If you want to get a feel for the state of our health system, a visit to a hospital emergency department is a good place to start. Hospital EDs are the one health service that never closes. As a result, any area of failure within the health system shows up, sooner or later, in hospital EDs.
This means that increasingly EDs are being used as the ‘last resort’ option in a health system riddled with inefficiencies, gaps, jurisdictional disputes,counter-intuitive funding mechanisms and perverse incentives for cost-shifting.
Emergency departments cannot provide the high quality care that patients deserve when they are overwhelmed by demand, staffed by overworked and stressed health professionals and are dealing with patients who have been let down or fallen through the cracks elsewhere in the system.
Below, Dr Simon Judkins, President, Australasian College for Emergency Medicine, describes how hospital EDs are the ‘canary in the mine’ for our health system. He outlines the many symptoms that indicate that our health system is not meeting the needs of our community and urges us to raise this issue with political leaders.
Simon Judkins writes:
On September 12 we recognised RUOK day, a day where we are encouraged to ask our friends or colleagues “RUOK?” to foster a conversation about mental health. I support the day and conversations about mental health. I’m a strong advocate for patients, families and communities being able to access mental health care for them and their loved ones when and where they need it.
I’m a strong advocate for a health system which supports clinicians to be at their best, mentally, physically and clinically, so they have the capacity, ability and time needed to deliver care to patients.
But, I haven’t been OK this week. In fact, I haven’t been OK for some time. Having spent almost two years as President of the Australasian College for Emergency Medicine, and time before that in various public health system and College roles, I have been in contact with many clinicians and patients, visited many hospitals and emergency departments (EDs). I reckon I have a pretty good feel about what is happening in our frontlines of care for our communities.
And, it is not OK.
A number of recent events have had an impact and prompted me to write this. The stories of healthcare failures which recently aired on Four Corners is one. Data from our own Professor Drew Richardson’s ongoing study into overcrowded EDs, detailing the worsening state of affairs, is another.
Additionally, my recent experiences visiting hospitals in Queensland and Tasmania; information coming from hospitals in South Australia; the terrible state of overcrowding in western Sydney EDs; ambulance ramping in Western Australia; Royal Darwin Hospital bursting at the seams; increasing numbers of mental health patients spending days in Victorian EDs; the ‘corridoring’ of patients in the ACT; daily stories from patients about their experiences; the desperate need for more clinicians in rural areas; and the funding crisis starving hospitals across the country.
At the moment, things are definitely not OK.
For a long time, we, Emergency Physicians, have been highlighting our concerns across the country, about the issues associated with overcrowded EDs and patients who should be in hospital beds, spending prolonged periods of time in EDs. Being mere employees in the system, many of us are gagged and unable to speak publicly. But the situation is worsening. We see who comes through the ‘front door’. And we see them wait for hospital beds.
The canary in the system
So why are we so concerned? Because the ED – our workplace – is akin to the canary in the coalmine of a dysfunctional system. Overcrowded and bed blocked EDs are one of the strongest indicators of a system in crisis; a system which is over capacity, over full, bursting at the seams and teetering at the edge of the cliff.
We know that a system at or over capacity leads to increased risk for patients; the data says so, we don’t just make it up for the sake of sensational headlines. Delays to critical care, increased risk of medical error, medication mistakes and other adverse events are all associated with a system stretched beyond its limits.
Ultimately, we know patients die in this system. Again, the data is clear. If a patient arrives in an ED where beds are occupied by admitted patients who should be in inpatient beds, where ambulances are ramped, where patients are being treated in corridors and waiting rooms, there is a clear increased risk of patient death.
We are knowingly running a public hospital system with EDs full most of the time with undifferentiated, unwell patients with sepsis, strokes, heart attacks, trauma, suicidal thoughts and overdoses, the most acutely unwell and high risk patient groups. EDs are operating at a level where all staff, not just doctors, are stretched and stressed, where beds are scarce, resources poor and patients are suffering. Health professionals are trying their best to save lives with barriers all around them.
Despite this knowledge, and despite the appreciation and understanding that demand is high and fiscal times are tough, we get lip service about promises of fixes that remain unfulfilled.
A systems problem
This situation can’t be managed by EDs and their staff alone. The fixes are in how inpatient teams manage access and patient flow through the hospital, how administrators create a culture where this is the norm and provide the resources so we can treat patients with dignity and respect in an environment which is not chaotic.
It’s in how we create space for patients and time for clinicians to think, and about how we ensure there is capacity in the hospital to admit patients from the ED 24/7. It’s up to everyone who works in our hospitals to step up and ask what they can do.
Next time you have the unfortunate need to seek help in the ED, or you’re in the back of an ambulance with chest pain, or visiting an unwell relative needing acute care, have a look around. If you see ambulances lining up and waiting to deliver patients because there is no space inside, patients in hallways because there is nowhere to go, staff running around trying to do their job under these unsafe conditions, please do not accept this as OK.
You need your EDs to be at their best when you or others close to you need them the most. So, contact your local MP, State and Federal health ministers and tell them it’s not OK. You and your family deserve better, we all deserve better. If we don’t get this sorted there is a chance that when you need us most, you may not be OK.
Author Information: Dr Simon Judkins is the President of the Australasian College for Emergency Medicine, the peak body for emergency medicine in Australia and New Zealand, responsible for training emergency physicians and advancement of professional standards.