COVER HEALTH

Big-city Headaches

D’ARCY JENISH January 8 2001
COVER HEALTH

Big-city Headaches

D’ARCY JENISH January 8 2001

Big-city Headaches

COVER HEALTH

D’ARCY JENISH

Betty Watt is about midway through a typically hectic 12-hour day. She is seated in her cramped, cluttered office on the second floor of Toronto General Hospital. Her desk is littered with papers, the phone is ringing, and the doctor at the door urgently needs her attention. Watt, a grandmother of four, shares responsibility with a partner for staffing and scheduling of what she calls “the most expensive real estate” in the hospital—22 operating rooms where some of the country’s top surgeons routinely perform complex, high-risk operations. On this mid-December day, four nurses have called in sick, three new patients have been admitted with life-threatening ailments, and a surgeon requires two operating rooms for a liver transplant in which a live donor will contribute tissue to a dying relative. “By the grace of God, we haven’t had to cancel any surgery today,” she says. “This is an unpredictable business, and we have no flexibility in the system.” That lack of flexibility is due primarily to staff shortages, says Watt, and it means she is constantly juggling personnel and resources to ensure that the operating rooms are fully utilized. Her department is currently nine nurses short of its full complement of 99, but she expected to fill the vacancies early in the new year with youthful nursing graduates.

In fact, the shortages have created unusual opportunities for talented young professionals such as Kristi Kerr, a 23-year-old from the small Northern Ontario community of Red Rock. Kerr joined the TGH staff in December, 1999, after completing a nursing degree at Lakehead University in Thunder Bay and a four-month postgraduate course for operating-room nurses. She assisted various surgical specialists until May, when she joined the cardiac team, a move Watt describes as “a quantum leap for a new nurse, like going straight from kindergarten to Harvard.” And Kerr admits that, initially, working across the operating table from topflight heart surgeons was intimidating. “It was stressful, very scary,” she says.

The shortage of nurses and other medical professionals is a major problem at Toronto General and two affili-

With every operating room in use, there is none available for emergencies

ated institutions—Princess Margaret Hospital and Toronto Western Hospital—that make up what is called the University Health Network. In midDecember, there were about 2,200 nurses working at UHN, the country’s largest hospital operator, but nearly 300 positions were vacant. Department heads also say they cannot hire enough cancer treatment specialists, physiotherapists and anesthesiologists, among other professions. The personnel crunch forced the organization to close about 50 of 920 beds throughout much of the fall, and almost 240 remained empty over the Christmas-new year period due to staff holidays. And for more than 100 days last year, the two emergency departments had to redirect ambulances to other hospitals because they did not have the staff available to admit additional patients. “Almost everywhere you look, there are shortages,” says UNH president Tom Closson. “Staffing is going to be our biggest issue for the next 10 years.”

Solving all the problems may take even longer. Dr. Robert Bell, a surgeon and vice-president at Princess Margaret, Ontario’s largest cancer-care operation, says his institution cannot find enough radiation therapists, the technicians who administer the treatment to cancer patients. There is also an impending shortage of radiation oncologists, the doctors who assess patients and determine the dosages they are to receive. The use of radiation has expanded dramatically over the past decade, usually as a secondary treatment to eliminate microscopic bits of tumour that may have been left behind in surgery. In Ontario, Bell notes, close to 30 per cent of all cancer patients now receive radiation.

But the training of therapists has not kept pace with demand. A class of 50 students are on course to graduate in May, 2002, from the radiation therapy program at Toronto’s Michener Institute for Applied Health Sciences, but as of Nov. 30, cancer-care facilities in Ontario had 66 vacant positions. Bell says Princess Margaret, which already employs about 120 radiation therapists, could easily use another 20. The hospital has 15 radiation machines that are in use up to 10 hours a day, but they could be operating 12 to 14 hours daily, given the patient load.

The lack of therapists has meant two things. Since April, 1999, Ontario cancer centres have sent 1,545 breast and

prostate patients, about nine per cent of their case load, across the border to clinics in Buffalo,

N.Y., Detroit and Cleveland for radiation treatment. In most cases, those patients had faced a wait of at least eight weeks following surgery before radiation could commence in Ontario. And since last January, Cancer Care Ontario, the organization that coordinates treatment provincewide, has been recruiting radiation therapists internationally. It has hired 71 from eight countries, including England, Australia, Nigeria and Trinidad, and an additional 74 came from provincial training programs or from across the country. But by midDecember, only 75 remained employed in Ontario, due to retirements or departures for positions elsewhere.

Meanwhile, says Bell, Ontario’s cancer treatment system is on the brink of a desperate shortage of radiation oncologists. The province’s medical schools are producing only one or two of the specialists per year, not nearly enough to replace those expected to retire within the next five years. Furthermore, there is no quick way to turn out more qualified practitioners because of the extensive training they need—four years of undergraduate study and another five at the graduate level. “We recognize the need, but we have to convince the medical schools and the government to fund more slots for radiation oncologists,” he says. “Then we have to attract more students.”

The personnel shortages have forced managers at the three UHN hospitals to be innovative and efficient. Catherine Kohm, the clinical utilization manager at Toronto Western, says her duties include working with department heads each day to ensure that resources are available to meet ever-changing demands. Sometimes it just isn’t possible. Two heavy snowfalls in mid-December brought an influx of patients with fractures requiring surgery. With the orthopedics floor quickly filled, new patients had to be assigned to beds in other wards and face a long wait for surgery. “One day, we had five patients we simply couldn’t operate on until we had the right beds post-surgery,” she says. “A big part of the problem was staffing. We have ortho beds closed because we don’t have nurses.”

On the TGH surgical floor, operating rooms are booked 100 per cent of the time, leaving no excess capacity for emergencies or for transplants, which must be done swiftly when an organ becomes available. “Everybody is working their tail off,” says surgeon-in-chief Dr. Bryce Taylor, “and we’re running so close to the line that it just invites difficulty.” Just ask Betty Watt. “If one or two nurses phone in sick and I can’t replace them, I have to cancel surgeries,” she says. “I spend half my life on the phone trying to find people.” In circumstances like that, everyone suffers, including the patient. CD

Watt (left) and Kerr: constantly juggling personnel to keep surgeries on schedule