Video of woman collapsing in ER waiting room played at Ontario inquest into her sepsis death

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The lawyer for triage nurse Andrea Demery, who triaged Winterstein the day she died, is now questioning Hayward.

Hayward tells Danielle Bisnar that it can be "mentally challenging" to be a triage nurse over a 12-hour shift in a high-paced, high-stakes environment.

Last week, Demery testified that she only saw Winterstein for a few seconds and she wasn’t reassessed, due to how busy and understaffed the emergency department was that day.

Bisnar says she has further questions for Hayward, so the inquest will wrap up for the day and continue Monday morning. 

Dr. Liz Boucher, a forensic pathologist who was scheduled to testify today, will also address the inquest when it resumes at 9:30 a.m. ET.

Hayward said it's a "nice idea" to have an area in the waiting room for priority patients so triage nurses can visually monitor them, but she doubts people would obey that. 

She also says long wait times in emergency departments are often caused by backups in other departments, so patients who should be admitted to wards end up being warehoused in the ER. 

Hayward is asked about recommendations she may have that would improve patients’ experiences in the hospital emergency department.

Full staffing in the ER area is critical to patient safety. 

"You can't close your doors" when short-staffed, she says.

She says making emergency department staffing is key.

Other ways to address staffing challenges could include having the charge nurse help with triage assessments and registered practical nurses aid in waiting room reassessments.

Increasing doctor staffing would help in getting patients seen in a timely manner, says Hayward, as would having a doctor in the triage or waiting room.

Hayward says she supports Niagara Health's addition to IV drug use as a criteria for sepsis screening.

Varrette asks Hayward about how staffing affects the triage process. 

Hayward says being short-staffed by even one nurse means it’s difficult to do the process and medical directives, and to check patients in the waiting room, she says.

Previously, the inqest heard from a triage nurse that the emergency department was short-staffed the day Winterstein died, at a time when the pandemic was causing overwhelming demand for care and nurses presenting any COVID-19 symptoms weren’t able to come to work.

Hayward says she has experienced burnout working in an emergency department setting.

Varrette questions Hayward about medical directives, which allow nurses to do procedures that would normally be out of their scope of practice, so wouldn’t need approval from a doctor.

Procedures that doctors would normally do including an electrocardiogram for someone with chest pains, says Hayward.

Having a clear picture of whether a medical directive would apply to a patient is important, she says.

Medical directives can help the triage nurse to relay important information to doctors, such as low hemoglobin uncovered in a blood test, says Hayward.

Hayward says a change in a patient's skin colour or level of pain would raise her concern for a patient in a waiting room. Under questioning, she adds she doesn't think frequent repositioning by the patient would raise an alarm bell as much.

Varrette, the inquest lawyer, asks if she would use a patient's prior emergency department visit the day before as part of her assessment.

Hayward says that may help staff learn more about a patient’s medical history. 

"It can be helpful to determine if I need to be more concerned."

Asked if she'd take extra steps for a person with a history of substance use, Hayward says that could be a concern for sepsis. 

"It can be a source of infection." 

For patients with more worrying signs, such as a fast heartbeat or high blood pressure, "anything abnormal is something to pay attention to," testifies Hayward.

On a low-volume day, it's easy to reassess in a timely manner, she says.

"On a day that's very backlogged … it is very easy to lose track of those 15 minutes.

"You just have to be constantly aware" of time passing by between reassessments.

Hayward says raising alarms too frequently may lead to nurses feeling “alarm fatigue,” meaning they’d stop listening to them. This has been backed by research, she says.

"It might not be possible some days" to meet reassessment time requirements.

Hayward is explaining how the CTAS score of severity is determined. 

She says nurses at Hamilton General Hospital where she works have the authority to increase the CTAS score based on certain modifiers. 

A patient given a CTAS 2 score, as Winterstein was, should see a doctor within 15 minutes of arriving, but that doesn't always happen, she says.

They should be reassessed every 15 minutes, she adds.

"Any patient in the waiting room is the responsibility of the triage nurses.”

The inquest has heard Winterstein was not reassessed in the 2½ hours that she waited in the waiting room until she collapsed.

A reassessment can be as simple as glancing into the waiting room to visually gauge if the patient is not in distress, or asking them a quick question, says Hayward.

"It doesn't have to be extensive and lengthy. It can be quite quick."

Hayward says that if patients coming into the emergency department aren’t hooked up to paramedic service monitors, which the triage nurse can use to confirm their vital signs, she would take their vital signs. 

She says she normally gets verbal reports from paramedics, not ambulance call reports.

Typically, patients arrive in a stretcher, except for uncommon cases when patients refuse to get on one, says Hayward.

She says triage nurses also assign a CTAS (Canadian Triage Acuity Scale) score to patients, ranging from Level 1 to 5, with Level 1 being the most serious.

"I work on a trust, but verify principle when it comes to working with paramedics,” says Hayward. “I will always verify that information. It's part of my process to confirm the information I've received is true." 

That can be done by asking the patient questions, she says, noting she would walk up to the patient on the stretcher to do that. 

The inquest has heard the triage nurse on Dec. 10, Winterstein’s second day in the ER, didn’t speak to her, and only looked towards her for two or three seconds as part of her assessment.

Hayward says ER patients are asked screening questions and staff get information gathered by paramedics. 

She says she verifies patients’ vital signs taken earlier by paramedics to check if they are accurate, delves into allergies, current medications and medical history, and will ask patients questions to clarify questions she might have.

Hayward says rechecking vitals is important because vitals can change quickly. 

"I like to verify that these things are true." 

She also confirms the respiratory rate because that's often inaccurately reported, she says.

The inquest has heard the triage nurse who was in the ER when Winterstein was there on the day she died didn't take her vital signs, relying instead on vitals taken by the paramedics.

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