more_vert
IN February of 2020, I was quoted in The Guardian as saying, “Part of the pandemic plan is ‘hospitals opening their surge capacity’. — now, I don’t want to alarm anyone, but there is no surge capacity; It’s all open … we are full every day; we’ve been saying this for years”.
“That capacity will be created through other means [cancelled surgery/outpatients]. But, there are no excess beds or staff. If there were, our [emergency departments (EDs)] wouldn’t be bursting, our ambulances ramping, and our staff burning out.
“Australia’s health system will manage [COVID-19] well, due to the hard work of healthcare workers. My point is that we operate our system at, or over capacity and to pretend there is ‘surge capacity’ is wrong.”
In order to prepare for the anticipated COVID-19 surge, elective surgery was cancelled. The homeless were housed. We moved to telemedicine. We went into lockdown. We saw a drop in infectious diseases of all sorts. Other presentations – trauma, acute myocardial infarction and stroke – declined; we remain unsure why.
The Australian response was world leading. The projections of thousands of lives lost did not eventuate, thanks to our public health planning and the commitment of the Australian population. At that time, we all understood the interconnected nature of community action, the broader health and welfare systems and the impact on the hospital system. We all acted to protect our citizens and protect the health system and it saved many lives.
But now, emergency medicine in Australia is in a dire state. Anecdotally, mental health presentations to EDs have increased, the adolescent and young adult cohort in particular, and the inpatient areas are full. Paediatric presentations have rebounded, higher than ever, but accessing GPs is difficult, with many trying to balance multiple competing demands, including the on/off again COVID-19 vaccination program, a lack of funding and resources. So EDs are the destination for many concerned parents.
I have observed aged care presentations rising, with care very limited in aged-care facilities, but medical and aged-care wards are full, so the elderly and frail lie in ED corridors, waiting.
I can see our ICUs bursting, with critical care patients spending longer in much needed resuscitation spaces, with the next resuscitation happening in a hallway, on an ambulance trolley.
The acute parts of the health care system (EDs and ambulance services) are spending part of most days in “Code Yellow” – a perpetual state of crisis escalation. Ambulance arrivals are up, and ramping is at record numbers, hitting the headlines across the country. Admission times to wards have blown out to record lows (admitted National Emergency Admission Times [NEAT] in many hospitals is below 10%), with the number of patients staying days increasing substantially. Some EDs, to my knowledge, have reported having upwards of 40–50 patients waiting for admission at the start of the day, expecting to see another 300 arrivals. “Waiting room medicine” is the norm, with patients waiting 7–8 hours to be seen.
There is a push to get our surgical lists under control and operate on those whose semi-urgent surgery has become urgent, but the beds aren’t there. They come to EDs because they are sicker or in pain.
We know that these circumstances lead to increased mortality. The Australasian College for Emergency Medicine (ACEM) recently released its position on admission targets, advocating that the hospital admission times are the most important indicator of patient mortality in an overwhelmed system. Of note, a recent article by Jones and colleagues points to an increase in mortality if a patient arrives to an ED where 10% of beds are occupied by admitted patients waiting longer than 8 hours. Currently, we are seeing levels of 70–80% of beds occupied by admitted patients (it is too early to have data other than our own lived experience); the current mortality risk is substantial. Anecdotes from ED directors, medical and nursing staff tell us this is happening now. Data collected over the next 12 months will tell us how bad this situation actually is.
In EDs, we spend significant time and resources caring for inpatients, instead of doing the job we are meant to do: seeing the undifferentiated, acutely unwell and providing emergency and critical care. The current key performance indicator, the NEAT, holds EDs responsible for things they cannot control and does not focus enough on reducing access block – defined by ACEM as “the situation where patients are unable to gain access to appropriate hospital beds within a reasonable amount of time, no greater than 8 hours” – which we now know, beyond the shadow of a doubt, is dangerous for our patients. It also requires a whole-of-hospital effort to fix.
It would be fair to say that what we are experiencing now is the worst I have seen in my 30 years in emergency medicine.
If we had no surge capacity pre-COVID-19, we are now in a situation where we can’t safely manage the “new normal” daily workload. The impact on staff is profound. I can see stress and burnout across many areas. I see staff moving out of the acute sector to COVID-19 clinics and vaccination hubs, citing a need to change paths for their own wellbeing. Many have reduced their hours or left the health system. As a result, in my experience, many beds are unable to be staffed and are closed, making things worse.
And winter is just around the corner. The tightrope we were balancing on pre-COVID-19 is now being shaken from both ends and we are seeing many people falling off.
What are the solutions?
In the short term, very little. If patients cannot access care elsewhere, they will come to EDs. If a patient can’t see their treating team in outpatients, if they can’t see their GP in time, if they can’t access community mental health care, they will come to the ED.
In the medium to long term, there needs to be a substantive review of how our hospitals are staffed and operated. No longer can we shut down over weekends or after 5 pm. No longer can we accept that many of our major urban hospitals, and most of our regional and rural hospitals, rely on doctors-in-training doing the bulk of the work. The reliance on visiting medical officer models, fractional appointments and an administrative view of minimising the presence of consultant staff on the ground needs to change. We need more senior clinicians in more substantive roles spending more time in the acute areas, making senior decisions and facilitating patient care, improving care and decreasing the growing risks.
And we need to reset community expectations about what is good and reasonable care. We need to boost the care available in aged care facilities to ensure that residents can be kept well and avoid trips to hospitals and ensure our GP colleagues are supported to do the job we rely on them to do; to be the linchpin in coordinating patient care.
We need more focus on prevention. The Australian health care system is largely focused on intervention. That’s where the big money is, so that’s where the industry focus is. Prevention will save money, not make it. Nobody earns a buck for not intervening or doing a procedure. Prevention needs to be supported, rewarded and remunerated. As an emergency physician, the best system I can imagine is one that prevents illness and disease and makes my job boring.
The solutions to this state of ED overcrowding and demand/supply mismatch don’t, to a large extent, sit within the rubbery walls of the ED. Sure, there are resources targeting EDs, which many will accept. Many EDs need more staff, an expanded short-stay unit or more nurses to keep all their beds open and deliver care. This will help address the symptoms, but not cure the disease.
The solutions need to focus on keeping patients well in the community and, when admission is required, freeing up access within the hospital’s systems to allow smooth and timely transition into ward care. This can only be done though creating more bed capacity (and staffing it), reducing length-of-stay within wards, and finding alternatives to inpatient management.
I would very strongly advocate that most hospitals would do well to look at the structures and staffing in their inpatient teams to ensure they are resourced to provide timely care every day. I have many colleagues across different specialty areas who would gladly take on substantive roles in our public hospitals, if only there were the funding to allow this to happen.
Change is needed.
EDs have become the pivot point of system failure. Whether it be mental health care, drug and alcohol care, homelessness, underfunded or inefficient outpatient clinics, lack of hospital capacity, all roads will eventually lead to the ED. We, our departments and the patients who increasingly have nowhere else to go, are the canary in the coal mine of system failure. We need to remember the lessons of COVID-19: that our systems of health, welfare and public health are fundamentally linked – a failure in one will inevitably lead to more ED presentations, longer waits and less safe emergency departments, for all of us.
Currently, our system is failing many who need it to be better. The solution is not bigger canaries, but a collaboration from all parts of the system, from GPs, through EDs to inpatient care and beyond, to ensure we all understand the risks patients are facing and work to rebuild a better system for all in a post-COVID-19 world.
Dr Simon Judkins is an emergency physician, the Immediate Past President of the Australasian College for Emergency Medicine and recently became a divisional representative for the Australian Medical Association Victoria.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
Loading ...
We need to look at the root of this crisis: Margaret Thatcher and economic rationalism.
Under Thatcher, public entities, like hospitals, changed to a “business” model.
This meant that my tertiary hospital, for instance, had 550 beds in 1984 and now has 210.
Before Thatcher, patients went to a hospital bed as soon as they were admitted.
The angloceltic countries, Britain, Australia, USA, adopted economic rationalism with fervour. Europe did not, with the result that most European countries still have functional public health systems whilst we do not.
As an ED Physician myself I sympathise with the sentiments that Simon has expressed.
We are seeing a return to pre-COVID numbers of presentations but with increased complexity due to inadequate maintenance / preventative care during the COVID lock-downs and ongoing inadequate access to primary care.
However, I work with an incredibly dedicated team of professionals in a public ED doing their best to care for patients, and although we do not always get ot right, the vast majority of our patients receive an excellent level of care when compared to most countries around the world.
So even though the system is not perfect, it is not at a point that we need to abandon it, and god-forbid introduce a system that focuses on profit and leaving the most vulnerable in our community locked out like in the US.
Yes we do need to reform healthcare and we do need to instill healthy lifestyles in our population, but we have been gradually doing this for many years and will keep doing so for a very long time to come.
I am a big believer in preventative healthcare and wellness for all workers including those in health and whilst we work out the system issues, at least we should spend each day helping those around us.
Interesting article. Having worked in New Zealand , we didn’t get psychiatric presentations in emergency departments , they were accessed by community assessment teams and had direct assessment by a psychiatrist and admitted straight into a psych ward (public system ) . There was no emergency department presentations which was excellent . The exceptions of course if overdose or self halm and needed medical treatment 1st.
Thanks for writing about an issue that we are all aware off but somehow only ED physicians acknowledge. Not acknowledging a problem would not make it any less significant or disappear. You have articulated your thought well about the problem . Unfortunately solutions are multidisciplinary and beyond the reach of ED physicians in a system that only responds to a crisis with bad outcomes that are visible to general population aka voters. I think the focus should be on educating common public and interested politicians about the risks of not having access to an ED bed.
I’m a wandering Locum /ED School drop out- Burn out, Bullies and Bad manners rs (mostly other drs and their egos) and my thoughts on what is needed for the community in and around EDs: Education on how to live well, look after your body, mind, spirit- and how to look after those around you, plus more money for GPs to stay and spend time with and to foster a relationship with; the people they are helping to live healthier. ED and radiology 24/7 makes that the support, then a robust “help you stay at home “ aged care/palliative team” and by George we’ve got it !?
This addresses many of the issues facing our health system , others include –
Who decided to close after hours and GP Superclinics ?
Why don’t we have emergency facilities for mental health presentations at dedicated facilities ?
Is there an upper age limit on patients admitted to ICU units ?
Surely the facilities at Private hospitals ED departments are under utilised , if cost is a factor they could be supported to lift their admissions .
Very well written and timely article Simon,
Thank you for championing the cause and advocating for patients and staff. You are greatly appreciated and I hope you continue to be a much needed thorn in the side of the controllers of the purse strings! It is a thankless job, but all of us on the floor are very glad you do it.
I’m a current ED trainee who is writing this as my anxiety about my job keeps me awake. I beleive comments in the article and all below are true and agree with the wellmeaning sentiments. Certainly the problem is intractible and its roots multifactorial. Nonetheless in the current model ED and hospital system is relied on so heavily that there is unfortunately little hope of meaningful change. Keeping people out of hospital and engaging service delivery is all well and good until you realise access block to gp services itself is a significant problem, and in turn this is driven by poor remuneration for GPs which depressed interest in an otherwise attractive speciality. Meanwhile the private hospital sector is protected from all this and patients who would prefer to access private treatment will be brought to public institutions so they can avoid exorbitant private ED flagfalls (regardless of private health insurance) – this places the burden of an expensive and time consuming workup on the public ED. Inpatient teams seem to look upon ED as a place where their chronic disease patients can have workups which could safely happen after emission, from the ward, in the case of an available bed. RACF meanwhile are chronically understaffed and continue to misuse the ambulance and ED services often despite the availablity of hospital specialist services, GP services, and worse still, sometimes against the express wishes if the family. It all adds up to be a depressing place to work for staff, and unsafe place to be treated for patients. At my institution moral is plummeting. As resignations and sick leave increase, the system is under increased stress as (as the article points out) things have only gone so well so far because of experienced and dedicated staff. I fear the situation is similar all over Australia, and if so there may be quite a crash coming
To the person who wrote comment 17.
Firstly this is off topic but Registered Nurses who work at triage level hold extensive post graduate qualifications such as masters degrees. Furthermore, triage level requires the RN to have extensive clinical experience as their scope of practice permits them to practice autonomously. Meaning medical care begins at triage which is initiated by the triage RN who orders diagnostics or administers certain drugs if required based on the triage assessment.
Secondly this system is required to keep structure and priorities clinical conditions ensuring that urgent clinical needs take priority. I.e not walking in with a letter and demanding to see a doctor like the comment from number 17.
Thirdly there’s often not enough Nurses on the wards meaning patient flow through ED to ward is delayed. I can’t identify this enough and what people don’t understand is limited Nursing resources means prolonged wait times. It’s all well and good for MO’s or NP’s to prescribe treatment but if there’s not enough resources then expect delays.
Fourthly a change definitely needs to occur yet I think I’ve outlined two aforementioned reasons that exacerbate waiting times.
Lastly GP’s and community healthcare services ideally need to be more accessible I.e not closed after 5pm and over weekends.
An excellent article and I agree with all the points raised by other comments on educating/training the general population regarding the function and use of EDs, and necessary improvements to the GP support. I I have worked in various State hospital systems for over 30yrs. However there is one glaring omission from the discussion only hinted at by:-
“Anonymous says:
April 26, 2021 at 9:53 pm
but now that there is a higher population of patients actually needing emergency care, we cannot accommodate these non emergencies.”
There is a higher population! Over the last 2 decades Australia has had a rapid, high immigration level, driving population growth, far higher than its infrastructure and services can cope with. This mass immigration level is not sustainable with maintaining the quality of life in Australia. This level of pop. growth is not inevitable, it is driven by Federal Govt. Policy. High immigration policies are supported by both major parties, without any long term planning for the commensurate needs & costs created by the fast pop. growth. Health is but one casualty, NSW Schools are at bursting point now, but there are not enough buildings or teachers for expected enrolments. Several communities I know of, no longer have adequate sewerage infrastructure for their expected residential developments! etc, etc. The pandemic has slowed this high pop. growth down for the present, but vested interests keep pressuring Govt. to re-start. Pre-Covid Australia had around 2 million temp. and permanent visa holders arrive each year. I think an urgent reassessment is needed of what future pop. growth the country can absorb post pandemic, as no-one is happy with the continued consequences of our overburdened systems and infrastructure.
As a consultant physician it is not just the ED which contributes to this problem. The wards are frequently bed blocked and often patients are staying for prolonged periods not for medical reasons but social reasons i.e awaiting rehab, awaiting nursing home, awaiting respite bed. Unfortunately allied health staff do not have the same impetus to work as crazily as medical staff to facilitate discharges and often if these discharges are not appropriate patients will almost certainly get readmitted. In my experience ‘quick fix’ plans never work.
I also agree with more senior doctor input as frequently it is the investigations I request or my personal reviews of the patients that have led to a diagnosis and to correct management. Often junior doctors are unable to quickly diagnose and manage complex patients.
Short stay medical models like a MAU have often worked well with their own staffing model to ease the load off the general ED.
I think there should also be more private hospital Emergency departments where the load could be taken off the public hospitals for those with private insurance. I do think the private system is under-utilised in Australia.
My summary of the solutions suggested in the article and the responses
1. improved access to same-day, primary care assessment by GPs, including bulk- billing clinics. Co location of
clinics with EDs ideal to allow easy transfer
2. diversion of acute mental health patients to alternative and more appropriate facilities
3. More effective and continuous triaging in ED with direct line to bed managers
4. Increased funding often leads to more administration, does not achieve better services. This
paradigm has to change
5. Many nursing home and aged care residents end up inappropriately in ED due to lack of advanced directives, or
staff failing to act on advanced directives for fear of later criticism or litigation
6. Better hospital bed management , creation of overflow wards and half way houses, better use of discharge
lounges
I am an Emergency Physician with over 25 years of medical experience, with 14yrs as a Consultant. I am one of those who has left the Public System for a simpler life through burnout and lack of appreciation for my skills. I have no regrets except to say wish I had done it sooner! Things have clearly only gotten worse…
I often say that the ED does such a good job that everyone wants a piece of it: we have quick and efficient systems in place they are meant to be for us to make a rapid diagnosis in an emergency, not for us to become holding bays and treat inpatients lying in the corridors.
A&E does NOT stand for Anything & Everything.
essentially covers all the important points we have all been feeling. well done simon.
Simon has well expressed the frustration of so many of us working in Emergency Medicine. One part of the puzzle of patient flow that is often overlooked is that of getting folk back out of hospital. Due to the already mentioned issues with providing care in the community, people, particularly the frail elderly, often stay in the hospital much longer than should be necessary due to lack of funded care packages that would allow them to return to their usual environment safely, or due to RACFs not having the resources to provide the necessary post-acute care. A significant factor in this is the Federal-State funding divide, in which hospital care is the responsibility of the States, while community care is largely funded by the Federal government. I don’t have a clear solution to the problem, but it is only going to get worse as the percentage of our population who are elderly with multiple comorbidities increases.
Governments need to restart public education campaigns on the proper use of the ambulance service, to stop people hospital shopping and stop the public requesting free Ultrasounds, CT or MRI scans just because they don’t want to wait a couple of weeks for community imaging or pay. Parents need more 24ht access to GPs. The excuses of not visiting GPs in the first place is astounding it all comes down to the dollar!
An outsider. The GP system has been downgraded, patients do not trust the referral systems to specialist or hospital care. Patients have learned that a trip to an ED can speed things up. More beds available and staffed in wards would or should ensure more timely treatment and alleviate the crush on emergency. ED ‘s should have GP clinics attached and after triage appropriate patients fed back into the GP system. MONEY ? Stop subsidizing the fossil fuel system to the tune of 11 billion dollars per annum and feed some of that money BACK into HEALTH
Thank you Dr Judkins you articulate this growing crisis in our EDs perfectly.
Let’s hope hospital executives read this article and take heed.
The long term solution is prevention and yet we’ve spent the last what, thirty years running general practice into this country into the ground?
Literally the specialists in preventative care.
I now look forward to seeing solutions offered by “experts” that completely ignore the entire sector and offer hospital based perspectives
The canary in the coal mine by the way was general practice. We’ve literally been screaming about this for years. The entire system needs a restructure away from the hospital and into the community. To continue as we are is unhealthy
The amount of unnecessary ED presentations has skyrocketed over the last 6 months. Education of the public of what constitutes an ED presentation, should be a high priority as people not requiring emergency care presenting to the ED is huge and would make up at least 50% of cases. They have always been there, but now that there is a higher population of patients actually needing emergency care, we cannot accomodate these non emergencies. “I have woken with a blocked right nostril”, “I have had this mole on my back for 6 months and thought I should get it checked out”, “I have had back pain for 12 months and thought I should come and have an X-ray”,……The list is endless. ED nurses are tired and fighting amongst themselves. No one wants to work in triage, to deal with these people. People are calling ambulances for non emergencies knowing that they will jump the waiting room Queue. The public need to help us out.
I worked as a junior Emergency Medicine trainee before changing to General Practice. Part of the problem is that community medicine is not well funded or resourced. Often the only way to get the appropriate level of support and care for our patients is in the inpatient setting. If I try and manage borderline cases in the community it is the patient and my medical licence / reputation that suffer. For example, I needed to get an ultrasound to exclude a DVT on a Saturday morning. The only way to facilitate that was ED. This happens often and we are trapped between a rock and a hard place. We have the ability to take some of this stress off the system if we are funded appropriately but community medicine and preventative care always seems to be an after thought.
This all dates back to Thatcher, Reagan, and economic rationalism. The conversion of hospitals from public resources to businesses. Most anglo-celtic countries reduced the bed numbers in their hospitals substantially in the 1980s in response to economic rationalism. Europe did not and does not have our current problems. My hospital for instance, had 550 beds in 1980 and has about 200 now. No wonder admitted patients stay in the ED for 3 days. Welcome to the third world of our current economic paradigm.
As a full time ED locum who works across several states, I have seen the same phenomenon in regional and rural hospitals happen over the course of the past decade. Much of the problem is clearly the lack of GPs in these communities, with a gradual (and in the past year, faster rate of) increase in presentations clearly not appropriate for the emergency room. Virtually all of these locations have recognized dire shortages of GPs, which I would at least partially attribute to stagnant Medicare fees, making the field that much more unattractive when a vast majority of Australian doctors already consider living outside of large regional and metro regions anathema.
Prevention requires federal government to fund it .The WOEFULLY inadequate medicare rebates for General Practice is a root cause of the crisis in Eds. Gps have to charge a gap to stay in business but are being squeezed the same way AGED care has been with ultimately the same unfortunate results. Whilst we have a government that’s equates level of bulk billing with health success & Conveniently ignores the obvious problems in ED AGED care until it explodes prevention will remain a pipe dream
Dr Judkins articulates beautifully the crisis that public EDs face in Australia. They are a ticking time bomb, with sick patients in waiting rooms and on ambulance stretchers that cannot get into a nursed bed. As Peter Jones work shows, patients are dying because if delays accessing a ward bed. 48 hour stays in EDs occur daily, and patients suffer greatly. It has never been this bad before, and substantial invesment and reform is required.
Simon is spot on, I work in a big metropolitan ED and we are the canary in the coal mine and we are taking our last breath at the moment. Post quarantine infections, Poor access to GP’s, poor levels of staffing, over crowded with admitted patients waiting up to and longer than 24hrs for ward beds some times over 90% of cubicles filled with admitted pts. Private emergency departments charge hundreds of dollars for a visit even with private health insurance cover. My family pay $600 a month insurance but it does not cover emergency department attendance unless being admitted. The mental health sector is in crisis. Emergency is the last place these people need to be but they are sent in with varying states of distress and prolonged time frames for assessment. I’m so embarrassed, devastated and disappointed with the care we are forced to deliver.
Thank you Simon. Well written article. The problem is global. Our ED in Solomon Islands is on brink of collapse and we still waiting for community transmission of Covid 19!
The whole Ed system is wrong. Triage nurses should be abandoned. The kpis used are simply wrong. If triage is needed it should be done by a senior doctor. If a patient attends with a letter from a doctor they need to be seen by an appropriate doctor from the appropriate speciality, not by a triage nurse. The ambulances should generally not be babysitting patients to make the (inappropriate) kpis look good. When Ed is overwhelmed all hospital doctors should be attending to cut through the backlog. The kpi should be the time from presenting to the time an appropriate specialist is aware of the patient and the patient is receiving appropriate tests and treatment. The concept that treatment can’t start until a bed is found needs to be abandoned.
Here in Melbourne we had some unique insights during 2020 into what it looks like when systems work together to keep people out of hospital.
Outreach into aged care facilities enabled vulnerable people with dementia and complex medical conditions to be managed at home in their residential facilities through improved and suddenly resource-boosted aged care outreach teams.
We saw the risk that covid19 posed to vulnerable elderly people if they attended hospital, and so we made and used ways to manage their care in the community.
So many times do elderly confused patients wait many hours in a busy, noisy, overstimulating and potentially dangerous emergency department, exposing them to numerous additional risks including falls, infections, delirium and potentially the need for physical or chemical restraint to manage risks of aggressive behaviour toward or assault on staff or other patients, purely to have a CT scan done post a fall in their nursing home, and then many more hours awaiting results and then transport back to their aged care facility.
I would love to see the scope of outreach healthcare extend to portable CT in aged care, knowing that already we have such a facility available here in Melbourne in the Stroke outreach service.
Of course it would be even more ideal if we could also improve staffing and resourcing in residential aged care facilities to decrease risk of falls and provide quality care to aged care residents in the first place.
A suggestion that might avoid sick patients languishing for long periods in ED. Every ED should have a dedicated triage person, who does a round of all ED patients regularly to check on progress. This could be either a senior doctor or senior nurse able to recognise when patients need to be ‘escalated’ ( to use the current jargon ) or have investigations , treatment or admission expedited. Recently a 7 year old girl languished in an ED for hours while her appendix ruptured, totally unacceptable . A triage clinician doing regular rounds would have picked that there was sick girl with nothing happening. The triage person could also act as a patient advocate and make sure communication is satisfactory . Senior ED staff may do this at times, i am suggesting it as a dedicated role. Worth a try ?
Exceptionally well written
As an ED nurse in a regional hospital this is spot on- we recently had over 30 inpatients a day awaiting beds over the period of a week. Some of those patients were frail elderly older persons who spent up to 6 days awaiting a bed
I may be looking back through rose-coloured glasses, but when I was an intern and registrar in Adelaide back in the 1970s i don’t remember patients waiting many hours to be seen in Casualty ( now called Emergency Departments ) . I suspect more people now attend EDs than in my day when there was generally an attempt to see a GP first, and most GPs could see patients the same day when needed. Now it is not uncommon to be told that Dr X can’t see you for two weeks, or even worse, Dr X is not taking any new patients. Closure of mental hospitals and diversion to public hospital EDs undoubtedly has exacerbated the issue, and drug problems, especially amphetamines are substantially worse. Also, as surgical registrars we made a point of seeing and admitting surgical referrals quickly, as often they were acutely unwell or in pain, and we also needed to plan our theatre work. We always found a bed for them somewhere in the hospital. The current situation, as reported is untenable and major reforms are needed.
If patients seeking emergent primary care at the GP or in the RACF had even half the purchasing power they had for a non-admitted ED presentation, the problem would very largely go away
A non-admitted ED patient (whatever category of triage) is valued in the several hundreds of dollars.
A hospital-avoiding GP attendance: a fraction of that.
BrAvo. Radiologists provide 24/7 via remote reports centres cover and would value consultant input after hours rather than helpful but not always clinically confident hmos.
Simon’s largely on the money with this. This is a wicked problem and the most public face of this challenge is how we go about driving real change through our Federation. Achieving a consistent view of how to change this nationally is always going to be difficult whilst our governance models and particularly our funding models are disconnected. That and the might of the Medico Industrial Complex (my term) which limits real change through self interest. In my view, as someone who has worked extensively across clinical, policy, organisational, and professional spaces, we’re not going to change this until we stop acting like experts and start thinking like users of the system. We simply have to involve our communities, our consumers, our users, those who own the system, in the meaningful design, delivery, monitoring, evaluation and improvement of the system. We need to accept that our expert led model has largely failed our communities in dealing with what have been very predictable occurrences. Oh and it would help if we stopped seeing public hospitals as the centrepiece of healthcare systems. The real gains are going to come from keeping people out of hospital – once people start voting for that, much of this problem will be solved because resources will follow the votes, or the potential votes. But that cant happen until we sort the governance out. Time for a single funder model where the money follows the consumer.
My dad is dying of Angiosacroma cancer. He was in Calvary Hospital for respite due to my mother having her own medical emergency requiring ambulance transfer to the ED. It took took 2 ambulance transfers( after inappropriate discharge the first time) and 15 hours in the ED over 2 dasy before Mum was admitted to a ward.
After 2 days in Calvary Dad was sent via ambulance to the same ED due to a fever, dehydration and confusion. Dad is on a very heavy dose of opioids at this stage. He was in the ED under bright lights, untreated with constant noises for close to 24 hours before being placed appropriately into the oncology ward. This ED experience was a horrifying and indignant experience for a suffering man in his last weeks of life. Nursing staff in the ED refused to give him an IV drip as they said he did not qualify for one. Re-hydration was why he was transferred there was my understanding? They suggested that if I wanted him to stay hydrated I would have to be prepared to stay by his side night and day to give him little sips of water. When I asked for pain relief for dad, I got the sense the staff in the ED were thinking I was a drug seeker. This was my third day in the ED (this time with a different parent) so I guess the staff could be forgiven for this. Dad was offered Panadol which really does not cut it as this point in his cancer journey. My dad has been a tax payer all his life, is privately insured and he has had the most terrible experience the public ED. Surely we can do better?
Having used Ed on a number of occasions, I know how long it takes to be seen. The worst was being on a trolley overnight after eventually being seen in the plastering room as there was no other space. More senior staff would have avoided a lack of diagnosis of shingles, which has exacerbated the ongoing effects.
It really is an utter disgrace and I fear future staffing issues in EDs will get much worse ( both quantity and quality) as who in their right mind as a junior doctor would choose Emergency medicine as a career nowadays except as a last resort. If things had been Iike this 25 years ago, I definitely would not have chosen it.
35 patients in the waiting room with nowhere to be seen apart from a corridor, 13 ambulances ramped up in the corridor with nowhere to offload, ridiculously unrealistic GP referrals spending 8 hours in the waiting room, patients in cubicles waiting 23 hours for admission, no beds in the hospital, what a joke !
well written and right on point Simon!
Although this has been written by an ED physician, and I agree that the Covid pandemic has put a great strain on the workload of hospitals. It is important to realise that hospitals work, or should work as integrated systems. Who does what needs to be better defined and treatments for common diseases need to be the same in ED as they are in the wards. There is no merit in prolonged investigation of a patient who needs to be admitted, except that in some hospitals, ED has priority for imaging, which is often critical. Medical and surgical staff need to be available at relatively short notice and at such a level that they can make decisions or have easy access to advice. So yes there is a need for change, but as the author says, it must occur across all sections of the hospital. Such change relies on excellent operational management
Having sat on a metropolitan public hospital board for six years, I came to the conclusion that the whole health funding model needs a complete review. Every part of the public system is under pressure with waiting times, and out-of-pocket expenses in the private sector are a major driver. Other countries like Singapore and the Netherlands have done a complete restructure, and so should Australia. One conclusion all these countries have reached is that an NHS-style system can never do the job. There is no reason why we should not be world leaders in this area, so the AMA should be actively lobbying the politicians.
An excellent summary of a very real crisis. The most telling point is that Emergency Physicians cannot do what they are trained for, because the space in which they work is occupied by admitted patients. As an obstetrician, I can only just conjure up my response if I couldn’t admit labouring women into Birth Suite because the beds were occupied by other (non-obstetric) patients. This is effectively the ED situation.
NEAT is a whole of hospital issue, but ownership of this KPI seems to be assigned to the ED specialist alone. Dr Judkins presents an evidence base that real harm is occurring. A ‘call to action’ for this current crisis is just as needed as it was for the COVID response.
So true. Preventive medicine is the key. We’ve seen it and practise it with Covid-19 and it can and should be done in all areas of medicine.
Considered, thought-provoking article – and good to see the emphasis on prevention as a key part of the approach we need to addressing pressures on EDs.
Hear hear. You want to try working in rural/remote – the ED fucntions as a GP clinic as there are just no appointments (and try getting a patient in to see a GP for ‘follow-up’). Yet, we are still held to full account for every little problem that arises. AS to senior presence, I work in places where the MOs are VERY senior, and there is stall a problem. If only admin types woun=ld come and visit – even the SMO doesn’t show his face to ED – there’d be WAY too much feedback to cope with.
Very good article Simon. As you say, the longterm solution is prevention. But we are so off track with educating the population about the importance of healthy eating and regular exercise as the key factors in maintaining a healthy body, that it will take at least two generations even if we were start tomorrow. Correcting our obesity epidemic is like trying to turn around an oil tanker. But when you have a government who has absolutely no control over companies that peddle rubbish food, and in fact encourage it purely for collecting tax revenue, then there’s no hope. And as for expecting them to fund an ever-expanding system based on intervention……..forget it.
As a surgeon in the twilight of my career I have spent 40 years in and out of the ED. I can only wish you luck.