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JOHN Kennedy once said: “We enjoy the comfort of opinion without the discomfort of thought”. Cynics may suggest that we have avoided significant discomfort in the public debate in regard to emergency health care.
Professional emergency health care has been transformed over the past four decades with the upgrading and modernisation of both prehospital and hospital-based acute care and the development of new professional roles of paramedic, emergency physician and emergency nurse.
While the improvements in health outcomes are unquestioned, this transformation has also been associated with system-wide congestion which is known to have adverse clinical, organisational and social outcomes, and which is caused by the combined impact of increased demand, access block and increased clinical capability.
However, the public policy responses have tended to be predicated on blaming someone rather than an in-depth understanding of the causes of the problem and designing solutions based on that understanding.
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We have tended to blame the patients by calling their attendance “inappropriate”. Or we blame the clinicians or the government for cost shifting, inefficiency or insufficient resourcing.
However, the evidence collated over the past 10 years in particular has shown an entirely different picture and the trends have been confirmed in the recent report into emergency department care by the Australian Institute of Health and Welfare.
Demand for emergency health care is growing by 2% per capita each year (3% for ambulance). Growth is among the more urgent triage categories, across all age groups and both genders and across the system as a whole.
Further, interviews with patients confirmed that the decision to seek acute medical care is generally a conscious and well considered decision based on weighing up the alternatives and often supported by advice from family, bystanders or health professionals.
However, to date the public policy responses have been based on opinion and not on sound evidence. Thus nurse-led telephone advisory services, public awareness programs on “appropriate use”, co-located primary care centres, and “super GP” clinics have not been shown to reduce emergency department (ED) demand; sometimes the contrary.
Increasing health literacy supported by public awareness campaigns tends to raise awareness of risks and thus tends to increase demand. Finally, the 4-hour rule – that 98% of patients arriving at the ED are to be seen and either admitted, discharged or transferred within 4 hours from the time of triage – was an attempt to focus whole-of-system attention to the problem of congested EDs. While this has provided some immediate relief, it has consequences, as trade-offs occur with quality and efficiency, and the system rapidly reaches a new equilibrium constrained by system-wide capacity constraints.
So what would be a thoughtful, if uncomfortable approach?
First, we need to accept that the growth in demand for emergency health care is not a conspiracy by anyone but rather a real representation of growing disease prevalence complemented by improved clinical technology and the capacity to intervene.
We need to accept the uncomfortable truth that there are more sick people seeking acute medical care and we need to design our emergency care systems to deliver that care in the most efficient and effective manner.
To reduce ED congestion we need a more comprehensive and strategic set of approaches:
- First, reduce or at least moderate the growth in demand by designing community-based services that may meet patients’ real needs. This may require changes to primary care or the creation of acute care centres such as have been introduced in the UK or greater reliance on paramedic and mobile GPs to provide care in the patient’s home.
- Second, we must speed system throughput by redesigning our services to improve their efficiency and effectiveness. There have been many strategies including fast-track and consultant-led care that aim to improve the internal efficiency of emergency health care.
- Finally, we must deal with the system-wide capacity constraint which causes access block — the principal cause of ED congestion. This ultimately involves enhanced inpatient capacity, although for many reasons that additional capacity needs to be well targeted and appropriate to patient need.
To do this we need to understand the complexity of the emergency medical system and to identify, design and evaluate strategies based on that understanding, as uncomfortable as that thought may be.
Professor Gerry FitzGerald is Director of the Centre for Emergency and Disaster Management at Queensland University of Technology’s School of Public Health
When the lights are on, the door open, and service is free, 24/7 , people will use it
Its the”department of available medicine”, and after hours, in most localities, the only available health rescourse.
Now,the public here want healthcare to be free, fast and good, and it can only be two at once.
Its currently good (very good if you are seriously ill) and free, so naturally, it wont be, and can never be, fast.
Fitgerald really is saying that “Therer arent enough beds”, and that beds have been withdrawn over the last 20 years, as they are the only lever the govermnent has to control costs, a bed costs about a million dollars a year.
No govt. wants to increase the bed supply, so much of the action is greasing the current system, yet it is probably a fully greased as can be.
One pressure point is elderly frail patients with no where to go, either no money for a nursing home place, or no suitalle home/family tyo care for them. As N/H beds are licensed by the Federal govermnent, and cost about 100K p/a to build and maintain annually, they are unlikely to open the purse.
So the congestion problem is here to stay?
As Michael says, “There’s no point telling people that emergency services aren’t appropriate if there is no where else they can reasonably go.” People come to EDs because they provide a service that is desired – unscheduled, a quick safety check at triage, a wait that is generally proportional to the urgency, a range of clinical skills, equipment and tests, and a wide range of treatments or referrals. Why do we have to feel bad that patients appreciate the service? If there were a single payer (rather than the federal-state funding split), and therefore no incentive to cost-shift, we might find that the lower complexity ED visits (generally injuries) are seen more efficiently and cheaply there than elsewhere.
OFten people have already been to their GP, and the issue either got worse, or the issue wasn’t solved, or the GP told them to go to ED anyway.
IN the rest of the world, having lots of people use a service that they like is not seen as a bad thing. We could contain both the costs and the time spent in ED by having experienced clinicians making pragmatic clinical decisions and not over-testing.
In response to er dr’s comments; I don’t see that Dr Fitzgerald said that it’s up to ‘Emergency Services to simply provide more and more’. One of his recommendations was the development of ”community-based services that may meet patients’ real needs’,that is address the paucity of after hours, forensic and affordable health care outside the ER. There’s no point telling people that emergency services aren’t appropriate if there is no where else they can reasonably go.
Having spent many years in Emergency Medicine and General Practice, both in Australia and the UK, I acknowledge the validity of all the comments mentioned above. However I would suggest, to Cornelius, that all nursing homes are well equiped to deal with dying patients and are staffed by caring people who are more than capable of palliating patients. Indeed that is the norm. The issue is invariably the relatives of a few nursing home residents who will insist that “everything be done” for their loved ones. There would be many General Practitioners and Nurses in aged care facilities that would consider Cornelius’ comment ill-informed
Medicine has that curious status as an ‘essential service’, but for which one cannot conscript.
Yet while we are opposed to removing incentive penalty rates for e.g. the catering sector on weekends, we will not ‘incentivize’ reward rates for health care, particularly for practitioners who have to pay award rates to staff on weekends.
I understand that health care is necessary 24/7, but what will encourage me to provide it?: particularly now that we recognise ‘work-life balance’ issues. Without incentive – increased rates of disease notwithstanding – people will increasingly need to attend A + E, because regular local medical services will not be open.
‘Facing up to the reality’ articles like this are eexcellent.
Professor Gerry FitzGerald’s thoughts appear to me to be well formed and informed. Systems re-engineering is a complex and dangerous enterprise. All change invariably delivers winners and losers. In a way, the modern emergency department was an example of disruptive rogue technology. Many pre-existing parts of the greater health system were either de-skilled or lost the incentive to acquire and maintain skills. More sophisticated clinical governance and risk minimisation didn’t help this situation. How much of EDs problems are of their own making? Perhaps a new disruptive rogue technology is needed. Could ICT be the vanguard of that change.
not sure that I agree that it is up to Emergency services to simply provide more and more.
There are far too many people attending Emergency departments with non emergencies, eg a sore shoulder for the past 3 months. People often are attending Emergency departments after hours because it is convenient socially for them to do so and because they don’t need an appointment nor have to pay any money. Too many socially disadvantaged people are ending up at Emergency departments because of homelessness, chronic mental problems or drug & alcohol problems because there is a paucity of after hours services anywhere else that they can turn to other than Emergency departments. The Police are bringing in far too many angry and/or mildy intoxicated people to Emergency departments because there is a paucity of Forensic medical officers to assess them in Police custody. There are far too many elderly nursing home residents being sent to Emergency departments at the drop of a hat when they really should be being treated, or dare I say palliated, in the nursing home. Yet Emergency departments more and more are being expected to provide end of life care to demented frail nursing home residents because it seems the nursing homes don’t want to manage deaths or are not equipped to do so. Should Emergency departments simply provide more and more whilst the rest of the health and welfare systems and society in general does nothing ? I don’t agree.
It is also a much more costly way of doing things.