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Death on the Doorstep

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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.

4 Responses »

  1. Allan, can I get your email address. There are some things I would like to discuss with you.

  2. Social factors at home are something we often don’t take seriously enough in healthcare, and I think you’re right in pointing out the benefits of a systemic approach for these issues given the multiple competing factors. On the one hand, if a patient is medically cleared, hospital resources need to be turned to the next patient – ED beds can’t be treated like subsidized hotel accommodations. But what and who are patients going home to? CCAC and home care often doesn’t seem to be up to the task for frail seniors with many chronic conditions, especially if family support is limited. All too often I see the tenuous situations at home when responding to people’s homes as a paramedic. But at what point does that become a reason to hold patients?
    Then the question is how should these patients get home? In these. 3 Winnipeg cases, patients died of coincidental or possibly missed underlying conditions, not exposure.
    But you mention “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,” an issue I see up close as a medic. Unfortunately emergency services are feeling the strain of increased demand just as hospitals are. Is it reasonable to expect an emergency health resource to be taken out of service in the community for say an hour, when a patient is going home, having been cleared for discharge and supposedly medically stable? In my area paramedic services are able to take more medically necessary transfers without escorts due to increased training and trust, even unescorted STEMIs, and that’s something we can do more of… but if paramedics are used as (MOH subsidized) taxi drivers, we’re not available for that either, not to mention 911 calls. In Ontario at least this speaks to the shortcomings of the unregulated patient transfer industry, which ideally could service the range of patients inappropriate for taxis, yet not requiring ongoing monitoring/care. Hard to know what the right answer or system is, but the issue isn’t going away anytime soon.

  3. Well said Al. We both know how long the issues related to ER overcrowding have been around and how long we (and other ER physician colleagues) have been advocating for provincial standards. Are we any closer to achieving that elusive goal? The Accreditation Canada standards are a good initiative at the national level.

    The Health Ministry sanctioned ER standards process I led back in 1999-2000 In Ontario resulted in some tremendous input from across all ER stakeholder groups but the standards were never mandated or officially published by the Ministry, likely because enforcement would have been problematic. I have not been closely tracking what’s been happening across the country in recent years, but do know that ON has had various ER initiatives underway or implemented.

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