9-1-1 Emergency: A call for ailing Sask. hospital system to help seniors

As Saskatchewan's senior population grows and dementia rates rise, hospitals are struggling to meet the needs of confused and elderly patients who find themselves in the emergency room.

Confused and frightened, 90-year-old Jean Thomas dialled 9-1-1 in the middle of the night from a room at the Regina General Hospital. She told the dispatcher she had been beaten and taken captive.

“So you know you’re calling from the hospital phone, so you must be at the hospital, right?” the dispatcher asked kindly.

Jean hesitated. “It’s a possibility. I was beaten up there and then taken some place here too,” she said, her voice shaking. She also told the dispatcher she was 99 years old instead of her correct age.

What culminated in a desperate 9-1-1 call from a hospital room started five days earlier.

Having difficulty breathing on Feb. 27, 2018, Jean was taken to the hospital by ambulance, accompanied by her children Gerry Thomas and Joanne Monz. She was diagnosed with a urinary tract infection, but Gerry and Joanne were also told their mother had suffered a heart attack and would be hospitalized for at least a week.

Jean was moved from the emergency department to Unit 3E, where she shared a room with three other patients.

With Jean’s poor eye sight making everything look shadowy, she often struggled to understand what was going on around her or which part of the day it was, said Joanne. Staying in a room without a window and not having her watch also contributed to her frequent confusion over the time of day.

Jean didn’t have dementia, but constant noise from people and objects around her only added to that confusion.

“It was hard on her because she was in a room with four people too, and right by the nurse’s desk … so it was always very noisy,” said Joanne. “Usually when we’d go see her in the daytime, she was sleeping because I think the poor thing couldn’t sleep most of the night.”

By the third day of Jean’s stay, hospital staff noted her disorientation on her Medicine Care Flow Report, documents the family received from the Saskatchewan Health Authority (SHA):

March 1: “Patient confused to time and place.”

March 2: “Patient confused at times.”

March 3: “Patient confused, asking if there are other patients in the hospital.”

Then around 9:15 p.m. on March 3, Jean wandered off her unit.

A nurse found her, sitting in her walker, in a different unit and tried to guide Jean back to her room. But she refused to go.

An agitated Jean slapped the nurse across the face. The nurse called security for help and contacted a doctor for permission to administer a dose of Haldol, an antipsychotic medication that can be used to treat delirium and agitation.

Four security officers soon arrived, and Jean was held still while the nurse administered the Haldol. Two other nurses also tried to persuade Jean to return to her room, but she continued to refuse. Together the security guards and the nurses forcibly returned Jean to her room, where she slapped a second nurse.

According to the SHA documents, ‘soft restraints,’ padded straps, were put on Jean’s wrists to keep her in her bed, then the security officers left. But a little while later, a nurse discovered Jean had freed herself. Still very agitated, the elderly patient tried to bite the nurse who was trying to put the restraints back on. Later, the nurse returned to remove Jean’s restraints.

In the hours that followed — alone, scared and confused — Jean called 9-1-1 to get help.

A stressed health care system

Saskatchewan is home to a growing number of seniors, putting more pressure on the province’s health care system and presenting new challenges.

In 2011, Saskatchewan had 153,849 residents 65 years old and over. As of July 1, 2019 that number had jumped to 184,697 — an increase of nearly 17 per cent in less than a decade.

With an aging population comes more trips to hospital emergency rooms, but compounding the issue is a growing number of seniors who experience confusion while they are in acute care or who already have dementia when they are admitted.

According to the Canadian Patient Safety Institute, an estimated 30 per cent of all elderly patients admitted to hospital are affected by delirium, a temporary condition characterized by an acute state of confusion.

People who are elderly, have coexisting health conditions, have dementia or have problems with hearing and vision are more likely to become delirious, says Alberta Health Service.

Delirium can also set in as a result of a stressful hospital environment, with some of the most common factors being medications, dehydration, pain, a lack of sleep and the use of physical restraints.

Dementia, on the other hand, is an umbrella term for several disorders that include symptoms of memory loss and difficulty thinking, problem solving or speaking, according to the Alzheimer Society of Canada. Alzheimer’s Disease is one of the most common forms of dementia.

Across the province, an estimated 19,000 people are living with dementia, but the Alzheimer Society of Saskatchewan expects to see that number climb to 28,000 by 2038.

Thomas Hadjistavropoulos is a psychology professor and Research Chair in Aging and Health at the University of Regina.

“Any person in an unfamiliar environment with no knowledge of what’s going on and no control would feel fear and apprehension,” said Hadjistavropoulos.

“But in a hospital, most of us wouldn’t because we understand why we’re there. We understand the situation. That’s not necessarily the case for a person with severe dementia.”

Between the new environment, cacophony of hospital sounds and any potential pain the senior may be experiencing from the initial cause of their hospital stay, Hadjistavropoulos said a confused senior can become agitated and frightened.

“As cognitive functions deteriorate, the more unfamiliar the environment, the more stressful it can be,” he said. “Seniors with dementia in an acute care hospital would need special attention.”

But as the province’s hospitals struggle with overcrowding and understaffing, the Saskatchewan Union of Nurses warns that the facilities are ill-prepared to effectively treat an increase in confused and elderly patients.

“Health systems don’t plan to fail people with dementia, but rather fail to plan what to do with them when they reach the inevitable crisis of needing more intense resources,” said Tracy Zambory, president of the Saskatchewan Union of Nurses (SUN).

Confused and elderly patients require more care

For patients who become confused in the hospital or come in with dementia, the level of care needed is higher.

Shelley Peacock, an associate professor at the University of Saskatchewan’s College of Nursing, said people with dementia need more time and attention from health care staff in order to understand what’s going on. If they feel rushed, they can become stressed because they perceive they can’t keep up.

“You need to be clearer in your instructions when you work with someone. Some people with dementia need step-by-step queuing. They’re still able to do things, but they need some support in order to remember how to do some of those things,” she explained.

“It just means being really patient and taking your time.”

Hadjistavropoulos said it is best to take a calm and reassuring approach by using gentle physical touch, making sure the patients are comfortable and not making sudden movements. Establishing daily routines in their care that are similar to their routines at home helps create a sense of familiarity.

Assessing for pain regularly is also key, especially for patients with severe dementia who may not be able to communicate if they are hurting. If pain goes undetected and untreated, this can increase a senior’s confusion and agitation, said Hadjistavropoulos.

It isn’t just the staff approach that makes a difference, however. The patient’s environment also plays a large role in minimizing confusion and fear.

“They’re bombarded with all of these … overhead systems and beeps from pumps. That’s unsettling for even someone who’s well,” said Peacock.

“If you’re unnerved by that, imagine what that’s like for someone with dementia.”

Keeping as few people in a room as possible, minimizing machine noises and making light switches easy to find are all ways Peacock said a hospital room can be made more dementia-friendly. Even picking furniture that is a contrasting colour to the floors and walls helps people with dementia, as this makes something like a chair more visible and reminds them they can sit in it.

“It’s the environment and sometimes the people that work with someone with dementia that can contribute to their distress,” said Peacock. “If we nip that in the bud, then we never get to that point where we might have to intervene.”

But the realities of Saskatchewan’s hospitals make giving this kind of attention to confused patients difficult.

A system that has not prepared itself

For Jean Thomas’s children, their mother’s hospital stay was far from ideal.

From the day Jean was admitted to her discharge, Gerry Thomas and Joanne Monz say their experience with the health care system was frustrating and confusing.

In a room with three other patients located directly across from a nurse’s station, Jean felt overwhelmed by the constant noise. Toward the end of her stay, a new patient in one of the beds added dramatically to the noise, frightening her.

“Quite an obnoxious man was placed in the bed across from her. She was scared … he was yelling all the time for nurses,” said Joanne.

She and Gerry also noticed that hospital staff were always extremely busy.

“Every time you went to ask a question, they had no time or you couldn’t find them,” said Joanne, who resorted instead to calling for information.

When Jean wandered from her unit and resisted the nurse’s attempt to guide her back to her room, Joanne wondered why the nurse’s first calls were to a doctor for a Haldol injection and to security.

“Your first call should have been to us … and then I would have said, ‘I’ll be right there. I’m five minutes away,’” said Joanne.

Instead, no family member was notified until about three hours after the incident, when a nurse called Gerry to tell him what had happened. The next day, when Gerry and Joanne visited Jean, they noticed large, dark bruising along her arms, hands and shoulder and began to ask questions about the incident. While Jean was on blood thinners that likely contributed to the severity of the bruising, Gerry and Joanne believe the marks also showed more force than necessary was used.

But it’s not just patients and their family members struggling with Saskatchewan’s current health care system.

Zambory said there’s one word she hears most often from nurses across the province — frustrated.

The frustration is caused by what the SUN president described as a system that does not provide nurses with the staffing levels or training needed to give the time and attention required for seniors with dementia or delirium.

“Registered nurses are trying to work inside a system that has not prepared itself for the onslaught of people with dementia,” she said.

“If you’re in an acute care ward where it’s short staffed, it’s overcrowded and you have such a mix of extremely ill people, how much time are you going to have to be able to actually see the client?”

John Ash, the SHA’s executive director of acute care services in Regina, said it recognizes the need for more delirium and dementia-specific staff training as the province’s elderly population grows.

“That’s something that is being developed,” he said, noting the training focus would be on early detection to prevent situations from escalating.

Nurses currently get training on dementia and delirium as part of their schooling, said Ash. They learn about dementia and how it progresses, how to recognize the symptoms, and de-escalation techniques, like being gentle and calm or removing noises. Depending on the unit they are working in, nurses may also receive additional online training.

Crowded hospitals — a topic raised in the Saskatchewan Legislature this fall after a woman was treated in the Pasqua Hospital hallway for nearly a week — aren’t easing the situation.

Zambory said there has been a “sharp rise” in the number of people coming into acute care with dementia. With nurses unable to meet the higher needs of these patients, confused seniors who become combative is also on the rise, she said.

In a 2019 survey SUN conducted with nearly 1,300 of its members, more than two-thirds of nurses reported experiencing physical violence at work. Nearly all reported experiencing verbal abuse.

Ash said hospitals also have a geriatric assessment unit (focused specifically on seniors) and a dementia assessment unit that can support nurses with confused seniors. Nurses can work together with the physician to identify if a senior patient needs extra support and can call in one of these units to help.

Increasing the family’s involvement in their loved one’s care is also top-of-mind at the SHA, said Ash. If a patient’s family has more opportunity to communicate any concerns they have to staff, then staff can react before the problem grows.

Especially for patients with delirium or dementia, family members are the ones best able to tell if their loved one’s behaviour is normal or concerning. If they notice something like a higher level of confusion than usual or being louder or more withdrawn, they can alert staff before the patient reaches a point of becoming combative.

With this objective in mind, Ash said the SHA introduced an Accountable Care Unit (ACU) team to a unit at the Pasqua Hospital as a pilot project in 2015.

The ACU team — typically consisting of a physician, nurses and other care staff — travels from room to room visiting each patient at the same time each day. This gives the care team a chance to update the patient and their family on the care plan, as well as answer any questions.

Since it was first introduced, ACU teams have seen positive results and been implemented in three more units at the Pasqua Hospital. Ash said the SHA plans to copy the program in the Regina General Hospital in the near future.

“It helps make everybody aware of those subtle changes so that we can be more responsive,” Ash said.

‘Absolute minimum:’ Physical force a last resort

But sometimes a confused and elderly patient’s needs are not met, and disorientation escalates to combative behaviour.

Zambory described this as a natural response to fear.

“Someone with Alzheimer’s or dementia, they don’t lose their humanity and they still have some personality in there. But they get scared,” she said.

“If you’re petrified and you don’t know what else to do and there’s things coming at you that you don’t even recognize anymore … you’re going to try to save yourself.”

When this happens, the safety of both the patient and staff need to be ensured. Ash said if a nurse has exhausted all options for gentle de-escalation or if they believe they, the patient or another person at the hospital is in danger, the nurse can call security.

In fact, nurses are encouraged to frequently communicate with security if they are working with a patient that has a history of becoming combative or if the nurse begins to feel unsafe.

“It’s not like you wait for things to get really bad. It’s, I think we’d like to give security a heads up here, or  we’re looking at maybe engaging security and some kind of early interventions to prevent escalation,” said Ash.

“Allowing those types of situations to progress aren’t good for the patient or the family or staff members.”

Russell Laidlaw, director of protective services and health emergency management for the SHA, said security officers in Regina and Saskatoon are trained in gentle persuasion and de-escalation techniques along with defensive tactics. When called by a nurse, the security response will vary depending on the situation described, ranging from a single officer to several.

Most rural hospitals, however, use court commissioners as security staff. They do not have the same training.

“They’re more of an observe and report mandate,” said Laidlaw, noting that if a situation does escalate beyond their training, they are told to call local police.

If a situation becomes quite aggressive, the SHA said medications and physical restraints can be used — “if the assessed risk warranted that level of control.”

Thinking back on their mother’s experience, Gerry and Joanne question the need for such a heavy security response. They were told by the SHA that the nurse had called in a Code White — which means a violent person — to security.

“They sent four guys to find an elderly woman sitting in her walker,” said Joanne. They were particularly upset restraints were used to keep their mother in bed.

“Of course when they’re trying to restrain her she was fighting,” said Joanne. “It was a horrible experience … It’s sad that something like that would have to happen to somebody who is in their 90s.”

Hadjistavropoulos recognized the need to make sure both the staff and patient are kept safe, but believes very few situations should require physical force by security officers.

“If it is necessary, it should be kept to an absolute minimum,” he said, noting any security response should always reflect the state of the patient.

“Security needs to know what they’re dealing with and that the patient who is confused is not the same as a person who is just aggressive.”

Zambory agreed, adding that even seeing a uniformed security guard could add to the fear of a patient with delirium or dementia.

“You can’t meet that kind of disoriented behaviour with aggression. It’s only going to escalate worse,” she said. She suggested security guards working on medicine units not wear the typical uniform to avoid this scenario.

SHA must evolve with growing number of seniors

By addressing the specific daily needs of patients with dementia, Hadjistavropoulos said nearly all cases of confused patients becoming combative can be prevented.

Peacock agreed, saying staff should have more patience with elderly patients with delirium or dementia and explain more about what they are doing.

“People with dementia just need someone that is calm and approachable and is trying to understand their perspective,” he said.

But with hospitals full to the brim and nurses struggling to keep up, Zambory said this is an impossible task for nurses in the current system.

“What we’re doing right now inside the system is not working for this growing part of the health care population … We have to be able to admit that we’ve got to make some changes.”

She said hospitals need to increase staffing so nurses actually have the time and energy to meet the needs of these patients, walk them through what is happening and answer questions.

Another specific change Zambory recommends is creating dementia-friendly areas in hospitals, although she recognized this comes with a hefty price tag. A dementia-friendly area would have individual rooms with softer lighting, less sounds and more visible signage.

Ash said the SHA does not currently have any spaces specifically designed for patients with dementia, and the idea has not really been considered.

He noted more training is being developed for staff members around patients with dementia, but recognized that hospitals need to make more changes as the province’s elderly population grows.

“We have to continue to evolve to make sure that we’re providing that safe environment for patients,” he said.

As for Gerry and Joanne, they know there is no simple fix for what they consider a failure by the health care system to meet the needs of their 90-year-old mother. Although any changes made come too late for Jean, who passed away in June 2018, her children would like to see more open communication between patients’ families and health care staff and a gentler approach to working with the elderly.

And they want no other patient to go through what their mother did.

lgiesbrecht@postmedia.com