Inaccessible medical records, non-functioning equipment, faulty backup phones and pagers and miscommunication by administrators plagued Queensway Carleton Hospital (QCH) for almost 20 hours in early September when the “code gray” was announced, internal records obtained through Freedom of Information submission request. Gray code refers to infrastructure failure. QCH called shortly after noon on Friday, September 9th, which lasted until 9:38am. of the following day.
According to QCH executives, one or two major computer hardware failures — first the main core, then the backup core — affected everything from medical devices to phones. “This is the worst-case scenario,” concludes the hospital’s vice president in a memo. In the hours after QCH lifted the code grey, several doctors expressed anger and frustration at the way the crisis had been handled. “I am very disappointed that we have been asked to continue seeing new patients when our department and the hospital had a serious/catastrophic gray code,” one doctor wrote in an email to hospital leaders. “Our ED (emergency department) should have been closed to allow us to care for the admitted and existing patients in our department… Once again I shake my head at the fact that our collective voice at the hospital we are not appreciated.” Inaccessible medical records, malfunctioning equipment, faulty backup phones and pagers and miscommunication by administrators plagued QCH for nearly 20 hours in early September when it was declared “code gray,” internal records obtained through a Freedom of Information request. (Jean Delisle/CBC) The cause of the outage has not yet been revealed. In a later statement to the CBC, a hospital spokesperson said the age of the equipment may have played a role and the parts in question have since been replaced. “It was a very difficult period of 20 hours, combined with the significant shortages of personnel and the fatigue experienced by the team after 2.5 years of dealing with the pandemic,” the statement said.

Patient and privacy concerns

Internal emails and notes exchanged between staff show that doctors have, at times, had to find unconventional and possibly unethical ways to overcome equipment challenges. “There was no access to CT scan reports. We had a nighthawk [radiologist] from Alberta and had to use our cell phone coverage to request imaging and get reports. “I may have violated some medical privacy rules there so we can help patients,” the doctor wrote in a message after the autopsy. At least four doctors expressed dismay at the “catastrophic event,” according to the records. The CBC is not identifying the four people because they were clearly protesting internally. Patients who came to the hospital on September 9 experienced long wait times in the ED due to equipment not working as a result of the network outage. (Jean Delisle/CBC) According to staff meeting notes, patient privacy questions were also raised about the “delivery of critical lab results over the radio” during the shutdown. The hospital’s chief privacy officer, Tim Pemberton, acknowledged that it was “not ideal, but the best we can do under the circumstances to ensure both privacy and patient safety,” according to the minutes from on September 9. In a later statement to the CBC, QCH said there were “no reported incidents of patient safety resulting in harm, or breaches of privacy.”

Chaotic showdown for backups

In the early hours of the code gray crisis, when most phones, internet and IT systems were down, staff scrambled to alert each other and find alternative ways to communicate. “We are currently experiencing issues that appear to be related to our network,” QCH chief information technology services officer Karen McMullen wrote in an all-executive memo. The emergency department was already full when the code gray was declared, but with none of the doctors able to fully access patient data or send medical orders, staff rushed to distribute backup pagers and radios to the various departments.
The hospital also hired “hand runners” to help pass handwritten notes. The emergency department was already full when the code gray was announced, but with none of the doctors able to fully access patient data or send medical orders, staff rushed to distribute backup pagers and radios to the various departments, according to insiders. documents received from CBC. (Jean Delisle/CBC) Patient call bells and bedside alarms were disconnected from the cordless phones that nurses normally use to answer them. In response, nurses were told to personally check on each patient every 15 minutes and rely on the “visual noise of the call bell and flashing light” in the hallway. “Do you guys have any spare cell phones down there?” wrote a staff member in a message typical of the first emails sent from an iPhone. According to the hospital’s IT department, the network outage was caused by a “core hardware failure.” A statement from the hospital noted that a “software bug” further prevented the backup system that was supposed to work and did not work accordingly. “Hopefully we’ll be back online in a few hours,” McMullen wrote in the afternoon after the code gray was announced. But it would be another 17 hours before McMullen’s department gave the “all clear.”

The emergency department remained open

As night approached, hospital leaders faced another dilemma — whether or not to keep the emergency department (ED) open. Ambulances were diverted to The Ottawa Hospital during the day, but the executive team at QCH chose to keep the ED open overnight, despite calls from doctors to do otherwise.
By dinnertime, a doctor was stationed in the triage area to assess patients. “There was a request to close the ED,” Yvonne Wilson, vice president of patient care, later revealed in an email dated Sept. 10. “We have balanced the risks of closing access to urgent care for our patients, the capacity of the other three hospitals [to] absorb these patients and the impact on EMS to provide services to our community against our providers being able to provide care with delays in imaging, lab results, and the use of shutdown procedures. These factors helped shape our decision to keep our ED open.” Wilson sent the explanation in response to a chain of complaints from doctors after the fact. In an email, a doctor who worked the night shift said he was “very uncomfortable” with the lack of access to phones, healthcare software and patient reports. “EMS had an EMS medic holding down the fort for some of their loads,” he wrote. “Ambulances no longer seem to have got the memo and started falling back around 11pm” Ambulances were redirected to The Ottawa Hospital during the day, but the executive team at QCH opted to keep the ED open overnight, despite calls from doctors to do otherwise, according to internal documents obtained by the CBC. (Jean Delisle/CBC) According to the minutes of the meeting, during the night rush, nine ambulances were dropping off patients, which “triggered” the ED. “Stayed for many hours,” the sign notes read.
Ottawa’s paramedic service said it experienced four hours of “ground zero” on the night of Sept. 9 — ambulances were at their peak from 5 p.m. to midnight. “QCH’s decision to keep its emergency department open during the shutdown helped ensure that patients across Ottawa could access care in a timely manner that evening,” said Pierre Poirier, chief of paramedics services. But another doctor said he “100 percent” agreed the hospital “should have closed the ER.” “Whoever was working that night was sticking their neck out forensically, trying to practice medicine with all the limitations … in detail,” he wrote, referring to his and his colleague’s medical and legal concerns. “I had to send a patient [The Ottawa Hospital] emergency room as I told him without a trace, “I cannot provide you with adequate care here in our ER in the condition we are in.” I told him point blank, “I cannot provide you with adequate care here in our ER in the condition we are in.”- QCH doctor during code gray The doctor explained that the patient who withdrew at night had come in with shortness of breath and other respiratory problems three months after a lung transplant. He said he was unable to help the patient because he “didn’t have access to any of his records or previous imaging.” When asked about its decision to keep the ER open, QCH told CBC it “had no choice but to stay open.” “It was more [out] necessity rather than decision. Unfortunately, it is the frontline team that bears the brunt,” the statement said.

“Mouth” on one, tiny screen

According to various minutes of the meeting, sometime during the evening, hospital staff found a way to use an old monitor to view CT scans. “There is a station set up in the CT scan and the ED doctors need to come in to see the images,” the internal notes read, adding that the monitor was attached to a single console. Based on subsequent complaints from doctors, it appears the screen was also used to view X-ray results. “We were informed that the on-call radiologist would not be able to provide readings for our department for unspecified reasons,” one doctor wrote. “I think the communication was that they weren’t comfortable reading images on that small screen because it didn’t provide enough resolution.” The doctor said it fell to him to interpret the CT scan by “twisting the tiny screen”. “Why is the expectation that we continue to provide care in a substandard environment, but our consultants are not given the same marching orders?” The doctor wrote referring to the on-call radiologist, adding that he did not feel it was an “all hands on deck” way…