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St. Michael’s after dark

Toronto, April 27, 2015

By Emily Holton and Dermot Covel

Every night at 11:30 p.m. and morning at 7:30 a.m., the director of hospital operations on duty sends an update to hospital leadership on what’s happened overnight.

Here’s a look at an average Tuesday night in February – a steady night for the inpatient areas and the Emergency Department. The main challenge was finding beds on the units for patients admitted from the ED. Several patients had to wait for many hours in the ED for a bed while units upstairs worked together to try to make space. Thankfully, there were no security concerns or emergency codes that night.

At St. Michael’s, we closely watch how long patients that get admitted wait in the ED, because that wait can be so difficult for patients. Imagine if you or someone you love has ended up in the ED and is sick enough to be admitted. Although you may be very tired and in pain, you are forced to remain on a stretcher, sometimes in a hallway or very busy area, for hour after hour while the hospital struggles to find you a bed.

All hospitals are required to track and report their performance on ED length of stay as part of their annual Quality Improvement Plans for the province. St. Michael’s goal for this year is to have nine out of 10 admitted ED patients wait no more than 21 hours between registering in the ED and moving on to an inpatient bed. Our latest numbers show that at St. Michael’s, nine out of 10 patients wait a maximum of 24.6 hours, so there is more work to do.

Working at capacity

We went into the night with no capacity to admit patients in the medical cluster. This means that several patients remained in the ED overnight because the units couldn’t take them. To help out, the Medical-Surgical ICU gave one of its beds to a medical patient, even though she didn’t need intensive care.

The ED evening/night shift overall

  • 85 ED patients total.
  • 43 patients admitted to hospital: 35 before midnight, 8 between midnight and 7 a.m.
  • 6 admitted patients waited in the ED more than 18 hours before they could move to an inpatient bed.
  • Between 3:30 p.m. on Feb. 24 and 7 a.m. on Feb. 25, 85 new patients arrived in the ED. That’s 73 arrivals before midnight and then 12 more between midnight and 7 a.m.

At one point in the evening, there were more than 70 patients in the ED.

ED snapshot at 11 p.m.

  • 47 patients in the ED
  • 12 patients admitted and waiting to be assigned an inpatient bed
  • 8 waiting for beds in General Internal Medicine
  • 3 waiting for beds in Mental Health and Addictions Program
  • 1 waiting for a bed in Neurosurgery

Isolation challenges

Eight of the 12 patients waiting for an inpatient bed needed to be isolated, to protect them or others from infection and/or viruses. Because isolation patients can’t share rooms, these cases can compound pressures on patient flow. For example, the Cardiovascular Unit had to close several beds that night to turn shared rooms into single isolation rooms. Cardiac Surgery took on four cardiovascular patients to help out.

Flood on the 17th floor

That night, several mental health beds were closed due to a flood. The director of hospital operations asked Toronto Police Services and Toronto Paramedic Services to reroute psychiatry patients to other hospitals wherever possible. Both services agreed to do so.

ED snapshot at 7 a.m.

  • 24 patients in the ED
  • 16 patients admitted and waiting to be assigned an inpatient bed

Ready for the day ahead

On Feb. 25, the Operating Room began the day open to external referrals, which means we had enough room in the schedule to accommodate elective surgeries as well as our urgent cases (such as trauma surgeries). Although there were very few available inpatient beds that morning, medical discharges were expected later in the day. The director of hospital operations decided that we could manage the day without issuing a bed alert status.

About St. Michael's Hospital

St. Michael’s Hospital provides compassionate care to all who enter its doors. The hospital also provides outstanding medical education to future health care professionals in 27 academic disciplines. Critical care and trauma, heart disease, neurosurgery, diabetes, cancer care, care of the homeless and global health are among the hospital’s recognized areas of expertise. Through the Keenan Research Centre and the Li Ka Shing International Healthcare Education Centre, which make up the Li Ka Shing Knowledge Institute, research and education at St. Michael's Hospital are recognized and make an impact around the world. Founded in 1892, the hospital is fully affiliated with the University of Toronto.