Fredericton ER waiting room nurses doing double duty on night patient died, documents reveal

The licensed practical nurses who were assigned to check on patients in the Fredericton ER waiting room on the night a patient died last summer were also assigned to other tasks that night and "could not commit to regular checks," internal Horizon Health Network documents reveal.

Staffing levels at the Dr. Everett Chalmers Regional Hospital emergency department were low, according to the documents obtained by CBC News through a Right to Information request.

"They were doing the best they could with limited resources as usual," acting nurse manager Neil Gabriel said in an email to Horizon's then-vice-president clinical services Margaret Melanson.

"Since [Oromocto Public Hospital] reduced their hours it is not uncommon for people to have to wait two hours just to be triaged," he said.

There were 17 admitted patients in the ER that night and 29 registered patients in the waiting room, according to correspondence from local representatives of the New Brunswick Nurses Union. This, they point out, is more than the number of patients admitted on an inpatient unit.

The nurse to patient ratio is alarmingly high and unquestionably … unsafe.- New Brunswick Nurses Union, DECH Local

"The nurse to patient ratio is alarmingly high and unquestionably … unsafe," the unidentified union representatives told Horizon after the patient died waiting for care July 12.

"30+ people is too much for one person to take care of alone and the waiting room [licensed practical nurse] should never be re-assigned into the department."

Witness John Staples told CBC the man, a senior, had been waiting alone in a wheelchair, in visible discomfort, for hours when he appeared to fall asleep. It was only during a routine check of people in the waiting room that a hospital employee realized the man had stopped breathing, he said.

The case prompted a major shakeup of New Brunswick's health-care leadership. Premier Blaine Higgs fired Horizon president and CEO John Dornan, saying "If we don't get better management results in our hospitals, we won't get better health care." Dornan has since been awarded a record-breaking $2 million in his unjust dismissal case against the province.

Higgs also dropped Dorothy Shephard as health minister, replacing her with Bruce Fitch, and removed the boards of both Horizon and Vitalité, installing a trustee for each health network instead.

No details about the patient or the circumstances surrounding his death have been made public and several sections of the 147 pages of internal documents have been redacted for privacy reasons.

Triage does not always capture severity of condition

But the morning after his death, in response to an email from Liberal health critic Jean-Claude D'Amours, Dornan agreed, "it is terrible that a patient dies in one of Horizon's or Vitalite's ER waiting area."

Dornan said he couldn't comment on the specific case because he didn't have any details about the patient's "presentation," but did say, "the assessment and triage upon entry to an ER does not always capture the severity of a patient's condition."

The acting nurse manager wanted the case reviewed "to see if anything could have changed the patient's outcome," according to the documents.

"Staff that were on that night are certainly upset by the situation — mainly one," Gabriel wrote, but the rest of the sentence is redacted.

Horizon reviews any "unexpected deaths that occur in our facilities to determine what took place and whether further action is required," Dornan told CBC at the time, and confirmed a review was launched "immediately."

Government pushed for answers

By July 19, the government was pushing for answers, according to the documents.

"I've been asked by the deputy [minister of health] how quickly we will have the process review completed with recommendations from the situation last week at the DECH ER," wrote Melanson, whom Higgs had named interim president and CEO after he fired Dornan.

"I believe they want something as quickly as possible," Melanson wrote.

She asked Sandra Rooney, Horizon's director of risk management, about holding a special meeting of the quality of care & safety of patients committee to review whatever recommendations came from the quality process review.

A scheduled meeting on Sept. 22 was "too long a gap," she said. "I have to get these to government."

Risks if patients suddenly deteriorate

On July 22, Steve Savoie, identified as regional director of medical device reprocessing and patient flow improvement, submitted an "Emergency Department Action Plan" to Melanson.

In it, Savoie outlined issues with monitoring patients in the ER waiting room.

"Due to short staff, ED staff will not be able to reassess and monitor patients at targeted interval times, causing risks if patients suddenly deteriorate," he wrote.

Savoie also noted a shortage of triage staff. 

"Our large sites should have [two] triage nurses per shift, but due to staff shortage, most time they operate with only [one] (50% capacity) creating a higher risk of increasing time for patients to be triaged during peak times," he wrote.

"Not knowing the reason why patients are waiting is a significant safety risk."

Nurses feared public backlash

The quality process review, completed on July 25, found, "The lack of consistent patient monitoring and the inability to meet standards in the emergency department waiting room decreases the likelihood for early recognition in patient health decline."

A quality process review helps to "determine the contributing factors that led to a patient safety incident with harm of a serious nature," and to identify recommendations for improvement, according to the documents.

"It will not investigate individual performance, identify individuals or determine fault in any circumstance."

Nurses feared "public backlash" over the death though, the documents reveal.

The union recommended "highly visible security at all times at triage, and waiting room areas … until this situation has settled down."

If security is not available, police or private security should be considered, the union urged.

"The public backlash from this incident not only poses a mental health risk, but a physical risk to staff working in the ER. Staff need to feel safe and not vulnerable while at work in order to proficiently complete their required tasks."

Neither the union nor Horizon responded to questions about whether nurses experienced a backlash or whether security was enhanced.

Improvement in staffing levels

Horizon declined to comment on the death review, which led to four "direct" recommendations, as well as four "indirect" recommendations, which are defined as "concerns raised during the quality process review that would not have prevented the incident but are important for patient/staff safety."

The findings have been communicated directly to the patient's family and Horizon "has nothing further to add," Steve Savoie, now administrative director and co-lead of emergency services, said in an email.

Among the recommendations was to "identify and implement a strategy to ensure all waiting room patients are reassessed according to the [Canadian Triage and Acuity Scale] reassessment guidelines."

Savoie did say Horizon has implemented a number of measures aimed at improving access in its emergency departments since last summer. He cited as an example the waiting room patient monitors, announced as a pilot last August and now a permanent service.

Licensed practical nurses and patient care attendants are providing patient monitoring services 24/7 in the five largest hospitals in Moncton, Saint John, Fredericton, Miramichi and Waterville, Savoie said.

"Feedback has been overwhelmingly positive and these staff members, through their skill and compassion, have played a critical role in improving the experience for many patients."

Horizon has also seen improvement in triage staffing levels in recent months, recruited a number of registered nurses to its ERs, and is using private travel nurses where needed, according to Savoie.

"We work to ensure appropriate, safe staffing levels are in place on all shifts,"  he said in an emailed statement.

"In situations where staffing levels are forecasted to be low on a certain shift, Horizon takes actions to redeploy support staff to assist with the delivery of care in the ED."

The three other key recommendations from the review were:

• Develop a regional policy to establish a standardized process for the triage of a patient who arrives via Ambulance New Brunswick, including times of hospital overcrowding.
• Create a standardized patient flow process to mitigate risk of health decline and facilitate [Canadian Triage and Acuity Scale] level 3 patients through the [emergency department] by enabling pre-investigation workup prior to seeing a health-care provider.
• Establish a regional policy that identifies the criteria and process to facilitate transfer of non-urgent admitted patients who are being "boarded" in the emergency department until an inpatient bed becomes available during ER overcrowding.