A quiet revolution in hospitals

By Paul Dalby

CAMPBELLFORD - Thirty years ago when Beth Van Dusen started her nursing career in nearby Trenton Hospital, nurses were mostly seen, not heard, and doctors called all the shots. Times have certainly changed.

Last month (March), Van Dusen returned to the world of the hospital ER as a Nurse Practitioner equipped with a new scope of practice that allows her to admit and discharge patients, order up diagnostic tests and prescribe certain drugs – in both the hospital and its ER. Ontario is the first province to give nurse practitioners this additional authority.

 CMH 2013 NW
(in photo - l to r) NP Beth Van Dusen, patient Helen Meyers and ER chief Dr. Normal Bartlett at Campbellford Memorial Hospital 

Van Dusen’s assignment at this 32-bed country hospital 90 minutes east of the GTA helps speed up treatment and reduce wait times in the busy Emergency Room, which has only one doctor on-duty but operates 24/7 and treats 22,000 patients a year. 

“This is acute care versus family practice,” said Van Dusen, who has worked the past decade as an NP in community clinics. “Now I’m getting to treat the people that I used to send to emerg.  The upside of this is that these people are going to get in and out quicker.”

“Folks who may have diabetic issues can be sitting there in the waiting room for four or five hours. They skipped breakfast, and likely need to have food. So if we can get them in and out in two hours overall it’s best for everyone,” said Van Dusen, an NP since 1998.

In her reintroduction to the world of the emergency room, she finds herself to be much more of an equal partner to the Campbellford Memorial Hospital’s ER chief Dr. Norm Bartlett. And he couldn’t be happier about the shifting landscape.

“People used to ask me, are you the only doctor working in here because there are 10 beds,” he said. “So I’m always moving around, it’s like being the only waiter in a 10-table restaurant.”

“Before Beth came, if I had to take a break for a meal, everything stopped,” said Bartlett, a 16-year veteran of hospital ER work. “Now Beth sees people and gets things rolling while I’m on break, and they’re all teed up when I get back.”

Bartlett said he had been lobbying for an NP in the hospital ER for over a decade but those pleas were always outweighed by budgetary constraints.

All that had changed in the past year with the province’s new emphasis on wait time reduction.

“Traditionally in an emergency department, the sicker patient is seen first and that’s how it needs to be, but with this new initiative the less urgent people are getting seen as well in a decent amount of time,” said ER manager Sue Robinson. “That’s why we just love having Beth.

“Even in just a short time she’s been here, we have lowered our average wait time from 4.9 hours to 4.5 hours and our target is to get that down further still to 4.3 hours on average,” Robinson said.

For Dr. Norm Bartlett, having an NP in ER just makes plain sense. “The primary care system long ago realized that NPs worked very effectively in primary care,” he said. “That’s why we’re fortunate to have Beth because she’s experienced in primary care but she also has some emerg experience and she has commonsense so she knows how things work.”

“Beth can get things started, ask the patient what’s going on, start an x-ray and call up blood work and give the feeling to the patient is that someone is listening to them right now.”

The new sense of teamwork between ER doctor and NP at Campbellford has been seamless with the triage system common to every hospital ER in Ontario. This divides patients into five categories:  Doctors handle categories 1 (‘resuscitation’, cardiac arrest) and 2 (‘emergent’, chest pains, cardiac in nature); category 3 (‘urgent’, abdominal pain, or simply extreme pain) is increasingly shared between doctor and NP; and the Nurse Practitioner handles category 4 (‘less urgent’, sore ears, lacerations) and 5 (‘non-urgent’, such as prescription renewals).

The Campbellford ER department treats around 60 patients a day, admitting an average of 5 into the hospital for further treatment. Many of the people coming into emerg are orphaned patients without a family doctor.

“Just last week a fellow came in with a terribly infected toe and I took one look at him and I knew he had vascular issues going on,” Van Dusen said.

“He had no family doctor so I referred him to a surgeon for vascular studies.

“The specialist saw the patient just two days later and the guy has had a full set of tests done. That guy would have just fallen right through the cracks, likely would have had to have that foot amputated if he had just toughed it out the way some people do.”

Van Dusen has been scheduled to work in the hospital ER’s busiest time period: 10 a.m. to 6 p.m., Monday to Friday. This will also make her the most familiar face to patients, (half-a-dozen doctors rotate through the 12-hour shifts).

“I’m going to be providing a wee bit of continuity even for the doctors to utilize because I’m here every day,” she said. “So when the patient comes back for a follow-up I can see how they’re doing.”

Van Dusen says the transition into the new role of an NP in a hospital setting has presented a few challenges. “In a way ER has sped up because the pace of this place is unbelievable for a small town, so you’re changing gears quicker.”

“I’ve had to do a fine tuning on myself. I’m 30 years graduated as a nurse so I’m dusting off some books, I can tell you,” she says with a laugh.

This story first appeared in the Toronto Star's Nurses Week insert on May 4, 2013 and is reposted on the Central East LHIN website in recognition of Nurses' Week with the permission of the author.