in some cases, in danger of dying.
Imagine knowing that your decisions and actions could very well mean the difference between life and death?
Sound like something you’d tackle on a daily basis?
Fifty-one fulltime nurses and two nurse practitioners work there – along with a number of part-time and casual employees. With more than 50,000 visits per year, it’s the biggest and busiest emergency department in the province. It never closes – but provides emergency care 24-7.
And the nursing staff is fundamental to the workings of the place.
Once registered as a patient, you move to a triage nurse, like Rayna Maynard. Her job is to rapidly assess patients’ signs and symptoms and determine how urgently they might need to see either an ER physician or nurse practitioner.
“Our priority as triage nurses is to recognize the signs and symptoms that pose a threat to life or limb,” Rayna adds. “We are trained to watch out for unstable vital signs, a change in level of consciousness, signs and symptoms associated with a heart attack, stroke, internal bleeding, etc.
“As a triage nurse, it is our job to determine which patients need immediate intervention and assessment by the ER physician.”
Who gets priority in the ER?
Triage nurses across Canada use the Canadian Triage and Acuity Scale (CTAS) – guidelines developed by the Canadian Association of Emergency Physicians and the Emergency Nurses Association. It is a standardized program that uses a scale of one to five to prioritize patients in emergency. One is the highest priority which means the patients with a CTAS score of one need to see the doctor immediately. Five is the lowest priority meaning patients can safely wait to see a physician.
Some examples of triage codes are:
- Resuscitation: cardiac/respiratory arrest, major trauma, unconscious patients
- Emergent: altered level of consciousness, cardiac chest pain, stroke, trauma
- Urgent: moderate trauma, abdominal pain
- Less Urgent: headaches, chronic pain
- Non Urgent: sore throat, prescription refills
Rayna says triage nurses understand that they’re the first point of contact in an emergency department – and that when patients and families come into the ER, they need to be heard.
“Triage nurses must try to be patient and understanding and each person who walks through the doors may be experiencing their own life crisis,” she adds.
“Therefore, the role of the triage nurse is to listen to the patients’ complaints, validate that we understand that they are not feeling well and assure them that we will do what is in our power to help them.”
Colleague Gail Dawe agrees – and says it also must be done as quickly and efficiently as possible, given the environment of an emergency setting.
“The emergency department is unique, as the staff have to know something about everything,’ she adds. “We also have to be ready for whatever comes through the doors – and usually with only a few minutes’ notice.”
Gail is a registered nurse and patient care facilitator in the emergency department, whose role is to keep the flow of patients moving….from the waiting room to be seen by the emergency room physician – and from the ER upstairs to the inpatient floor once they are admitted. She also monitors staffing to make sure shifts are covered for nurses and support staff, and makes sure that patients who leave the ER receive the proper follow up when ordered.
“Often, we are blocked with admissions waiting to go upstairs to the inpatient units, so we run out of places to assess the other emergency patients,” Gail says. Then there is an extra wait for those who are stable enough to wait in the waiting room – some of our biggest challenges are keeping the flow moving.”
“Work in our ERs is very fast paced, so our nurses must be energetic, focused and have the ability to adjust to changing priorities rapidly,” says Katherine Chubbs, Chief Nursing Officer and Vice President with Eastern Health. “Our emergency room nurses have taken a very active role in process improvement and improving patient flow is a big part of that work. Our ER nurses, and thousands of their nursing colleagues, provide outstanding care every day across our region and the province.”
Patient flow has also been improved by placing Nurse Practitioners (NPs) in emergency rooms. Their scope of practice is higher than a nurse’s – lower than a physician’s.
An NP can do an assessment, and also order X-rays, ultra sounds, laboratory work and medications, write a prescription and diagnose the problem. Consultation to specialist services such as neurology, medicine, surgery and ophthalmology, etc. is also within the NP range of responsibilities.
Therefore, many patient conditions can be taken care of by the Nurse Practitioner. Dorothy Bragg is one of two NPs at the Health Sciences Emergency Department.
“It’s very important to have an NP in Emergency to keep patient flow moving; often a major trauma or several very ill patients arrive around the same time, which can bring an ER to a “screeching halt,” according to Dorothy. “The sickest patients get seen first, so the non-urgent people often wait longer times to be seen and the waiting room becomes congested.”
Dorothy says her role as an NP complements the work of both RNs and physicians, and allows patients to continue to be seen, treated and return home.
“The physicians are freed up to assess more complicated patient problems, while I can see to the less urgent, or continue a management plan that was ordered by physicians,” she adds.
“Meanwhile, the RNs have quick access to a Nurse Practitioner to discuss a patient who may have just presented at the triage window – who may need x-ray or blood work – or just to bounce their opinion of a patient’s condition off an experienced practitioner.”
Nurse Practitioners are not the only means of addressing patient congestion in the ER. In recent years, a number of things have been implemented at the Health Sciences to enable people to be seen more quickly – and to improve patient flow throughout the hospital or to other facilities.
Including Darlene Smith, a registered nurse in Emergency who is introducing ‘LEAN processes’ in the department that are designed to improve both efficiency and effectiveness.
“Increased patient volume, staff shortages, availability of beds and limited access to after-hours walk-in clinics, GP’s, or specialty services all contribute to clogged emergency rooms and long wait times,” Darlene says. “Demand outweighs supply most days. Ours in not unique. I have worked in many other areas that unfortunately have similar stories.”
Darlene says help has also come in other ways, as well:
- Over the past few months, additional long-term care beds have opened with more to come. As patients are discharged from hospital into long-term care homes, more hospital beds open up, which improves flow out of the emergency department.
- Inter-professional teams have been formed to start the discharge planning from hospital – right from the emergency department stage.
- A ‘rapid response’ team member has been placed in the emergency department to arrange home supports for patients who actually require assistance at home rather than admission to hospital.
It has made a difference. The length of time it takes for a patient to be admitted to hospital from the emergency department has improved – from 125.4 minutes in 2010-11 to 96.7 minutes in 2014-15.
Meanwhile, people who left without being seen has improved as well – from 10 per cent in 2010-11 to 6.4 per cent in 2014-15.
But by its very nature, the emergency department will always be an intense place to work, as staff deal with major trauma, heart attacks, respiratory issues, patients on life support, to name a few. Challenges remain. Patients who are sick and scared sometimes take their frustration out on frontline staff – and sometimes take their frustration public.
Nurses take it all in stride, according to Amanda Whelan, the divisional manager for the emergency department.
“They work hard every day, under stressful conditions, but are well able to handle whatever is thrown at them,” Amanda adds. “Nurses work 8-12 hour shifts – and are still able to help a patient with a smile on their faces. They are concerned when they hear about complaints related to care – and feel they do their very best, but there are days when it is challenging to meet all the needs of the department.”
“We as health care providers certainly do not want you or your family member to wait extended periods of time,” adds Darlene Smith. “Patients are triaged according to need – not time of arrival – and the most urgent are the highest priority. We are trying our best to make their ER experience as timely as we can.”
And as fair as they can, says Dorothy Bragg.
“No one skips the line; the sickest are seen first – that’s our obligation,” she says. “So please be patient. We will get to you and address your issue – as efficiently and effectively – as we can.”
And finally, from Gail Dawe, a powerful and very local analogy:
“Emergency is like an iceberg; most people see only the tip of it – their own situation – which is understandable,” she says. “What they don’t see is the other nine-tenths of the iceberg – all the other people that we’re trying to help. I’d like to encourage people to remember that as well.” ■
This story was written by Deborah Collins, a communications manager with Eastern Health, based in St. John’s