N.S. government's emergency department plan gets mixed reviews
Some practitioners welcome the changes, but many worry they don't go far enough
In his last four shifts working in the emergency department at the Halifax Infirmary, almost none of the patients Dr. Sam Campbell treated were in emergency department beds.
"Apart from a couple resuscitation patients, every patient I saw was in an ambulance hallway, in a family room, in a non-traditional space, because every single bed I had was filled with an admitted patient," the veteran doctor said in an interview with CBC News.
Campbell is one of more than three dozen emergency doctors at the Infirmary who signed an open letter Thursday in response to a suite of changes the provincial government announced Wednesday. The shift is aimed at improving patient access to emergency departments around Nova Scotia in the wake of the deaths of two women whose care came either too late, or not at all, after hours of waiting.
Measures announced Wednesday include bringing more nurse practitioners and physician assistants into emergency departments, having doctors designated to help triage patients as they arrive by ambulance and using tools to help divert less acute patients to virtual care.
While that might help at some regional hospitals, Campbell and his colleagues in Halifax say the measures announced Wednesday are unlikely to help at the Infirmary, where the biggest problem is bed availability.
When all hospital beds are full, patients admitted from emergency departments have nowhere to go. Often, those inpatient beds are occupied by someone waiting for a room in long-term care. That can lead to patients staying in emergency departments for days before getting an acute care bed.
The doctors in Halifax argue the new services and people being deployed to emergency departments would be better used helping to speed up patient discharges to free up beds. Officials with Nova Scotia Health have said a new "command centre" that maintains real-time data about bed availability and patient status should help with this effort.
Although Wednesday's announcement focused on emergency care, the provincial government is taking steps to increase bed capacity.
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Last month, the government announced plans to build two new emergency departments and add 400 beds to the hospital system in the Halifax area. It will also build two patient transfer facilities where people in acute care beds who no longer need them, but are not well enough to go home, can be transferred while they continue to recover or await a long-term care placement.
The government announced last week plans to add 600 more long-term care beds to the system. Other than the patient transfer facilities, however, it will be years before all the new beds are open.
Scopes of practice must be expanded
In the meantime, the government has also announced plans to expand training for paramedics and increase the scope of practice for pharmacists.
Allison Bodnar, CEO of the Pharmacy Association of Nova Scotia, said pharmacists in the province have the broadest scope of practice of any province except Alberta.
Steps must be taken, however, to capitalize on that, said Bodnar.
"The issue really here in Nova Scotia is we haven't funded most of that."
Bodnar, like other people who talked to CBC on Thursday, said the province must continue to ensure all health-care professionals are working to their full scope of practice as a way to ease the burden on some professionals who are spread too thin.
For instance, pharmacists could be doing more public health immunizations and drug therapy management for chronic diseases, said Bodnar.
Dr. Leisha Hawker, a family doctor and president of Doctors Nova Scotia, said Wednesday's announcement was "a good news story," but she cautioned anyone who thinks making changes at emergency departments is all that's required to fix a health-care system that is under extreme pressure.
Hawker said attention must also be paid to primary care, including efforts to expand the use of the 'medical home' model where a patient is attached to a practice that has a variety of professions and sees the most appropriate team member based on their need.
That could mean seeing a doctor or nurse, said Hawker, but it could also mean seeing a dietitian, social worker or another practitioner.
"I'm not the best social worker or dietician — I didn't learn that in medical school," she said.
"So it doesn't make sense for me to do dietary counselling. It makes sense for a nutritionist to do that work and I could be focused on making complex diagnosis and management plans."
Getting a single electronic health-care record system in place would also create "significant efficiencies" in the system, said Hawker.
Along with the expansion of technology and scopes of practice, however, there were also calls Thursday for more staff.
Nova Scotia Nurses' Union president Janet Hazelton said the government needs to find ways to attract and retain more nurses. That includes paying for the training required so a licensed practical nurse can upgrade to become a registered nurse and an RN can upgrade to become a nurse practitioner.
It's unreasonable to ask working nurses to leave their jobs and go into a study program when they're also trying to support families, said Hazelton. She said a program that offers financial support for a small cohort of RNs to become nurse practitioners is a great initiative and it needs to be expanded.
"If we're funding 10 and there's 50 that want to [upgrade], let's fund 50."
Hazelton also expressed concern about putting patient advocates with no clinical training in emergency department waiting rooms. It would be more appropriate and useful, she said, for those positions to be filled by licensed practical nurses who can monitor patient vital signs and alert triage staff of any changes in condition.
Earlier this month, the Nova Scotia Government and General Employees' Union sent 59 recommendations to the province for ways to improve the situation. Hazelton said she's hoping the government acts on those, along with recommendations from her own union.
But Health Minister Michelle Thompson told reporters on Thursday that the patient advocate roles are intended to be non-clinical positions that offer support to people waiting. She said more details are coming about clinical roles that will also help monitor patients.
Thompson said her government is doing what it can to bring immediate help to the system, but she acknowledged other changes are going to take more time.
"I'm heartened by the path we're on, but there's a lot of work to do."
Too little, too late
In an emailed statement on Thursday, Gunter Holthoff, whose wife Allison Holtoff died at the Cumberland Regional Health Care Centre on Dec. 31, described government's announcement on Wednesday as "too little and it's too late."
Holthoff said it lacks a sense of urgency as most of the measures announced have been in discussion for months or years.
He said the provincial and federal governments have the means and resources to solve the problem faster.
"We need more health professionals in our emergency rooms now and it's time to call on them, similar to what we've seen in other emergency situations like COVID," Holthoff said in the statement.
"This is a true emergency, and although this problem may have grown steadily and quietly over the last number of years — we do not have years to quietly address it. "
All political parties need to work together to solve the crisis, Holthoff said, or the health system will fail others as it did his wife.
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With files from Nicola Seguin, Kate McKenna, Jean Laroche and Tom Murphy