sherman's proof (batch 2)

8/7/2019 Sherman's Proof (Batch 2)

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o SAH in Dawson Creek BC accepted by neurosurgery despite no ICU beds in region. Took> 30 minutess of prolonged discussion to divert patient to Vancouver. ConsultantsWITHIN UAH completely unaware of how unsafe and overcrowded the ED was.

o Female with query appendicitis accepted at 2200 by General surgery from Edsonwithout informing anyone in ED, and despite the fact that the patient was completelystable and likely needed an ultrasound that couldn't be obtained untilthe next morning- Patient with severe back pain reg at 1322, moved to bed at 1900 for analgesia and assessment.- Patient with a DW and severe leg pain, > 6hrs to get a bed for analgesia, assessment and

treatment. When finally in a bed the patient was crying and screaming at all health careproviders in frustration of prolonged wait in pain without care.- Multiple CP patients with prolonged waits for ECG and bed:o 63yo with CP reg at 14i-0, no bed until 1843o 69yo with CP reg at 1-701-, no bed to even do an ecg until 2000- 38yo patient with DKA - Na L18, K=5.7, ++ dehydrated. No acute monitored bed to treat patientfor prolonged period.- Young female 20 weeks pregnant with contractions and abdominal pain. Was going to leavewithout being seen due to prolonged wait. Manual pelvic exam done in triage assessment area(not considered a private area) at patients request to check cervix and risk of premature delivery- Known free air under diaphragm and perforation from family docs office, presented at 1615, nobed for analagesia, assessment and treatment until 1800.- Patient with RLQ pain registered at1,927, diagnosed with an acute appendicitis in the WR at2230, straight to the OR from the WR. NEVER got into a proper care area for analgesia ortreatment.- 23yo female with upper Gl bleed and hematemasis, arrived with EMS at2207, still no bed atmidnight.- 38yo M with new onset tachycardia arrived at 2245 with heart rate of 150. Still no care space forassessment or treatment at 0015.- 26 ElPs, 8 definite to be admitted and > 25 in WR at midnight.o 22yo male with new onset seizure registered at 1733, admitted by neurology in the WR,

still no bed at 0030.o Patient with a liver transplant, presented with hypertension and headache at 1818, stillno bed at 0030.- Midnight shift, 30 ElPs,5 definitive admissions pending, and greaterthan 10 "hold overnights".

Some examples of prolonged delays in decision making due to consultation or radiology:o Reg at 2139, requiring non-emergent ultrasound which is unattainable at night, stillawaiting ultrasound at 0930.o Reg at 2226, requiring non-emergent ultrasound which is unattainable at night, still

awaiting ultrasound at 0930.o Reg at 2322, requiring non-emergent ultrasound which is unattainable at night, stillawaiting ultrasound at 0930.o Patient registered at 2738 with signs and symptoms of possible cauda equina, informedMRI not available at night, hold untilAM for MRl.


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o Patient with abdominal pain and Gl consulted at2200, Gl staff had still not seen to makea disoosition decision at 0930 the next dav.

Patientwith a Hipfracture registered at L1.38, no analgesia ortreatment until in a bed at L751.Patient with urinary retention registered at 7229, still not in bed at 1730.Patient with acute appendicitis - registered at 1541, work-up all done in WR. CT at 2100 fromWR. Still no bed for analgesia or treatment when admitted in WR at2200.Elderly patient with a pneumonia, WBC of 28.9, Troponin of 0.2'1., and Glucose of 1.9 registeredatl7O4, not in ED care bed until 2200. Hypoglycemia was missed and not treated by the triagedoctor and nurses as there were >40 other patients in the WR and the environment wascompletely out of control and unsafe.Patient with an acute appendicitis registered at 1534 and went to OR from WR. General surgerystaff was upset because the patient had no orders or antibiotics prior to getting to the OR, butthe patient was never in an ED care area at any point - the patient's care was as optimal aspossible due to the overwhelming overcrowding.No beds in ED, and multiple consultants still accepting patients from out of region despiteprotests by ED staff:o Stable patient sent for CT to rule out PE, never made it to a care space.o PTtransferred from Ft McMurray for plasma exchange despite no beds in hospital/ED.Patient presented tachy at 136 and SBP of 69. Reg at 1656, no acute care beds for assessmentand treatment until 1732. Found to have a leaking AAA.28yo with depression and suicidal, victim of spousal abuse, waited > 5hrs and then attempted toleave without being seen, persuaded by TLP to await formal assessment.Patient with hypokalemia of 2.8 waited >2hrs for a bed for assessment and treatment2 patients with Febrile Neutropenia (+++ High riskfor infections, requiring isolation) in WR forprolonged waits.Patientfrom Fort McMurray with cardiaccontusion accepted directto Cardiology, in ED > 48hrswith no admission or service taking responsibility for the patient's care. Never actually admittedto any service, so never counted as an ElP, or a blocked bed. Multiple hand-overs to numerousemergency physicians with no reasonable continuity of care for entire stay.Two different patients with small bowel obstructions who were in ED > 48hrs without admissionorders by general surgery. (Both patients were clear SBO's, requiring NG tubes and lV fluids.)Due to severe overcrowding two intentional overdoses left the WR without being seen. Thatnight there were > tO% of registered patients who left without being seen (LWBS). Meanwhilemultiple services continued to accept direct without notifying anyone in the ED - ENT andNeurosurgery were exa mples.36yo male with Malignant hypertension (2201150), registered at 1230, asked to leave withoutbeingseeing numerous times, ultimatelyfound to have a troponin of 0.4! and a creatinine of199. No bed available until 1510 for treatment of his hypertensive emergency. Patient wouldhave left without treatment if the TLP hadn't persuaded him to stay - this patient had clearevidence of end organ failure and without treatment would have been at significant risk ofimminent myocardial infarction, stroke, or renal failure as examples.Only 15 ElPs - we actually had flow and the department almost worked like a real ED.


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- BAD - 22 ElPs, 10 awaiting to be admitted, absolutely no flow, > 40 patients in WRo Patient with dehydration and a sodium of 72O, reg at 2105, no bed until 0230.- 32 EIPS, only 1 available patient care space. Absolutely no movement. Executive on callcontacted who was unable to provide any relief.o Patient in Hinton with an aortic dissection - NO beds in entire region to accept thepatient.o Patient with K of 6.5 in WR for prolonged time with NO bed for assessment/treatment.- 25 ElPs with 5 more definite to be admitted, numerous with prolonged workups and nomovement pending. Discussed with multiple executives on call with no impact. The operatingrooms went on with full slate of scheduled surgeries despite no discharges pending and the EDbeing completely non-functional due to overcrowding.o Meanwhile a patient was in CHEMS HALLWAY with absolutely no privacy, urinating infull public view.- Patient with an acute cholecystitis transferred from Drayton Valley, arrived at 1043, no bed until1600. >5hs in ED WR with 10/10 severe RUQ pain with no analgesia, assessment or treatment.


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Hotmail Windows Live

To: [email protected],D!,la n.Tayl * rQ ca p it-r I hee ltlr.ca,[email protected]: Thursday, October 9, 2AAB,2:09:35 PMSubjecr: Follow-up on: Patient Relations Prisnr #TXXXXX

i;,11'=== ;====;= ;==- = c ri g i n a I messa g eDear Debbie Gordon, Dylan Taylor and Bill Johnston,I am sending this email with the hopes of getting anofficial reply onthe matter of adverse outcomes due to systemicovercrowdino.i have broached this topic in a number of emails,and in person toyourselves at the GEMS meeting in August - I'veinclr,rded the initialpatient complaint, and the previous emails beiow torefresh memoriesaS neod lro - :nr{ h:rra rraf tO haVe a fespgnse.As you are all well aware, system overcrowding hascomprornised thedelivery of care within the UAH ED to the pointwhere prolonged waits,prolonged delays in definitive standard of care, andsign ifica ntsub-optimal outcomes are the norm and not theexception.Due to sevefe systemic overcrowding, we are at thepoint where weroutinely CANNOT meet any of the CanadianEmergency Medicine Standardsor Recommended Guidelines for emergency care topatients presenting tothe UAH ED. The data that the region coliects dailyclearly elucidateshow compromised care delivery is within the region,and it must beemphasized that tlris is not an alarmist opinion, buta statement offact.

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Patients arrive at the UAH ED expecting a level otcare that iscurrently impossible to deliver.I am fully aware of the extraordinary efforts that areunderway toaddress this crisis irr access to acute heaith care, andI havepersonally volunteered my time to assist in whateversmall way I mightbe useful. We are ali aware that the "fix" will be yearsin themaking.While changes are instituted to address this systemwideissue, what is being done to protect emergencyhealth care providerswho are routinely forced to provide sub-standardlevels of care? (Wehave been operating in a mode of "some care isbetter than no care"for far too long.)Specifically:- Is there a formal process for senior executive to beinvolved incomplaints that are clearly related to systemovercrowding issues?- Is the forrral policy for disclosure of adverse eventsbeingreassessed to account for systemic overcrowdingissues? Is it reallyfair or appropriate to have individual ERF'saddressing systemicovercrowding issues based soiely on drawing theshort straw of beingon shift when tlre place is out of control?(UrTfortunately, the ED isnearly ALWAYS out of control lately.)- What are the medical legal ranrifications for myselfand mycolleagues in regards to cdntinued practice in anunsafe anddangerously cvercrowded ED?- What is Capital Health doing to actively publiclydisclose howovercrowded and unsafe our ED's are?This complaint was lodged against myself on July10th, and as oftoday(October gth, 2008), I have not had a response to myouestions. and

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,titl huuu no idea as to how this complaint was dealtwith. Given thecurrent lack of functioning in the UAH ED, it strikesrne as trulyremarkable that I do not have hundred's of similarpatient complaintspendirrg against myself - all directly related io theuntenable systemovercrowding impairing my ability to deliver timely

i would really appreciate your response to thesequestions, and yourassistance with this urgent matter.Tlrank you for your time.

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007 - I think I may have stopped sending cc's to the Minister at this point as I was receiving NO replies fromthem..To: "Gordon, Deb" Date: Thursday, October 9, 2008, I2:4L:34 PMSubject: UAH/Stollery System Overcrowding WorkPlan= = =$4 = = = = = = = = = = = = - -Original meSSage tgxt- - - - - = = = = = = =.= = =Hello Debbie,Thank you very much for the feedback from the System Overcrowdingmeeting' I know that Dr' llhut submitted some suggestions andcomments, and I wanted to take the time to raise my concern regardingone component of the Workplan: Public Communication'Public communication is listed as a long term goal (with no definitivetime-line), and as High Difficulty/Low Urgency. This piece of thesolution needs to be the most urgent and highest priority portion ofthe solution.We are working in a system that is severely overcrowded to the pointof non-functioning, and unfortunately we cannot provide a modicum ofstandard of care to the majority of patients who present to ouremergency depaftment. The emergency medicine health care providers onthe front line are doing the absolute best they can, but unfoftunatelythey are routinely faced with being unable to provide timely analgesia,antibiotics, interventions, or even a place for our patients in needto lie down. (This inability to provide care is the norm, NOT theexception.)The university of Alberta Hospital (and in extension Alberta HealthServices) has a fiduciary duty to inform the public that our abilityto care for them is compromised, and that the standard of care theyhave grown to expect is not currently available.In order to allow the health care providers to continue to functionwhile the workPlan is implemented, we absolutely must educate thepublic that health care delivery in the ED is NoT what it used to be:- waits for assessment, analgesia, and care will often be greater than6 hours. Everything will be done to treat them as expeditiously aspossible, but patients are treated according to need rather thanpresentation time.- they may get their full care delivered in the waiting room (TLP)- they may be off-loaded to hallways and non-standard waiting areas(CHEMS), and their full care may be delivered there- they may have their entire hospital admission and care occur in theED (EIPs staying in the ED for >48hrs)- they may need to be discharged to be cared for at home' oralternative caring facilities, sooner then they would have in thepast.The message needs to be: System overcrowding is impairing the deliverof acute care, We are urgently working to address this critical issue.In the meantime, please be patient and understand that the health careprwiders are doing their absolute best to help you in your time of


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. Message bodyneed.In the emergency depaftment, we are being held to a standard of carethat is undeliverable in the current health care system. Continuedwork in an environment where these impossible patienflconsultantexpectations exist is unsustainable.

t,"K We have been pleading for public education for over ten months now.Delivery continues to degrade, system overcrowding continues toworsen. The public must be informed as to the current state of affairsregarding the lack of timely access to acute health care. What can weas emergenqy physicians do to assist in the deliver of this essentialeducation immediately?

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' Hotmail Windows Live

To: paddy.meade@ hhas.ca, chris.eaSlE(i:)c*lSa ry$reallhre$ion.ca,De b.Go rcl o n S ca p iti: I hea ltlr.caDate: Friday, November 7,2AA8,11:53:37 AMSu bject: Corn pletely non-fu nctio na I emergency depa rtment== =$( = == === = = ===== =Qyigi66l meSSagetext===============Dear Paddy, Chris, and Debbie,I am writing to follow up on the ongoing crisis in EmergencyMedicinecare in Alberta, nrost specifically at the University of AlberlaHospital.I know that we will be meeting again on November 14th, bLrt Ithoughtit might be useful to share with your how horrendouslyovercrowded thenight shift I just came off was.I started my shift at 0000 on Nov 7th to 34 EIPS in the ED, r,vithanother 8 definite admissions pending. I spent tlre vast majority ofmyshift doing non-clinical damage control - discussing the situationwith the bed coordinator and executives on call, cajoling servicesinto admitting sick patients that obviously needed their care, andtaking critical care calls for patients in the periphery for whom Icould not safely accept their transfer.Despite all efforts by the bed coordinator and executiveadministrators on call, arrd despite some creative movement of afewadmitted EIPs out of the ED (we even metastasized and held someEIPsin the Peds ED), at 0900 when I left my shift there were37 EIPs, 4 more patients who were definitely going to requireadmission, and very little expectation that future in-patient bedswere imminent, (There are only 42 stretcher areas in our ED,47 ifyoucount our five "fast track" beds that do not contain monitors andwere expressly created for low acuity, non-admitted patients,) 41outof 42 emergency beds blocked is deplorabie and utteriy unsafe.The only reason the waiting room decanted is because peopletired ofthe extraordinary waits, and sirnply left withoui beir,g seen

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(LWBS).There were 29 patients (out of 211- who presented) that LWBS,whichamounts to a staggering 14o/o of the patients presenting to ourED. Oneof the first patients that did finally receive an ED bed was a 70 yearold male who waited in the waiting room over 10 hours with alargebowel obstruction.In regards to our ED's ability to deliver timely acute emergencyca re,the shift can only be described as an unmitigated disaster.If multiple severely ill patients had arrived iri the night - as is afrequent occasion at our ED - we r,vould have been completelyunable toprovide them wiih care or to intervene on their behalf.Considering ihe UAH is held to be one of the prenriere tertiaryLCtCemergency departments within Canada, our ability to delivertirnelycare was so impaired as to be essentially nonexistent.Urrfortunately last night was not a freak one time occurrence.Sinceour meeting, and despite all of the shoft term crisis initiatives thathave been implemerrted, the region's data show that theovercrowding issteadily worsening.I sincerely hope that this email is received as the plea forimmediatelasting assistance as it is intended to be. if the overcrowding crisisis allolryed to continue unabated, preventable deaths will occr:r.I anxiously await your ihoughts and reply.

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' Message body010... not sure if I could have been more pleading in this case... read my last paragraph,To : "Gordon, Deb" < Deb.Gordon @ca pital health.ca >, Dylan.Taylor@capita lhealth.caDate: Thursday, January 15, 2009, 3:06:01 AMSubject: Follow-up regarding prolonged delays in admission due to GIM Overcapacity= = =$4 = = = = = = = = = = = - - -Ofiginal meSSage teXt- - - - - = = = = = = = = = =Regarding the prolonged delay in admission forPT HN:)CC0)C(rc(nCX (the B4yo female who couldn't ambulate independently,and who GIM refused to admit as well as assist in attaining adisposition yesterday)Unfoftunately the patient still had no admission at 1930 tonight, andas TLP I had to become involved to try to procure an admittingservice. This was despite the executive on call being involved lastnight, and assuring the emergency doctor that they would personallyarrange for a service to admit first thing in the morning.I will provide all specifics below, but would like to stress that thisis only a prime example of the ongoing disposition issues occurring atthe UAH in light of the ongoing critically unsafe systemic overcrowding.- The patient was brought in by EMS and registered at @ 0901 Jan 13th- The patient went to a CHEMS bed @ 1026 (This is a hallway areawithout privary, and is merely an extension of the waiting room,)- Due to systemic overcrowding, specifically the housing of admittedinpatients within emergency department care spaces, the patientlanguished in the hallway bed until an F-POD bed was available at2048.- This deserves repeating: the patient did not get to an ED carespace for almost 12 hours. unfoftunately this is routine for ourcenter, despite all efforts to mitigate the ongoing crisis of systemicovercrowding,- the TLP discussed the case with Internal medicine staff sometimearound 2700-2200 when it was clear the patient couldn't ambulate andcare for herself. Family medicine was already over census, and hadalready indicated they could not accept anymore admissions. The ONLYservice available for this patient - as per our admission protocol, andcurrent ooeratino realities - was internal lvledicine. But Dr. J-refused ro acjmit, anci also reiuseci to suggest another apprEfimf-service.- Tne patient was seen by tne rotationai dury ED oocior lorJ2225, after the TLP had already attempted to procure an admittihQservice for the patient.- at -2330 all three emergency doctors within our department wereinvolved with an extremely difficult intubation in A-pod, and itwasn't until 0015 that Dr.],ould again address the fact thatthere was no service to admlt the patiepl- a 0100 call with th" ;"* ;;;i,6;:, and Dr.Jrovedcompletely unhelpful, and it was left that the executive on call wouldpersonally arrange for an admitting service at 0800 the next morning.- at 1000. there was still no assistance from administration, sogeriatrics were consulted. The emergency physician at the time had noidea what else to do - the system had completely failed the patientthus far.5iT'i:" i 1 i:*1 11 1 l{i",'l y1' "': ?r i:l'l:i-"i?: 11"1:, - ! - ! - -

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i'm begging for help.


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Message body

service - she was a placement issue - but suggested the patient get anurgent MRI (which was req'd at 1145, but was slotted for sometimeTOMORROW afternoon).- at 1900, upon hand-over to a fifth DIFFERENT emergency physician, itbecame clear that no one was adequately caring for this patient, andthat a disposition was not being actively worked on. A conference callwith the executive on call resulted in GIM agreeing to admit thepatient as they were again "open for business".- the patient was admitted by GIM at 2255 Jan 14th.This all occurred in the background of -30 EIPS, and > 30 patients inthe waiting room all day long. Waits to get to an ED bed wereroutinely greater than 12 hours, and the waiting room only decantedbecause patients left without being seen.It is impossible to provide timely emergent care in the currentenvironment, and has been for over a year. I applaud my generalinternal medicine colleagues attempts to provide safe and timely careto the admitted patients who manage to be admitted to the hospital,but would strongly suggest that sporadic capping and non-consistentadmission policies only harm their undifferentiated futurepatients-to-be desperately seeking medical attention at our institute,Wouldn't it make more sense for GIM to admit ALL consults requiringadmission and then have senior physicians decant to other services at0800 the next morning? I eagerly await guidance regarding a reasonableconsistent poliry to procure admission in our ongoing completelydysfunctional work environment.I've taken the time to document this case to plead with CHadministration for assistance, as I have on numerous occasions overthe past year. Due to overwhelming systemic overcrowding, Edmontonianshave NO reasonable expectation to timely acute medical care.

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' Hotmail - [email protected] - Windows Live Page 1 of 1I

To: Paddy M eade < pad$St.mtecjel$ai l::efi n he*lthservic*s.tc >,Chris Eagle < chris.es$lc($cal$cryl':e*lthr*$ion.ca >, "Gordon,Deb" < Deb.GnrdonSc*r.:italh*;rl th.c:r >Date:Thursday, Janr-rary 15, 2009, 3:36:58 AMSubject: Follow-up regarding ongoing horrendous systemicovercrowding.--*at ----*nri^inat m6...---0\ ---=:===uflglnal messagetext---=======:====Dear Paddy, Chris, and Debbie,i m writing again to plea for some immediate assistance regardingourdaily inability to provide timely standard of care to patientspresenting to major urban emergency deparlments in Alberta.Our ED's continue to remain dangerously overcrowded wiihadmittedpatients, our waiting rooms are standing room only, and extensivedelays and sub-optimal outcomes are still the norm.At the University Hospital general internal medicine has beguncapping their admissions, we still do not have an admissionprotocolthat is consistent, capacity is overwhelmed, no single point ofenilyexists, and most systemic overcrowding implementations remainreactiveand temporizing. More than half of our city's ED capacitycontinuesto function solely to house EIPs.If there is no mitigating the crisis, tlren at the least we must befrank with our public and inform them that we cannot provide thelevelof care they have grown to expect and demand. They come to ourED'ssick, in pain, and in need of timely medical care, and we rcutinelyfailthem. *---I anxiously await your reply.


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FW: Urgent Care CentresRaj ShermanTt: 5r0rics i'.,:irni;i

l attachment (8.8 MB)20741Ove...pdfDorr,:rrioi:ci(8.8 M B)

27 /1I/20A1Rsply

Hotmail Ariiv* \ciei+

Page 1 of3el,\tl

Download as zipSpence,I have to agree with nrany of the comments beiow.Acute care nurses are leaving the acute care system"..for what isprobably the most expensive Medicenter Care possi[:le. Wealready have Urgent Care Centres within the ED's...tlrey are calledthe "fast track" side of the FD. Unfortunately the fast tracks areplugged with admitted patients.This is your bcss...l w.o.uld have to disagree with this approach atllljs time with the current state of affairs. As I have alwaysreiterated...lots of new exoensive buildincs...creatino lots of newand easv iobs...at a time of staffirra shor-taoes, where do vou think--that the health care providers are gcing to go?.....to the easy new..-_--i--#iob that offers the same benefits.Is it any wonder that the iCU's and CCU's and the emergerrcydepartments cannot staff their beds. Does Dave know that tl-resebecls are closino?As I have said before, it's only a matter of time that an"unfofturrate" i@aitinq room or EMSsneTafier.:fino.-oau-ill have to answer for it.Do what ever you think is best with this e-mail.R.

Raj,


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Hotmail -ffi - windows Live Page2 of3?7??? got a copy of this and forwarded it to me. Thiswas drafted by a comrnittee ??T? ???? was on butthey kicked him off because he disagreed with muchof what they were trying to do. I find it interestingthat the 3 cases thai are described as the type ofcase appropriate for Urgent Care Clinics, at least 2 ofthem may not be ideal even for the NEHC wnere youare fully staffed with EPs (the seizing peds kid andthe trauma). The young woman with the flu may beokay for an UCC.The advanced ambulatory care centers are just walk-in clinics (the worst abuse of health care dollars theprovince expends [no accountability for F/\-) care, noafter hours care responsibilities, etc.l). This moneyand support should go towards promoting thePrimary Care networks to provide after hours care,not walk-in clinics.Does this group understand that at the UAH oururgent patients (CTAS level 3) have a26a/o admissionrate and the average length of stay for evaluationand treatment is about 6 hours.Is that the kind ofcapacity they plan for these urgent care clinics?If this process moves forward and the EDs remainblocked and 20-30 of our patients leave every daywithout being seen, there will be no way to staff theEDs adequately with EPs. We will all need to work inthe UCCs and it is hard to know who will provide theED coverage when in fact there is momentary flowand multiple patients need to be seen by the one Epleft orr duty,I smell the power-ful lobby of private for profitbusinesses at work here (they will be controllingthese advanced anrbulatory care and UCC clinics)and just like the private operating establishmentswill skim of the simple, stable patients and refer allthe complicated ones to hospital, while the hospitalsgive up and collapse. Is Dave aware of theslrortcomings of this kind of approach?Anonynrous


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Hotmail

-WindowsliveMike,Thanks you forthe copy of the report. The section will be meetnigtomorrow evening to formulate a reply.l hope that MinisterHancock was able to attend the meetino on Fridav.Cheers.Raj

Sub.ject: HQCA -- R.eview of Emergency and UrgentCare Services in the Calgary Health Regionli;offi'nCC: S MT@ albertadoctors.org;'";,#i,:Hg?.ffi;'nThe Health Quality Council of Ali:erta (HQCA) todayreleased the report cited irr the subject lirre. Thereport is attached below:(See attached file: HQCA CHR ED ReviewRe pa rt_F I N A L V ER S fi N.pdf1We have not yet had an opportunity to discuss thiswith the Section of Fmergerrcy Medicine, but hopeto do so in the next ccuple o{ days. This may bedone at RF depending on the availability of thoseattending. The President of the section has beenincluded in this email.We have not yet been asked to comment by themedia. Some very prelinrinary thor"rghts from stafffollow:There is much in the report that can be supported. Ittparticular, we agree witir the approach taken by theHQCA cf contrasting Calgary Health Region (CHR)processes and practices wjth nationai andinternational best practice. In many areas the reportencourages the continuation of tvork that the CHRhas already started, which should provide somecomfoft to Calgarians that some right steps arebeins taken.

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HotmailS-windowsLive Page 2 of3Having said that, the AMA has comnrents on fourbroad issues raised in the report.l-. fresource Shortages:The report focuses onmaking the best use of available fesources. While weagree with this, we would highlight another pointmentioned in the report of the many problemscaused by resource shortages.In particular, it iscritical for the provincial government to significantiyaddress the shortages of physicians and other healthcare providers. The deficits in facilities also needs tobe addressed.2. Accountsbility :In specific reference tophysicians and the CHR, the report's fourthrecommendaticn calls for tlre effective alignment of,"incentives, performance and accountabiiity". Whileappreciating the basic point, it should also bementioned that physiciarls are accountable on anumber of levels -- not just to the system per se, butto tlreir patients and to their profession. It essentialthat the patient.physician relationship, whichrequires the physieian to always acting in theinterest of the patient, remain a cornerstone of thehealth care system.3. Change Leaders: The report nrakes reference tothe use of change leaders -- to lead the way to moreeffective and efficient health care. We agree with thisand suggest that the most imporlant change leadersto consider are the providers who deliver the care.Much can be learned by listening and acting on therecommendations of health professionals. In thisregard, it shouid be noted that one of theinnovations lauded in the report, PCNs. was initiallyproposed and advanced by the AMA RepresentativeForum, subseqr-tently negotiated with regions andgovernment, and then implemented through thejoint activity of local regions and physicians. Anotherinnovation in Alberta, often cited elsewhere asieading the way, is the Hip and Knee Project. Again,this was spearheaded and lead by physicians. Thereare many such opportunities for grass rootsinitiatives in Alberta.4. Patient Respansibility and Support: The reportdoes make any recommendations related to patientresponsibility. Albertans need to be supported inmaking the right decisions about their access. When,for example, is it appropriate to access the newlyminted Urgent Care Centers versus hospitalelnergency departments^


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Hotmail

-windowslive

Just some initial thoughts.Mike

Michael GormleyExecutive DirectcrAiberta Medical Association

albertadoctors.orgwww.a I beft adoctors.o rq

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Windows Live

Emergency IssuesRaj ShermanT* D*vs liencock, Fred Horne, lJ*il V/ilkinsc

L attachment (73.0 KB)Edmonton ...docView onlin*Downloaci(73.0 KB)

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l..}nrarnln:r{ r< zinDave/Fred/Neil,Here is my presentation to Sheila, Ken Gardener, Susan Mummy,and Michelle Lahey regarding the state of affairs in CapitalHealth's emergency departments.I wish you and your families the Merriest Christmas and a HappyNew Year!

God Bless.Raj


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Thank vou. . ...IntroductionsI'd like to thank everyone for participating today.We have met over the past year on a number of occasions towork on improving the emergency services for the communitythat we all serve. Together we achieved a few successes thathave been notable.We have approximately 200 emergency beds that serviceEdmonton and Northern Alberta. Of those, last year we had attimes 100-150 plugged up with admitted patients...thusoperating the emergency departments with 50-100 beds. Wepresented cases of bad outcome and near misses that occurredin the ED's under these conditions and..... you took action.With the implementation of the FCP, Capital Health reducedthe time that patients had to wait in the ED for care as well asEMS red alerts. In fact, the emergency physicians had to addshifts in order to keep up with the increased ability to treatpatients.

The implementation of the TLP had helped to reduce thenumber of patients that left without treatment (LWOT) andhelped to identify ill patients in the waiting room that weremissed by the triage nurse.I had the privilege to acknowledge Capital Health's successesat a wait times conference in Vancouver as a success in theCanadian Health Care system.Due the Summer bed closures, we lost many of the gains thatwere made. In a way this has been a success in that we havemade do with less by improving our efficiency.


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Edmonton now faces a few challenges as our population hasgrown by 36,000 over the past year. In addition we are servingmore people from Northern Alberta. Patients that present tothe ED's are sicker and their care is more complicated. We arein DIRE need of more emergency beds to treat the untreatedand undifferentiated patients that present for care.We have these beds, they are just plugged up by patients whoshould be treated upstairs after their admission.Earlier this year, across the province, we asked our colleaguesto document cases of bad outcomes and near misses and to passthem on to administration for quality control and safetypurposes and to pass them on to us to keep us in the loop.In Calgary there were a rash of bad outcomes in a period ofone month....and it was after we presented these cases to theregion that overarching changes were implemented that havereduced their ED boarding times and subsequently theirLWOT's for admitted patients.In Edmonton, for a few months, we did not hear anything. As aresult of the bed cuts and increasing EIP's (Emergency in-patients), here are the stories that we are starting to hear.


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A. PROBLEM---The FCP is failing as a result of long termcare or WTS patients occupying increasingly more acute carebeds.1. Misericordia Hospital:Raj's story: I have been knocking on doors 4-5 days per weekand hear this regularly from the people at the door that thewaits are up to 6-8 hours again. After door knocking, I visit theED every second week and things have gone from bad toworse.CASE- political candidates relative-The FCP has failed-We are running the ED out of the waiting room and thehallways.- there are regularly L8-24 beds (total 28 beds) plugged up withnon-emergency patients.-Capital health has not kept their promise of maximum 8 EIP'sin the department- The EIP numbers are misleading because there areSPOTTED patients (patients who are transferred in foradmission but are not yet admitted and are not an emergencypatient) that are not included in the EIP numbers.

2. Grev Nuns HospitalStory: 3 weeks ago we had 25-26 beds (out of 30 beds) pluggedup by admitted/spotted patients). Triage desk is beingrenovated. A patient who had been waiting with chest pain forhad an ECG done in the tent in the ambulance bay. After a


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wait his heart stopped and his resuscitation was run in the tentin the ambulance garage....no trauma beds,-The FCP has failed-Medicine has CAPPED admissions and refuses to admit...thisdoes not show up in the time to admit- the ED is run out of hallway stretchers and waiting roomchairs3. The UofA HospitalStory: "We were so plugged up that a resuscitated cardiacarrest was left waiting in the hallway on an EMS stretcher tooffload."-Admitted patients in the waiting room.. 2 casesUAH, a 78 year old man, presented with generalized weakness. Hestayed in the WR from t209 to 1745. He was brought in by hisdaughter because he was increasingly unable to care for himself andunable to walk properly over the preceding two weeks. I found himhypoxic (PaO2 of 52 on room air), and ultimately diagnosed him withmultiple large pulmonary emboli (blood clots).UAH, a 25 year old man with end stage renal disease, on hemodialysis,was transferred from a peripheral hospital because he was complainingof chest pain. He waited in the WR from 1415 to L842. He was knownto have an elevated troponin (of unknown significance). Upon arrivalinto the department, he was found to have a potassium of 7.0. A CT ofthe chest confirmed a pericardial effusion.The only reasonable way that patients like this can be seen is improvethe output problem in the ED (admitted patients have to moveupstairs). All the efforts that we have aimed at looking after the inputproblem (ambulance diversion, TLP, greeters, paramedics in the WR),will not help these types of patients get seen soon'


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- TLP near misses in the WRWhile on TLP, I admitted 2 patients to gen surg withappendicitis, one mild CVA 3 weeks post-CABG to neurology, and abowel obstruction in advanced esophageal cancer, All were admittedfrom the waiting room. All were briefly assessed in a triage stretcherand then sat in chairs for much of the day. One (that I know of) wentfrom the WR to the OR. That same day a ?meningitis developed herrash while waiting for a bed and fortunately her mother sought us outto tell us of that 'minor chanqe' in her condition.-The FCP has failed.-It's only a mater of time, when we have a preventable death inthe waiting room4. Roval Alex HospitalFor the most part, we are happy with the deal that CapitalHealth has kept on the number of EIP's in the department andAdministration and Reverdi Darda must becongratulated....BUT.. .Raj's two cases...AIl of our trauma bays were full of ICUpatients.1. open cardiac massage in the hallway(the full meal deal)2. 2 Cardiac arrests - one run in the hallway and another ina storage room in the emergency.Royal AIex Problems:

l. Closed beds in the ED2. When all other ED's are not working, the Royal Alex getsslammed by EMS volumes3. Lack of CCU and ICU beds....trauma beds in the ED fullof ICU patients.


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4. Sturgeon Hospital-"May as well be turned into a long term care facility as morethan half of the acute care beds have long term patientsadmitted to them".There is no Full Capacity Protocol.5. This is a SYSTEM PROBLEM and the main causes are:a. Lack of investments and attention to long-term care andcommunity care.b. Closed beds due to the shortage of nurses...especially ICU,CCU, in hospital medicine and emergency beds.c. Not to mention the impact of an increasing and agingpopulation.

B. EFF'ECTS1. Pre-hospital care...Ambulance Red Alerts and offload timesare at a record high....no ambulance on the street for 15minutes last week. . ..EMS transfer paramedics are a temporary solution to thisproblem...but this will not address the ED issue...in fact sickerpatients will be waiting to be assessed untreated in the hallwayon EMS stretchers. . . .Calgary examples. . ..5 deaths in early2007.2. Emergency carea. LWOT - Record numbers of patients are leaving withouttreatment. The evidence is that when they come back they aresicker and their death rate is higher.


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b. Patient 2nd mos t at Risk (Patients who wait in waitingroom to be assessed and treated)c. Patient at 3'd greatest risk (ADMITTED to ER .sometimesthis patients never makes it to the ward....wrong nurse...wrong doctor.... in the wrong place.3. INFECTION RISKAs admitted patients are warehoused in the ED's (sometimes fordays) in close quarters, this is a breeding ground for crosscontamination for infections and resistant bugs (MRSA).Eventually, these patients are moved to the hospital area wherethey will contaminate the hospital.4.In the event of a multi-casualty incident, we are ill prepared todeal with it.4. SolutionsLet's examine what's worked (RAH and Calgary) and whathasn't (the rest of the hospitals)Let's look at what Calgary has done. . ..with fewernurses/100,000. It must be acknowledged that Edmonton hasan older population and a higher aboriginal population.

1. Calgary - HFEMA Study... GRIDLOC project toimprove flow of patients through the system1. Decreased Admitted LOS (length of stay)in the ED from25-16 hours2. As a result decreased EMS wait times and red alerts3. Most importantly, they decreased LWOT's at a timeemergency volumes went uP


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4. HQCA - Patient satisfaction increased from 10o/o togl'h .... Accountability piecei. increased ED volumesii. EMS volumes unchangediii. Decreased EMS wait timesiv. Triage to bed time decreased (250min-110min)v. Bed to doctor time increased (80 min-100 min)vi. bed request time to admission (10-4 hrs)vii. decreased Admitted LOS (25-16)viii. As a result, decreased LWOT's (1 6.7%-6%)a. HOW???By making it a priority....created a special position for...emergency & unscheduled visits (Dr. Rob Abernathy)

1. Creation of additional inpatient Full Capacitybeds....Proactive triggers for the use of overcapacity bedsbased on the number of sick patients in the waiting room.2. Getting buy-in from others in the system...convincing thatthese are system patients and not just emergency patients.3. Providing support for staff on the wards...hospitalists,nursing assistants.4. ...rapid discharges...Readmissions rates have notincreased. Convincing all physicians to pay attention to theSYSTEM vs. the individual patients...5. Educated society - Town hall forums in the cify.6. Improved utilization of current ED capacity- subwaitingrooms, 2 On-call emergency physicians for the city,redirected ALC patients who didn't need to go to ER orthe hospital.7. Invested in long term care


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Problem: Long consultation times. 50-80 WTS patients.Nursing shortages and acute care bed closures. 1900 acutecare beds, 80-90 full capacity beds.

2. Edmonton - ESSC (Emergency Services System Capacityproject)Problems: 400 WTS (waiting transfer of service/long termcare) patients plugging up scarce acute care beds.This results in pressure to discharge sicker patients before theyare ready to be discharged. Readmission rates are higher.We haven't fixed anything, We had come back form the edgeof the ABYSS.... And now are back on that edge again.While we wait for the long term solutions to kick in....we haveworked on decreasing the input into the system and not enoughon the output from the hospital and into the community (longterm care).What we have failed in doing in Capital Health is to convinceothers that this is a system problem and not just emergencypushing their problem upstairs. Rather, the emergencyproblem is a problem of the system not functioning as itshould.We need to convince people to work together as a team and tofocus on the patient.What we need is LEADERSHIP and a commitment to solvethis problem.


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You have an immense responsibility not only to the people thatyou represent, but also to society.If we fail, we will have bad outcomes and preventable deathsdespite the processes that we have implemented as a result ifwe do not act now before the FLU hits.My hope is that we will get through this winter by workingtogether.

THANK YOU


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. Hotmail Windows Live

RE: Urgent Care CentresTo see nlessages related to this one, gri:up

Raj Sherman' Tr: Sptnce idicit'-*l#Spence,

Slck ta rr:3ssil$os ifxe$silrilrs i:y ro nv*rsnticrr

08/12/2007K*pry

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r

Another anonymous letter being forwarded to you. The rebellionof Edmonton's ED docs (justifiably) is starting. Capital Healthwants rrore rnoney from your boss, Dave.".for what? And theyhave don't have encugh for long term care. Tsl< TskFeel free too share this with Dave.CheersRaJ

Colleagues,I think the urgent care centre issue deservescomment from [dmorrton FPs. Please pass this on toyour gfoups in [dmonton. It has recently come tclight {again!), tlrat Capital Health is nroving forwardwith centres for both Advanced Ambr-rlatory Careand for Urgent Care. These will be built and fr-rnded"through existing global budgets for regional healthauthorities".AAC is basically an after hours FP cffice with lab andperhaps DL This is a stop-gap measure until all ofthe Primary Care Networks begin offeringfull after-hours services. Urgerrt Care (UC) is a mirri-tD which accepts ambulance traffic but does not"provide routine ongoing care and nronitoring".They aim for "urgent", but not "emergent", patients.Last I checked we rryere admitting 7 9c/o al our triage

4 and 5s, none of whom are even 'urgent' and theyhave no bed to be admitted to. Neither of these aremodeled after Health First Strathccna, but I suspectsimilar issues may arise.


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' Hotmail,:ry - Windows LiveI ne nrstory t0 tnls ts tnat one ot our tps was aconsultant to the working group 2 years ago, butwas dropped after providing feedback, A year and ahalf ago our colleagues at the Mis were approachedto staff one of these UCCs, and I believe they wererather reticerrt to do tM outside an tD. (Comments?)Within the past year, Capital Health had plans tobuild an Urgent Care Centre in the IJAH, separatefrom the ED. This was quickly turned into anexpanded ED fasttrack as soon as the section heardabout it. Our feedback counts. And our patientsdeserve cur advocacy.I strongly believe that we need a cohesive, unifiedresponse to this ill-conceived plan. (Perhaps this is arole for EEPA and the Section?)Below are some examples of patients THEY believeto be suitable for UCCs, without input fromemergency physicians.From "When would people use andACC/UCC?'':. A young woman with asthma is havingdifficulty breathing and her regularmedication does not seem to be working.She goes to the Advanced Ambulatory Care' Centre where she's checked by a physicianand receives treatment..A couple is involved in a car crash on arural highway. The injuries do not appearto be life threatening so the ambulancetakes them to the nearby Urgent CareCentre where they receive treatment andfurther tests.. A six-month old baby has had a highfever for several hours and suddenly goesinto convulsions, The parents call 911 and,because their community does not have ahospital, the baby is taken to the UrgentCare Centre where a doctor stabilizes thebaby, diagnoses the problem, and arrangesfor transfer to the nearest hosoital.Last I checked asthmatics unresponsive to beta-agonists,and trauma patients are sometime very sick. And theurgent care pitstop for the febrile seizure before "transferto the nearest hospital" is nonsense and

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dangerous. Please note that the phrase "because theircommunity does not have a hospital" refers tocommunities withln Edmonton and the CH region. Theseare going to be built in the city, not in distant, underservedbedroom communities.Like the Medicentres ofthe 1980s which promised toimprove primary care, I wonder ifthese are PR-drivenmoney pits which will not serr'e our patients' bestinterests. Though ill-conceived, they will not be ill-fated. Our patients who are tired of waiting in our EDswill happily put availability of a bed before the abilityof that facility to care for them. And our EMScolleagues who spend too much oftheir shift in ourEDs will likely be happy to take patients there. Ifthepay scale is anywhere near Health First's wages, theywill have no problems staffing these. And in the endwe will have fewer resources to solve our curentsystem problems. By the way, if we rernain plugged upwith admitted patients, how are they going to get theirsick palients into the REAL ED's, especially when ourstaff will all working in these centres?

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Time BombsRaj ShermanTc Neil \,Vi kin5orr, Neil Willi:nson, rijlhafl:ia

Neil,

08/12/2007Re p l),

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FYI. While the elective surgeries were cancelled, this was thesituation in the ED's. I just thought that I'd keep you in the loop.lhese are 5 'ticking iime-bombs" in one day at one site...and fluseason has not yet hit! Thanks to you, we have scheduled ameeting with Sheila, Ken and Susan for 8am Dec 18th. I fear thatwe will have a preventable death very soon as soon as the flu hits.The section is under pressufe to say and do something.If you can do something to lean on Shejla and the COO's to rectifythis asap, it will save us a lot of grief. The Full Capacity protocolhas failed at a few sites in the cit,.CheersRaj

Dear Raj,While on TLP December - ,l admitted 2 patients to gen surg withappendicitis, one mild CVA 3 weeks post-CABG to neurology, anda bowelobstruction in advanced esophageal cancer. All were admittedfrom the"vaiting room, All were briefly assessed in a triage stretcher andthen sat in chairs for much of the day. One (that I kno\ / of) wentfrorn the WR to the OR. That same day a ?nreningitis developedner rasnwhile waiting for a bed and fortunately her mother sought us outtotell us of ihat 'minor change' in her condition. I can get youspecifics if you need them.That day I did speak to Executive twice. One lssue Ilentified was regarding the hesitarrcy of executive to cancel::::"ri"r if there were any vacant FCP beds. We had 4 FCP beds

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. Hotmail--Windowslive Page 2 of 3day on surgery. I was told that none of our 22 EIPs (over the limitof 12 that you negotiated on our behalf )were appropfiate forthose beds... and that until those beds were full. we couldn'tcancel surgeries. Admittedly some of our EIPs were on isolation/monitors or a two-person assist. Most otheB were deemed "tooheavy"for the RNs upstairs because of frequent analgesia/medicationneeds,personal care issues etc... I am all for protecting our RNs so theydon't all quit, but it is obvious the FCP beds at the UAH are notbeing utilized. It was felt by our bed coordinator and Exec McD. ,11.00h, that if we found suitable tenants at some point during thedayfor those beds. that would be firre.

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' Hotmail {tfFWindowslive

RE: some points for your thoughts.....Rai Shermanf- ,r,rr)roo,Rcply

Best wishes for your family this Christmas and a Happier NewVear!

Raj> Date: Fri, 21 Dec 2A07 00:00:34 -0700> To: rajsherma n@ hotma ii.com> From: [email protected]> Subject: some points for your thoughts.....> Thanks very much Raj I,r> Here are some suggestions for points to consider:> - The current ED situation is totally untenable. Lack of access toED> beds for potentially seriously ill patients and patients already> diagnosed with critical conditions is guaranteed to contr;bute to> serious Inorbidity or mollality. The problematic situation intertiary> care EDs is primarily related to occupancy of ED beds byadmitted> patients, There are other lessor contributing factors (ie delays in> medical decision making and admissions ) but these areexceedinglY> minor irr comparison. The critical situation and resultantprofound> risks to patient safety (and potential for serious patientcon pronr ise> and death) have been clearly and repeatedly articulated foryears to> sentor executlves.: -, _ -,,.

lrttp://snl06w.snt106.mail.live.com.imaillInboxLight.aspx?n=28226619

rThank you.

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' Hotmail - [email protected] Windows Live> - | ne puu L lredny pclLerve dnu e)(PeL! ule Et, tu tul|||r L e ture> of "safety net". They expect the ED to perform in an efficientand> effective manner when they have a health crisis. A failure of the> emergency system to perform as expected (especially with abad> outcome) will be exceedingly damaging to the system andthose> accountable for the health system. The current reality is the> net" is in tatters and cannot be relied upon. These public> expectations are reasonable - the fact is we cannot meet them.> - The rural public expectations are that tertiary care EDs will> assist with caring for critically & seriously lll rural patients.> This is a crucial and appropriate role in our provincial health> system. The reality is that the tertiary care emergency and acute> care system cannot be guaranteed to provide this support and> frequently actually is unable to provide that backup. The tertiary> acute and emergency care systems are typically in a state ofc risis, and system overload and tlrus frequently is not able to backthelr> colleagues in a rural setting. The crisis in tertiary care EDs is a> provincial issue!> - When the emergency system is able to deliver good qualitycare. lt> is likely due to the dedication of of individual care providers not' because of system capability or reserve.> -The acute and emergency care system currently has a total lackof> any "surge capacity". The system typically is running far overlQo'/.> capacity. That level of intensity combined with staff shortages> rendets the system completely incapable in effectively dealing.vith> any rapid increase in demand (from small MCI to a pandemic).'u> - Standardized performance parameters for throughput need tobe> implemented. Maximum ED wait times after the patient isadmitted> need to be defined (l would suggst an absolute minimumperformance> Ievel could be that 90% of patients should be transferred to> inpatient appropriate setting within 4 hours of admission).> - Occupancy of acute care beds by patients "waiiing transfer of

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' Hotmail-ffiWindowslive Page 3 of 5> service" "WTS" is a completely inappropriate use of anextremely> scarce commodity - acute care beds. While appropriateplacement of> these patients may take some time - an immediate interventionwouto> be to prioritize the resolution of this misuse of preciousresources.> There needs to be very well defined performance parameters,> milestones and mandates for resolution of the problem andongorn9> accountability for occupancy of acute care beds by patients thatdo> not require acute cafe services.> - Nursing staffing in health care is a crisis. An obJective,> unbiased, and non,threatening (to staff) (would suggest nonRHA> driven) review of factors contributing to loss of experiencednurses> and other retention issue as well as development of animmediate> strategy to retain the experienced RNs must be undertaken> - There must be a wholesale change in management stylerelated to> throughput and capacity management in acute care as well ascreatron> of very clear accountability (including incentives &consequences)> for pedormance. The current approach is totally reactive , waitfor> a crisis and only then intervene to decompress the situation. The> approach should be proactive - the typically # of acute care> admissions frorr an ED is remarkable. The institution should be> planning a day ahead - considering # of planned discharges,proJecred> # of admits (both ED and scheduled surgeries). Additionallywhen the> situation is becoming problematic there must be a proactiveseries of> interventions triggered when the situation reaches a specifictevet,> Currently it seems like the crisis needs to be reaclred before an> intervention occurs that lras any possibility of addressing the> situation and we repeatedly have to go through the sameprocess over> and over again without learning from it or being proactive.> - The current initiatives to develop urban urgent care centers (as

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. Hotmail.tll- Windowslive rage 4 oI )> "solution" to the emergency problems) demonstrate a profoundlack of> understanding of the issues compromising effective delivery of> emergency care. The system does not need more',fast foodmedicine" -> it needs EDs with qualified staff to delivery effective & tirnely> emergency care that are integrated with both primary andspecrarry> care systems. Current "fast food" medicine options are inaou ndance> providing the public w;th many rapid alternatives - that aspectof> the system does noi need expansion. The long term care. rehaband> other ALC systems need significant expansion. Care must takento not> allow this expansio|r to be driven by private interests that are> profit driven,can "pick & chose" patients and have little> accountability to the entire health system to accept patientsfrom> acute care in a timely manner.> - Current EMS system crises are directly related to lack of ED> throughput and occupancy of ED care spaces by admjttedinpatients.> The solution to that aspect of EM5 problems is to improve ED> th roug hput and output.> - The profound inability of ED MDs RNs and other staff todeliver the> standard and quality of care that they expect of themselves that> results from ED lack of throughput is devastating staff morale.T hese> professionals will not tolerate this ongoing and worseningsituation> - they wili leave. The system will take many years to rebuild with> the loss of these qualified individuals.> - There are many examples of effective programs to address EDand> institutional throughput. The US "Urgent Matters', program andUK NHs> ED throughput initiatives are 2 examples.

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Hotmail indows Live

Date: Mon, 14.lan 2008 20:58:19 -0700rrom: G,

Everyone, I had a long tall< with Dr. Raj Shermantoday in my role in Triage.The ED at GN H has norv reached a crisis with theovercrowd ino issue.Today when I arrived at 1000 for nry Triage Shift, thefollowing were ln place:ar The e ur"ere no avai able beds lo see pat,erls in.b) The 0700 shift day ED Doc had 22 tfansferredpatients he was responsible forfollowing through on, in addition to any newpatients he would see during hisshift.c) 18 admitted patients were living in the ED, with,n^ihpr 11 r1Aiio,1lc ihpre'pend ing admission'.d) 3 Cardiac patients were in the hall on moniters,and a NSTEMI was assssed anddiagnosed in the Fast Track Tent due to lack ofavailable beds. Bear in mind herethat there are !e assigned nurses to hallway patientsrl,r in


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' to*utlill- windowslive Page 2 of 3

on bv rhe rur:inq, and phvsitial 5taff irl artenddnce.fo be lhe worst we have evet-see. o-ollt-Department.My further Lrnderstanding is that this situation is thesame in all Depaftrnents in the Refr6i-ifiE!6ill-

hallway patrents to aliow trattic to be more thansing le-file in the hall.g) I discovered hypotensive pdtients pla.od n rhewaiting room due to lacl< of any otherspace, and this was not a 'triage efror' by stafl butall they could do in triage giventhe situation.Tt is ny prolesq onal opinion drre- 20 \earc \erviceto ihe Edrnonton community, that soon apreventa ble death will occurii'r,our ED if the situation is not renredied.The workino conditions today u,ere widely agreed

in response to a request by Dr. Sherman that thevarious hospital ED Depaftments wofk in concert tobrir.rg this matter to immediate attention of thesenior Capital Heaith Administration, the followingsranoout as noteworthyl

information to the appfopriate senior administration(these latter three with patient identifiers removed).h,'/16 :.6 ,.',"^ t",t!n ri. rolp a,. .D i 'prtor'onruard rhese ernails dE?ily to il^eCOOIG N H/Caditas.

in his rolearitas who concu rs

wtrnthis and is planning to do same.d) My understanding is that Dr.conlacting rl^ e Caraoran VleoicafDto lE?tjveAssociation tosee whether our malpractice coveraqe will prevail in

http://sni 06w.snt I 06.rnail.live.com/mail/InboxLight. aspx?n:3 78253 3 4zl

a) If any ED physiqg{gs cause for alartn due to thesitu-5-fi6 n ?'iie to oote)1tial or actual harmt6-liTiEiii[lease e !!.]]_!19 tin ny ole as CQI,TQA5n reqTor the ED) as well

n his role as ED Director,

as they are centralg and forwarding this

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this environment, or whether it is now untenable,and would ask that he forward this information assoon as available to us all.Tomorrow I am returning to this situation.

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Staff PhysicianGNH Site, Caritas Healih GroupCa pital Health Region

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Message body Page I

From:To: [email protected]: - tnanKsDate: Fri,Fred,

11 Jan 2008 72:23:04 -0700

It was good to meet you thls am. I hope that I was able to give you some useful advice.I un:uld ask you to keep the Delegate report I by not sharing it with anyone (it is for your eyes only).ues not to shed Ca rn a

These are just some examples. I wouldrevealed and effortsasked them to instead of going public as this is the most appropriate forum to deal withThanks again for taking time from your busy schedule and thanks for breakfast.Happy Door Knocking!Raj

of1

l:

I haveSecondly, can younot wanr

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ERIssues-lAgreeRaj ShermanJ() C;.Care. (cll,

Ken,

29/12/2007Roply

Page I of4

'should be monitor nq tl^e srluation 24 r' ours,/dav a.rd not i:rit'tihe effect is felt after rhe TLP has left.The main reason to keeplqgrself and Sheila in the loop is so that-----'-'-----. (--)"::-"--'=vou cal judge for voirrset{ how iEe-IFfiT iGiI]6El,,t r.;.hsjtes are function well and which ones need some help.

]t's good to lrear that you are able to spend some time with farniryover the holidays. By the by, you,re not old enough to be ag randpa I

A bird on the wall said that we may have an election call in earlyFebruary, so I may not be in a position to meet regarding theserssues, howevar, Peter Kwan (president Lethbridge), Chris Evans,Dan Barer and Paul parks (UofA-ER) will continue to work with youon this issue.I wouid personally like to thank you, Susan, Sheila, Neil and therest of Capital Health Senior Administrat;on for your help andunderstanding. It has been a great experience to be a part ofsomeihing important. By cooperating, we have accomplishedsome great thtngs togeiher.Hope that yoLr have a Happy New yearlAgain, thank you and God BlessRaj

Subject: RE: ER IssuesDate: Fri, 28 Dec 2007 09:34:04 -0700From: capitalhealth.caT^.

Cood ideas. I ag"ee thal all problems need to be sorved,ocallv ineacn tdc Ty drd trat tJ-e tocai tevel ot adninis drion neeos to be

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From: Ra ShermanImailtoSent;PFI 07 II:47To; Gardener, Ken; Gardener,Cc: Paul ParkSubject: ER IssuesDear Ken,

I hope all is well for you and your familythis holiday season. I would like to beginby thanking you for your time and effortsin making the delivery of emergency careto the patients of Capital Health aprrority.

Raj,Thanks, I was able to spend some good time withthe family. l\4y two grandsons were a hoot this year.In adliitjon to bnr.tqinq instances to my artentjon.I tnrnK tnev shourd also be fed uo to the srie chief_q ofemergelcy alllasites who can then take thEE-fomdrdlolh.63tem-edlffiT-dr,?EEi^r ^n., !!. ^ ^i+ -- - - - ---- " -''wr q!l!--uLE-.tltE-ftF-i^-^.


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: Page 3 of4she wished to be kept informed orr angngoing basis regarding the situarron onemergency deparlments in the CapitalHealth region.

After careful consideration andconsultation with colleagues, it occurs tous that the best person to collect this datais the TLP (triage liason physician) as rhatperson has the best overview of theemergency department during the tirnethey are on duty. We would be happy toprovide the infonnation collected to youso that you are able to keep Sheilainformed in relation to any ongolngadverse outcornes that mighL occur inCapital Health emergency departments asa result ofovercrowding. Before weinstruct TLP's in the Region to moveforward on collection of such informationand dafi for review, ws_glg.askilg-for.your approval for use of TLP tirne in thiqendeavor.

Again, on behalf of my colleagues, thar From:> To:> CC:> Subject: Unsafe ED> Here is the deal with the ED this evening. Significan y unsafe-at> about 2230, there were 31 EiPs, 40 people in the waiting room, and at> least 10 waiting for admission. There were 7 or B ambulances waiting> and B triage category 2s, Experienced triage nurses stated they have

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I :"";""i,'ff l::",ff ?T:T:i:,]ffi jil,..*mh!ilffii> (who came in to help), The de> This situation is untenable and is completelv failino the needs of our

.,r-_--'---::-> par|ents. { rsly:! slrEgglgl.llrns with an ED tike this before a

> midnight, a woman presented in labor (contractions q Z min and dilated> 6 cm) and the only place available to put her was in the trauma room.> In addition, there were 28 patients who left without being seen (the> majority of which were triage category 3s). One of the patients wno> left was a 24 year old palliative patient who came to the ED for> analgesic and left without getting any.> cilg:lpplghappens despite the best efforts of the people in the ED> Thanks for calling last njght and checking on the depadment!

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Message body Page 1 of3To: [email protected]; [email protected]; [email protected];gl]!ln:[email protected]'ca; neil.wirkinson@capitarhearth,ca; [email protected]; fred. [email protected],ca;Subject: One Death - Grey Nuns HospitalDate: Tue, 15 Jan 2008 22:31:32 -0700Everyone,It is my regret to inform all of you that we have had our first documented death in Capital Health due to delaysin care. I cannot stress the impoftance of cooperation and understanding through this very difficult time.It is time to impiement the disaster plan.Raj

Date: Tue/ 15 Jan 2008 19:56:23 -0700From:Subject: Re: The Overcrowding Crisis: F/U #1To:CC:Less than 2 hours after my completing my email to you all yesterday, we have hadour first death in the ED temporally related to the ED overcrowding rssue.The case will be reviewed formally in-camera by the GNH ED eA committee nextweek, and patient identifiers sent in confidence by separate emair as rriel to or.J to,- hi,review as ED Director.The first interim analysis was done today by myself and the charge Nurse on duty yesterday.It is based on a review or the Elvls record, the ED chart, interview with both triage nurses onduty when the patient arrived for the remainder of their shift, and the last EMS irew supervisinopatlent prior to her being placed in an ED room and the nursing staff taking over care formally.-In briet the case is as follows:lyr old. Caucasian female brought by EtyS (ALS) to GNH ED from NHWiTfr Hx of suspected cI Bleed (coffee ground emesis and dark brown diarrhea)and decreased LOC this am. Past Hx of Ht disease.arrived ED: t072 am.Triaged by ED Physician (me) at 1052 am, (initial delay entailed bythe sheer volume of patients that had yet to be physician triaged jn the firsthour of my duty).Initial blood work ordered at this time, as well as orders left for ECG to bedone when patient placed in stretcher and room. The ECG was ordered onlyas a precaution in case an issue of potentiai cardiac ischemia develooed while beinoworked up for the suspected GI bleed. not because of any chest painDre-arriva l.l::i: ll,:T: i 11 j 1,1 ", 11Yrry:h ?1 :":yi ::i:l.i : ! :": i:t::"d bv E'v, s staf f

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until being placed in a room at 2020 hours. (a fulLle heljls ltcI),She remained, hemodynamically stable throughout with one transientrecorded BP drop to 97 systolic at - 1215 hrs that the paramedics rncreased the IVfor. There was no tachycardia with this and the patient did not have chest pain at thetime. This was repofted to the Triage nurse, and she was reassured that the onlvreal problem appeared to be persistent nausea, and periodic throat dlscomfort related to this.By 1600 hours she had required only 1 liter total IV infusion to remain stable.No obvious ongoing bleeding was noted by the EMS crews, and no mention ofeither bleeding or chest pain was forwarded to me or the nursing staff.During her time under EMS care in the hallway, one of the triage nurses was reassigned in thedepartment to other duties no less than three times due to staffing issues.At 1750 just prior to my concluding my shift, I reviewed her blood work, and noteda HB of 96 (l'1CV borderline elevated), but had no clear indication of how acute this anemia wasgiven her previous medical Hx.When this patient was finally placed in a room at 2020 hours, the nurse attendinq her noteo nercomplain ing ofsevere sharp left-sided chest pain.The ECG ordered at 1057 was finally done at - 2040 hours, and the ED Doc on duWattended the patient 2104.The EcG was markedly different from the 1z lead recorded by the EMS crew pre-arrival,and compatible with ACS/NSTE|VII MLSoon after, while investigations and treatment continued, she developed crushing chestpain, became hypotensive, unresponsive by 2305, and died before 2400 hours.It would have been very difficult, if not impossible, for the EMS crews toestablish whether any angina was ongoing throughout the day as the patient did not speakEnglish.It is very difficult in retrospect to say whether seeing the ECG earlier, and having an attendingstaff Physician on duty review it, the patient, and the EMS EcG would have madl a difference.

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' Message body Page 3 of 3commlttee and I will reouestthat Dr,tforward my concerns to the COO/GNH,As well tomorrow (when I return to the same situation again), the Canadian Medical ProtectiveAssociation will be returningmy call to them for advice re this, and future potentially preventable tragedies,

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' Message bodyFrom: rajTo:Subject: RE: l.4isericordia ERDate: Wed, 16 Jan 2008 11:16:25 -0700

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't\{'I

Thank you for your e-mail and for taking the time to chat during a busy time on your shift. I have passed youre-mail to the section leadership (!t,OWe met with Cgpjle! Hgi]!!._ggliSlexgg late yesterday and are hopeful that we can get some much needed reliefto the emergency departments in Edmonton. The Minister's office has also been briefed of the circumstances.Again, thank you.Rai

Date: Tue, 15 Jan 2008 02i47 i28 -0700From:Subject: Misericordia ERTo: rajHello Raj,Fufther to our conversation earlier this evening, accept this as a more formal update to thesituation in our emergency department:- We have not been in a position to safely see patients requiring urgent care for several monthsnow. On average, 70-100% of our emergency beds are occupied with admitted inpatients, and asI write this, we have 24 admitted inpatients in out 27 bed department.- Admitted inpatients routinely wait 3-5 days for an inpatient bed, and we often have patients waitfor over a week to go upstairs.

f - Wabave had a multitude of issues with inadequate and dangerous care provided in the Fn,' including septic patients treated in the waiting room, a pregnant patient (who was unaware of hergestational age) who laboured with severe abdominal pain for tvvo hours in the waiting roombefore delivering a term infant 5 minutes after being put in a room, and so on. CTAS triage criteriatime limits are virtually never met. The triage nurse routinely has to choose between a largenumber of seriously ill patients to decide who goes into limited treatment space. I could provide anumber of examples of poor and/or dangerous care each shift as a result of the extremeovercrowding the department now faces.I hold out little hope of meaningful change from Caritas, Capital Health, or the currentgovernment, but good luck in your effofts. Our site chief has been writing letters to this effect formonths, and the situation continues to deteriorate in an accelerated manner.

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From: rajTo:CC:Subject: Misericordia Er overcrowdingDate: Wed, 16 Jan 2008 22:33:'13 -0700

I,Your word is all I need,

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Y".terday,lnd I have met with senior exec at capital Heatth and have expressed thg urqent needto address this issue. We will just have to see what they are going to implement in the next few-dffi:-r:-r-c-We continue to encourage all of our emergency colleagues to carry on the best that we can desplte theresources that we have been given. We have also made the point with exec that the system is being held _toqether by a first class group of peoble who are goinq above and beyond their ceTfo*idu$-Fd5FlE=[iF;1yoursetves.I have attached this response to our section etrEc'to Keep the in the loop. Peter Kwan is section president. Paul:il:il*"iliT*lii::i;:1,"Hl,?ll;ffi !S", i:ti:f,ffi i$il"-fi 'flil jii!".'i;lJJ","Thank you.Rai

Date: Wed, 16 Jan 2008 11:59:08 -0700From:Subject: Er overcrowdingTo: rajRaj, do you have a fax no.? I would like to fax you a copy of the EDIS screen from yesterdayshowing that we had 25 admitted patients in our 26 bed department (a 100o/o utilization!!).rccc(rco{{x

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Hotmail -F Wrndows Lrve

Follow Up Emergency - Long term careRaj ShermalTa Fr(".d 1-lorne,

Dear Fred,Here as a report on the state of affalrs of theemergency departments.we met withnl F:c6d L'i ihforlrard. The/^^rr6,nm6nF r

Sh-j la l^JeaLheril.I and Ken cardener and- -\----Ene resources avat table to f.-n ua'-their reception and solrltions putfonger tern solutions 1ie in our hands

77 /01/2408Reply

Hage i oI 4

The state of affairs today:1. RAH Much Bettert !t- 18 EIP s (admlLted emergency in patients) vs30-44 over the past kreek- 5 LWOT,S (1eft wiLhout breatment) vs. 25-33per day over the weekend- 21 stck patients to be seen in the waitingroom Reasonable) vs. 58 on monday (unreasonabLe)UofA - Moderately bet ter,-22 EIP,s vs. 30-40 last neek8 LWOT's vs. 28 in the midst of Lhe cr.isis-21 patients to lle seen in the waiiing room vspac lenc s

3. Grey Nuns - a Little better...manageable, Maj.nproblen exists in that the internal medicinephysicians retusirg !.o aomi! paEiejlES afLer tney havereached a rcap. of 25 patients.

40

4. The Mj,sericordia (hopital in My RIDING) ..NO CTLANGEAT ALL....UNSAFE CA.RE IN THE ED! II-27 EIP, s -ns...24-25 pre-crisis.-There are currentfy 29 post-op hips ar.raitingtransfer to other sites in the hospital . Long termcare iS a big issue city v7ide, but especially at Lhissite. f heard that the ltisericordla discharges 2-4patients per day. The emergency is sti1l run out ofthe walting room and hallways. One site notfuncEionrng well 6ffe.Ls al1 oLher s:res neg-itweJy.Ic appears thaL rhe CariE.as HospiEals \qve elrner noEdispLayed the Leadership or] are s1mplv not able !o

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FWindows Liverrth their i ssues (especia l1y aE. the Mise.ricordiahe Nuns) as the RAH and UAIJ hawe. Slgl]g_ hedred that Carjcas 1s a separare board. Dr. Jeffson ls lhe -nedlcal Lead at CartLas, He could usena -:11 f-^- .'^,.I h-r'e to rhark yor a'd Dave lor the pressure, I

peful that we can mdlnLain chese gains. Looking6 PAIr -'.nh6.< w.r. .r- ^i--.rtw qaa fha irvarcc \;.lation between EIP's and LWOT's and sick oatienis y/*--e lvaltrng room, i-/ \ne if there were no admj-tted patients in anency department . . . . as there should be. The best

on the political end. These gainE are usuallyfived when the pressure goes a\,ray. During Ehership race, v,/e made i!. a leadership issue a1dtook hold of it. These conditions existed lastry and lmproved d1.re Eo che ECp (whic1 was a shorrfrx) . We saved a 1ot o' bad oSo, the FCP shoufd stay implemented (afways)as aer to improve the efficiency process.eal so.IuLions are rrves_ments inLo _ono rerm care.l4l!g -igEeli9d. Here is a conridentlal look.e minds of Lhe ER-docs in ,L1berta.-TiElian is tothis an election tssue louhl ic a.lvn.r^v) Th6so#s can be made an eleclion p atform issue tor our. . .Lhe Premier addlessing Lhe energency issuesrnking ir co long term cdte and senior care and.Lments in our seni ors. Tl:S__fgae_he__Sa+-s+euJ--++=ha'c :rrl rh?r LrF --rve that he truly does.v/oufd 90 over very well and silence those in the. lines....and address EMS issues at the same: you


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From: rajTo:Subject: RE: OvercrowdingDate: Thu, 21 Feb 2008 23:46:29 -0700

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-, Thanks for the e-mail. I will forward the contents of your e-mail without your name.CheersRaj> Date: Thu, 21 Feb 2008 22:42:53 -0800> From:> To:> CC: raj> Subject: Overcrowding> Raj, as per our discussion Feb 21 2008.> I was the TLP 1600-2400 at UAH HosDital.> Upon arrival to the department there was 29 patients in the WR and no beds to> see patients. At 2400 there was 29 patients in the waiting room. l.4any people> left prior to being seen. Multiple triage 3's patients. Some cases with life> threatening consequences as a result of overcrowding:> 1. Transfer to Neurology in WR Troponin 1.23 - in WR for hours.> 2. Seizure patient waited t hours for bed> 3.Fracture dislocation with skin compromise waited 2 hours in WR> 4.Patient with fall and confusion CT while in WR showed subdural with> intracerebral blood- waited 3 hours.(Senior nurse reminded me to book a CT in> WR- otherwise patient may have left).> 5. 78 yo Patient with focal weakness who left prior to being seen ? CVA> 6,73 yo Female with possible cI bleed in WR for 8 hours and still waiting when> I left at 2400! | !!!!> From a physician and personal point of view I feel helpless in the TLp role> and Emergency Physician as I get the sense of all of my colleageus getting> extremely frustrated, I also get the feeling the nurses are very Frustrated as> well. lt4any are looking for jobs outside the region. One nurse is leaving for> Victoria. Our goal of recruiting nurses but how do we retain the excellent ED> nuTses.> My other concern is the plan to build an urgent care center. Where are the> staff going to come from? it will clearly take nursing and other health care> professionals from local hospitals. It will no way improve patient care in the> Capital health Reglon. If the PC plan is to build urgent care centers. I am> completley against this policy and will vote for another party. As Dave> Hancock is running in my riding, I am very disappointed to see his website> announce a new urgent care center after all the Emergency physician input to> prove Urgent Care Centers do not improve patient care in the Emergency> Department.> Raj, please feel free to forward this email and information to Dave Hancock> and Premier Stelmach so they are aware of the crisis we face everyday in the> emergency depaftment.

,L--#--

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Hotmail indows Live

Raj Sherman's Father-Emergency IssuesRaj Sherrranio :rireiia n,eaiitefjil, i;,..1 f,;1:crra! l'r t-lJ ir;,.,r.r'r 22/02/2A08iir"p ly

Dear Sheila,l wish to tell you about anotlter near miss (near Death) last weekthat took place at the u offiTR.The patient presented to the ER on Friday, Feb 15ih at 12:O0rroonar'rd registered at 12:29.Therc were 31 EIp's (admitted emergenc)in-palients) in the ER plus capped admissions further reducing thenumber of available ER stretchers in which to treat sickpatients. He was triaged as a CTAS 3. The CTAS standard oi carefor treatment is 30-60 minutes upon presentation. There were 30patients to be seen ahead of this patient. He was exanrined by theTriage Liason Physician (TLP) at 14:36 and labs were ordered.There was no ernergency bed available for the patient so he wasieft in the waiting roorn. He presented with a 2 day history of feverand weakr.ress and had a history of heart problems and diabetes.He had normal vitals upon presentation. Lab tests were drawn at15:45pm.After an agonizing 5 hour wait, the patient was admitted to a bedin the ER at 1725pm. He was examined pronrptly by the ER doctorat 1735pm and was found to be clintcally dehydrated with mildacute on chronic renai failure. In light of his heart conditior.t, acautious fluid bolus was given. At about midniglrt, the patientwerlt into flash pulrronay edema (heart failure) and was ventilaiedon BiPAP. His troponin was 0.12 at midnight and subsequentlywas 29.95 by the morning....ind icating that he had a myocardialinfarction (Hear1 Attack) in the ED. This was likely secondary to hisdehydration which led to a sequence of events that piaced aburden on his already weakened heari (10 15% ejectionfraction) and exacerbated his underlyirrg coronary aftey disease. Iam sure that his life expectancy lras been shortened as a result oithis sequence of events.After reviewing the case, he received exemplary care in theER.....once he got into a bed and treatment was started. What isnon defensible is the fact that he sat in the waiting room for 5hours with a CTAS 3 designatiorr.My main concern lies in the fact that someone (unknown) called

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Hotmail l:El- windows Liveffi ""il: ilJT: ::ffi;il:Jl'fi ;lft? illT';,';'i iJ", "" oas h;s wait likely would have been 7-9 hours. The reason that iknow these details is that I was there when MY FATHFR reglsteredat 12:29 and was there when he was struggling to breaihe and"vas fighting for his life. After I dropped him off at the UofA ER forsimple dehydration from the flu, I trusted that he was in a safeplace and that he would be looked after in a reasonable time.After all, we had just had meetings in December and January overthis issue.My greater concern is for all of those other patients who do nothave the advantage that my father had. Many of them are muchsicker upon initial presentation and wait just as long in the waitingroom AFTER a diagnosis by the Triage Liason Physician, This isonly one case on what is a string of daily cases of near nrisses andbad oLrtcomes in all of the ER's in Capital Health. Many sick anddying paitents actually leave the ER witlrout treatmer.rt on a dailybasis and Cod only knows if they sulvive or retunl for care.My other concern is that when I was emergency section president,we have had multiple meetings over ihis issue and things are,vorse than they have ever beenl With our input, 1am glad thatyou were kind enough to implement some stlategies suchas portions of the FCP and the TLP. Had they not been done,things would have been a lot worse. I thought that l should let yo-know that the emerger'rcy physicians of Alberta are frustrated withthe state of affairs and the inability to deliver care to ill patients ina timely manner and may make this an election issue in the next"veek. Below, as you requested, I have also passed onto youcomments from my colleaguesso that you can be kept in the loop.

J :n:::i,"ff ::I li'i:H i "*.T;",:il':il1il:i :; ""Alberta ns, including my fatheas.Thank you for calling and expressing youf concerns for rny fatherhea ll n.

Sincerely yours,Raj Sherman, M.D.This message and any attachments are for the use of the intendedrecipient(s) and are confidential. If you afe not the intendedrecipient,you are hereby notified that any review, retransmission,converslo n to hardcopy, copying, circulation or any other use of this message andan'yattachments is strictly proh'biied. If you are not the intendedreciPient.

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Hotmai l!-r-4n - Windows Live Page 3 of 5please notify the sender immediately by return email and deletethismessage and any attachments from your system. Thank you.

A day in the UofA ERRaj, as per our discussion.I was the TLP 1600-2400 a1 UAH Hospital.Upon arrival to the department there was 29 patients in the WRand no beds tosee patients, At 2400 there was 29 patients in the waiting room.Many peopleleft prior to being seen. Multiple triage 3's patients. Some caseswith lifetlrreatening consequences as a result of overcrowding:1. Transfer to Neurology in WR Troponin 1.23 - in WR for hours.2. Seizure patient waited t hours for bed3.Fracture dislocation with skin compromise waited 2 hours in WR4.Patient with fall and confusion CT while in WR showed subduralwttnintracerebral blood- waited 3 hours.(Senior nurse reminded me tobook a CT inWR- otherwise patient may have le{t).5. 78 yo Patient with focal weakness who left prior to being seen ?CVA6.73 yo Female with possible GI bleed in WR for 8 hours and stillwaiting whenI left at 2400!M!!From a physician and personal point of view I feel helpless in theILP roteand Emergency Physician as I get the sense of all of my colleageusgettingextremely frustrated. I also get the feeling the nurses are veryfrustrated aswell. Many are looking for jobs outside the region. One nurse isleaving forVictoria. Our goal of recruiting nurses but how do we retain theexcellent EDnurses.My other concern is the plan to burld an urgent care center.Where are thestaff going to come from? It will clearly take nursing and otherhealth careprofessionals from local hospitals. lt will no way improve patientcare in theCapital health Region. If the PC plan is to build urgent carecenters. I amcompletley against this policy and will vote for another party. AsDave

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sherman's proof (batch 2)

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