A Chatham-only ER plan is being endorsed by the Medical Advisory Committee (MAC) of the Chatham-Kent Health Alliance (CKHA.) The panel of doctors announced during a press conference, held at the Frank and Mary Uniac Auditorium in Chatham on Tuesday, their unanimous support for the hospital’s capital and operating plans.
Concerned about the current public dialogue
Dr. Ranjith Chandrasena, chief of medical staff at CKHA, said at the start of the press conference that the Medical Advisory Committee wanted to provide accurate information and their clinical expertise related to emergency services and related issues of quality and patient safety.
“There have been concerns expressed at the Medical Advisory Committee about patients and families, and also physicians, who had been concerned about things that have been out there in the media, which were not correct,” Chandrasena said.
“After some discussion at the meeting and afterwards, we felt as physician leaders it was very important to us to give the media an opportunity to look at the clinical facts as it relates to the plan that was presented.”
What is emergency medicine?
Dr. Indraneel Ghosh, chief of emergency medicine and the senior medical director of strategy, access and flow, provided a background about what emergency medicine consists of at the CKHA.
“At the end of the day we evaluate, diagnose and treat… this is what most of us know, but the other thing I think people miss out is we have got to coordinate care,” Dr. Ghosh said.
“That means we may take care of the acute issue but we may uncover other chronic issues that have not been paid attention to. We have to make sure you get to the right provider. We may uncover two or three things that need acute treatment and we may need two or three different specialists to take care of them.”
While discussing the agenda for the media conference, Dr. Ghosh said it would be difficult to talk about a lot of the items.
“At one of the conferences that was organized here, the speaker came and spoke about courage,” Dr. Ghosh said.
“He said it comes from the french word… which means to have heart. I urge you all to open your hearts, and I’m going to try and open mine.”
Canadian Triage Acuity Score
Dr. Ghosh said the CKHA, along with all emergency departments in Canada, use the Canadian Triage Acuity Score to determine what level of care is necessary for a particular patient.
“It’s a score of one to five, one being the sickest and five being the least sickest,” he said.
“CTAS 1 & 2 are the smallest segment of the population but demand the highest resource, demand the highest skill and demands above all the radar, not just from physicians, but from nurses and allied health workers. You have to have a radar to see which chest pain is a collapsed lung and which chest pain is a pulled muscle.”
Focusing on the most critical patients, as a team
Willi Kirenko, vice president and chief nursing executive, spoke about how providing emergency services at the CKHA is a team effort.
“The Canadian Nurses Association is an organization that recognizes specialty certification in emergency nursing,” Kirenko said.
“We know that experience drives quality. Having the critical care experience helps to maintain these critical care skills and expertise. The ER team is made up of physicians, nurses, respiratory therapists, others and speciality consultants and paramedics are also members of the team. They make up an important part of the team for caring for these patients. (Paramedics) are trained to provide life saving skills and use their experience to identify certain cues and conditions to arrange for transfer or transport to the most appropriate facility.”
Kirenko said paramedics prepare the patient in a “prehospital way” in order to get the patient to the right facility and the team can be prepared to receive those patients.
Kirenko said an example of this teamwork is evidence through the regional stroke strategy at the CKHA.
“The regional stroke strategy is a coordinated plan to improve care and survival of patients who experience stroke,” she said.
“Our prehospital providers are paramedics… they have specialized skills and training to recognize stroke. Across Ontario, patients with stroke symptoms are brought to the district stroke centre, and for our region that is here at the Chatham campus. The emerge team, made up of nurses, physicians, respiratory therapists, interim medicine specialists, who specialize in stroke, are pre-alerted to the arrival of the patient and they are skilled in delivering the specialty critical care to improve stroke outcomes.
Kirenko added: “This regional strategy is set up to save lives.”
Best care, every patient, every time – where?
Dr. Ghosh said while “the borders are obviously going to be a little fuzzy” the CKHA wants deliver the best care, for every patient, every time to people within the entire catchment area of Chatham-Kent.
“A patient coming in from the Northern region, the south in Blenheim… we want to make sure no matter who you are, no matter when you access our system, you’re getting the best care every time, and that is reproducible from A, to B to C,” he said.
“Our focus is on the critical patients. The patients that if we don’t intervene in a timely fashion, if we don’t have a multi-disciplinary team, if we don’t have specialized backup, if we don’t have the volume to sustain and maintain our skills, a bad event and outcome could happen.
Dr. Ghosh added: “We want to focus on these patients and we want to make sure that these patients, no matter where they live in Chatham-Kent, get the same access to services.”
Safety, quality, access
Dr. Ghosh said the CKHA is following two fundamental principles when driving change.
“One is volume drives quality… we know that,” he said.
“When we did our residency training often times in your first year, second year training you do locations that are not in your speciality… why does an emerg doctor go to anesthesia, why does an emerge doctor need to go to ICU… it’s because we need the skills and the training. We need a critical number in order to obtain the skills. It doesn’t apply just to physicians, it applies to nurses, it applies to our multi-disciplinary team.”
Dr. Ghosh said back-up specialized care is the other important driving principle for change.
“If I have a really sick kid that I am resuscitating and I have a pediatrician in-house, I am going to call the pediatrician. If I have a pediatrician on-call, I’m going to call the pediatrician. Part of our training tells us and in fact candidates will fail exams in emergency medicine… if you don’t call for backup early, you will fail the station,” he said.
“It’s in our DNA when you do emergency medicine that you have to have backup. Not that you need it, but if they are critical patients, you need backup.”
CTAS breakdown in Wallaceburg and Chatham
Dr. Ghosh said the vast majority of people coming into the CKHA emergency rooms, are not critical patients.
“If you look at CTAS 1 & 2 (at the Chatham Campus) you can see 1 is small, which not unusual, 2 is fairly big,” he said.
“When you look at Sydenham, in terms of proportion 1 is fairly small and 2 is pretty big, not as big.. a smaller percentage, but a smaller percentage of a smaller total number.”
Dr. Ghosh added: “It’s important to remember, the vast majority of people at both campuses are not critically ill patients. The vast majority arriving to Sydenham are not critical patients and can be served quite adequately with non-critical interventions. We’re focusing on how do we create a system that helps these people.”
Emergency critical patients per month
Calling this “important data”, Dr. Ghosh said it is important to talk about the skills, expertise and training when discussing volume driving quality:
– In Chatham about 38.5 people need to be resuscitated (life saving measure performed) per month, while it is 11 per month approximately at the Sydenham Campus.
– In Chatham about 7.3 intubations (putting an airway in to help patients breathe) are performed per month, while 1.6 take place per month at Sydenham Campus.
– In Chatham about 4 TNK administrations (medicine given to severe heart attack patients) per month are done while 0.6 a month are done at Sydenham Campus.
“If you beleive volume is quality, and I certainly do, these numbers tell a story,” Dr. Ghosh said.
“To personalize it, if it is your family member who is critically ill, do you want to go to a place that does 40 resuscitations a month, or 11? Do you want to go to a place that intubates 7.5 a month, or 1.5? The cost is an extra 25 minutes drive. It’s important to think about this from the context of best care, every patient, every time.”
Triage to balloon time
Dr. Ghosh said in October of 2015 Windsor Regional hospital changed their cardiac catheterization lab to a 24/7 operation, and thus became the CKHA’s primary cath site for severe heart attack patients.
“With each minute that is ticking that we’re not restoring blood flow, the heart muscle cells start dying,” Dr. Ghosh said.
“As each heart muscle cell dies, the heart function starts decreasing. Time is incredibly important.”
Referring to “preliminary data” from October to December of 2015, Dr. Ghosh said from the time a patient saw the triage nurse, to the time a balloon is inserted at the cath lab in Windsor – it took 162 minutes on average when coming from the Chatham campus, compared to 370 minutes from the Sydenham Campus.
“When looking at more current data, from October to now these numbers are still the same,” Dr. Ghosh said.
“There is a big difference between patients seen in Chatham and patients seen in Wallaceburg.”
Dr. Quoc Tran, chief of internal medicine at the CKHA, said time is very important in trying to save the heart muscle.
“If somebody has a heart attack the time before the heart starts to damage is about 30 minutes from the start of the sequence or the chest pain,” Dr. Tran said.
“The longer we wait, the more heart damage. The heart may be so damaged that you don’t have a good pump to continue to function as normal. So the difference between 30 minutes to an hour can be the difference between somebody carrying on with their normal activities or someone that will walk half a block and have shortness of breath.
Dr. Tran said the time delay from Sydenham is due to “many, many factors.
“We do not have enough equipment there now… many times a chest pain coming in it can be from a heart attack, it can be from a blood clot, or it can be from a rupture of the vessel. It takes time to figure it out,” he said.
Dr. Tran added: “If I had a heart attack, where would I like to go? Even if I am in Wallaceburg, I’d probably prefer to go to Chatham… for the time savings and the chance of having minimal damage.”
Change and consolidation is needed
Dr. Ghosh said the Medical Advisory Committee advocates for their patients and also for the community at large.
“Emergency medicine is very different today than it was 10 years ago and it is going to be very different 10 years from now,” he said.
“Often times change is forced upon us from other things that we can’t control. Wouldn’t it be nice if some of us were proactive enough and we change the system for the better so our patients 10 years from now are reaping the benefits. We have a chance to make a change.”
Dr. Ghosh said none of the committee members would be requesting or proposing the change if they didn’t feel that more patients lives were going to be saved, patients outcomes were going to be better and patients would have better and improved access to care.
“At the end of the day this clinician agreement by consolidating all of our critically ill patients at one site, the best site, whatever that site might be, where we can house all of our resources and be able to treat these patients in a timely, expedited fashion would be the best care for our patients,” he said.
Chatham-only ER model
Dr. Elizabeth Haddad, chief of surgery and the senior medical director for performance and utilizations, said it is the mandate as physicians to provide the best quality of care for Chatham-Kent.
“Not for Chatham, not for Wallaceburg, not for Walpole, not for Blenheim, not for Tilbury not for anybody even for out-of-country or out-of-province… for this is for Chatham-Kent, but really it is for every patient and every person that comes,” she said.
“I think that is extremely important. This was unanimously carried by all of the physicians at MAC. All of these physicians encompass almost every area of specialty for this hospital and for this community. That is our mandate, not what we like to do, this is what we do for all of you.”
Here is a link to the full powerpoint presentation shown by the MAC on Tuesday afternoon: FULL PRESENTATION
– Sydenham Current featured photo
– Graphics/powerpoint slides provided by the Chatham-Kent Health Alliance