EVEN without a natural or man-made disaster, Australia’s public hospitals struggle daily with acute clinical care and elective surgery (here and here). To be seamlessly efficient, a hospital should operate at no more than 85% capacity, yet Australian hospitals operate at 90–95% capacity, leaving little room for contingency situations.

Increasing demand for emergency medical and inpatient care results in overstretched ambulance services and congested chaotic emergency departments (ED). Threadbare hospital bed capacity filled to the rafters – paired with Spartan clinical staffing – is a sure recipe for a disaster.

As an emergency physician, I admit that my routine work life feels as though I am skating on thin ice.

There is a high risk of adverse outcomes for communities because of ambulance, ED and hospital capacity being overwhelmed by the unsustainable demand for acute and elective health care. Overcrowding stems from hospital access block due to inadequately staffed hospital beds, and leads to more frequent medical errors, decreased patient satisfaction and increased staff workload and stress.

Ambulance congestion or diversion, where stressed and overworked paramedic crews spend hours driving around trying to find a hospital that can take their patient, merits attention, with a third of patients arriving at hospital by ambulance nowadays. A significant number will remain on stretchers for long periods in the care of paramedics, awaiting entry into the ED. The so-called “ramping” adversely affects patient outcomes, incurs delays to time-critical treatment and reduces ambulance service capability to respond to new calls.

September 2016 witnessed a 175% increase in ambulance ramping in metropolitan Perth, with paramedics spending 2200 hours caring for patients waiting to be admitted.

ED overcrowding is clearly associated with increased death rates, hospital length of stay and longer door-to-needle or balloon times for heart attack and stroke treatment. The care of patients who are critically unwell is compromised by lower staffing levels in the ED than an ICU that has no bed or nursing capacity to take further patients. Already congested and understaffed EDs are expected to keep their doors open for new and minor cases. Patients needing resuscitation are at risk of far worse outcomes when stuck for hours in ever busier EDs.

Such harm may similarly be imposed on ambulance-transported patients who have a critical illness and face delayed admission to ED, or even diversion from their usual hospital to one that is unfamiliar or ill-equipped to deal with complex, high acuity and specialised care.

Without electronic records, these patients’ medical notes are frequently hard to access.

Ambulance load sharing doesn’t make sense if it leads to the patient being brought to the wrong hospital or some ending up far from their “home hospitals”. For example, a patient who was dying and in palliative care was diverted by ambulance to my hospital after being discharged the same day from his distant home hospital, where he had previously spent several weeks and was close to his family. Similarly, a patient discharged hours after having vascular surgery was brought to us with heavy bleeding from his wound.

Escalating ED workload due to greater demand and acuity in overcrowded spaces creates stressful environments that contribute to higher staff turnover and burnout. Ambulance congestion’s negative impact on staff results from busier and stressful caseloads. The impact of this is mostly felt by paramedics, triage nurses and nursing shift coordinators. According to interviews with ED staff and ambulance crews conducted in southeast Queensland, staff are less inclined to present for duty and the crowded ED–ambulance interface causes strain on relationships between hospital staff and paramedics. Due to access block, it is my experience that most hospitals routinely operate at the level of an internal disaster.

Ambulance crews endure high levels of stress, poor morale, forced overtime and are unable to be deployed to far more pressing call-outs. This was recently borne out in Melbourne’s thunderstorm asthma episode when more than 2000 people suffered breathing difficulties. Ambulances attending to twisted ankles and alcohol overindulgence cases would not be available to respond to such an urgent surge that exceeded ambulance capacity.

The latter contributes to increased workload for crews who are not waiting on hospital ramps, as there are fewer crews available to respond to calls. There is also confusion regarding professional boundaries and responsibility for those patients waiting to be admitted to the ED.

Ambulance congestion and diversion could be mitigated by increasing hospital capacity, underpinned by improved medical and nursing staffing in ED and in hospital wards.

It is crucial to have excellent teamwork and communication between the triage nurse and medical and nursing shift coordinators to expedite patient flow, as is a whole of hospital response to threadbare resourcing. Public health education to better enable people to manage their own health and use health services appropriately may prevent non-emergent presentations and inappropriate use of ambulance.

Although hotly debated, there is credible evidence that demand for hospital care is reduced by triaging patients out of the ED to alternative health services such as dentists and GPs. Patients with minor complaints who agree to seek community care  did not suffer worse outcomes and may in fact have gotten more timely and satisfying care. Hospital avoidance programs such as Hospital in the Nursing Home and a home IV service also help.

However, we now face the newer crisis of people who are ill being unable to access hospital care because they can’t even get through the front door.

Improving hospital capacity and staffing could decongest the ambulance queue I often encounter with dread every Monday morning. Moreover, the community needs to treat all health care resources as finite, limited and valuable. Using ambulance, ED and hospitals as though they were an apparently free entitlement for minor illness is injurious to those patients who cannot afford to wait for their emergency care. We need to do more to educate the public that requesting an ambulance for a sore finger risks delaying paramedics from attending a serious road accident.

Joseph Ting is an adjunct associate professor in the School of Public Health and Social Work at Queensland University of Technology in Brisbane.

 

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11 thoughts on “Rising burden of emergency department congestion

  1. Philip Dawson says:

    (1) to stop minor care cases crowding hospitals, give only necessary emergency care eg an ambulant patient on a sunday with a sore throat diagnosed as tonsillitis in the emergency department gets only enough penecillin capsules to last a day, no scripts no certificates off work, see their GP. They soon stop coming to ED if thats all they get. When I worked in ED decades ago a regular night shift nurse noted the same patient presented at 3 am wheezy every month saying he had run out of ventolin. Now awake to his scam, we refused to give him a free inhaler, gavve him a ventolin neb, instructed to return in 4 hrs for another se GP in morning. He soon stopped coming. These stategies have not been implemented in most hospitals, many interns wishing to play GP and see the minor cases, in some cases asking them back for reviews. Not the EDs job when they cant see all the emergencies. Re ambulance ramping, out ambulance service has bough extra trolleys, a stable patient is wheeled in to the ED accompanied by an ambulance volunteer, leaving the ambulance free to leave the ramp and pick up another emergency. Seriously unwell patients are of course prioritized by ED, its only category 2 and 3 who wait, category 1 in ur hospital goes straight in, no waiting for the cath lab by being ramped.

  2. Lynette Reece says:

    A well thought out article with clear articulation of the problems. These problems wont be improved until the goverments stop cutting corners and giving us hospitals too small to cope with the demand.
    The danger in running at 90-95% capacity is well documented but it seems to be ignored.

  3. Carol Skinner says:

    It would help a little if hospitals communicated a bit better with patients. I went to an ED because it was Saturday and my GP was closed – not an emergency, but I didn’t know how else I could get help. I did not know that the hospital had a list of doctors who were open at weekends, and was not told about this until I decided to leave without treatment, after a long wait. Why not put signs on the wall, telling patients that this info is available? Most of us would happily go to a GP if we knew where to find one out of hours. Similarly, an explanation of the triage system would reduce aggressive confrontations by people who think it is “first come, first served.”

  4. David Mountain says:

    Although the article correctly summarises the problems and concerns related to overcrowded ED, ramping and access block the author is seriously misguided in his suggested solutions. It is unfortunate that an Emergency physician continues to fixate on minor issues/ GP type patients which have no meaningful impact on Ramping, access block or ED dysfunction. The literature (3 articles below all from mJA) is clear that for major EDs minor/GP type work is neither a large issue in terms of numbers, and even less so in terms of resource use or actual compromise to ED function. EDs are overcrowded almost exclusively when they cannot get their hospitals to provide capacity/beds/ organisation to take the sickest patients to an appropriate bed and instead they are left in the ED, compromising both those patients care and the care of other sick people trying to access the ED. Superficial suggestions such as those described by the author are just the sort ogf myth making politicians / administrators latch onto so they can divert more money / attention way from the real issues (beds/capacity/ disorganised administration) towards non -solutions like after hrs clinics/ urgent care centres and telephone lines.
    If this is the advice/ myth-making our own specialists are giving administrators it is no wonder they stay fixated on these non-problems.

    https://www.mja.com.au/journal/2009/190/7/myths-versus-facts-emergency-department-overcrowding-and-hospital-access-block?inline=true
    https://www.mja.com.au/journal/2013/198/11/quantifying-proportion-general-practice-and-low-acuity-patients-emergency
    https://www.ncbi.nlm.nih.gov/pubmed/12656784

  5. Malcolm Brown says:

    People with non-urgent conditions go to EDs because their GP may not be available, because the care is free, and because they expect they’ll get all the investigations, diagnosis and treatment at one place. If we build more and bigger EDs, more and more people will go there instead of to their GP. The whole system of health care provision and funding needs a radical re-think, and the AMA should be leading the debate.

  6. Anonymous says:

    You need to start charging patients and they will think twice about fronting up to the emergency department for minor problems that any GP can manage.
    We did that successfully overseas in Hong Kong because some people were coming in on a Sunday in a chauffeur driven Rolls Royce to have their plaster change for free.

  7. Dr Raymond Yeow says:

    “,…..We did that successfully overseas in Hong Kong because some people were coming in on a Sunday in a chauffeur driven Rolls Royce to have their plaster change for free…”
    I Love that….eventually any service free or cheap will be abused

  8. Ian Hargreaves says:

    4 houses are demolished to make a block of 50 units. The local schools have demountable buildings on what used to be play areas. In my suburb, the state government’s urban consolidation policies result in about 20,000 extra population over 10 years. The state government takes the stamp duty on the new buildings but does not earmark it for vital infrastructure.

    The local hospital, the Royal North Shore, was rebuilt, but without significant additional capacity to reflect the rapidly increasing population, and expanding indications for modern technologies like cardiac stenting or stroke thrombolysis.

    The logical solution is smarter politicians. Or failing that, accepting that emergency healthcare, like traffic flow, is doomed.

  9. Kylie Fardell says:

    Thought-provoking article. I can’t agree that the resourcing is ‘threadbare’, however, and I think there needs to be more consideration of what we could do within EDs to make better use the available resources. In particular, close supervision of JMOs to prevent over-investigation as a means to compensate for lack of clinical experience and excessive reliance on protocols might be helpful and shorten the duration of the stay of some patients. (I’m thinking particularly of presentations of chest pain that are clinically highly unlikely to be cardiac, and patients with vertigo that clinically is unlikely to be central in origin but who are still subjected to brain imaging, for example).

  10. Anonymous says:

    There few ways to stop this rising burden of ED congestion. One , put a big note on the door that says – this department is for emergency cases only. Unfortunately, laymen’s emergency is not the same as that of a doctor’s hence the triage. Which is number two – the triage nurse explains the situation and if needed, inform the patient on what to do , which includes seeing the GP or if close, seeing a clinic that is open after giving proper advice . Three, charge patient if still wanting to be seen for minor problems but advice about the wait – as things are prioritised. And lastly , educate the public. There have been ads on television about this , reinforce it.

  11. Sue Ieraci says:

    Other commenters are correct in noting that it is not the minor, non-complex cases that clog our EDs, but the sick, complex and high-risk cases – the frail elderly, cancer patients, heart failure and COPD patients with yet another acute exacerbation, and many patient referred from GPs or community specialists for “rule-outs” or other tests, because we are all scared to accept risk.

    Community providers displace risk to ED by referring patients, and ED clinicians may displace the risk again by referring for inpatient admission. Admission ‘just in case’ is seen as the safest option – and realistically, one can be crucified for sending home “the patient who died”, but not for admitting patients who would have done better out of hospital.

    If the solutions were simple, we would not still be discussing them.

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