“We are fed up, broken and exposed…[The] hospital system is in the worst state we have ever seen it. Things are deteriorating, with no end or reprieve in sight.”
Those stark words begin a media release issued in May 2022 by the Australian College of Emergency Medicine on behalf of Queensland’s emergency doctors.
The commentary is a masterpiece of plain English writing. There’s a pervading sense of exhaustion as if the writer, Dr Shantha Raghwan, no longer has the energy to do anything but tell the unvarnished truth about a “situation [that] isn’t normal. It is not fair, and it is not safe.”
There is no silver bullet for fixing Australia’s emergency department (ED) crisis. As the Australian Medical Association (AMA) notes,
“The current crisis does not originate in EDs but it does manifest there…Performance improvement will involve a range of reforms across capacity, process, systems, staffing, digital integration, avoidable admissions, and out-of-hospital care.”
Here, we explore the pressures on hospital emergency physicians and consider how improvements to infrastructure could facilitate patient flow.
ED doctors under intolerable pressure
When emergency physicians declare themselves unable to handle the pressures of their work, something is very seriously wrong.
After all, emergency doctors, as a group, handle pressure extremely well. These are people who have chosen to work in a non-stop, demanding, intense and highly varied environment.
Each patient requires them to think fast yet make sound decisions, be decisive yet function as part of a team, see how the big picture is created by many small details, and draw on extensive knowledge of many different facets of medicine.
In short, ED physicians thrive on pressure. But there is only so much that anyone can take.
Dr Raghwan describes how,
“We are straining to give patients the timely care they need – the care that we desperately want to give them – and we are worried about missing things amongst the current chaos. We are worried a patient will suffer, or worse, and that we will be held personally responsible for something that occurred because of systemic pressures that we have no control over.”
Working in EDs has become so bad that, after working the crest of every COVID-19 wave in Melbourne, one senior doctor recently took 3 months’ leave for the first time since 1995. Dr Stephen Parnis realised,
“I wasn’t myself and if I’d continued doing what I was doing I might have ended up having some sort of flame out. It was important to have time and space. My GP and my psychologist have been an important part of that time, but so have trusted friends and colleagues.”
Taking that time was a wise move – and yet our EDs would collapse if every staff member did the same. Many can’t even take regular annual leave due to staff shortages.
Overcrowding in the ED
As researchers at Macquarie University note,
“Crowding in EDs is the product of input, throughput and output factors such as the volume of patients arriving to be seen, the time taken to assess and treat patients, and the availability of beds in hospital wards.”
In an ideal world, patients would complete their visit to the ED within 4 hours, after which they would be admitted to a ward, referred to another hospital, discharged or leave at their own risk. This is considered a key performance indicator.
The AMA’s public hospital report card found that in 2020-21:
- Only 67% of patients completed their ED visit in 4 hours, a 3% decline on pre-pandemic levels
- 90% of patients completed their ED visit within 8 hours
- For patients who needed hospital admission, 90% had to stay in the ED for almost 13 hours, ranging from over 10 hours in Queensland to over 22 hours in Tasmania.
Those statistics tell us that one of the most important ways to improve patient flow through the ED is to improve the admissions process. That relies on having the right number of beds for the right types of patients.
Improving admissions for older patients
A closer look at the cohort of patients most likely to present at EDs and most likely to need admission shows that Australia’s ED crisis is linked to our ageing population.
The AMA reports that older people are more likely to present to the ED and three times more likely to need hospital admission (60% of 75-84-year-olds compared to 21% of 15-24-year-olds).
This means that most of those poor patients waiting over 12 hours in the ED for a hospital bed will be elderly – the very people we would most wish to ensure were quickly made comfortable and treated with dignity and respect.
Improving hospital capacity to care for older people is one important way to improve patient flow through the ED.
How could infrastructure improve patient flow?
Easing pressure on EDs requires a multifaceted approach that includes:
- Reducing the numbers of patients presenting by improving access to primary care, creating GP-led urgent care centres for non-emergency cases and ensuring a higher level of medical or nursing care in residential aged care facilities
- Tackling bed-block by improving timely discharge. This could be achieved by expanding Hospital in the Home. It also links back to the provision of better medical care in residential aged care facilities and disability care.
However, Australia also, undoubtedly, needs greater capacity in its EDs and hospitals. Capacity has clearly not kept up with demand, either for ED services or hospital admissions.
As the AMA states,
“A key metric of public hospital capacity is their ability to cater for the number of older people (65+) in the community…People aged 65 and over represent 16 per cent of the population, but account for 50 per cent of total admitted bed days in hospital…An increase in public hospital bed capacity must be part of the solution to avoid deepening the public hospital access crisis…”
The AMA’s projections show that, if current trends continue, by 2030-31:
- Average daily admissions from the ED will exceed 20% of total bed capacity (we’ve already hit 10%)
- There will be approximately 7,150 fewer beds than needed for the older population.
That means it’s time to start planning for increased capacity. It will be needed – indeed, it already is.
Mobile and modular healthcare facilities offer a cost-effective, time-sensitive way to:
- Extend and enhance ED capacity
- Assessment areas
- Short-stay units
- Dedicated, secure spaces to treat patients presenting with mental health conditions (a growing cohort)
- Better waiting areas
- Improving air purification to reduce the risk of COVID-19 transmission
- Create negative pressure isolation rooms for COVID-19-positive patients or those presenting with symptoms of other respiratory diseases
- Private video telehealth offices to support virtual triage
- Extend hospital capacity
- Creating new wards for patients most likely to need admission from the ED, namely older patients or those with chronic conditions or mental health needs
- Creating additional surgical capacity to tackle the backlog of elective cases and reduce the likelihood of patients presenting to the ED.
The AMA is lobbying for a suite of reforms, including partnership funding between the States and Commonwealth to “add more beds (in the ED and across the hospital).” They want public hospitals “to be given additional funding to expand their capital infrastructure where needed…to fund proposals that would result in improvements for EDs, given this is a priority area.”
If you would like to learn more about how mobile and modular healthcare facilities could improve capacity in your ED and hospital wards, please contact Q-bital Healthcare Solutions.