New Emergency Department hits the ground running hard

Calmer atmosphere despite dramatic spike in volume of patients in an upgraded facility

The crisis had passed, and now Michael and Suzanne Hunter could finally breathe easy and pause for a closer look at their surroundings in the new JGH Emergency Department in Pavilion K. What they saw—and felt—startled them: though this was known to be one of the busiest emergency facilities anywhere in Quebec, the atmosphere was eerily calm.

Dr. Alice Yu meets with a patient in a cubicle in the Rapid Assessment Zone.
At first, the Hunters figured they had been lucky to arrive on what they assumed was a fairly slow Tuesday in early April. Mr. Hunter had come in with chest pains around 11:30 a.m. and, after a prompt assessment by a nurse, was given an electrocardiogram. Since the results indicated he was in no immediate danger, he was directed to an examining room where, at 1:30 p.m., he had an ultrasound test.

Now, at 1:45, as he waited for a blood test to be administered in the Rapid Assessment Zone (RAZ), Mr. Hunter eased back in his padded reclining chair and marvelled at the unexpected mood of tranquillity.

Yet, appearances to the contrary, this was actually one of the Emergency Department’s most hectic days since moving into Pavilion K in mid-February. The apparent lack of frenetic activity was—and remains—a byproduct of a unique, decentralized design, in which patients are categorized by the seriousness of their condition and are directed to one of several self-contained areas for treatment.

In each of those areas, the design (along with reorganized staffing) promotes efficiency, privacy and an absence of crowding— all of which are blended together in an effort to create an exceptional patient experience.

That’s not to say every obstacle has been overcome in the new facility. Waiting times, though improved, are still significant. The number of patients is also up sharply since the February launch—27 percent more stretcher patients, with an overall increase in volume of 18 percent. “Staff are coping, but with difficulty, because they feel the pressure of the magnitude of the added burden,” says Dr. Lawrence Rosenberg, JGH Executive Director.

“It’s as if we’re walking on a tightrope across Niagara Falls. One strong gust and who knows where we’ll be.” The spike in volume is believed to be the result of a combination of factors: the newness and modernity of the Emergency Department, the strongly positive word-of-mouth, the ER’s reputation for efficiency (even at the busiest of times), and the high quality of care throughout the hospital.

“We expected a certain amount of extra volume, but nothing like this,” says Dr. Rosenberg. “It’s very hard to shoulder this kind of increase, which hasn’t occurred anywhere else in the city or the province. It means we’ll have to make substantial changes to other parts of the hospital to accommodate ourselves to the additional Emergency patients. It will also create substantial challenges for the healthcare network.”

In addition, a number of other kinks are still being ironed out during the months-long shakedown period. Many patients are not accustomed to heading for the Emergency Department’s main doors at 5777 Légaré Street, near the corner of Bourret Avenue. Which is why, when Pauline Willett needed treatment for shingles this past spring, her husband inadvertently dropped her off at the old entrance. “Now I have to call him and tell him not to pick me up there,” she sighed.

In the yellow pod, where Joyce Vineberg was being treated in April for a heart attack and infection, her relatives praised the calmness and spaciousness of her private Emergency room. However, her daughter, Sharyn Hoppenheim, said her family needed a better explanation about which parts of the pod are reserved for staff, and how to attract the attention of staff when information is needed.

“The Emergency Department is always in a continuous process of refinement,” says its Interim Head Nurse, Valerie Schneidman. “We’re not static; our patients and families share their opinions with us and we listen. It’s an unpredictable environment, but we try to stay ahead of the curve.”

Fortunately, the clogged and crowded waiting rooms and corridors of the old Emergency Department have disappeared, as patients and their families are now more evenly distributed throughout the new facility. The result is a generally quieter and more placid atmosphere that eases psycho-logical pressures on patients and staff alike, and makes waiting more bearable.

“The way it’s set up for the patients seems much less stressful,” said Mrs. Hunter, noting that even though the members of staff seem calm, “I’m sure they’re running and they’re busy, busy, busy. They look like they appreciate their surroundings.”

“I also find that this hospital communicates really well,” added Mr. Hunter. “Whatever they’re doing differently here seems to be working. They’re less bogged down, I think. Things just don’t feel confused or chaotic.”

This impression is confirmed by many Emergency personnel, who say they’re under great pressure from the heavier volume of patients, but they’ve also benefited from JGH-wide improvements to the movement of patients through the hospital. This inter-disciplinary effort results in hospitalized patients being dis-charged more quickly, so that new patients can be admitted more promptly via the Emergency Department. Thus, on an average day, many more patient visits are being accommodated in the new premises than could be handled in the old one.

The Emergency Department continues to attract more than half of its patients (about 57 percent) from beyond the hospital’s catchment area. Dr. Marc Afilalo, Chief of Emergency Services, says a study by his department found that 80 percent of JGH emergency patients choose the hospital because of its trusted reputation, while 20 percent are attracted by its nearby location. The reverse is generally the case among emergency patients elsewhere: 80 percent make a bee-line for the nearest hospital, while 20 percent opt for an institution with a good reputation.

Of significant help to employees in bearing the strain is the design of the new treatment areas, each of which includes a section that’s off-limits to patients and their families. In the new configuration, personnel can give their undivided attention to urgent matters, without being side-tracked by repetitious, unnecessary or irrelevant questions from patients.

Linda Ciavarella, Coordinator of the department’s Blue Unit, recalls that in the old Emergency Department, staff were frequently detained for insufficient reasons, and this significantly slowed the process of assessing, treating and discharging patients.

Dr. Will Grad, an Emergency physician, hastens to note that, as always, members of JGH staff place a high priority on communicating with patients about their diagnoses, tests and waiting times. But, he says, this is now done at appropriate moments and not randomly, such as when patients or relatives happen to spot and then approach a doctor or nurse who is passing by.

“I accept that I’m going to be bombarded with many things at the same time in the Emergency Department,” says Dr. Grad. “But there are certain things that we should be able—and now are able—to control, and that includes choosing the moment when information is provided. I may now still be fatigued at the end of the day, but I don’t feel drained from being constantly distracted and having to explain, over and over, about things that aren’t necessarily relevant to the patent’s problem.”

Even when the pace is intense (as it usually is), “you really feel that it’s overwhelming you,” adds Nurse Astrid Gabriel. “When you’re in one of the pods, what you focus on is happening within that pod. Staff are in the central administrative area, and your patients are all around you in their individual rooms. So you don’t have constant chaos. And the noise level isn’t there any more, which is amazing, because that decreases stress levels tremendously.”

Another big advantage is the RAZ, says Dr. Alex Guttman, an Emergency physician. The presence of reclining chairs, rather than stretchers, conveys the distinct message to patients that their stay will be relatively short. This contributes to quicker turnover.

“The literature has shown that people who are placed in a stretcher stay longer for the exact same problem,” explains Dr. Guttman. “Once they’re lying on a stretcher and are comfortable, it’s tough to get them to go back out to the waiting room to wait for the results of their tests. By contrast, the mindset in our Emergency Department is that anybody who you think is going to go home within the next 12 hours doesn’t need a stretcher. Let’s get them into the RAZ.”

“Even as chaotic as it sometimes is, I would never do anything else,” says Ms. Garbriel. “I’ve worked in ERs in Ontario and the U.S., and I came back here. Regardless of how tired and crabby you get sometimes, this is still a home away from home.”


Areas of specialized Emergency treatment

A patient’s room, as seen from the central administrative area of the yellow pod. Only staff may use the sliding door to enter the room. Visitors enter through a separate door from the public corridor, visible through the glass at right.
Resuscitation: Stretcher patients in severe condition receive immediate treatment in one of five resuscitation rooms or in the procedural room—all located near the triage area, the ambulance bay and the three pods.

Pods: Each pod is a large treatment unit, consisting of a central administrative area where staff confer and review patients’ electronic records. The central hub is surrounded by private rooms, each containing a stretcher patient.

• The green pod has 19 rooms for the sickest patients.

• The yellow pod, with 16 rooms, treats patients in serious condition.

• The orange pod has 17 rooms for stretcher patients in the least serious condition.

Rapid Assessment Zone (RAZ): Treatment is provided to patients who require prompt attention but are in no immediate danger. In the old Emergency Department, these patients probably would have been assigned to a stretcher; in the RAZ they are treated in one of 20 padded reclining chairs, each in its own cubicle.

Blue Unit: Patients with relatively light problems—e.g., a mild asthma attack or nosebleed—are seen in an examination room and then are treated or discharged.


Adding it all up

Just how busy has the new Emergency Department been since moving to Pavilion K? “Mega-busy, it’s huge, more than anyone expected, including me” says Dr. Marc Afilalo, Chief of Emergency Services.

Between mid-February and early April, the total number of Emergency patients jumped 18 percent, including a 27-per-cent spike in stretcher patients.

Typical was April 3, when 237 people were seen at the JGH, says Judy Bianco, Associate Director of Nursing for Medi-cine, Geriatrics and Emergency. On that same day, at two local hospitals whose stretcher capacity is comparable to the JGH’s, one logged 198 visits, while the other had just 144. On some days, the total at the JGH has shot up as high as 280 visits.

This situation is unexpected and untenable, says Dr. Lawrence Rosenberg, JGH Executive Director. “It places an enormous strain on our staff, unlike anything that is being experienced in any other hospital in Montreal or Quebec.”

Members of staff examine the equipment in one of the Emergency Department’s resuscitation rooms.

This article was originally published in JGH News: Summer 2014.

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