The emergency department (ED) is the most significant interface the hospital has with the public.
It is critical that the new Dunedin hospital ED is fit for purpose, as the current one most certainly is not. It is more often than not overcrowded, exceeding both physical capacity and the capacity of staff to care for the patients well.
Patients commonly wait for inordinately long times in the emergency department, first to just be seen, and even when they are adjudged to need admission to the hospital can wait many hours, even a day or more, to get into an inpatient bed.
These patients still need ongoing nursing care in a facility poorly suited to this, and by nurses who are overloaded and should be focusing on dealing with the new arrivals. Most people I speak to dread having to go there or take a family member there.
As explained in my first article, a health system’s function can be best understood by considering the three components of people, plant and process, how each of these affects the others and how coherence between all three is essential for optimal function. Probably the most critical aspect of the problems in the ED is the plant, i.e. the facility, and issues with people and process largely stem from this.
Plant
The footprint of the department has changed little since I started as a surgical registrar in 1983, apart from the addition of the short stay unit back in the 1990s. Other than that there has been some minor refurbishment, but on the same footprint this has been very cramped. The other major facility problem has been the inadequate number of inpatient beds, which provides a major block to patient flow out of ED.
The department’s design is so cramped and cobbled together that it is very poorly suited to streaming, a standard concept in most modern emergency departments. Streaming physically separates groups of patients into ambulatory (walking), those needing assessment or workup and true emergency patients (requiring immediate assessment and resuscitation). Each of these groups of patients requires a different focus and targeted processes to achieve good patient flow.
Process
The result of having barriers to admission and no clear separation of streams on top of a relentless historical growth of presentations to the ED is that all the designated bed spaces are often full and a whole lot of patients with different needs end up either back in the waiting room or stacked up on trolleys in corridors, with thousands of staff hours spent in shuffling patients repeatedly in and out of the waiting room, corridors or treatment spaces, none of which adds value to care.
For patients it is a most uninviting experience, with almost no privacy, as almost everything can be overheard.
In an overcrowded department, deterioration in a patient’s condition is very easy to miss among the noise, with sometimes serious and potentially fatal consequences.
Historical changes in process and people
In the 1980s the "Accident and Emergency" (A&E) Department was staffed by a handful of doctors (not specialty trained in emergency medicine) and not many more nurses. Most patients sent in from a GP were referred directly to the inpatient specialty registrar that the GP thought most appropriate for the presumed diagnosis.
Those registrars assessed and managed these patients with assistance from the nurses but little input from A&E doctors. If patients, once seen, were adjudged as needing admission, they were then admitted by the team’s house officer either in the A&E or on the ward. Only walking wounded, emergency ambulance presentations or undifferentiated self-presentations were seen primarily by A&E medical staff.
Things have changed dramatically over four decades. Emergency medicine has emerged as a specialty (coincident with the change of name to emergency department), availability of general practitioners to see urgent problems in the community (especially after hours) has declined massively, and the numbers of patients self-presenting to ED has surged.
Over that time it is true that staff numbers in the ED have grown substantially, some of which has been a result of the emergence of emergency medicine as a specialty, but much of it, particularly the growth in nursing numbers, has been a reactive rather than pro-active response, a consequence of relentless overcrowding and crises rather than a plan.
Management have had to be dragged kicking and screaming to approve staff increases. It is likely that fewer staff would be needed, and staff would add much more value to patient care if the causes of congestion and overcrowding were properly addressed, but as is customary in our health system we seem always to start with the cart rather than the horse and want to cut or limit inputs before the process or plant has been fixed.
What do we need for the ED to function optimally?
Clearly there are some things beyond the immediate purview of the ED itself which are necessary to manage demand and congestion. These are ready access to primary care, particularly after hours, ready access to rapid investigations and sufficient inpatient beds and prompt response from inpatient medical teams. Within the ED, however, there are several things that are absolutely required in the new Dunedin hospital. These are an adequate number of clinical beds (with privacy), proper streaming as outlined above, medical and surgical assessment units and a holding ward or unit.
Assessment units
The ED clearly needs an assessment or workup area as one stream for unwell but undiagnosed/undifferentiated patients who present primarily to the department.
However, any patient who has been assessed by a doctor pre-hospital and is considered to need referral to an inpatient specialty for probable admission does not need to be re-assessed by an ED doctor or to add to the chaos of an overcrowded ED. With the safety proviso that they are checked by the triage nurse to ensure they are not critically unwell and need to be going to the resuscitation area, they should be directed to either a medical assessment unit or a surgical assessment unit where they can be assessed by those inpatient specialties and appropriate action taken (either admission, or treatment and discharge).
The same is true for undifferentiated patients assessed by an ED doctor and then referred. Neither of these latter two units need to be within the footprint of the ED, although having them close is desirable.
Does the ED need a holding facility?
While the ideal process in ED is rapid clinical assessment and urgent treatment with a prompt decision to either get the patient admitted as an inpatient or discharged to home or community care, this is not always possible, as more information is needed before such a decision can be safely made.
Chest pain is a clear example. Sorting this out and eliminating (or establishing) one of the more serious causes (such as an acute coronary event) may take a few hours, and the patient needs a less busy, more private and comfortable place to wait and be cared for than an ED corridor.
There are a number of patients for whom the passage of time is the best diagnostic test, and a few hours observation will see many of them come right, without the need to admit to an inpatient ward.
Further, even if otherwise medically safe to discharge, it is not appropriate, decent or kind to discharge at 2am a frail patient in their 80s who lives alone, or a patient from a rural community who has no-one to drive them home.
So a holding ward/unit in the ED is absolutely necessary, but careful rules and vigilance about its use are needed so it doesn’t reduce the urgency of freeing up inpatient beds or becomes a convenience that allows unnecessary procrastination in assessments and decision-making.
Perhaps, just perhaps, if those that seek to cut everything back are able to grasp these issues, we might see the end of "corridor patients" and a better experience for all.
— Mike Hunter is a retired consultant general surgeon and consultant intensive care specialist.
