December 14, 2018

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Ready for surgery

The controversial overhaul of Winnipeg's health-care system begins Tuesday morning; the architect of the massive plan and the people who are putting it in place are confident the long-suffering patient will make a full recovery

Dr. David Peachey, Lead Consultant for Health Intelligence

RUTH BONNEVILLE / WINNIPEG FREE PRESS

Dr. David Peachey, Lead Consultant for Health Intelligence

Hey there, time traveller!
This article was published 29/9/2017 (440 days ago), so information in it may no longer be current.

Dr. David Peachey was more than halfway through his 18-month review of Manitoba health care before the idea of closing three of Winnipeg's six emergency departments to improve service reached the table.

Peachey, who led the Health Intelligence Inc. team tasked with the substantive review, started his reform deliberations with critical care — people whose lives are at immediate risk: the woman having a heart attack, the man whose lungs are choked with blood, the little boy or girl who isn't breathing.

His analysis was that the level of service at one hospital did not match the level at another; someone needing life-saving care might not have access to the same specialists or equipment at one hospital as they would at a second, even though both facilities are expected to offer the same service.

“You can’t support the hardware and the people for critical-care services across six sites,” says Peachey, the Nova Scotia-based consultant who spearheaded health-care reform in several provinces before tackling Manitoba at the request of premier Greg Selinger's government.

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Hey there, time traveller!
This article was published 29/9/2017 (440 days ago), so information in it may no longer be current.

Dr. David Peachey was more than halfway through his 18-month review of Manitoba health care before the idea of closing three of Winnipeg's six emergency departments to improve service reached the table.

Peachey, who led the Health Intelligence Inc. team tasked with the substantive review, started his reform deliberations with critical care — people whose lives are at immediate risk: the woman having a heart attack, the man whose lungs are choked with blood, the little boy or girl who isn't breathing.

His analysis was that the level of service at one hospital did not match the level at another; someone needing life-saving care might not have access to the same specialists or equipment at one hospital as they would at a second, even though both facilities are expected to offer the same service.

Where you should go for care:

Click to Expand

To an ER:

  • Stroke/facial weakness/extremity weakness
  • Heart attack/chest pain or tightness
  • Unable to wake/unconscious
  • Sudden onset of severe headache or confusion
  • Seizure and/or severe head injury
  • Severe difficulty breathing or trouble speaking
  • Uncontrolled or severe bleeding
  • Major trauma such as loss of limb
  • Severe allergic reaction
  • Severe burns

To an urgent care centre:

  • Illnesses, injuries or infections requiring same-day attention
  • Dehydration
  • ICuts that won’t stop bleeding
  • Injured limbs that might be broken or sprained

To your doctor or a clinic:

  • Minor illnesses, flu, rashes or infections
  • Diagnosis and specialist referral
  • Ongoing management of health conditions and preventative care
  • Prescriptions, vaccinations and inoculations

 

jane.gerster@freepress.mb.ca

"You can’t support the hardware and the people for critical-care services across six sites," says Peachey, the Nova Scotia-based consultant who spearheaded health-care reform in several provinces before tackling Manitoba at the request of premier Greg Selinger's government.

"You don’t have critical mass."

So, you start by recommending critical-care consolidation, he says, and then back it up from there.

If a hospital doesn’t have an intensive-care unit, does it really need to offer the same type of emergency surgeries? And if there are no intensive-care beds available at a facility for an incoming patient should the ambulance not be rerouted? Is the emergency service at that hospital even required at that point?

"We took people on the trip with us," says Peachey, who sat down with the Free Press earlier this week while in town to help the province usher in the first phase of his reforms.

The pieces for reform locked in place over the course of a few months, he says. Once the critical-care physicians were on board, he says the conversation shifted to include emergency-room physicians and from there, to the surgeons.

"We were prepared to make decisions without agreement," he says, but "we got agreement."

How Winnipeggers use the emergency room

Click to Expand

Take a look at the reasons we visited emergency departments in 2016, according according to patient complaint summary data obtained by the Free Press

On Tuesday, one of Peachey's most contentious recommendations — that critical care and emergency care be consolidated to just three hospitals — starts to become a reality: Victoria General Hospital's ER becomes an urgent-care centre. The big red Emergency sign will be removed, all signage linked to the colour-coded floor lines guiding people to the ER will be swapped out and, as of 8 a.m., patients with life-threatening conditions will be stabilized and transferred elsewhere.

Although not actually a direct result of Peachey's recommendations, the Misericordia Health Centre loses its urgent-care centre Monday night. It will, however, continue to offer 24-hour emergency eye care. New signage directing patients appropriately will go up shortly.

Even though the backlash to the changes has continued unabated since April's announcement, Peachey isn't bothered; he says no effective reform happens in small increments.

"Just tweaking the edges wouldn't do much," he says. "It never does in health care."

But whether his prescription will fix what ails Winnipeg's health-care system remains to be seen.

"It's a very long-standing history of dysfunctional emergency service dating back to the early 1990s, with many high-profile media stories about people either dying while waiting or dying having waited," says Alan Drummond of the Canadian Association of Emergency Physicians. "Something has to give."

The emergency department at the Grace Hospital.

WAYNE GLOWACKI / WINNIPEG FREE PRESS

The emergency department at the Grace Hospital.

The through-line of opposition critiques have, largely, centred on simple math: in a city that consistently struggles with some of the longest ER wait times in the country, how does reducing the number of ERs by half improve things for Winnipeggers?

"We don't care how many emergency departments there are," says Drummond. "We care that if you show up in the emergency department with a bona fide life-threatening injury... you're going to have timely access to care."

And that, he says, means beds.

"It's been very, very clear the reason that we have a crowded emergency department is that we have a crowded hospital," he says. "You need to increase bed capacity."

The Winnipeg Regional Health Authority plans to open dozens of transitional-care beds later this fall. It's also spending millions to add new intensive-care beds, as well as an expanded ER minor-treatment area at Health Sciences Centre. But many of those expansions won't be ready until late next year or early in 2019. Those timelines have not exactly set people's minds at ease, considering the more immediate changes at Victoria and Misericordia.

How HSC is trying to cut down ER wait times

Click to Expand

Currently, patients who arrive at the adult ER at HSC are streamed by the following categories:

  • Resuscitation
  • Main area (urgent but not life-threatening)
  • Mid-acuity (less urgent)
  • Minor (non urgent)
  • Mental health

Resuscitation patients are seen immediately, whereas mid-acuity and minor patients tend to be triaged and wind up in the main area. That tends to clog available beds and increase wait times.

The new team will stream patients who present as mid-acuity or minor in an effort to keep them out of the main area beds, which has shown through trials to be an effective way to cut wait times throughout the ER.

But Dr. John Sokal, who heads up the Health Sciences Centre's ER, says he expects it will be able to handle the influx of new patients "without too much difficulty within our existing space."

That has to do, in large part, with a new plan for streaming patients that's geared towards freeing up beds and has already, during trial runs, cut down on wait times by as much as 40 per cent. The plan involves teams made up of one doctor and one nurse who are tasked with directing the flow of less-serious cases.

Right now, front-line staff at HSC triage a patient into one of five streams: resuscitation, the main unit, mental health, mid-acuity or minor treatment. The main unit, Sokal says, is the problem area because it is, in a way, a dumping ground where many less-urgent and non-urgent patients can languish alongside urgent, but not life-threatening patients.

"That's the most valuable real estate," he says, "and that's where we get all our blockage."

It has not been a very effective system, WRHA vice president Lori Lamont says.

"If you were in the main department, regardless of what your need was, you go onto a stretcher and you tended to stay on that stretcher until everything was completed."

For two years now, HSC has been doing trial runs with these teams on a limited basis. Their job has been to do a more in-depth assessment of patients who've already been designated less urgent in an attempt to divert them, if possible, from the main unit.

"For some people it's very clear where they need to go, but for others, not so much," Sokal says.

While it might be obvious when someone comes in with chest pain that its a heart attack or pneumonia, he says, "there's a large population in there where you don't clearly know what it is."

In that case, the team steps in to ascertain whether it might be something like a muscle ache that doesn't require a bed. Then they'll divert that person from the main-unit stretchers to keep them clear for those in need.

How ER changes will affect ambulances

Click to Expand

Ambulances in Winnipeg have a destination priority protocol, which means they’re directed to take acute patients to the centres most prepared to treat them. That means that cardiac patients are taken to St. Boniface, even if another ER might be closer.

That protocol won’t change very much when ERs start to close. The only change will be a cutback on ambulance transfers between facilities. That means a patient who arrived at the Victoria General Hospital ER but was later transferred to St. Boniface for cardiac care won’t be transferred back to Victoria, which occurred occasionally in the past.

According to WRHA figures, there were more than 15,000 such interfacility patient transports during the 2016-17 fiscal year.

How many patients did each facility transfer?

  • HSC: 3,236
  • St. Boniface: 4,114
  • Grace General Hospital: 1,621
  • Concordia Hospital: 2,109
  • Seven Oaks General Hospital: 2,390
  • Victoria General Hospital: 1,928 

During two 24-hour trial runs in August and September, Sokal says the teams cut wait times across ER units between 20 and 40 per cent. They'll be operating 24 hours a day by Tuesday. Lamont says there will be additional personnel scheduled until all staff moving from other facilities to join HSC are in place by the end of October.

Because Victoria's ER already tends to see more minor patients than HSC, Sokal says there'll be very little change required at the facility. Staff are already versed in transfer protocols for cases in which a patient requiring emergency care walks in.

Ultimately, the effectiveness of the emergency changes will serve as a good indication of whether the system-wide reform is working, says Juliana Wu, manager of acute and ambulatory care information services with the Canadian Institute for Health Information.

"ED data is valuable because it's a barometer into how well the health-care system is doing," Wu says. CIHI releases an annual report tracking ER data including wait times, how they vary along age lines, and what injuries or illnesses people show up with. Year over year, she says the reasons people go to the ER tend to stay fairly consistent.

"If that changes that's probably indicative of something in the system that's different," Wu says, which may mean that a cut or alteration to service elsewhere is resulting in more ER visits.

Lamont says the WRHA has plans to closely monitor all emergency facilities in the city 24 hours a day, seven days a week to make sure the changes are going according to plan. She expects to provide the public with weekly updates throughout October and into November.

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