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.