Sherman's Proof (Batch 2)

o SAH in Dawson Creek BC accepted by neurosurgery despite no ICU beds in region.
Took
> 30 minutess of prolonged discussion to divert patient to Vancouver. Consultants
WITHIN UAH completely unaware of how unsafe and overcrowded the ED was.
o Female with query appendicitis accepted at 2200 by General surgery from Edson
without informing anyone in ED, and despite the fact that the patient was completely
stable and likely needed an ultrasound that couldn't be obtained untilthe next morning
- Patient with severe back pain reg at 1322, moved to bed at 1900 for analgesia and assessment.
- Patient with a DW and severe leg pain, > 6hrs to get a bed for analgesia, assessment and
treatment. When finally in a bed the patient was crying and screaming at all health care
providers in frustration of prolonged wait in pain without care.
- Multiple CP patients with prolonged waits for ECG and bed:
o 63yo with CP reg at 14i-0, no bed until 1843
o 69yo with CP reg at 1-701-, no bed to even do an ecg until 2000
- 38yo patient with DKA - Na L18, K=5.7, ++ dehydrated. No acute monitored bed to treat patient
for prolonged period.
- Young female 20 weeks pregnant with contractions and abdominal pain. Was going to leave
without being seen due to prolonged wait. Manual pelvic exam done in triage assessment area
(not considered a private area) at patients request to check cervix and risk of premature delivery
- Known free air under diaphragm and perforation from family docs office, presented at 1615, no
bed for analagesia, assessment and treatment until 1800.
- Patient with RLQ pain registered at1,927, diagnosed with an acute appendicitis in the WR at
2230, straight to the OR from the WR. NEVER got into a proper care area for analgesia or
treatment.
- 23yo female with upper Gl bleed and hematemasis, arrived with EMS at2207, still no bed at
midnight.
- 38yo M with new onset tachycardia arrived at 2245 with heart rate of 150. Still no care space for
assessment or treatment at 0015.
- 26 ElPs, 8 definite to be admitted and > 25 in WR at midnight.
o 22yo male with new onset seizure registered at 1733, admitted by neurology in the WR,
still no bed at 0030.
o Patient with a liver transplant, presented with hypertension and headache at 1818, still
no bed at 0030.
- Midnight shift, 30 ElPs,5 definitive admissions pending, and greaterthan 10 "hold overnights".
Some examples of prolonged delays in decision making due to consultation or radiology:
o Reg at 2139, requiring non-emergent ultrasound which is unattainable at night, still
awaiting ultrasound at 0930.
o Patient registered at 2738 with signs and symptoms of possible cauda equina, informed
MRI not available at night, hold untilAM for MRl.
o Patient with abdominal pain and Gl consulted at2200, Gl staff had still not seen to make
a disoosition decision at 0930 the next dav.
Patientwith a Hipfracture registered at L1.38, no analgesia ortreatment until in a bed at L751.
Patient with urinary retention registered at 7229, still not in bed at 1730.
Patient with acute appendicitis - registered at 1541, work-up all done in WR. CT at 2100 from
WR. Still no bed for analgesia or treatment when admitted in WR at2200.
Elderly patient with a pneumonia, WBC of 28.9, Troponin of 0.2'1., and Glucose of 1.9 registered
atl7O4, not in ED care bed until 2200. Hypoglycemia was missed and not treated by the triage
doctor and nurses as there were >40 other patients in the WR and the environment was
completely out of control and unsafe.
Patient with an acute appendicitis registered at 1534 and went to OR from WR. General surgery
staff was upset because the patient had no orders or antibiotics prior to getting to the OR, but
the patient was never in an ED care area at any point - the patient's care was as optimal as
possible due to the overwhelming overcrowding.
No beds in ED, and multiple consultants still accepting patients from out of region despite
protests by staff:
ED
o Stable patient sent for
CT to rule out PE, never made it to a care space.
o PTtransferred from Ft McMurray for plasma exchange despite no beds in hospital/ED.
Patient presented tachy at 136 and SBP of 69. Reg at 1656, no acute care beds for assessment
and treatment until 1732. Found to have a leaking AAA.
28yo with depression and suicidal, victim of spousal abuse, waited > 5hrs and then attempted to
leave without being seen, persuaded by TLP to await formal assessment.
Patient with hypokalemia of 2.8 waited >2hrs for a bed for assessment and treatment
2 patients with Febrile Neutropenia (+++ High riskfor infections, requiring isolation) in WR for
prolonged waits.
Patientfrom Fort McMurray with cardiaccontusion accepted directto Cardiology, in ED > 48hrs
with no admission or service taking responsibility for the patient's care. Never actually admitted
to any service, so never counted as an ElP, or a blocked bed. Multiple hand-overs to numerous
emergency physicians with no reasonable continuity of care for entire stay.
Two different patients with small bowel obstructions who were in ED > 48hrs without admission
orders by general surgery. (Both patients were clear SBO's, requiring NG tubes and lV fluids.)
Due to severe overcrowding two intentional overdoses left the WR without being seen. That
night there were > tO% of registered patients who left without being seen (LWBS). Meanwhile
multiple services continued to accept direct without notifying anyone in the ED - ENT and
Neurosurgery were exa mples.
36yo male with Malignant hypertension (2201150), registered at 1230, asked to leave without
beingseeing numerous times, ultimatelyfound to have a troponin of 0.4! and a creatinine of
199. No bed available until 1510 for treatment of his hypertensive emergency. Patient would
have left without treatment if the TLP hadn't persuaded him to stay - this patient had clear
evidence of end organ failure and without treatment would have been at significant risk of
imminent myocardial infarction, stroke, or renal failure as examples.
Only 15 ElPs - we actually had flow and the department almost worked like a real ED.
- BAD - 22 ElPs, 10 awaiting to be admitted, absolutely no flow, > 40 patients in WR
o Patient with dehydration and a sodium of 72O, reg at 2105, no bed until 0230.
- 32 EIPS, only 1 available patient care space. Absolutely no movement. Executive on call
contacted who was unable to provide any relief.
o Patient in Hinton with an aortic dissection - NO beds in entire region to accept the
patient.
o Patient with K of 6.5 in WR for prolonged time with NO bed for assessment/treatment.
- 25 ElPs with 5 more definite to be admitted, numerous with prolonged workups and no
movement pending. Discussed with multiple executives on call with no impact. The operating
rooms went on with full slate of scheduled surgeries despite no discharges pending and the ED
being completely non-functional due to overcrowding.
o Meanwhile a patient was in CHEMS HALLWAY with absolutely no privacy, urinating in
full public view.
- Patient with an acute cholecystitis transferred from Drayton Valley, arrived at 1043, no bed until
1600. >5hs in ED WR with 10/10 severe RUQ pain with no analgesia, assessment or treatment.
Hotmail Windows Live Page 1 of3
trc,
To: Deb.Gsrdcn@capitaihealtlr.ce,
D!,la n.Tayl * rQ ca p it-r I hee ltlr.ca,
Biii.Johnston@capitalhealth.ca
Date: Thursday, October 9, 2AAB,2:09:35 PM
Subjecr: Follow-up on: Patient Relations Prisnr #
TXXXXX
= c ri g i n a I messa g e
i;,11'=== ;====;= ;==-
Dear Debbie Gordon, Dylan Taylor and Bill Johnston,
I am sending this email with the hopes of getting an

official reply on
the matter of adverse outcomes due to systemic
overcrowdino.
i have broached this topic in a number of emails,

and in person to
yourselves at the GEMS meeting in August - I've
inclr,rded the initial
patient complaint, and the previous emails beiow to
refresh memories
aS neod lro - :nr{ h:rra rraf tO haVe a fespgnse.
As you are all well aware, system overcrowding has

comprornised the
delivery of care within the UAH ED to the point
where prolonged waits,
prolonged delays in definitive standard of care, and
sign ifica nt
sub-optimal outcomes are the norm and not the
exception.
Due to sevefe systemic overcrowding, we are at the

point where we
routinely CANNOT meet any of the Canadian
Emergency Medicine Standards
or Recommended Guidelines for emergency care to
patients presenting to
the UAH ED. The data that the region coliects daily
clearly elucidates
how compromised care delivery is within the region,
and it must be
emphasized that tlris is not an alarmist opinion, but
a statement of
fact.
http://snl06w.snt106.mail.live.com/mail/Inboxlight.aspx?n:1798802884 06/03/2011
Hotmail Windows Live Page 2 of 3
Patients arrive at the UAH ED expecting a level ot

care that is
currently impossible to deliver.
I am fully aware of the extraordinary efforts that are

underway to
address this crisis irr access to acute heaith care, and
I have
personally volunteered my time to assist in whatever
small way I might
be useful. We are ali aware that the "fix" will be years
in the
making.
While changes are instituted to address this system

wide
issue, what is being done to protect emergency
health care providers
who are routinely forced to provide sub-standard
levels of care? (We
have been operating in a mode of "some care is
better than no care"
for far too long.)
Specifically:
- Is there a formal process for senior executive to be
involved in
complaints that are clearly related to system
overcrowding issues?
- Is the forrral policy for disclosure of adverse events
being
reassessed to account for systemic overcrowding
issues? Is it really
fair or appropriate to have individual ERF's
addressing systemic
overcrowding issues based soiely on drawing the
short straw of being
on shift when tlre place is out of control?
(UrTfortunately, the ED is
nearly ALWAYS out of control lately.)
- What are the medical legal ranrifications for myself
and my
colleagues in regards to cdntinued practice in an
unsafe and
dangerously cvercrowded ED?
- What is Capital Health doing to actively publicly
disclose how
overcrowded and unsafe our ED's are?
This complaint was lodged against myself on July

10th, and as oftoday
(October gth, 2008), I have not had a response to my

ouestions. and
http:i/snl06w.sntl06.mail.live.com/mail/Inboxlight.aspx?n:1798802884 06/03120r1
Hotmail Windows Live Page 3 of3
,titl huuu no idea as to how this complaint was dealt

with. Given the
current lack of functioning in the UAH ED, it strikes
rne as truly
remarkable that I do not have hundred's of similar
patient complaints
pendirrg against myself - all directly related io the
untenable system
overcrowding impairing my ability to deliver timely
i would really appreciate your response to these

questions, and your
assistance with this urgent matter.
Tlrank you for your time.
http://sn106w.snt106.mail.live.com/mail/Inboxlight.aspx?n:1798802884 06t$Darl
Message body Page 1 of2
Il
007 - I think I may have stopped sending cc's to the Minister at this point as I was receiving NO replies from
them..
To: "Gordon, Deb" <Deb.Gordon@capitalhealth.ca>

Date: Thursday, October 9, 2008, I2:4L:34 PM
Subject: UAH/Stollery System Overcrowding WorkPlan
== =$4 ============ - -Original meSSage tgxt- - - - - = = = = = = =.= = =

Hello Debbie,
Thank you very much for the feedback from the System Overcrowding
meeting' I know that Dr' llhut submitted some suggestions and
comments, and I wanted to take the time to raise my concern regarding
one component of the Workplan: Public Communication'
Public communication is listed as a long term goal (with no definitive

time-line), and as High Difficulty/Low Urgency. This piece of the
solution needs to be the most urgent and highest priority portion of
the solution.
We are working in a system that is severely overcrowded to the point

of non-functioning, and unfortunately we cannot provide a modicum of
standard of care to the majority of patients who present to our
emergency depaftment. The emergency medicine health care providers on
the front line are doing the absolute best they can, but unfoftunately
they are routinely faced with being unable to provide timely analgesia,
antibiotics, interventions, or even a place for our patients in need
to lie down. (This inability to provide care is the norm, NOT the
exception.)
The university of Alberta Hospital (and in extension Alberta Health

Services) has a fiduciary duty to inform the public that our ability
to care for them is compromised, and that the standard of care they
have grown to expect is not currently available.
In order to allow the health care providers to continue to function

while the workPlan is implemented, we absolutely must educate the
public that health care delivery in the ED is NoT what it used to be:
- waits for assessment, analgesia, and care will often be greater than
6 hours. Everything will be done to treat them as expeditiously as
possible, but patients are treated according to need rather than
presentation time.
- they may get their full care delivered in the waiting room (TLP)
- they may be off-loaded to hallways and non-standard waiting areas
(CHEMS), and their full care may be delivered there
- they may have their entire hospital admission and care occur in the
ED (EIPs staying in the ED for >48hrs)
- they may need to be discharged to be cared for at home' or
alternative caring facilities, sooner then they would have in the
past.
The message needs to be: System overcrowding is impairing the deliver

of acute care, We are urgently working to address this critical issue.
In the meantime, please be patient and understand that the health care
prwiders are doing their absolute best to help you in your time of
http:llsnl06w.sntl06.mail.iive.com/mail/RteFrame.html?v:1 5.4.3079.0223&pt:pf 06103120r1

. Message body Page2 of2
need.
In the emergency depaftment, we are being held to a standard of care

that is undeliverable in the current health care system. Continued
work in an environment where these impossible patienflconsultant
expectations exist is unsustainable.
t,
"K We have been pleading for public education for over ten months now.
Delivery continues to degrade, system overcrowding continues to
worsen. The public must be informed as to the current state of affairs
regarding the lack of timely access to acute health care. What can we
as emergenqy physicians do to assist in the deliver of this essential
education immediately?
http:llsnl06w.snt106.mail.live.com/mail/RteFrame.html?v:|5.4.3079.0223epFpf 06103/2011
' Hotmail Windows Live Page I of2
IL
To: paddy.meade@ hhas.ca, chris.eaSlE(i:)c*lSa ry$reallhre$ion.ca,

De b.Go rcl o n S ca p iti: hea ltlr.ca
I
Date: Friday, November 7,2AA8,11:53:37 AM

Su bject: Corn pletely non-fu nctio na I emergency depa rtment
== =$( = == === == ===== =Qyigi66l meSSage

text===============
Dear Paddy, Chris, and Debbie,
I am writing to follow up on the ongoing crisis in Emergency

Medicine
care in Alberta, nrost specifically at the University of Alberla
Hospital.
I know that we will be meeting again on November 14th, bLrt I

thought
it might be useful to share with your how horrendously
overcrowded the
night shift I just came off was.
I started my shift at 0000 on Nov 7th to 34 EIPS in the ED, r,vith

another 8 definite admissions pending. I spent tlre vast majority of
my
shift doing non-clinical damage control - discussing the situation
with the bed coordinator and executives on call, cajoling services
into admitting sick patients that obviously needed their care, and
taking critical care calls for patients in the periphery for whom I
could not safely accept their transfer.
Despite all efforts by the bed coordinator and executive

administrators on call, arrd despite some creative movement of a
few
admitted EIPs out of the ED (we even metastasized and held some
EIPs
in the Peds ED), at 0900 when I left my shift there were
37 EIPs, 4 more patients who were definitely going to require
admission, and very little expectation that future in-patient beds
were imminent, (There are only 42 stretcher areas in our ED,47 if
you
count our five "fast track" beds that do not contain monitors and
were expressly created for low acuity, non-admitted patients,) 41
out
of 42 emergency beds blocked is deplorabie and utteriy unsafe.
The only reason the waiting room decanted is because people

tired of
the extraordinary waits, and sirnply left withoui beir,g seen
http://sni 06w.sntl06.mail.live.com/mall/Inboxlight.aspx?n:1798802884 06/03/2011

Hotmail - Windows Live Page 2 ofZ
(LWBS).
There were 29 patients (out of 211- who presented) that LWBS,
which
amounts to a staggering 14o/o of the patients presenting to our
ED. One
of the first patients that did finally receive an ED bed was a 70 year
old male who waited in the waiting room over 10 hours with a
large
bowel obstruction.
In regards to our ED's ability to deliver timely acute emergency

ca re,
the shift can only be described as an unmitigated disaster.
If multiple
severely ill patients had arrived iri the night - as is a
frequent occasion at our ED - we r,vould have been completely
unable to
provide them wiih care or to intervene on their behalf.
Considering ihe UAH is held to be one of the prenriere tertiary

LCtC
emergency departments within Canada, our ability to deliver

tirnely
care was so impaired as to be essentially nonexistent.
Urrfortunately last night was not a freak one time occurrence.

Since
our meeting, and despite all of the shoft term crisis initiatives that
have been implemerrted, the region's data show that the
overcrowding is
steadily worsening.
I sincerely hope that this email is received as the plea for

immediate
lasting assistance as it is intended to be. if the overcrowding crisis
is allolryed to continue unabated, preventable deaths will occr:r.
I anxiously await your ihoughts and reply.
htto://snl06w.snt106.mail.live.com/maililnboxl-isht.aspx?n:1798802884 061031201r
' Message body Page 1 of2
r<
010... not sure if I could have been more pleading in this case... read my last paragraph, i'm begging for help.
To: "Gordon, Deb" < Deb.Gordon @ca pital health.ca >, Dylan.Taylor@capita lhealth.ca
Date: Thursday, January 15, 2009, 3:06:01 AM
Subject: Follow-up regarding prolonged delays in admission due to GIM Overcapacity
= = =$4 = = = = = = = = = = = - - -Ofiginal meSSage teXt- - - - - = = = = = = = = = =

Regarding the prolonged delay in admission for
PT HN:)CC0)C(rc(nCX (the B4yo female who couldn't ambulate independently,
and who GIM refused to admit as well as assist in attaining a
disposition yesterday)
Unfoftunately the patient still had no admission at 1930 tonight, and
as TLP I had to become involved to try to procure an admitting
service. This was despite the executive on call being involved last
night, and assuring the emergency doctor that they would personally
arrange for a service to admit first thing in the morning.
I will provide all specifics below, but would like to stress that this
is only a prime example of the ongoing disposition issues occurring at
the UAH in light of the ongoing critically unsafe systemic overcrowding.
- The patient was brought in by EMS and registered at @ 0901 Jan 13th
- The patient went to a CHEMS bed @ 1026 (This is a hallway area
without privary, and is merely an extension of the waiting room,)
- Due to systemic overcrowding, specifically the housing of admitted
inpatients within emergency department care spaces, the patient
languished in the hallway bed until an F-POD bed was available at
2048.
- This deserves repeating: the patient did not get to an ED care
space for almost 12 hours. unfoftunately this is routine for our
center, despite all efforts to mitigate the ongoing crisis of systemic
overcrowding,
- the TLP discussed the case with Internal medicine staff sometime
around 2700-2200 when it was clear the patient couldn't ambulate and
care for herself. Family medicine was already over census, and had
already indicated they could not accept anymore admissions. The ONLY
service available for this patient - as per our admission protocol, and
current ooeratino realities - was internal lvledicine. But Dr. J-
refused ro acjmit, anci also reiuseci to suggest another apprEfimf-
service.
- Tne patient was seen by tne rotationai dury ED oocior lorJ
2225, after the TLP had already attempted to procure an admittihQ
service for the patient.
- at -2330 all three emergency doctors within our department were
involved with an extremely difficult intubation in A-pod, and it
wasn't until 0015 that Dr.],ould again address the fact that
there was no service to admlt the patiepl
- a 0100 call with th" ;"* ;;;i,6;:, and Dr.Jroved
completely unhelpful, and it was left that the executive on call would
personally arrange for an admitting service at 0800 the next morning.
- at 1000. there was still no assistance from administration, so
geriatrics were consulted. The emergency physician at the time had no
idea what else to do - the system had completely failed the patient
thus far.
5iT'i:" i 1 i:*1 l{i",'l y1' "': ?r i:l'l:i-"i?: 11"1:, ! ! --

11 1 - -
http://sn106w.sntl06.mail.live.com/mail/RteFrarne.html?v:15.4.3079.0223&pf:pf 0610312011
Message body PageZ of2
service - she was a placement issue - but suggested the patient get an
urgent MRI (which was req'd at 1145, but was slotted for sometime
TOMORROW afternoon).
- at 1900, upon hand-over to a fifth DIFFERENT emergency physician, it
became clear that no one was adequately caring for this patient, and
that a disposition was not being actively worked on. A conference call
with the executive on call resulted in GIM agreeing to admit the
patient as they were again "open for business".
- the patient was admitted by GIM at 2255 Jan 14th.
This all occurred in the background of -30 EIPS, and > 30 patients in
the waiting room all day long. Waits to get to an ED bed were
routinely greater than 12 hours, and the waiting room only decanted
because patients left without being seen.
It is impossible to provide timely emergent care in the current

environment, and has been for over a year. I applaud my general
internal medicine colleagues attempts to provide safe and timely care
to the admitted patients who manage to be admitted to the hospital,
but would strongly suggest that sporadic capping and non-consistent
admission policies only harm their undifferentiated future
patients-to-be desperately seeking medical attention at our institute,
Wouldn't it make more sense for GIM to admit ALL consults requiring
admission and then have senior physicians decant to other services at
0800 the next morning? I eagerly await guidance regarding a reasonable
consistent poliry to procure admission in our ongoing completely
dysfunctional work environment.
I've taken the time to document this case to plead with CH

administration for assistance, as I have on numerous occasions over
the past year. Due to overwhelming systemic overcrowding, Edmontonians
have NO reasonable expectation to timely acute medical care.
http://snl06w.snt106.mail.live.com/mail/RteFrame.html?v:15.4.3079.0223&pFpf 06103t20rr
' Hotmail - rajsherman@hotmail.com - Windows Live Page 1 of 1
I4
To: Paddy M eade < pad$St.mtecjel$ai l::efi n he*lthservic*s.tc >,

Chris Eagle < chris.es$lc($cal$cryl':e*lthr*$ion.ca >, "Gordon,
Deb" < Deb.GnrdonSc*r.:italh*;rl th.c:r >
Date:Thursday, Janr-rary 15, 2009, 3:36:58 AM
Subject: Follow-up regarding ongoing horrendous systemic
overcrowding.
m6...
---0\
--*at ---=:===uflglnal
----*nriînat message
text---=======:====
Dear Paddy, Chris, and Debbie,
i m writing again to plea for some immediate assistance regarding

our
daily inability to provide timely standard of care to patients
presenting to major urban emergency deparlments in Alberta.
Our ED's continue to remain dangerously overcrowded wiih

admitted
patients, our waiting rooms are standing room only, and extensive
delays and sub-optimal outcomes are still the norm.
At the University Hospital general internal medicine has begun

capping their admissions, we still do not have an admission
protocol
that is consistent, capacity is overwhelmed, no single point of
enily
exists, and most systemic overcrowding implementations remain
reactive
and temporizing. More than half of our city's ED capacity
continues
to function solely to house EIPs.
If there is no mitigating the crisis, tlren at the least we must be

frank with our public and inform them that we cannot provide the
level
of care they have grown to expect and demand. They come to our
ED's
sick, in pain, and in need of timely medical care, and we rcutinely
failthem. *
---
I anxiously await your reply.
http://sn1 06w. snt 1 06.maii. live.com/mail/Inboxl.ight.aspx?n:640 47 403 0 06t03t20r1

Hotmail - Windows Live Page 1 of3
,\el
tl
FW: Urgent Care Centres
Raj Sherman 27 /1I/20A1

Tt: 5r0rics i'.,:irni;i Rsply
l attachment (8.8 MB) Hotmail Ariiv* \ciei+

20741Ove...pdf
Dorr,:rrioi:ci(8.8 M B)
Download as zip
Spence,
I have to agree with nrany of the comments beiow.
Acute care nurses are leaving the acute care system"..for what is
probably the most expensive Medicenter Care possi[:le. We
already have Urgent Care Centres within the ED's...tlrey are called
the "fast track" side of the FD. Unfortunately the fast tracks are
plugged with admitted patients.
This is your bcss...l w.o.uld have to disagree with this approach at

llljs time with the current state of affairs. As I have always
reiterated...lots of new exoensive buildincs...creatino lots of new
and easv iobs...at a time of staffirra shor-taoes, where do vou think
that the health care --
..-_--i--#
providers are gcing to go?.....to the easy new
iob that offers the same benefits.
Is it any wonder that the iCU's and CCU's and the emergerrcy
departments cannot staff their beds. Does Dave know that tl-rese
becls are closino?
As I have said before, it's only a matter of time that an

"unfofturrate" i@aitinq room or EMS
sneTafier.:fino.-oau-ill have to answer for it.
Do what ever you think is best with this e-mail.
R.
Raj,
http ://sn 1 06w.snt 1 06.mail. live. com/mail/Inboxl,ight. aspx? n:28226619 06/03/20rr

Hotmail -ffi - windows Live Page2 of3
?7??? got a copy of this and forwarded it to me. This

was drafted by a comrnittee ??T? ???? was on but
they kicked him off because he disagreed with much
of what they were trying to do. I find it interesting
that the 3 cases thai are described as the type of
case appropriate for Urgent Care Clinics, at least 2 of
them may not be ideal even for the NEHC wnere you
are fully staffed with EPs (the seizing peds kid and
the trauma). The young woman with the flu may be
okay for an UCC.
The advanced ambulatory care centers are just walk-
in clinics (the worst abuse of health care dollars the
province expends [no accountability for F/\-) care, no
after hours care responsibilities, etc.l). This money
and support should go towards promoting the
Primary Care networks to provide after hours care,
not walk-in clinics.
Does this group understand that at the UAH our
urgent patients (CTAS level 3) have a26a/o admission
rate and the average length of stay for evaluation
and treatment is about 6 hours.Is that the kind of
capacity they plan for these urgent care clinics?
If this process moves forward and the EDs remain
blocked and 20-30 of our patients leave every day
without being seen, there will be no way to staff the
EDs adequately with EPs. We will all need to work in
the UCCs and it is hard to know who will provide the
ED coverage when in fact there is momentary flow
and multiple patients need to be seen by the one Ep
left orr duty,
I smell the power-ful lobby of private for profit
businesses at work here (they will be controlling
these advanced anrbulatory care and UCC clinics)
and just like the private operating establishments
will skim of the simple, stable patients and refer all
the complicated ones to hospital, while the hospitals
give up and collapse. Is Dave aware of the
slrortcomings of this kind of approach?
Anonynrous
hnp ://sn 1 06w.snt I 06.mail. live. com/mail/Inboxlight. aspx?n:2 82 266r g 06/a3/201r

Hotmail Page 1 of3
-Windowslive
Mike,
Thanks you forthe copy of the report. The section will be meetnig
tomorrow evening to formulate a reply.l hope that Minister
Hancock was able to attend the meetino on Fridav.
Cheers.
Raj
Sub.ject: HQCA -- R.eview of Emergency and Urgent

Care Services in the Calgary Health Region
li;offi'n
CC: S MT@ albertadoctors.org
;'";,#i,:Hg?.ffi;'n
The Health Quality Council of Ali:erta (HQCA) today
released the report cited irr the subject lirre. The
report is attached below:
(See attached file: HQCA CHR ED Review

Repa rt_F I N A L V ER S fi N.pdf1
We have not yet had an opportunity to discuss this

with the Section of Fmergerrcy Medicine, but hope
to do so in the next ccuple o{ days. This may be
done at RF depending on the availability of those
attending. The President of the section has been
included in this email.
We have not yet been asked to comment by the

media. Some very prelinrinary thor"rghts from staff
follow:
There is much in the report that can be supported. Itt

particular, we agree witir the approach taken by the
HQCA cf contrasting Calgary Health Region (CHR)
processes and practices wjth nationai and
international best practice. In many areas the report
encourages the continuation of tvork that the CHR
has already started, which should provide some
comfoft to Calgarians that some right steps are
beins taken.
http / / snIO6w. snt 1 06.mail. live.com/mail/Inboxl-ight.

: a spx? 1282266 19 06/03/2011
HotmailS-windowsLive Page 2 of3
Having said that, the AMA has comnrents on four

broad issues raised in the report.
l-. fresource Shortages:The report focuses on

making the best use of available fesources. While we
agree with this, we would highlight another point
mentioned in the report of the many problems
caused by resource shortages.In particular, it is
critical for the provincial government to significantiy
address the shortages of physicians and other health
care providers. The deficits in facilities also needs to
be addressed.
2. Accountsbility :In specific reference to

physicians and the CHR, the report's fourth
recommendaticn calls for tlre effective alignment of,
"incentives, performance and accountabiiity". While
appreciating the basic point, it should also be
mentioned that physiciarls are accountable on a
number of levels -- not just to the system per se, but
to tlreir patients and to their profession. It essential
that the patient.physician relationship, which
requires the physieian to always acting in the
interest of the patient, remain a cornerstone of the
health care system.
3. Change Leaders: The report nrakes reference to

the use of change leaders -- to lead the way to more
effective and efficient health care. We agree with this
and suggest that the most imporlant change leaders
to consider are the providers who deliver the care.
Much can be learned by listening and acting on the
recommendations of health professionals. In this
regard, it shouid be noted that one of the
innovations lauded in the report, PCNs. was initially
proposed and advanced by the AMA Representative
Forum, subseqr-tently negotiated with regions and
government, and then implemented through the
joint activity of local regions and physicians. Another
innovation in Alberta, often cited elsewhere as
ieading the way, is the Hip and Knee Project. Again,
this was spearheaded and lead by physicians. There
are many such opportunities for grass roots
initiatives in Alberta.
4. Patient Respansibility and Support: The report

does make any recommendations related to patient
responsibility. Albertans need to be supported in
making the right decisions about their access. When,
for example, is it appropriate to access the newly
minted Urgent Care Centers versus hospital
elnergency departments^
http //sn i 0 6w. snt

: 1 0 6. mai l. live. c orn/ mail/Inb oxl- i ght. a spx? n:2822 6 619 06/03/2011
Hotmail Page 3 of3
Just some initial thoughts.
Mike
-windowslive Michael Gormley

Executive Directcr
Aiberta Medical Association
albertadoctors.org
www.a beft adoctors.o rq
I
http ://sn 1 06w. snt 1 06.mail. live. c orn/matIllnboxl.i ght. aspx?n:282 26619 0610312011
Windows Live Page I ot I
Emergency Issues
Raj Sherman 21/12/2047

T* D*vs liencock, Fred Horne, lJ*il V/ilkinsc R*ply '
L attachment (73.0 KB) Hotmail Active Vielv

Edmonton ...doc
View onlin*
Downloaci(73.0 KB)
l..}nrarnln:r{ r< zin
Dave/Fred/Neil,
Here is my presentation to Sheila, Ken Gardener, Susan Mummy,

and Michelle Lahey regarding the state of affairs in Capital
Health's emergency departments.
I wish you and your families the Merriest Christmas and a Happy
New Year!
God Bless.
Raj
http ://sn 1 06w. snt I 06.mail.live. c ornlmail/Inboxlight.aspx?n:2822661 9 06103/2011

Thank vou. . ...Introductions
I'd like to thank everyone for participating today.
We have met over the past year on a number of occasions to

work on improving the emergency services for the community
that we all serve. Together we achieved a few successes that
have been notable.
We have approximately 200 emergency beds that service

Edmonton and Northern Alberta. Of those, last year we had at
times 100-150 plugged up with admitted patients...thus
operating the emergency departments with 50-100 beds. We
presented cases of bad outcome and near misses that occurred
in the ED's under these conditions and..... you took action.
With the implementation of the FCP, Capital Health reduced

the time that patients had to wait in the ED for care as well as
EMS red alerts. In fact, the emergency physicians had to add
shifts in order to keep up with the increased ability to treat
patients.
The implementation of the TLP had helped to reduce the

number of patients that left without treatment (LWOT) and
helped to identify ill patients in the waiting room that were
missed by the triage nurse.
I had the privilege to acknowledge Capital Health's successes

at a wait times conference in Vancouver as a success in the
Canadian Health Care system.
Due the Summer bed closures, we lost many of the gains that
were made. In a way this has been a success in that we have
made do with less by improving our efficiency.
Edmonton now faces a few challenges as our population has
grown by 36,000 over the past year. In addition we are serving
more people from Northern Alberta. Patients that present to
the ED's are sicker and their care is more complicated. We are
in DIRE need of more emergency beds to treat the untreated
and undifferentiated patients that present for care.
We have these beds, they are just plugged up by patients who

should be treated upstairs after their admission.
Earlier this year, across the province, we asked our colleagues

to document cases of bad outcomes and near misses and to pass
them on to administration for quality control and safety
purposes and to pass them on to us to keep us in the loop.
In Calgary there were a rash of bad outcomes in a period of

one month....and it was after we presented these cases to the
region that overarching changes were implemented that have
reduced their ED boarding times and subsequently their
LWOT's for admitted patients.
In Edmonton, for a few months, we did not hear anything. As a

result of the bed cuts and increasing EIP's (Emergency in-
patients), here are the stories that we are starting to hear.
A. PROBLEM---The FCP is failing as a result of long term
care or WTS patients occupying increasingly more acute care
beds.
1. Misericordia Hospital:
Raj's story: I have been knocking on doors 4-5 days per week
and hear this regularly from the people at the door that the
waits are up to 6-8 hours again. After door knocking, I visit the
ED every second week and things have gone from bad to
worse.
CASE- political candidates relative
-The FCP has failed

-We are running the ED out of the waiting room and the
hallways.
- there are regularly L8-24 beds (total 28 beds) plugged up with
non-emergency patients.
-Capital health has not kept their promise of maximum 8 EIP's
in the department
- The EIP numbers are misleading because there are
SPOTTED patients (patients who are transferred in for
admission but are not yet admitted and are not an emergency
patient) that are not included in the EIP numbers.
2. Grev Nuns Hospital
Story: 3 weeks ago we had 25-26 beds (out of 30 beds) plugged

up by admitted/spotted patients). Triage desk is being
renovated. A patient who had been waiting with chest pain for
had an ECG done in the tent in the ambulance bay. After a
wait his heart stopped and his resuscitation was run in the tent
in the ambulance garage....no trauma beds,
-The FCP has failed

-Medicine has CAPPED admissions and refuses to admit...this
does not show up in the time to admit
- the ED is run out of hallway stretchers and waiting room
chairs
3. The UofA Hospital
Story: "We were so plugged up that a resuscitated cardiac

arrest was left waiting in the hallway on an EMS stretcher to
offload."
-Admitted patients in the waiting room.. 2 cases

UAH, a 78 year old man, presented with generalized weakness. He
stayed in the WR from t209 to 1745. He was brought in by his
daughter because he was increasingly unable to care for himself and
unable to walk properly over the preceding two weeks. I found him
hypoxic (PaO2 of 52 on room air), and ultimately diagnosed him with
multiple large pulmonary emboli (blood clots).
UAH, a 25 year old man with end stage renal disease, on hemodialysis,
was transferred from a peripheral hospital because he was complaining
of chest pain. He waited in the WR from 1415 to L842. He was known
to have an elevated troponin (of unknown significance). Upon arrival
into the department, he was found to have a potassium of 7.0. A CT of
the chest confirmed a pericardial effusion.
The only reasonable way that patients like this can be seen is improve
the output problem in the ED (admitted patients have to move
upstairs). All the efforts that we have aimed at looking after the input
problem (ambulance diversion, TLP, greeters, paramedics in the WR),
will not help these types of patients get seen soon'
- TLP near misses in the WR
While on TLP, I admitted 2 patients to gen surg with
appendicitis, one mild CVA 3 weeks post-CABG to neurology, and a
bowel obstruction in advanced esophageal cancer, All were admitted
from the waiting room. All were briefly assessed in a triage stretcher
and then sat in chairs for much of the day. One (that I know of) went
from the WR to the OR. That same day a ?meningitis developed her
rash while waiting for a bed and fortunately her mother sought us out
to tell us of that 'minor chanqe' in her condition.
-The FCP has failed.

-It's only a mater of time, when we have a preventable death in
the waiting room
4. Roval Alex Hospital
For the most part, we are happy with the deal that Capital
Health has kept on the number of EIP's in the department and
Administration and Reverdi Darda must be
congratulated....BUT.. .
Raj's two cases...AIl of our trauma bays were full of ICU

patients.
1. open cardiac massage in the hallway(the full meal deal)
2. 2 Cardiac arrests - one run in the hallway and another in
a storage room in the emergency.
Royal AIex Problems:

l. Closed beds in the ED
2. When all other ED's are not working, the Royal Alex gets
slammed by EMS volumes
3. Lack of CCU and ICU beds....trauma beds in the ED full
of ICU patients.
4. Sturgeon Hospital
-"May as well be turned into a long term care facility as more
than half of the acute care beds have long term patients
admitted to them".
There is no Full Capacity Protocol.
5. This is a SYSTEM PROBLEM and the main causes are:
a. Lack of investments and attention to long-term care and

community care.
b. Closed beds due to the shortage of nurses...especially ICU,

CCU, in hospital medicine and emergency beds.
c. Not to mention the impact of an increasing and aging

population.
B. EFF'ECTS
1. Pre-hospital care...Ambulance Red Alerts and offload times

are at a record high....no ambulance on the street for 15
minutes last week. . ..
EMS transfer paramedics are a temporary solution to this

problem...but this will not address the ED issue...in fact sicker
patients will be waiting to be assessed untreated in the hallway
on EMS stretchers. . . .Calgary examples. . ..5 deaths in early
2007.
2. Emergency care
a. LWOT - Record numbers of patients are leaving without
treatment. The evidence is that when they come back they are
sicker and their death rate is higher.
b. Patient 2nd mos t at Risk (Patients who wait in waiting
room to be assessed and treated)
c. Patient at 3'd greatest risk (ADMITTED to ER .sometimes

this patients never makes it to the ward.
...wrong nurse...wrong doctor.... in the wrong place.
3. INFECTION RISK
As admitted patients are warehoused in the ED's (sometimes for
days) in close quarters, this is a breeding ground for cross
contamination for infections and resistant bugs (MRSA).
Eventually, these patients are moved to the hospital area where
they will contaminate the hospital.
4.In the event of a multi-casualty incident, we are ill prepared to

deal with it.
4. Solutions
Let's examine what's worked (RAH and Calgary) and what

hasn't (the rest of the hospitals)
Let's look at what Calgary has done. . ..with fewer

nurses/100,000. It must be acknowledged that Edmonton has
an older population and a higher aboriginal population.
1. Calgary - HFEMA Study... GRIDLOC project to

improve flow of patients through the system
1. Decreased Admitted LOS (length of stay)in the ED from
25-16 hours
2. As a result decreased EMS wait times and red alerts
3. Most importantly, they decreased LWOT's at a time
emergency volumes went uP
4. HQCA - Patient satisfaction increased from 10o/o to
gl'h .... Accountability piece
i. increased ED volumes
ii. EMS volumes unchanged
iii. Decreased EMS wait times
iv. Triage to bed time decreased (250min-110min)
v. Bed to doctor time increased (80 min-100 min)
vi. bed request time to admission (10-4 hrs)
vii. decreased Admitted LOS (25-16)
viii. As a result, decreased LWOT's (1 6.7%-6%)
a. HOW???
By making it a priority....created a special position for
...emergency & unscheduled visits (Dr. Rob Abernathy)
1. Creation of additional inpatient Full Capacity

beds....Proactive triggers for the use of overcapacity beds
based on the number of sick patients in the waiting room.
2. Getting buy-in from others in the system...convincing that
these are system patients and not just emergency patients.
3. Providing support for staff on the wards...hospitalists,
nursing assistants.
4. ...rapid discharges...Readmissions rates have not
increased. Convincing all physicians to pay attention to the
SYSTEM vs. the individual patients...
5. Educated society - Town hall forums in the cify.
6. Improved utilization of current ED capacity- subwaiting
rooms, 2 On-call emergency physicians for the city,
redirected ALC patients who didn't need to go to ER or
the hospital.
7. Invested in long term care
Problem: Long consultation times. 50-80 WTS patients.
Nursing shortages and acute care bed closures. 1900 acute
care beds, 80-90 full capacity beds.
2. Edmonton - ESSC (Emergency Services System Capacity

project)
Problems: 400 WTS (waiting transfer of service/long term

care) patients plugging up scarce acute care beds.
This results in pressure to discharge sicker patients before they

are ready to be discharged. Readmission rates are higher.
We haven't fixed anything, We had come back form the edge

of the ABYSS.... And now are back on that edge again.
While we wait for the long term solutions to kick in....we have
worked on decreasing the input into the system and not enough
on the output from the hospital and into the community (long
term care).
What we have failed in doing in Capital Health is to convince

others that this is a system problem and not just emergency
pushing their problem upstairs. Rather, the emergency
problem is a problem of the system not functioning as it
should.
We need to convince people to work together as a team and to

focus on the patient.
What we need is LEADERSHIP and a commitment to solve

this problem.
You have an immense responsibility not only to the people that
you represent, but also to society.
If we fail, we willhave bad outcomes and preventable deaths

despite the processes that we have implemented as a result if
we do not act now before the FLU hits.
My hope is that we will get through this winter by working

together.
THANK YOU
. Hotmail Windows Live Page 1 of4
r)
RE: Urgent Care Centres Slck ta rr:3ssil$os i
To see nlessages related to this one, gri:up fxe$silrilrs i:y ro nv*rsnticrr

' Tr: Sptnce idicit'-*l K*pry
#
Spence,
Another anonymous letter being forwarded to you. The rebellion

of Edmonton's ED docs (justifiably) is starting. Capital Health
wants rrore rnoney from your boss, Dave.".for what? And they
have don't have encugh for long term care. Tsl< Tsk
Feel free too share this with Dave.
Cheers
RaJ
Colleagues,
I think the urgent care centre issue deserves

comment from [dmorrton FPs. Please pass this on to
your gfoups in [dmonton. It has recently come tc
light {again!), tlrat Capital Health is nroving forward
with centres for both Advanced Ambr-rlatory Care
and for Urgent Care. These will be built and fr-rnded
"through existing global budgets for regional health
authorities".
AAC is basically an after hours FP cffice with lab and

perhaps DL This is a stop-gap measure until all of
the Primary Care Networks begin offering
full after-hours services. Urgerrt Care (UC) is a mirri-
tD which accepts ambulance traffic but does not
"provide routine ongoing care and nronitoring".
They aim for "urgent", but not "emergent", patients.
Last I checked we rryere admitting 7 9c/o al our triage
4 and 5s, none of whom are even 'urgent' and they
have no bed to be admitted to. Neither of these are
modeled after Health First Strathccna, but I suspect
similar issues may arise.
http : II snl06w. snt 1 06.mail. live. com/mail/Inboxl-ight.aspx?n:2 8226619 06la3D01r

' Hotmail,:ry - Windows Live Page 2 of 4
I ne nrstory t0 tnls ts tnat one ot our tps was a
consultant to the working group 2 years ago, but

was dropped after providing feedback, A year and a
half ago our colleagues at the Mis were approached
to staff one of these UCCs, and I believe they were
rather reticerrt to do tM outside an tD. (Comments?)
Within the past year, Capital Health had plans to
build an Urgent Care Centre in the IJAH, separate
from the ED. This was quickly turned into an
expanded ED fasttrack as soon as the section heard
about it. Our feedback counts. And our patients
deserve cur advocacy.
I strongly believe that we need a cohesive, unified

response to this ill-conceived plan. (Perhaps this is a
role for EEPA and the Section?)
Below are some examples of patients THEY believe

to be suitable for UCCs, without input from
emergency physicians.
From "When would people use and

ACC/UCC?'':
. A young woman with asthma is having

difficulty breathing and her regular
medication does not seem to be working.
She goes to the Advanced Ambulatory Care
' Centre where she's checked by a physician
and receives treatment.
.A couple is involved in a car crash on a

rural highway. The injuries do not appear
to be life threatening so the ambulance
takes them to the nearby Urgent Care
Centre where they receive treatment and
further tests.
. A six-month old baby has had a high

fever for several hours and suddenly goes
into convulsions, The parents call 911 and,
because their community does not have a
hospital, the baby is taken to the Urgent
Care Centre where a doctor stabilizes the
baby, diagnoses the problem, and arranges
for transfer to the nearest hosoital.
Last I checked asthmatics unresponsive to beta-agonists,
and trauma patients are sometime very sick. And the
urgent care pitstop for the febrile seizure before "transfer
to the nearest hospital" is nonsense and
http : // sn106w. snt I 0 6.mail. live. c ornlmatlllnboxlight. a spx? n:28226 61 9 06/03120r1

- Windows Live Page 3 of 4
Hotmail -
dangerous. Please note that the phrase "because their

community does not have a hospital" refers to
communities withln Edmonton and the CH region. These
are going to be built in the city, not in distant, underserved
bedroom communities.
Like the Medicentres ofthe 1980s which promised to

improve primary care, I wonder ifthese are PR-driven
money pits which will not serr'e our patients' best
interests. Though ill-conceived, they will not be ill-
fated. Our patients who are tired of waiting in our EDs
will happily put availability of a bed before the ability
of that facility to care for them. And our EMS
colleagues who spend too much oftheir shift in our
EDs will likely be happy to take patients there. Ifthe
pay scale is anywhere near Health First's wages, they
will have no problems staffing these. And in the end
we will have fewer resources to solve our curent
system problems. By the way, if we rernain plugged up
with admitted patients, how are they going to get their
sick palients into the REAL ED's, especially when our
staff will all working in these centres?
http://sn 1 06w.snt 1 06.mail.live.com/mail,4nboxli ghlaspx?n=2822661 9 0610312011

Hotmail - Windows Live Page 1of3
Time Bombs
Tc Neil \,Vi kin5orr, Neil Willi:nson, rijlhafl:ia Re p l),
Neil,
FYI. While the elective surgeries were cancelled, this was the
situation in the ED's. I just thought that I'd keep you in the loop.
lhese are 5 'ticking iime-bombs" in one day at one site...and flu

season has not yet hit! Thanks to you, we have scheduled a
meeting with Sheila, Ken and Susan for 8am Dec 18th. I fear that
we will have a preventable death very soon as soon as the flu hits.
The section is under pressufe to say and do something.
If you can do something to lean on Shejla and the COO's to rectify

this asap, it will save us a lot of grief. The Full Capacity protocol
has failed at a few sites in the cit,.
Cheers
Raj
Dear Raj,
While on TLP December - ,l admitted 2 patients to gen surg with

appendicitis, one mild CVA 3 weeks post-CABG to neurology, and
a bowel
obstruction in advanced esophageal cancer. All were admitted
from the
"vaiting room, All were briefly assessed in a triage stretcher and
then sat in chairs for much of the day. One (that I kno\ / of) went
frorn the WR to the OR. That same day a ?nreningitis developed
ner rasn
while waiting for a bed and fortunately her mother sought us out
to
tell us of ihat 'minor change' in her condition. I can get you
specifics if you need them.
That day I did speak to Executive twice. One lssue I

lentified was regarding the hesitarrcy of executive to cancel
if there were any vacant FCP beds. We had 4 FCP beds
::::"ri"r
http://sn 1 06w.snt I 06.mail.live.com/mail/InboxLight.aspx?n=2822661 9 o6t03/201r

. Hotmail--Windowslive Page 2 of 3
day on surgery. I was told that none of our 22 EIPs (over the limit
of 12 that you negotiated on our behalf )were appropfiate for
those beds... and that until those beds were full. we couldn't
cancel surgeries. Admittedly some of our EIPs were on isolation/
monitors or a two-person assist. Most otheB were deemed "too
heavy"
for the RNs upstairs because of frequent analgesia/medication
needs,
personal care issues etc... I am all for protecting our RNs so they
don't all quit, but it is obvious the FCP beds at the UAH are not
being utilized. It was felt by our bed coordinator and Exec McD. ,
11.00h, that if we found suitable tenants at some point during the

day
for those beds. that would be firre.
http://sn 1 06w.sntl 06.mail.live.com/mail/Inboxl,i ght.aspx? n:2822661 9 06/03/z0lr

' Hotmail {tfFWindowslive Page I of5
RE: some points for your thoughts.....

Rai Sherman ,r,rr)roo,
f- Rcply
rThank you.
Best wishes for your family this Christmas and a Happier New
Vear!
Raj
> Date: Fri, 21 Dec 2A07 00:00:34 -0700

> To: rajsherma n@ hotma ii.com
> From: bholroyd@ualbena.ca
> Subject: some points for your thoughts.....
,r
> Thanks very much Raj I
> Here are some suggestions for points to consider:
> - The current ED situation is totally untenable. Lack of access to

ED
> beds for potentially seriously ill patients and patients already
> diagnosed with critical conditions is guaranteed to contr;bute to
> serious Inorbidity or mollality. The problematic situation in

tertiary
> care EDs is primarily related to occupancy of ED beds by
admitted
> patients, There are other lessor contributing factors (ie delays in
> medical decision making and admissions ) but these are
exceedinglY
> minor irr comparison. The critical situation and resultant
profound
> risks to patient safety (and potential for serious patient
con pronr ise
> and death) have been clearly and repeatedly articulated for
years to
> sentor executlves.
: -, _ -,,.
lrttp://snl06w.snt106.mail.live.com.imaillInboxLight.aspx?n=28226619 06t0312011
' Hotmail - rajsherman@hotmail.com.- Windows Live Page 2 of 5
> - | ne puu L lredny pclLerve dnu e)(PeL! ule Et, tu tul|||r L e ture
> of "safety net". They expect the ED to perform in an efficient
and
> effective manner when they have a health crisis. A failure of the
> emergency system to perform as expected (especially with a
bad
> outcome) will be exceedingly damaging to the system and
those
> accountable for the health system. The current reality is the
> net" is in tatters and cannot be relied upon. These public

> expectations are reasonable - the fact is we cannot meet them.
> - The rural public expectations are that tertiary care EDs will
> assist with caring for critically & seriously lll rural patients.
> This is a crucial and appropriate role in our provincial health
> system. The reality is that the tertiary care emergency and acute
> care system cannot be guaranteed to provide this support and
> frequently actually is unable to provide that backup. The tertiary
> acute and emergency care systems are typically in a state of

c risis
, and system overload and tlrus frequently is not able to back
thelr
> colleagues in a rural setting. The crisis in tertiary care EDs is a
> provincial issue!
> - When the emergency system is able to deliver good quality

care. lt
> is likely due to the dedication of of individual care providers not
because of system capability or reserve.

'
> -The acute and emergency care system currently has a total lack
of
> any "surge capacity". The system typically is running far over
lQo'/.
> capacity. That level of intensity combined with staff shortages
> rendets the system completely incapable in effectively dealing
.vith
>
'u any rapid increase in demand
(from small MCI to a pandemic).
> - Standardized performance parameters for throughput need to

be
> implemented. Maximum ED wait times after the patient is
admitted
> need to be defined (l would sugg€st an absolute minimum
performance
> Ievel could be that 90% of patients should be transferred to
> inpatient appropriate setting within 4 hours of admission).
> - Occupancy of acute care beds by patients "waiiing transfer of
http ://sn I 06w.snt 1 06.mail.live.com./mailllnboxl,ight.aspx?n:28226679 06t03t2011

' Hotmail-ffiWindowslive Page 3 of 5
> service" "WTS" is a completely inappropriate use of an

extremely
> scarce commodity - acute care beds. While appropriate
placement of
> these patients may take some time - an immediate intervention
wouto
> be to prioritize the resolution of this misuse of precious
resources.
> There needs to be very well defined performance parameters,
> milestones and mandates for resolution of the problem and
ongorn9
> accountability for occupancy of acute care beds by patients that
do
> not require acute cafe services.
> - Nursing staffing in health care is a crisis. An obJective,

> unbiased, and non,threatening (to staff) (would suggest non
RHA
> driven) review of factors contributing to loss of experienced
nurses
> and other retention issue as well as development of an
immediate
> strategy to retain the experienced RNs must be undertaken
> - There must be a wholesale change in management style

related to
> throughput and capacity management in acute care as well as
creatron
> of very clear accountability (including incentives &
consequences)
> for pedormance. The current approach is totally reactive , wait
for
> a crisis and only then intervene to decompress the situation. The
> approach should be proactive - the typically # of acute care

> admissions frorr an ED is remarkable. The institution should be
> planning a day ahead - considering # of planned discharges,
proJecred
> # of admits (both ED and scheduled surgeries). Additionally
when the
> situation is becoming problematic there must be a proactive
series of
> interventions triggered when the situation reaches a specific
tevet,
> Currently it seems like the crisis needs to be reaclred before an
> intervention occurs that lras any possibility of addressing the
> situation and we repeatedly have to go through the same
process over
> and over again without learning from it or being proactive.
> - The current initiatives to develop urban urgent care centers (as
http://sn I 06w.snt1 06.mail.live.com/maiVlnboxl- ight.aspx?n=28226619 06t03/2011

. Hotmail.tll- Windowslive rage 4 oI )
> "solution" to the emergency problems) demonstrate a profound

lack of
> understanding of the issues compromising effective delivery of
> emergency care. The system does not need more',fast food
medicine" -
> it needs EDs with qualified staff to delivery effective & tirnely
> emergency care that are integrated with both primary and
specrarry
> care systems. Current "fast food" medicine options are in
aou ndance
> providing the public w;th many rapid alternatives - that aspect
of
> the system does noi need expansion. The long term care. rehab
and
> other ALC systems need significant expansion. Care must taken
to not
> allow this expansio|r to be driven by private interests that are
> profit driven,can "pick & chose" patients and have little
> accountability to the entire health system to accept patients
from
> acute care in a timely manner.
> - Current EMS system crises are directly related to lack of ED

> throughput and occupancy of ED care spaces by admjtted
inpatients.
> The solution to that aspect of EM5 problems is to improve ED
> th roug hput and output.
> - The profound inability of ED MDs RNs and other staff to

deliver the
> standard and quality of care that they expect of themselves that
> results from ED lack of throughput is devastating staff morale.

T hese
> professionals will not tolerate this ongoing and worsening
situation
> - they wili leave. The system will take many years to rebuild with
> the loss of these qualified individuals.
> - There are many examples of effective programs to address ED

and
> institutional throughput. The US "Urgent Matters', program and
UK NHs
> ED throughput initiatives are 2 examples.
http://sn I 06w.snt I 06.mail.live.com/mail/Inboxl ight.aspx?n:2g2266 I9 0610312011

Hotmail indows Live Page 1of 3
['-
Date: Mon, 14.lan 2008 20:58:19 -0700

rrom: G,
Re: The Overcrowding
Everyone, I had a long tall< with Dr. Raj Sherman

today in my role in Triage.
The ED at GN H has norv reached a crisis with the

overcrowd ino issue.
Today when I arrived at 1000 for nry Triage Shift, the

following were ln place:
ar The e ur"ere no avai able beds lo see pat,erls in.

b) The 0700 shift day ED Doc had 22 tfansferred
patients he was responsible for
following through on, in addition to any new
patients he would see during his
shift.
c) 18 admitted patients were living in the ED, with

,nîhpr 11 r1Aiio,1lc ihpre
'pend ing admission'.
d) 3 Cardiac patients were in the hall on moniters,

and a NSTEMI was ass€ssed and
diagnosed in the Fast Track Tent due to lack of
available beds. Bear in mind here
that there are !e assigned nurses to hallway patients
rl,r in <r:ffinn ra(tri.ti^n<
e) 13 patients were in the hallway, and the

department had no available stfetchers.
f) The incompletely renovated new Acute'area had

to be opened to temporarily house
http ://sn1 06w.sntl 06.mail.live.com/mail/lnboxli ght. aspx?n:3 78253 344 06t03t201r

' to*utlill- windowslive Page 2 of 3
hallway patrents to aliow trattic to be more than

sing le-file in the hall.
g) I discovered hypotensive pdtients pla.od n rhe

waiting room due to lacl< of any other
space, and this was not a 'triage efror' by stafl but
all they could do in triage given
the situation.
Tt is nyprolesq onal opinion drre- 20 \earc \ervice

to ihe Edrnonton community, that soon a
preventa ble death will occur
ii'r,our ED if the situation is not renredied.
The workino conditions today u,ere widely agreed

on bv rhe rur:inq, and phvsitial 5taff irl artenddnce.
fo be lhe worst we have evet-see. o-ollt-
Department.
My further Lrnderstanding is that this situation is the

same in all Depaftrnents in the Refr6i-ifiE!6ill-
in response to a request by Dr. Sherman that the

various hospital ED Depaftments wofk in concert to
brir.rg this matter to immediate attention of the
senior Capital Heaith Administration, the following
srano
out as noteworthyl
a) If any ED physiqg{gs cause for alartn due to the

?'iie to oote)1tial or actual harm
situ-5-fi6 n
t6-liTiEiii[lease e !!.]]_!19 tin ny ole as CQI,TQA
5n reqTor the ED) as well
n his role as ED Director,
as they are central

g and forwarding this
information to the appfopriate senior administration
(these latter three with patient identifiers removed).
h,'/16 :.6 ,.',"^ t",t!n ri. rolp a,. .D i 'prtor

'onruard rhese ernails dE?ily to ilê
COOIG N H/Caditas.
in his role
aritas who concu rs
wtrn
this and is planning to do same.
d) My understanding is that Dr.

conlacting rl^ e Caraoran VleoicafDto lE?tjve
Association to
see whether our malpractice coveraqe will prevail in
http://sni 06w.snt I 06.rnail.live.com/mail/InboxLight. aspx?n:3 78253 3 4zl 06103/2011

Hotmail - Windows Live Page 3 of3
this environment, or whether it is now untenable,

and would ask that he forward this information as
soon as available to us all.
Tomorrow I am returning to this situation.
Staff Physician
GNH Site, Caritas Healih Group
Ca pital Health Region
http://sn106w.snt106.mail.live.com./mail/Inboxli ght.aspxTn:378253344 06103/2011

Message body Page I of1
From: l:f
To: lfTorne@gov.ab.ca
suDlefi: - tnanKs
Date: Fri, 11 Jan 2008 72:23:04 -0700
Fred,
It was good to meet you thls am. I hope that I was able to give you some useful advice.
I un:uld ask you to keep the Delegate report I by not sharing it with anyone (it is for your eyes only).
I have ues not to shed Ca rn a
Secondly, can you These are just some examples. I would

not wanr revealed and efforts
asked them to instead of going public as this is the most appropriate forum to deal with
Thanks again for taking time from your busy schedule and thanks for breakfast.
Happy Door Knocking!
Raj
http://sn106w.snt106.mail.live.com/mail/RteFrame.html?v:15.4.3 079.0223&p?=pf 06t03120t1

Hotmail Windows Live Page I of4
ERIssues-lAgree
C;.Care. (cll,
J() Roply
Ken,
]t's good to lrear that you are able to spend some time with farniry
over the holidays. By the by, you,re not old enough to be a
g randpa I
Cood ideas. I ag"ee thal all problems need to be sorved,ocallv in

eacntdc Ty drd trat tJ-e tocai tevel ot adninis drion neeos to be
'
should be monitor nq tlê srluation 24 r' ours,/dav a.rd not i:ri
t't
ihe effect is felt after rhe TLP has left.
The main reason to keeplqgrself and Sheila in the loop is so that

-----'-'-----. (--)"::-"--'=
vou cal judge for voirrset{ how iEe-IFfiT iGiI]6El,,t r.;.h
sjtes are function well and which ones need some help.
A bird on the wall said that we may have an election call in early
February, so I may not be in a position to meet regarding these
rssues, howevar, Peter Kwan (president Lethbridge), Chris Evans,
Dan Barer and Paul parks (UofA-ER) will continue to work with you
on this issue.
I wouid personally like to thank you, Susan, Sheila, Neil and the
rest of Capital Health Senior Administrat;on for your help and
understanding. It has been a great experience to be a part of
someihing important. By cooperating, we have accomplished
some great thtngs togeiher.
Hope that yoLr have a Happy New yearl
Again, thank you and God Bless
Raj
Subject: RE: ER Issues

Date: Fri, 28 Dec 2007 09:34:04 -0700
From: capitalhealth.ca
T^.
http ://sn I 06w.snt1 06-mail.live.com/mailllnboxli ght. aspx?n=2922661 9 06t03 t2011

Hotmail Windows Live Page 2 of 4
Raj,
Thanks, I was able to spend some good time with

the family. l\4y two grandsons were a hoot this year.
In adliitjon to bnr.tqinq instances to my artentjon.

I tnrnK tnev shourd also be fed uo to the srie chief_q of
emergelcy alllasites who can then take thEE-
fomdrdlolh€.63tem-edlffiT-dr,?EEi^r
ftF-i^-^.<-
^n., !!. ^ î+ -
- - - ---- " -''wr q!l!--uLE-.tltE-
vrl\,u\1.- rne tLp may be rn a very good position
1o roentrfy tssues but I'm not sure it should be limried
to them since they're not always on duty (i.e. we
don t have 2417 cavenge). I thrnk rt's critical to also
involve the s,te teacjership in ttrs pEEEEEZEIiE-
srTESeEiCSFoTs-Sle-Tdf l?n ple mentin g the various
sirategies and for the standard of care.
The meetings we have with you will ihen afford a

higher level forum for discussior
Let me know what you think.
Ken
From: Ra Sherman
Imailto
Sent; 07 II:47
PFI
To; Gardener, Ken; Gardener,
Cc: Paul Park
Subject: ER Issues
Dear Ken,
I hope all is well for you and your family

this holiday season. I would like to begin
by thanking you for your time and efforts
in making the delivery of emergency care
to the patients of Capital Health a
prrority.
In relation to our recent meetilc

on Decernber 18th. wgfog4glqib_
W""rn"rilt, tt . CeO
say that sl)q lvasn't aware of some of the
adverse patient events thalwqplglp!1Ieli
that were a result of entergency
ot ercro
9eparrment
turther to say lhar she uould be interesred
jnffi
rae6a^1 1^ fhaaa f\'ne< an,l thqf
^f.'cce
http://snl 06w.sntl 06.mail.live.com/mail/Inboxl-isht.aspx?n:2 g2266 1 9 06t03t2011

: Page 3 of4
she wished to be kept informed orr an

gngoing basis regarding the situarron on
emergency deparlments in the Capital
Health region.
After careful consideration and

consultation with colleagues, it occurs to
us that the best person to collect this data
is the TLP (triage liason physician) as rhat
person has the best overview of the
emergency department during the tirne
they are on duty. We would be happy to
provide the infonnation collected to you
so that you are able to keep Sheila
informed in relation to any ongolng
adverse outcornes that mighL occur in
Capital Health emergency departments as
a result ofovercrowding. Before we
instruct TLP's in the Region to move
forward on collection of such information
and dafi for review, ws_glg.askilg-for.
your approval for use of TLP tirne in thiq
endeavor.
Again, on behalf of my colleagues, thar <

you. Best wishes to you and your family
for the Christmas Season as well as the
New Year!
Sincerely,
Raj Shennan
Past-President
Section of Emergency Medicine
Alberta Medical Association
hnp://sn 1 06w. snt 1 06.mail. live.com/mail/InboxLight.aspx?n:2g2266 9

1 06/03120r1
' Hotmail-tWindowsLive
Sent: Saturday, January 12,2008 2:31 plvl

Subiect: Suggestions - Please respond by
Tuesday Jan '15th
Gentlemen,
I recently met with iVinister Hancock's

representative. He will be meeting with Capital
\ealtr rhls week regarding lne emergen.y issues.
In order to improve the emergency issues, the
system issue nrust be addressed.
I wouJd like to arm l.tim with constructive

solutions/suggestions that can be irnplemented at
low cost, with the current labour challenges and
more imponantly, IMMEDIATELY to improve tl.te
situation in our eme[gency departments so that
we can get through flulvirus season.
To get Vour (rpative Jlces i ow ng here a.e sone

suggestions that have been n'lade to date: Feel
free to agreeldisagree and to add your input.
1. Provide suppod for nursing staff upstairs in

hospitals...ie NA's, aides, porters to do work that
nurses shouldn't be doing. ie.cleanirrg beds,
moving patients around, clean inglbathing
patients.
2. Provide support in the comrnunity/long term

care sector to move long term care patients out of
acule care beds.
3. 1n hospital communications sessions so that

everyone can firstly understand the problem and
the and only then will they feel like they are a part
of solving the problem.
4. Fully utilize the full capacity beds in every site.

Insiead of putting the new and sickest paiients
from the ER in that bed, the improving patient that
is 1-2 days away from discharge should go to
those beds. In Calgary, they have discharge
sunrooms that are full of these patients. The
infectior.r risl< is also a lot lower with this approach.
http://sn 1 06w. snt 106.mail.1ive.com/mail/Inboxl-ight.aspx?n= 1798 802884 06/03/2011

Hotmail - Windows Live Page 2 of 3
5. Mal<e it a priority/mandate for each hospital to

have their emergency beds oper-r to service the
community and be that safety valve for society.
6. Put a moratorium/hold on creating more.jobs in

the comrrunlty for nurses, because the in-hospital
nurses will leave and take those jobs as they are
dorng now.
7. Ask/mandate the nurses in Healthlink to work a

proportion of their time in clinical settings.
B. Ask/mandate all nurses in all managerial

positior.ts to work part of their time clinically. A
great way to build bridges and show suppoft with
floor nurses that are burning out in record
numbers.
9. S rrce their are c o<e5 wards :n hospitals..otle,

daycare services to Nurses who are not r,irorking
due to this concern, but will come back io work if
offered this service ons ite.
10. Communicate with ihe long term sector to

lrave the advance directives for all patients up to
date and to transport only those patients who
should go to an acute care institution for care.
11. Resource the long term places for rnore

palliative beds in their institutions..ie. Good
Samaritiarr
l2.IMAGINT:
a. if a BUSLOAD of 50 school children was hit by
a semr-tfactor truck on the Henday/Deerfoot.
b. if SARS hit the cornrnunity or worse yet,

imagine if SARS entered a hospital and
contaminated one hospita l.
c. if that airplane had actually crashed in

Calga rylEdmonton.
and ask Capital t-lealth and Calgary Health that

question. We would have to impletnent the
dtsaster plan (we feel that it should be
implemented with the current state o{ affairs).
Then Have Capital Health & Calgary Health Run a

MOCK DISASIER SCENARIO for next week and
see how the system fesponds. NO notice should
be given to any services about this mock scenario,
because in reality, this couid happen 15 minutes
http://sn 1 06w.snt 106.mail.live.conr/mail/inboxl-ieht.aspx?n= i 798 8028 84 06t03t201r

Hotmail indows Live Page 3 of3
from me sending this e-mail.
In running this scenario, palients who do not need

to be in hospital will be moved out immediately .
and we will see what flex is in the system and will

see how it responds ;n th€ event of a mu{ti-
casualty scenario before that scenario actually
happens.
The benefit will be that the acute care system

will get some immediate relief (l mean a trend
towards normalcy) for a brief period. This may
help us ride out the flu season.
This may also be a great way for cooperation and

communication at all levelsl Miliiary, EMS/Fire,
acute care,/long term care, primary care.
l-3. Ask/mandate the nursing & Medical colleges

(UofA.Uo{C. Mount Douglas, Norquest, Gfanl
McEwan..etc) to participate with a volunteer
service component in the acute care,/long term
care system and ask them to participate in the
disaster scenario as part of thelr curriculum. Get
the young people used to the idea of caring for
old/sick people, the challenges that lies for
Hea lthcare.
Thank you,
http://sn1 06w.snt106.mail.live.com/mail/Inboxlight.aspx?n:17988028 84 06103t2011

HotmailG-windowsLive Page 1 of 1
u\
Date: N4on, 14 Jan 2008 7940:42 -070O
!i,lffi'n"*"
ro:l*r
RaJ,
I ihink you have made nrany valid points. The system

is understaffed and more acute ntedical beds are
.lor ng H_o, u ,"g,on aun
"uo,learl
new centers of ercel enre (ie ltrst;t.rre) ,,\'lho,_t
p'ovrdrnq ,or lhe Dastc r-ealth needs of the
population is beyond me. The unfortunate stories
appear ng in the Calgary o,ess regard ng bao
outcon.res in overcrowded enviroments aJso exist
here.
It isjust a malter of time and the Emergency
Departments wili functionally close. We already
routir.rely fun out of stretchers and care fof patients
in their entirety in hallways, and the waiting room.
The care is not optimal but it is the best we can do
with the resources given us. The risk of errors is
er'rornoL,q,n I he5e .itcltrnsid^(e5
Thanks for your lobbying efforts.
Keep in touch.
http://sn I 06w.snt1 06.mail.live. com/mail/inboxlieht.asnx?n:3 78253 3 44 06103t2011

Windows Live Page 1 of 1

Jo dava, hancock, ired Horne. ired horne RePIY '
Dave,
Call me in the morning. We really need to talk....in person.

Your reputation and leadership is on the line!
Raj
http://sn 1 06w.snt 1 06.mail.live.com/mail/InboxLight.aspx?n:31 82533 44 06t03/2011

Message body Page 1 of 1
Subject: Grey nuns comments

Date: Tue, 15 Jan 2008 18:31:18 -0700
Hey Raj,
I was working at the nuns yesterday. I ar surel-ave you the low down about our situation. I heard it
was stupid crazy everywhere. I had a discussion with an internist about the situation and he suggested
garnering public support for change in the ED.
He had suggested having all pts that are unhappy with the wait times, but NOT WITH THE CARE they are
receiving, sign a letter stating so that would be sent to CEO Caritas, Sheila Weatherall, and the edmonton
iournal.
As you know. Sheila doesn't like bad press #

As it stands now, Full capacity protocol is a joke,,.no offense, We now have more admissions waiting in the
department than ever before and, there is no movement in the medicine wards. As of yesterday at the nuns,
there were 52 of 109 medicine beds that were destined for LTC or higher level of care.
Medicine cap (max of 25 admissions allowed per team) have now given the medicine services a way out so that
they do not have to take any more admissions. This obviously has a direct impact on us in the ED as we are now
responsible for these patients.,some for days. f4y collegue had 23 sign overs yesterday and was able to see only
10 patients. This will invariably lead to a negative outcome in the future if this continues, perhaps even death.
Maybe it will take someone dying for capital health and the province to step in and do something
I won't even go into the fact that we had 5 EMS crews waiting to offload patients for HOURS. Everyone was
getting upset..,EMS, patients, Triage, because nothing can be done.
Thank goodness I am going on a long vacation because working in Emergency in Edmonton SUCKS.
Regards,
http://snl06w.sntl06.rnail.live.com/mail/RteFrame.html?v:15.4.3 079.0223&pFpf 06103/20t1

Message body Page I of 1
Date: Tue/ 15 lan 2008 03:12:08 -0700

> From:
> To:
> CC:
> Subject: Unsafe ED
> Here is the deal with the ED this evening. Significan y unsafe-at
> about 2230, there were 31 EiPs, 40 people in the waiting room, and at
> least 10 waiting for admission. There were 7 or B ambulances waiting
> and B triage category 2s, Experienced triage nurses stated they have
I :"";""i,'ff l::",ff ?T:T:i:,]ffi

> (who came in to help), The de
jil,..*mh!ilffii
> midnight, a woman presented in labor (contractions q Z min and dilated
> 6 cm) and the only place available to put her was in the trauma room.
> In addition, there were 28 patients who left without being seen (the
> majority of which were triage category 3s). One of the patients wno
> left was a 24 year old palliative patient who came to the ED for
> analgesic and left without getting any.
> This situation is untenable and is completelv failino the needs of our
> par|ents. {.,r-_--'---::-
rsly:! slrEgglgl.llrns with an ED tike this before a
> cilg:lpplghappens despite the best efforts of the people in the ED
> Thanks for calling last njght and checking on the depadment!
http://snl 06w.snt106.mail.live.com/mail/RteFrame,html?v:15.4.3 079.0223 &of-of 061031201.1

To: sheila.weatherill@capitalhealth.ca; ken.gardener@capitalhealth.ca; kgardene@cha.ab.ca;

gl]!ln:.@cha.ab'ca; neil.wirkinson@capitarhearth,ca; dave@hancock.ab.ci; fred. horne@gov.ab,ca;
Subject: One Death - Grey Nuns Hospital

Date: Tue, 15 Jan 2008 22:31:32 -0700
Everyone,
It is my regret to inform all of you that we have had our first documented death in Capital
Health due to delays
in care. I cannot stress the impoftance of cooperation and understanding through
this very difficult time.
It is time to impiement the disaster plan.
Raj
Date: Tue/ 15 Jan 2008 19:56:23 -0700

From:
Subject: Re: The Overcrowding Crisis: F/U #1
To:
CC:
Less than 2 hours after my completing my email to you all yesterday, we have had
our first death in the ED temporally related to the ED overcrowding rssue.
The case will be reviewed formally in-camera by the GNH ED eA committee next
week, and patient identifiers sent in confidence by separate emair as rriel to or.J to,- hi,
review as ED Director.
The first interim analysis was done today by myself and the charge Nurse on duty yesterday.
Itis based on a review or the Elvls record, the ED chart, interview with both triage nurses on
duty when the patient arrived for the remainder of their shift, and the last EMS irew supervisino
patlent prior to her being placed in an ED room and the nursing staff taking over care formally.-
In briet the case is as follows:
lyr old. Caucasian female brought by EtyS (ALS) to GNH ED from NH

WiTfr Hx of suspected cI Bleed (coffee ground emesis and dark brown diarrhea)
and decreased LOC this am. Past Hx of Ht disease.
arrived ED: t072 am.
Triaged by ED Physician (me) at 1052 am, (initial delay entailed by

the sheer volume of patients that had yet to be physician triaged jn the first
hour of my duty).
Initial blood work ordered at this time, as well as orders left for ECG to be
done when patient placed in stretcher and room. The ECG was ordered only
as a precaution in case an issue of potentiai cardiac ischemia develooed while beino
worked up for the suspected GI bleed. not because of any chest pain
Dre-arriva l.
s staf f
j
bv
l::i: ll,:T: i 11 1,1 ", 11Yrry:h ?1 :":yi ::i:l.i : ! :": i:t::"d E'v,
http://snl 06w.snt106.mail.live.com/mail/RteFrame.html?v=15.4.3 079.0223&of=of 06/03/2011

until being placed in a room at 2020 hours. (a fulLle heljls l€tcI),
She remained, hemodynamically stable throughout with one transient

recorded BP drop to 97 systolic at -
1215 hrs that the paramedics rncreased the IV
for. There was no tachycardia with this and the patient did not have chest pain at the
time. This was repofted to the Triage nurse, and she was reassured that the onlv
real problem appeared to be persistent nausea, and periodic throat dlscomfort related to this.
By 1600 hours she had required only 1 liter total IV infusion to remain stable.
No obvious ongoing bleeding was noted by the EMS crews, and no mention of
either bleeding or chest pain was forwarded to me or the nursing staff.
During her time under EMS care in the hallway, one of the triage nurses was reassigned in the
department to other duties no less than three times due to staffing issues.
At 1750 just prior to my concluding my shift, I reviewed her blood work, and noted
a HB of 96 (l'1CV borderline elevated), but had no clear indication of how acute this anemia was
given her previous medical Hx.
When this patient was finally placed in a room at 2020 hours, the nurse attendinq her noteo ner
complain ing of
severe sharp left-sided chest pain.
The ECG ordered at 1057 was finally done at - 2040 hours, and the ED Doc on duW
attended the patient 2104.
The EcG was markedly different from the 1z lead recorded by the EMS crew pre-arrival,
and compatible with ACS/NSTE|VII ML
Soon after, while investigations and treatment continued, she developed crushing chest
pain, became hypotensive, unresponsive by 2305, and died before 2400 hours.
It would have been very difficult, if not impossible, for the

EMS crews to
establish whether any angina was ongoing throughout the day as the patient did not speak
English.
Itis very difficult in retrospect to say whether seeing the ECG earlier, and having an attending
staff Physician on duty review it, the patient, and the EMS EcG would have madl a difference.
- rl
is clear is that an elderly, vulnerable woman died quickly in the ED after a huge delay before
-*<What
'standard
/l ED manaqement could be undertaken.
What is clear is that she is representative of the people most at risk here (the elderly, infirmed,
ano otsaDte0 ) -
the very people
what is clear is that there is every reason to believe these events will continue to occur until
t!*yerceryqqg lssue is effectively addressed Uy serii6ieEpiiat Heatth Adminjstration.
The same day we had delivered to our site a 56 yr old man in cardiac arrest who had a delayed
EMS response time
of over 12 minutes, due to the fact that there were so many crews attending patients in the ED,
that a unit had to be dispatched
from North Edmonton,
As I stated at the onset of this letter, this case will be reviewed formally next week by the ED QA
http://sn 1 06w.sntl06.mail.live.com/mail/RteFrame.html?v:15.4.3 079.0223&nf:of 06/0312411

' Message body Page 3 of 3
commlttee and I will reouest

that Dr,tforward my concerns to the COO/GNH,
As well tomorrow (when I return to the same situation again), the Canadian Medical Protective
Association will be returning
my call to them for advice re this, and future potentially preventable tragedies,
http://sn106w.snt106.mail.live.com,/mail/RteFrame.html?v:15.4.3 079.0223&pFpf 061031201I

' Message body Page 1 of 1
From: raj
To:
Subject: RE: l.4isericordia ER 't\
Date: Wed, 16 Jan 2008 11:16:25 -0700 {'
I
Thank you for your e-mail and for taking the time to chat during a busy time on your shift. I have passed your
e-mail to the section leadership (!t,O
We met with Cgpjle! Hgi]!!._ggliSlexgg late yesterday and are hopeful that we can get some much needed relief
to the emergency departments in Edmonton. The Minister's office has also been briefed of the circumstances.
Again, thank you.
Rai
Date: Tue, 15 Jan 2008 02i47 i28 -0700

From:
Subject: Misericordia ER
To: raj
Hello Raj,
Fufther to our conversation earlier this evening, accept this as a more formal update to the
situation in our emergency department:
- We have not been in a position to safely see patients requiring urgent care for several months
now. On average, 70-100% of our emergency beds are occupied with admitted inpatients, and as
I write this, we have 24 admitted inpatients in out 27 bed department.
- Admitted inpatients routinely wait 3-5 days for an inpatient bed, and we often have patients wait
for over a week to go upstairs.
f' - Wabave had a multitude of issues with inadequate and dangerous care provided in the Fn,
including septic patients treated in the waiting room, a pregnant patient (who was unaware of her
gestational age) who laboured with severe abdominal pain for tvvo hours in the waiting room
before delivering a term infant 5 minutes after being put in a room, and so on. CTAS triage criteria
time limits are virtually never met. The triage nurse routinely has to choose between a large
number of seriously ill patients to decide who goes into limited treatment space. I could provide a
number of examples of poor and/or dangerous care each shift as a result of the extreme
overcrowding the department now faces.
Ihold out little hope of meaningful change from Caritas, Capital Health, or the current
government, but good luck in your effofts. Our site chief has been writing letters to this effect for
months, and the situation continues to deteriorate in an accelerated manner.
lrnp://sn l06w.sntl06.mail.live.com/mail/RteFrarne.html?v= 15.4.3 079.0223&pf=pf 0610312011

From: raj
To:
CC:
Subject: Misericordia Er overcrowding
Date: Wed, 16 Jan 2008 22:33:'13 -0700
I,
Your word is all I need,
Y".terday,lnd I have met with senior exec at capital Heatth and have expressed thg urqent need
to address this issue. We will just have to see what they are going to implement in the next few-dffi:-
r:-r-c-
We continue to encourage all of our emergency colleagues to carry on the best that we can desplte the
resources that we have been given. We have also made the point with exec that the system is being held _
toqether by a first class group of peoble who are goinq above and beyond their ceTfo*idu$-Fd5FlE=[iF;1
yoursetves.
I have attached this response to our section etrEc'to Keep the in the loop. Peter Kwan is section president. Paul
:il:il*"iliT*lii::i;:1,"Hl,?ll;ffi !S", i:ti:f,ffi i$il"-fi 'flil jii!".'i;lJJ","

Thank you.
Rai
Date: Wed, 16 Jan 2008 11:59:08 -0700

From:
Subject: Er overcrowding
To: raj
Raj, do you have a fax no.? I would like to fax you a copy of the EDIS screen from yesterday
showing that we had 25 admitted patients in our 26 bed department (a 100o/o utilization!!).
rccc(rco{{x
http://sn106w.snil06.mail.live.com/mail,/RteFrame.html?v=15.4.3 079.0223&pFpf 061031201ll

Hotmail -€F Wrndows Lrve Hage i oI 4
Follow Up Emergency - Long term care

Raj Shermal 77 /01/2408
Ta Fr(".d 1-lorne, Reply
Dear Fred,
Here as a report on the state of affalrs of the

emergency departments.
we met with Sh-j la l^JeaLheril.I and Ken cardener and

-\----
nl F:c6d
-
Ene resources avat table to f.-n ua'-
L'i ih their reception and solrltions put
forlrard. The fonger tern solutions 1ie in our hands
/^^rr6,nm6nF r
The state of affairs today:

1. RAH Much Bettert !t
- 18 EIP s (admlLted emergency in patients) vs
30-44 over the past kreek
- 5 LWOT,S (1eft wiLhout breatment) vs. 25-33
per day over the weekend
- 21 stck patients to be seen in the waiting
room Reasonable) vs. 58 on monday (unreasonabLe)
UofA - Moderately bet ter,

-22 EIP,s vs. 30-40 last neek
8 LWOT's vs. 28 in the midst of Lhe cr.isis
-21 patients to lle seen in the waiiing room vs
40 pac lenc s
3. Grey Nuns - a Little better...manageable, Maj.n

problen exists in that the internal medicine
physicians retusirg !.o aomi! paEiejlES afLer tney have
reached a rcap. of 25 patients.
4. The Mj,sericordia (hopital in My RIDING) ..NO CTLANGE

AT ALL....UNSAFE CA.RE IN THE ED! II
EIP, s -ns...24-25 pre-crisis.
-27
-There are currentfy 29 post-op hips ar.raiting
transfer to other sites in the hospital . Long term
care iS a big issue city v7ide, but especially at Lhis
site. f heard that the ltisericordla discharges 2-4
patients per day. The emergency is sti1l run out of
the walting room and hallways. One site not
funcEionrng well 6ffe.Ls al1 oLher s:res neg-itweJy.
Ic appears thaL rhe CariE.as HospiEals \qve elrner noE

dispLayed the Leadership or] are s1mplv not able !o
http://sn106w.snt 106.mail.live.com/mail/Inboxl-ight.aspx?n:1798 8028 84 06/03t2011

FWindows Live
rrth their i ssues (especia l1y aE. the Mise.ricordia

he Nuns) as the RAH and UAIJ hawe. Slgl]g_ hed
red that Carjcas 1s a separare board. Dr. Jeff
son ls lhe -nedlcal Lead at CartLas, He could use
na -:11 f-^- .'^,.
I h-r'e to rhark yor a'd Dave lor the pressure, I

peful that we can mdlnLain chese gains. Looking
6 PAIr -'.nh6.< w.r. .r- qaa fha irvarcc
lation between EIP's and
î--.rtw
LWOT's and sick oatienis
\;.
y
/*--
\
e lvaltrng room, i-/
ne if there were no admj-tted patients in an
ency department . . . . as there should be. The best
on the political end. These gainE are usually

fived when the pressure goes a\,ray. During Ehe
rship race, v,/e made i!. a leadership issue a1d
took hold of it. These conditions existed last
ry and lmproved d1.re Eo che ECp (whic1 was a shorr
frx) . We saved a 1ot o' bad o
So, the FCP shoufd stay implemented (afways)as a
er to improve the efficiency process.
eal so.IuLions are rrves_ments inLo _ono rerm care.

l4l!g -igE€eli9d. Here is a conridentlal look
.e minds of Lhe ER-docs in ,L1berta.-TiElian is to
this
# an election tssue louhl ic a.lvn.r^v) Th6so
s can be made an eleclion p atform issue tor our
. . .Lhe Premier addlessing Lhe energency issues
rnking ir co long term cdte and senior care and
.Lments in our seni ors. Tl:S__fgae_he__Sa+-s+euJ--++=
ha'c :rrl rh?r LrF --
rve that he truly does.
v/oufd 90 over very well and silence those in the

. lines....and address EMS issues at the same
: you
From: raj
To:
Subject: RE: Overcrowding
Date: Thu, 21 Feb 2008 23:46:29 -0700
-,
Thanks for the e-mail. I will forward the contents of your e-mail without your name.
Cheers
Raj
> Date: Thu, 21 Feb 2008 22:42:53 -0800

> From:
> To:
> CC: raj
> Subject: Overcrowding
> Raj, as per our discussion Feb 21 2008.

> I was the TLP 1600-2400 at UAH HosDital.
> Upon arrival to the department there was 29 patients in the WR and no beds to
> see patients. At 2400 there was 29 patients in the waiting room. l.4any people
> left prior to being seen. Multiple triage 3's patients. Some cases with life
> threatening consequences as a result of overcrowding:
> 1. Transfer to Neurology in WR Troponin 1.23 - in WR for hours.
> 2. Seizure patient waited t hours for bed
> 3.Fracture dislocation with skin compromise waited 2 hours in WR
> 4.Patient with fall and confusion CT while in WR showed subdural with
> intracerebral blood- waited 3 hours.(Senior nurse reminded me to book a CT in
> WR- otherwise patient may have left).
> 5. 78 yo Patient with focal weakness who left prior to being seen ? CVA
> 6,73 yo Female with possible cI bleed in WR for 8 hours and still waiting when
> I left at 2400! | !!!!
> From a physician and personal point of view I feel helpless in the TLp role
> and Emergency Physician as I get the sense of all of my colleageus getting
> extremely frustrated, I also get the feeling the nurses are very Frustrated as
> well. lt4any are looking for jobs outside the region. One nurse is leaving for
> Victoria. Our goal of recruiting nurses but how do we retain the excellent ED
> nuTses.
> My other concern is the plan to build an urgent care center. Where are the
> staff going to come from? it will clearly take nursing and other health care
> professionals from local hospitals. It will no way improve patient care in the
> Capital health Reglon. If the PC plan is to build urgent care centers. I am
> completley against this policy and will vote for another party. As Dave
> Hancock is running in my riding, I am very disappointed to see his website
> announce a new urgent care center after all the Emergency physician input to
> prove Urgent Care Centers do not improve patient care in the Emergency
> Department.
> Raj, please feel free to forward this email and information to Dave Hancock
,L-
> and Premier Stelmach so they are aware of the crisis we face everyday in the -#--
> emergency depaftment.
http://sn l06w.snt106.mail.live.corn/mail/RteFlame.html?v: i 5.4.3 0j9.0223&of-$ 06t03t2011

Hotmail indows Live Page 1 of5
Raj Sherman's Father-Emergency Issues
Raj Sherrran 22/02/2A08

io :rireiia n,eaiitefjil, i;,..1 f,;1:crra! l'r t-lJ ir;,.,r.r'r iir"p ly
Dear Sheila,
l wish to tell you about anotlter near miss (near Death) last week
that took place at the u offiTR.
The patient presented to the ER on Friday, Feb 15ih at 12:O0rroon

ar'rd registered at 12:29.Therc were 31 EIp's (admitted emergenc)
in-palients) in the ER plus capped admissions further reducing the
number of available ER stretchers in which to treat sick
patients. He was triaged as a CTAS 3. The CTAS standard oi care
for treatment is 30-60 minutes upon presentation. There were 30
patients to be seen ahead of this patient. He was exanrined by the
Triage Liason Physician (TLP) at 14:36 and labs were ordered.
There was no ernergency bed available for the patient so he was
ieft in the waiting roorn. He presented with a 2 day history of fever
and weakr.ress and had a history of heart problems and diabetes.
He had normal vitals upon presentation. Lab tests were drawn at
15:45pm.
After an agonizing 5 hour wait, the patient was admitted to a bed

in the ER at 1725pm. He was examined pronrptly by the ER doctor
at 1735pm and was found to be clintcally dehydrated with mild
acute on chronic renai failure. In light of his heart conditior.t, a
cautious fluid bolus was given. At about midniglrt, the patient
werlt into flash pulrronay edema (heart failure) and was ventilaied
on BiPAP. His troponin was 0.12 at midnight and subsequently
was 29.95 by the morning....ind icating that he had a myocardial
infarction (Hear1 Attack) in the ED. This was likely secondary to his
dehydration which led to a sequence of events that piaced a
burden on his already weakened heari (10 15% ejection
fraction) and exacerbated his underlyirrg coronary aftey disease. I
am sure that his life expectancy lras been shortened as a result oi
this sequence of events.
After reviewing the case, he received exemplary care in the

ER.....once he got into a bed and treatment was started. What is
non defensible is the fact that he sat in the waiting room for 5
hours with a CTAS 3 designatiorr.
My main concern lies in the fact that someone (unknown) called
http://sn 1 06w.snt 106.mail.live.com/mail/Inboxlight.aspx?n:i 798 8028 g4 0610312011

Hotmail windows Live
l:El- Page 2 of 5
ffi ""il: ilJT: ::ffi;il:Jl'fi ;lft? illT';,';'i iJ", "" o

as h;s wait likely would have been 7-9 hours. The reason that i
know these details is that I was there when MY FATHFR reglstered
at 12:29 and was there when he was struggling to breaihe and
fighting for his life. After I dropped him off at the UofA ER for
"vas
simple dehydration from the flu, I trusted that he was in a safe
place and that he would be looked after in a reasonable time.
After all, we had just had meetings in December and January over
this issue.
My greater concern is for all of those other patients who do not

have the advantage that my father had. Many of them are much
sicker upon initial presentation and wait just as long in the waiting
room AFTER a diagnosis by the Triage Liason Physician, This is
only one case on what is a string of daily cases of near nrisses and
bad oLrtcomes in all of the ER's in Capital Health. Many sick and
dying paitents actually leave the ER witlrout treatmer.rt on a daily
basis and Cod only knows if they sulvive or retunl for care.
My other concern is that when I was emergency section president,

we have had multiple meetings over ihis issue and things are
,vorse than they have ever beenl With our input, 1am glad that
you were kind enough to implement some stlategies such
as portions of the FCP and the TLP. Had they not been done,
things would have been a lot worse. I thought that l should let yo-
know that the emerger'rcy physicians of Alberta are frustrated with
the state of affairs and the inability to deliver care to ill patients in
a timely manner and may make this an election issue in the next
"veek.
Below, as you requested, I have also passed onto you
comments from my colleaguesso that you can be kept in the loop.
J :n:::i,"ff ::I li'i:H i :; ""

Alberta ns, including my fatheas. "*.T;",:il':il1il:i
Thank you for calling and expressing youf concerns for rny father
hea ll n.
Sincerely yours,
Raj Sherman, M.D.
This message and any attachments are for the use of the intended
recipient(s) and are confidential. If you afe not the intended
recipient,
you are hereby notified that any review, retransmission,
converslo n to hard
copy, copying, circulation or any other use of this message and
an'y
attachments is strictly proh'biied. If you are not the intended
reciPient.
hnp://su 106w. snt l06.mail.live.com/rnail/Inboxl-ight.aspx?n:1 7988028 84 06t03/2011

Hotmai l!-r-4n - Windows Live Page 3 of 5
please notify the sender immediately by return email and delete

this
message and any attachments from your system. Thank you.
A day in the UofA ER
Raj, as per our discussion.

I was the TLP 1600-2400 a1 UAH Hospital.
Upon arrival to the department there was 29 patients in the WR
and no beds to
see patients, At 2400 there was 29 patients in the waiting room.
Many people
left prior to being seen. Multiple triage 3's patients. Some cases
with life
tlrreatening consequences as a result of overcrowding:
1. Transfer to Neurology in WR Troponin 1.23 - in WR for hours.
2. Seizure patient waited t hours for bed
3.Fracture dislocation with skin compromise waited 2 hours in WR
4.Patient with fall and confusion CT while in WR showed subdural
wttn
intracerebral blood- waited 3 hours.(Senior nurse reminded me to
book a CT in
WR- otherwise patient may have le{t).
5. 78 yo Patient with focal weakness who left prior to being seen ?
CVA
6.73 yo Female with possible GI bleed in WR for 8 hours and still
waiting when
I left at 2400!M!!
From a physician and personal point of view I feel helpless in the
ILP rote
and Emergency Physician as I get the sense of all of my colleageus
getting
extremely frustrated. I also get the feeling the nurses are very
frustrated as
well. Many are looking for jobs outside the region. One nurse is
leaving for
Victoria. Our goal of recruiting nurses but how do we retain the
excellent ED
nurses.
My other concern is the plan to burld an urgent care center.
Where are the
staff going to come from? It will clearly take nursing and other
health care
professionals from local hospitals. lt will no way improve patient
care in the
Capital health Region. If the PC plan is to build urgent care
centers. I am
completley against this policy and will vote for another party. As
Dave
http://snl06w.sntl06.mail.live.com/mail/lnboxlight.aspx?n:1798802884 06103/2011
Hotmail of
ffiwindowslive Page 4 5
Hancock is running in my riding, I am very disappojnted to see his

webs;te
announce a new urgent care center after all the Emergency
Physician input to
prove Urgent Care Centers do not improve patient care in the
Emergency
Department.
Raj, please feel free

to forward this email and information to Dave
Ha ncock
and Premier Stelmach so they are aware of the crisis we {ace
everyday in the
emergency department.
h@://sn1 06w.snt1 06.mail.live.com/mail/Inboxl.ieht.aspx?n=1 798802884 06t03120r1

Sherman&#39;s Proof (Batch 2)

Hochgeladen von

Dokumentinformationen

Originalbeschreibung:

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Sherman&#39;s Proof (Batch 2)

Hochgeladen von

Copyright:

Verfügbare Formate

o SAH in Dawson Creek BC accepted by neurosurgery despite no ICU beds in region.

I am sending this email with the hopes of getting an

i have broached this topic in a number of emails,

As you are all well aware, system overcrowding has

Due to sevefe systemic overcrowding, we are at the

Patients arrive at the UAH ED expecting a level ot

I am fully aware of the extraordinary efforts that are

While changes are instituted to address this system

This complaint was lodged against myself on July

(October gth, 2008), I have not had a response to my

,titl huuu no idea as to how this complaint was dealt

i would really appreciate your response to these

Tlrank you for your time.

To: "Gordon, Deb" <Deb.Gordon@capitalhealth.ca>

== =$4 ============ - -Original meSSage tgxt- - - - - = = = = = = =.= = =

Public communication is listed as a long term goal (with no definitive

We are working in a system that is severely overcrowded to the point

The university of Alberta Hospital (and in extension Alberta Health

In order to allow the health care providers to continue to function

The message needs to be: System overcrowding is impairing the deliver

http:llsnl06w.sntl06.mail.iive.com/mail/RteFrame.html?v:1 5.4.3079.0223&pt:pf 06103120r1

In the emergency depaftment, we are being held to a standard of care

To: paddy.meade@ hhas.ca, chris.eaSlE(i:)c*lSa ry$reallhre$ion.ca,

Date: Friday, November 7,2AA8,11:53:37 AM

== =$( = == === == ===== =Qyigi66l meSSage

I am writing to follow up on the ongoing crisis in Emergency

I know that we will be meeting again on November 14th, bLrt I

I started my shift at 0000 on Nov 7th to 34 EIPS in the ED, r,vith

Despite all efforts by the bed coordinator and executive

The only reason the waiting room decanted is because people

http://sni 06w.sntl06.mail.live.com/mall/Inboxlight.aspx?n:1798802884 06/03/2011

In regards to our ED's ability to deliver timely acute emergency

Considering ihe UAH is held to be one of the prenriere tertiary

emergency departments within Canada, our ability to deliver

Urrfortunately last night was not a freak one time occurrence.

I sincerely hope that this email is received as the plea for

I anxiously await your ihoughts and reply.

= = =$4 = = = = = = = = = = = - - -Ofiginal meSSage teXt- - - - - = = = = = = = = = =

5iT'i:" i 1 i:*1 l{i",'l y1' "': ?r i:l'l:i-"i?: 11"1:, ! ! --

It is impossible to provide timely emergent care in the current

I've taken the time to document this case to plead with CH

To: Paddy M eade < pad$St.mtecjel$ai l::efi n he*lthservic*s.tc >,

i m writing again to plea for some immediate assistance regarding

Our ED's continue to remain dangerously overcrowded wiih

At the University Hospital general internal medicine has begun

If there is no mitigating the crisis, tlren at the least we must be

http://sn1 06w. snt 1 06.maii. live.com/mail/Inboxl.ight.aspx?n:640 47 403 0 06t03t20r1

FW: Urgent Care Centres

Raj Sherman 27 /1I/20A1

l attachment (8.8 MB) Hotmail Ariiv* \ciei+

I have to agree with nrany of the comments beiow.

This is your bcss...l w.o.uld have to disagree with this approach at

As I have said before, it's only a matter of time that an

Do what ever you think is best with this e-mail.

http ://sn 1 06w.snt 1 06.mail. live. com/mail/Inboxl,ight. aspx? n:28226619 06/03/20rr

?7??? got a copy of this and forwarded it to me. This

hnp ://sn 1 06w.snt I 06.mail. live. com/mail/Inboxlight. aspx?n:2 82 266r g 06/a3/201r

Sub.ject: HQCA -- R.eview of Emergency and Urgent

(See attached file: HQCA CHR ED Review

We have not yet had an opportunity to discuss this

We have not yet been asked to comment by the

There is much in the report that can be supported. Itt

http / / snIO6w. snt 1 06.mail. live.com/mail/Inboxl-ight.

Sherman's Proof (Batch 2)

Sherman's Proof (Batch 2)

To: Paddy M eade < pad$St.mtecjel$ai l::efi n helthservics.tc >,