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鈥攁nd felt鈥攕tartled them: though this was known to be one of the busiest emergency facilities anywhere in Quebec, the atmosphere was eerily calm.
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鈥檚 most hectic days since moving into Pavilion K in mid-February. The apparent lack of frenetic activity was鈥攁nd remains鈥攁 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鈥� all of which are blended together in an effort to create an exceptional patient experience.
That鈥檚 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鈥�27 percent more stretcher patients, with an overall increase in volume of 18 percent. 鈥淪taff are coping, but with difficulty, because they feel the pressure of the magnitude of the added burden,鈥� says Dr. Lawrence Rosenberg, JGH Executive Director.
鈥淚t鈥檚 as if we鈥檙e walking on a tightrope across Niagara Falls. One strong gust and who knows where we鈥檒l be.鈥� 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鈥檚 reputation for efficiency (even at the busiest of times), and the high quality of care throughout the hospital.
鈥淲e expected a certain amount of extra volume, but nothing like this,鈥� says Dr. Rosenberg. 鈥淚t鈥檚 very hard to shoulder this kind of increase, which hasn鈥檛 occurred anywhere else in the city or the province. It means we鈥檒l 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.鈥�
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鈥檚 main doors at 5777 L茅gar茅 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. 鈥淣ow I have to call him and tell him not to pick me up there,鈥� she sighed.
In the yellow pod, where Joyce Vineberg was being treated in April for a heart attack and infection, her relatives praised the听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.
鈥淭he Emergency Department is always in a continuous process of refinement,鈥� says its Interim Head Nurse, Valerie Schneidman. 鈥淲e鈥檙e not static; our patients and families share their opinions with us and we listen. It鈥檚 an unpredictable environment, but we try to stay ahead of the curve.鈥�
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.
鈥淭he way it鈥檚 set up for the patients seems much less stressful,鈥� said Mrs. Hunter, noting that even though the members of staff seem calm, 鈥淚鈥檓 sure they鈥檙e running and they鈥檙e busy, busy, busy. They look like they appreciate their surroundings.鈥�
鈥淚 also find that this hospital communicates really well,鈥� added Mr. Hunter. 鈥淲hatever they鈥檙e doing differently here seems to be working. They鈥檙e less bogged down, I think. Things just don鈥檛 feel confused or chaotic.鈥�
This impression is confirmed by many Emergency personnel, who say they鈥檙e under great pressure from the heavier volume of patients, but they鈥檝e 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鈥檚 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:听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鈥檚 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鈥檚 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听and then approach a doctor or nurse who is passing by.
鈥淚 accept that I鈥檓 going to be bombarded with many things at the same time in the Emergency Department,鈥� says Dr. Grad. 鈥淏ut there are certain things that we should be able鈥攁nd now are able鈥攖o 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鈥檛 feel drained from being constantly distracted and having to explain, over and over, about things that aren鈥檛 necessarily relevant to the patent鈥檚 problem.鈥�
Even when the pace is intense (as it usually is), 鈥測ou really feel that it鈥檚 overwhelming you,鈥� adds Nurse Astrid Gabriel. 鈥淲hen you鈥檙e 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鈥檛 have constant chaos. And the noise level isn鈥檛 there any more, which is amazing, because that decreases stress levels tremendously.鈥�
Another big advantage is the RAZ, says Dr. Alex Guttman, an听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.
鈥淭he literature has shown that people who are placed in a stretcher stay longer for the exact same problem,鈥� explains Dr. Guttman. 鈥淥nce they鈥檙e lying on a stretcher and are comfortable, it鈥檚 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鈥檛 need a stretcher. Let鈥檚 get them into the RAZ.鈥�
鈥淓ven as chaotic as it sometimes is, I would never do anything else,鈥� says Ms. Garbriel. 鈥淚鈥檝e 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.鈥�
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Areas of specialized Emergency treatment
Pods: Each pod is a large treatment unit, consisting of a central administrative area where staff confer and review patients鈥� electronic records. The central hub is surrounded by private rooms, each containing a stretcher patient.
鈥� The green pod has 19 rooms for the sickest patients.
鈥� The yellow pod, with 16 rooms, treats patients in serious condition.
鈥� 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鈥攅.g., a mild asthma attack or nosebleed鈥攁re seen in an examination room and then are treated or discharged.
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Adding it all up
Just how busy has the new Emergency Department been since moving to Pavilion K? 鈥淢ega-busy, it鈥檚 huge, more than anyone expected, including me鈥� 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鈥檚, 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. 鈥淚t places an enormous strain on our staff, unlike anything that is being experienced in any other hospital in Montreal or Quebec.鈥�
This article was originally published in .
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