The recent deaths of two patients discharged from the emergency department of the Grace Hospital in Winnipeg and sent home by taxi has raised concerns about the safety and standardization of ER discharges.
This is not just a Winnipeg problem. This past year two elderly female patients were released from emergency departments in the Vancouver area in the middle of the night, in their pyjamas and by taxi causing considerable outrage by family members.
The situation in Winnipeg clearly raises the issue of potential misdiagnosis. That being said, however, sudden death is a reality and these deaths may not at all be related to the assessment and treatment in the ER. The coincidence, if it proves to be that, is indeed unfortunate.
The other issue is the standardization and safety of ER discharges.
This is an important topic as patient safety is high on the list of concerns for emergency physicians and nurses and does not merely end when the patient leaves the ER. Simply put, we have a responsibility to make sure, as much as possible, that when a patient is discharged there are reasonable grounds to anticipate their safe arrival at home. This is why we don’t discharge those with alcohol intoxication unless there is somebody with them.
With respect to standardization, there simply aren’t any. There are, with the exception of the recent Accreditation Canada standartds, no provincially mandated standards with respect to the processes of care in the ER. There are common understandings and perhaps institutional expectations but no province in Canada has provincial ER standards save for Nova Scotia and even they are just common sense rules. With respect to standards, there is no “there” there.
This leaves us with shared judgment and common sense by the ER physician and nursing staff and to be quite frank there is nothing to suggest that its absence is common place. To the contrary emergency physicians and nurses have a tremendous sense of community service and social justice which is why they may choose to work in the ER in the first place.
Common sense can’t be codified in an ER standard but the thoughtful process of discharging a patient safely is innate to every patient encounter.
Common sense however may be undermined by the pressures of urban emergency room practice. We have unprecedented levels of ER crowding (in and of itself a danger to patients) and thus ER stretchers have become a priceless commodity. This may well put the ER physician in the unwanted role of gatekeeper and perhaps force a discharge which in the cold light of day seems heartless but at the time seemed entirely reasonable.
Having put a patient in a taxi means the patient was able to ambulate and the ER tyeam felt safe with this manner of discharge.
The other reality that must be considered is that just as a patient can be admitted to the ER at any time of the day they can equally likely to expect to be discharged at any time of the day. That is the sad reality.
In my small rural hospiatl with low patient volumes I may have the opportunity to hold people overnight because I’m not pressured for beds; the same is not true for my urban colleagues.
Some ERs have holding units to allow more prolonged evaluation of patients with complex presentations; this would help solve the perception of the inappropriate discharge but this is not what this concept was developed for.
What about discharges by taxis. This is not at all uncommon. We often can’t get an ambulance for hospital transfers and they seem to resist the concept of their role as a transport service for dischraged ER patients.
The elderly often don’t have relatives who are ready and sometimes willing to retrieve them when discharged in the middle of the night so the quite reasonable alternative is by taxi. That being said, I have been made aware of some jurisdictions in which nurses are called to the mat for issuing taxi chits and causing expense.
Last year Vancouver, this year Winnipeg, next year Quebec perhaps.
The issue of safe discharge from the ER is extremely important. It isn’t codified and perhaps it should be. The ever pressing need for ER stretchers to mitigate crowding is forcing discharges at unsociable hours. Families need to step up and advocate for their loved ones. Emergency physicians must continue to use their best judgment in assessing the safety and appropriateness of discharge.
But most importantly we need to have a national discussion of the pressures and inconsistencies associated with emergency service delivery in Canada. For the Canadian public, perception is the reality and the perception is that we are heartless or stupid. We are neither.