Emergency rooms differ in the detail

I read with interest the article by Schull.¹ I have recently moved to Trinidad and find that the problems in A&E are the same as the UK: overcrowding, waiting times, lack of facilities of trained staff. Each of these problems differ in detail.

Overcrowding and waiting times are less severe in Trinidad than the UK. In my department (a paediatric facility seeing 40,000 patients per year) our average time to see a doctor is less than half an hour. Is this a reflection of good practice? In most departments in Trinidad, staffing is at a junior level. Doctors in the Emergency Room provide limited care for patients before referral. This leads to shorter waiting times, but patients suffer through multiple referrals before receiving definitive care. This is more in the adult departments, where the average waiting time is less than that quoted, while the admission rate is higher (40% for adult departments compared to 10% for the children’s hospital). Quicker care is not necessarily better care.

The availability and use of inpatient facilities has an impact on throughput. In most departments in Trinidad, overcrowding on the wards is a part of life. Space is ‘made’ on wards by accommodating patients two to a bed, or making room for trolleys. The only area in which this policy is not feasible is ICU. The availability of ICU beds is much less than in developing countries and threshold for admission much higher.

Finally, staffing is a problem. Juniors with no specific interest in Emergency Medicine staff most departments. An audit of our paediatric emergency room suggests that senior staff can reduce both the admission rate and waiting time, but patients stay longer while receiving more comprehensive care.

In summary, the problems of all Emergency Rooms are similar, but vary in detail. Achieving better waiting times in the Emergency Room may be at the expense of the quality of care in the entire system, if managed in isolation.