Halifax hospital rewrites wait-time rules after dying man's ER experience

A Nova Scotia hospital has rewritten wait-time rules and end-of-life protocols in response to the disturbing story of how a 68-year-old man dying from pancreatic cancer languished for six hours in an ER hallway.

A report on the death of Jack Webb says that as of July 1, the Halifax Infirmary requires internal medicine specialists to meet their patients within two hours when transferred to the hospital after being seen by another facility.

Webb's widow, Kim D'Arcy, provided the internal report to The Canadian Press. It outlines changes made by the Nova Scotia Health Authority after the saga of his treatment emerged in late April.

The review that followed a public outcry over his case has also brought changes to training of medical students and some procedures for treating dying patients.

It also says that "unstable" patients in ER are to be admitted to the hospital "after a direct conversation" between emergency and the senior internist.

Webb's ordeal

Webb was supposed to have been seen by an internal medicine specialist upon arrival at the Halifax hospitalwhen he was transferred there from a suburban ER.

Instead, nobody was waiting and he lay shivering in a crowded emergency room hallway lineup with his paramedics.

D'Arcy saidafter his wait, Webb spent time in ER with an intravenous that couldn't pump fluid, and he was later bumped from his private room by another dying patient into a medical teaching unit.

He was also repeatedly asked by various staff if he would agree to a do-not-resuscitate order, even though he hadn't been given any clear information on how long he had to live.

On the last day of his life, after being sent for a scope test, Webb lay in a recovery room and overheard staff yell, "If he stops breathing, don't resuscitate," D'Arcy said.

Under the changes, medical students will be guided in simulated conversations on how to talk to dying patients like Webb about their prognosis. In addition, a written "goals of care" form is being introduced that documents the varying types of care patients with terminal diseases want to receive.

'Wouldn't you think that's the way it should be?'

Jason MacLean, the president of the Nova Scotia Government and General Employees Union, said the reforms are useful steps, but added: "Wouldn't you think that's the way it should be?They are telling you something that should have been [in place]."

Public records indicate the underlying issues of crowded ERs and proposed solutions have been raised for years before Webb's case highlighted the problems.

For example, the former provincial adviser on emergency care, Dr. John Ross, said in a 2010 report that, "the emergency department CANNOT be used forholding areas for in-patients transferred from other hospitals."

This is precisely what occurred in Webb's case.

There were also recommendations at the time, accepted by the medical advisory committee of the health authority, that specialists take over care of ER patients within two hours of a consultation showing they needed to be admitted.

Widow's reaction

Still, D'Arcy said she's pleased some measures are being taken as a result of her husband's death. "They're putting it in writing and they have people assigned to it now so now someone's accountable."

She first raised the issue of Webb's care just prior to the recent provincial election campaign, helping draw attention to the problems of hospital crowding in the Nova Scotia Health Authority.

I think it is in everyone's best interest, that there be a common understanding of what the expectations are.- Dr. Mark Taylor,medical director

His story began weeks before his Feb. 1 death, when the couple wasn't informed he had just weeks to live after a diagnosis of rapidly spreading pancreatic cancer, and nobody discussed the possibility of palliative care with him.

By mid-January, Webb was struggling to breathe, leading to his visit to the Cobequid emergency department on the outskirts of Halifax and his transfer to the Halifax Infirmary.

The infirmary was in the midst of daily special alerts known as "code census" where the ER declares it's overcrowded and sends patients into regular wards that may already be struggling to cope.

In the quality review, Webb's case has been formally acknowledged as relevant to a wider "right care, right place initiative" that is currently examining the issue of hospital crowding.

'A step in the right direction'

Dr. Mark Taylor, a medical director at the health authority, said in a telephone interview that he's pleased with the steps taken to date as a result of the review in Webb's case.

"It's certainly a step in the right direction," he said in a telephone interview.

"I think it is in everyone's best interest, that there be a common understanding of what the expectations are and hopefully that can lead to improved standardized care for a patient."

A spokespersonfor the health authority said the numbers of people coming to the hospital's emergency over the summer were roughly the same as last year, though in July they reached an average of 218 people daily at the Halifax Infirmary.

Meanwhile, there has been an increase in bed capacity, he said.

"There was an increase of eight beds for internal medicine in the fall of 2016, to bring the total to 94, but no other changes since," wrote John Gillis in an email.

Beds at the Camp Hill hospital that are unused by veterans have been used when required for patients from other Halifax-area hospitals, he said.

Gillis said the changes to internal medicine admissions resulting from the Webb case, along with the return of beds at the Dartmouth General Hospital that were closed due to renovations last year, should improve the flow of patients through the hospital this winter and increase its capacity.

However, MacLean said he remains concerned, as health staff are telling him volumes of patients remain similar, and there are still days when the ERs are overcrowded.

"There's no indication things are getting lighter that we see," he said. "I talked to my members in ER and they say nothing has changed."