Sue Ieraci: ED risks take off

COMPARISONS are frequently made between health care and aviation in terms of safety and there is no doubt medicine has learned a lot from the airline industry.

Safety systems in medicine that developed from aviation include staff factors like training and seniority and the effects of fatigue, and procedural issues like checklists, drills and simulation training. The practice of anaesthesia, in particular, has incorporated many lessons from aviation. “Time-out” procedures and cross-checking have reduced patient identification mistakes, drug errors and procedure errors.

Of course, no system is perfect, as the ongoing media coverage about the missing Malaysian Airlines plane makes clear.

Even so, it remains a mystery to me why a health system staffed by smart, motivated people can’t eliminate mistakes. What does aviation have that we don’t? Don’t we value health care more than travel?

The key difference is that health care is an often unpredictable necessity and air travel is a discretionary luxury.

Imagine if commercial airlines operated like emergency departments (EDs). You could turn up at any airport at any time, unannounced, expecting to travel. You would join the queue and demand to board. If all seats were full but people were still waiting, they could queue in the aisle.

A tired pilot would still have to fly a double-shift if a colleague called in sick. And what if no pilots were available? The flight steward would take over the plane — there would be no option to cancel the flight.

While quality and safety have improved markedly in emergency medicine during my career — with better staffing, skills and equipment than ever before — the systematic limitations to safety remain. On top of that, the ED is now more than ever the safety valve for the whole hospital.

Sick patients denied access to the intensive care unit remain in the ED. Patients considered too sick to go to the wards remain in the ED. Inpatient units expect patients referred to them from the ED to be investigated, stabilised and have a provisional diagnosis, while performance requirements expect this to be done in a limited time.

Is it any surprise that ED care generates complaints and errors — especially when seen in retrospect? Not only is the ED providing the community with the right to access unscheduled health care, it is also protecting the rest of the hospital by carrying the greatest load of risk.

This doesn’t mean that EDs should be exempt from continuously learning about and trying to improve safety and performance, but it does mean that expectations should be both realistic and explicit.

The demands of the community and of the rest of the hospital concentrate risk in the ED. It is therefore inevitable that the service provided to each patient will be a compromise, depending on competing demands.

Once this has been acknowledged, it can be managed in various ways. It can be accepted as an inevitable consequence of the way our services are currently designed. It can be improved by spreading the risk across the hospital. Or it can be mitigated by significantly improving ED resources.

Whatever approach is chosen, it is no longer acceptable to blame the ED for its circumstances. We need to be explicit about both expectations and constraints.

A system can’t be safe unless it’s not only designed but is also allowed to be safe.
 

Dr Sue Ieraci is a specialist emergency physician with 30 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management.