Rising burden of emergency department congestion

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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