Five hours into his shift, Dr. David Rauchwerger, Chief of Emergency Medicine, in the Nick and Roseanne Cortellucci Family Emergency Department (ED) at Mackenzie Richmond Hill Hospital has already seen more than 30 patients.
His patients have had conditions ranging from chest and stomach pain to lumps, bumps, bruises, nosebleeds and headaches. It has been a fairly routine day and any downtime has been brief—but the quick pace and constant challenges are what attracted the doctor to emergency medicine.
“We never know what illnesses or injuries will come in the door,” he says. “Each patient and family situation is different and we work hard to give everyone the best possible emergency care.
“My colleagues and I know we have an opportunity to make a real difference in the lives of others when they need help most. I consider that a real privilege.”
As part of the expert team of emergency care professionals, Dr. Rauchwerger is one of more than 200 staff and physicians who work in the ED. Today, he and the team will care for hundreds of people with various needs ranging from life and death situations to patients who require urgent care only available at the ED.
Visual cues are everywhere in the ED: colour-coded tags clipped to folders indicate which patients are waiting for lab results or to be assigned to a specific doctor, and electronic screens display a bed management system that tells the team, at quick glance, what is happening in the care of each patient.
To a patient or visitor, it may seem like organized chaos, but to the ED team, it is all part of the infrastructure and system of caring for more than 260 patients each day, and more than 95,000 patients annually including over 17,300 patients that arrive by ambulance.
“Two years ago, Mackenzie Health made a commitment to create an exceptional care experience for emergency patients.," Altaf Stationwala, Mackenzie Health President and CEO "With this goal as our foundation, we have focused on raising the bar on the quality and timeliness of care for patients and are pleased that they have noticed a difference.”
Taking Charge
Charge nurse Claudia Suciu arrives for her 12-hour shift to find 11 ambulances in the ambulance bay and a high volume of walk-in patients waiting to be triaged for care. She enters the department with a smile on her face, greets the team — and quickly gets to work.
After being briefed by the departing charge nurse, Ms. Suciu directs nurses from areas across the department to help triage the new ambulance arrivals and incoming patients in the waiting room. Though soft-spoken, her leadership is evident as she quickly pulls the team together to begin treating multiple patients including a woman having trouble breathing, a middle-aged man with chest pain, and a teen with the broken leg.
“It’s a team effort caring for patients,” she says. “No one can do it all alone. We all work together.”
In her role, Ms. Suciu keeps a running tally of all patients in the ED: Who needs immediate care? How many are waiting to be seen by the triage nurses? Who is waiting for or receiving treatment or diagnostic testing? When can an admitted patient expect a bed upstairs?
Her challenge—the team’s daily challenge— she explains, is to maintain the flow of patients, while ensuring every one receives exceptional care.
“It’s very important for us that patients and families are pleased with the quality of care they receive,” Ms. Suciu adds.
To help manage the constant demand for in-patient services, the hospital holds daily or more frequent “bed meetings” providing an opportunity for team members from across the hospital to come together to assess and coordinate how expected admissions, discharges and needs for community supports can best be supported. Decisions are made on who can safely be discharged home and how the team can support this transition to make room for the next patients waiting in the ED for a bed.
Needs based care
“The ED,” explains Ms. Suciu, “is divided into ‘zones,’ to care for patients depending on the severity of their illness or injury. Team members are assigned to a specific zone each shift, but are trained and ready to jump in wherever they are most required.”
Patients are assessed by a triage nurse upon arrival and based on symptoms are assigned care in one of these designated areas. Patients requiring immediate attention for conditions that threaten their life or a limb are seen immediately; those with conditions that have the potential to become critical are also flagged for urgent care. All other patients are prioritized and cared for as quickly as possible.
“Patients with life threatening conditions such as a heart attack or stroke need to be cared for first,” says Ms. Suciu. “No one likes to wait, but patients and families usually understand why they’re waiting once they realize the urgency and life-threatening conditions others are experiencing.”
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In the blue zone, an area dedicated to patients needing acute care, nurse Ruth Appiah-Boateng’s has had a busy morning. Her first patient was a woman with a rapid heart rate—ranging between 120 and 160 beats per minute, which is fast compared to a normal heart rate of 60 to 100.
Following pain medication, the patient received a cardioversion, a procedure that successfully returns her heart rate to normal and she was safely discharged with a follow-up appointment at one of the hospital’s cardiac clinics. Her visit was complete in less than 6 hours. Conditions needing this level of care followed by discharge home are quite common, thanks to the expert care of the team.
An urgent call comes in from the emergency services dispatcher. An ambulance is en route with a woman showing signs of a stroke. As the District Stroke Centre, Mackenzie Health is the only hospital in York Region that provides a clot busting drug called tPA (tissue plasminogen activator),a medication that can reverse the damaging effects of stroke, if administered within 4-1/2 hours of the first signs of a stroke occurring.
Paramedics bring patients experiencing stroke symptoms from across York Region for assessment and expert stroke care. The team in the blue zone, including Ms. Appiah-Boateng reacts quickly. A neurologist is called to the ED and a bed prepared for initial examination. A CT scan will determine if she has had a stroke and requires tPA.
Luckily, this time, the CT scan reveals the patient has experienced a TiA or mini stroke, and requires a follow-up in the stroke prevention clinic to review medication and lifestyle factors that could help prevent a full stroke in the future.
A few hours later, as they prepare to leave the ED, her grateful family thanks the team for their quick and professional response. With a family history of stroke, this warning has reminded them to be more aware of potential signs of stroke and things they might do to avoid a stroke.
“We’re more aware now,’ her son says. “This was a wakeup call for all of us.”
With referral to the clinic in hand they leave, thankful that follow-up care is available close to home.
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All day, the flow of incoming patients continues. The team works as quickly as possible to assess incoming patients. Two car accident victims have arrived on stretchers, followed by an elderly woman. One of the paramedics details the woman’s symptoms to Ms. Suciu who determines what immediate care is necessary, while the other gets her husband a chair so he can stay close to her.
Over in the green zone, an area for ambulatory patients with less serious illnesses or injuries that require assessment and investigation, manager Andreea Anton gathers nurses for a quick “huddle” to talk about an upcoming process change and to gather feedback from the team. Following a quick discussion, the team is back to their patients.
In all areas of the ED, explains Ms. Anton, nurses use medical directives to order standard tests like blood work, urine test, ECG, x-rays to help streamline the care process. With test results in hand the team has a better picture of what a patient needs before he or she sees the doctor.
“Patients want to spend as little time as necessary in the ED,” she says, “We start processes to keep patients moving and to get them on their way as soon as is safely possible.”
When recommended by the ED physicians, staff book follow-up appointments with a variety of hospital outpatient clinics: medical urgent care for patients with mild COPD or deep-vein thrombosis, for example, pediatric urgent care, stroke prevention, chest pain, fracture and the plastic surgery clinic are some of the more common referrals. When patients leave, Ms. Anton explains, they know what their next steps are—whether that’s recovery at home, a next-day appointment at one of the clinics or follow-up with their family physician or other community care provider.
Supporting the team as flow navigator in the green zone, is nurse Samira Abessi .
In this role she streamlines care by acting as one contact and voice between all the nurses and physicians and other team members in this area. It’s a busy day for the green zone, so Ms. Abessi, who has the energy to match the fast-paced environment, is also helping with direct patient care where she can.
“Good communication and strong team work are very important to us here,” she says.
Meanwhile, an elderly man has arrived by ambulance after biting a staff member at the long-term care facility where he lives. It’s his second visit to the ED in six months and it is important to understand what is happening with his medical condition that is leading to this type of behaviour.
Jerry Anim-Ansah, one of two geriatric emergency management (GEM) nurses in the ED specializing in caring for older adults cares for him this visit. He first met this patient several months ago, when his wife brought him to the hospital because she was no longer able to cope with his worsening dementia and associated aggressive behaviour.
During the previous visit, Mr. Anim-Ansah worked with community partners to successfully locate the patient a bed in long-term care. Today, he shows compassion and patience as he thoroughly reviews the man's medical history and again accesses hospital and community resources.
"I have a real passion for helping,” says Mr. Anim-Ansah, noting the aging population will mean growing demand for this type of care. “I like being involved in finding the best solution for each patient."
Pleased to learn Mr. Anim-Ansah is in the ED today, the patient’s wife updates him on her husband’s condition since he was last in the ED and recent changes in his behaviour.
“He was very helpful when we first came and reassured me that we were in good hands,” she said. “He took the time to get to know us and understand my husband’s medical circumstances, as well as my needs,” she added.
“Seniors often need additional support for complex or worsening conditions,” says Ms. Suciu. “We are very fortunate to have experts in geriatric care ready to help and make recommendations for community services.”
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Over in the red zone, a fast-track area, the healthcare team treats straightforward injuries such as cuts, sprains, strains and fractures. Open daily from noon to midnight, this is where Dr. Rauchwerger and orthopedic technologist Alex Carlos are providing a “reduction” for a teen who has dislocated a finger playing basketball. Alex holds his hand still while the doctor treats the affected finger. The teen winces through the process, but declares it feels a lot better once it’s done. A second x-ray confirms all is well.
Alex moves on to a middle-aged man who caught his thumb in the garage door the day before. The patient had hoped the pain and swelling would subside, but the thumb is now blue and throbbing. An x-ray shows a small fracture. The doctor drains some blood to relieve the pressure and then splints the thumb.
“I was surprised to learn it was broken,” commented the patient. “Now that I know, I’m glad I came and had it taken care of. They were fast and reassuring, making me feel like it was worth checking,” he added.
Recently honoured with a ‘Kudos Award,’ for his consistently friendly and professional patient care, Alex was nominated for the award by colleagues, in recognition of his exceptional care and service.
Mr. Carlos’ nomination included a letter of thanks from a grateful mother who appreciated the care her son received in the ED following an injury.
“He was so engaged and understood our concerns. I cannot thank him enough for his role in my son’s care,” the letter reads. “Mackenzie Health served us well…. the medical professionals were competent, compassionate and care about and for (my son).”
At the end of his shift, Dr. Rauchwerger reflects on his day, “we all work together and are focused on providing the best possible care for patients. In the ED, we have made significant changes in recent years to improve the experience for patients and are pleased by the positive response we have received. We know we are making a real difference when patients and families take the time to thank us for providing exemplary care.”
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What our patients and families say:
“The changes that have been made to Mackenzie Health are impressive and we look forward to seeing even more positive changes.”
“Hats off to all of you. Don’t change a thing; you have mastered true customer service in a Hospital environment. Wow!”
“My family and I noticed a huge change since our last visit to your Emergency Department. As soon as you walk in you are greeted properly, staff address you in a nice calm manner and make sure that they look after you and check you until you go to the next step. We were also very pleased with the flow of registration and the volunteers and the staff were really helpful.”
“I love to see the hospital has changed so much. The staff are not only professional, friendly and caring, but you can tell they are there to help.”
“It is great to know that our Emergency Department provides such wonderful and good care to all patients. It means a lot to know you are reliable, caring and compassionate when my family and I need it. Thanks again everyone!”
“Everyone in the emergency department, from the volunteer greeter to the triage nurse, registration personnel, technicians, and medical staff treated us in a professional and caring manner. The doctor was terrific – approachable, personable and very thorough. He went well beyond what we had experienced in the past with Emergency Department doctors. Rather than simply relying on test results that indicated no immediate issues and sending us home, he listened, asked probing questions and arranged for follow-up treatment based on information not immediately obvious in the tests. And, he had a sense of humour. The total visit took only three hours – a very welcome surprise.”
“I would like to express my greatest thanks and appreciation to the doctors who cared for me for their unmatched level of professionalism, care, attention, devotion and, above all, the friendliness displayed during my six hour stay in the Emergency Department. I was suffering from Atrial Fibrillation with a heartbeat rate of 130 or more and needed an immediate electric shock to my heart which was perfectly done with utmost care, precision and a smile. My sincere thanks also go to the entire Emergency Department staff for their determination to have things done so quickly and efficiently.”