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The international crisis in emergency care
The papers by Trzeciak1 and Fatovich,2 along with the commentary by Schull,3 highlight the international dimension to the problem of crowed emergency departments (ED). To deal with this problem the United Kingdom National Health Service has published ambitious plans that state that all patients should be seen, assessed, treated, and either admitted or discharged within four hours.4 As part of this initiative, department times in the EDs in England were assessed during the last week in March. The published results indicated that almost all EDs met the interim “target” of having at least 90% of patients being discharged or admitted within four hours of arrival.
The question that many are asking is what does this target mean from the patient’s perspective? Few would disagree with using department times as a surrogate measure of efficiency and progress. All patients seem to take high quality care for granted and waiting time is the most important factor in most patient satisfaction surveys. Unfortunately, for many hospitals, the target itself has become the goal. Consequently extra resources and procedures were implemented only for the duration of the assessment period of one week. Some hospitals even cancelled elective surgery.5 This aim for a short-term solution rather than a whole system approach has generated much debate and criticism.
The commentary by Schull shows that it is possible to meet emergency care demands in the short-term by focusing the considerable capacity of health care systems on handling emergency admissions. The emergency rooms in Toronto were very quiet during the recent outbreak of severe acute respiratory syndrome (SARS). This was mainly due to fewer patients coming to the ED and more hospital beds being available for emergency admissions because of the cancellation of elective surgery.
ED overcrowding is a symptom that an emergency health care system cannot cope with its workload. Each component of the system, including the ED, needs to review its own practice and maximise effectiveness, but it seems that it is the availability of hospital beds that is one of the main determinants of delays for all ED patients (exit block).6 As a department becomes crowded with patients awaiting admission its efficiency plummets along an exponential curve. There is no space to see the patients and both nursing and medical staff become increasingly tied up in dealing with their ongoing care. Meanwhile the queue of new patients grows, patients become frustrated, and staff feel overwhelmed.
The fact that the same picture is emerging from many economically advanced societies, indicates that the problem has its roots in major forces within society. These include shifts in social structures, demographics, reduced capacity in the hospital sector, and in the changes of our emergency care systems.
The increased social mobility of western society has led to a weakening of the normal support structures of the extended family. Vulnerable groups, especially the elderly, come to rely on friends, neighbours or professional help. Such carers provide a huge amount of support in the community but may be less willing than extended family to deal with the added burden or risks of minor and moderate illness. Often the easiest solution seems to be a call to the emergency medical system (for example a 999 or 911 call), an ambulance arrives to provide immediate relief and the patient is taken to hospital.
During the late 1980s and 1990s there was a great drive to reduce hospital costs. Centres were closed, bed numbers were reduced, and staffing levels were minimised in the quest for efficiency. With hospitals now running at over 95% bed occupancy there is no slack to cope with emergency demand. Compounding this problem is the fact that primary care doctors are becoming less involved in out of hours, weekend, and holiday cover.
Any solutions must try to address these major social and health system changes. Simple cosmetic surgery will not succeed. Such surgery can make things look a bit better temporarily but is doomed to fail in the longer term.
We need more capacity for health care, not necessarily in hospitals but increased support and care for those living at the margins of safety in the community. Intermediate care is seen as a solution, and probably is, but we have seen little progress in making this effective.
We need to stem the demands on emergency care. There are no votes for politicians in trying to set the limits on the expectations of the population for health care. Perhaps the medical profession is also guilty of fuelling patients’ ideas that medicine has the answer to every problem and can deal with every risk. Some very basic honesty is required by all or we will be discussing the problem of ED overcrowding for ever.
The international crisis in emergency care