Uncomfortable truth about emergency care

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