Inside the ED: Caught in the middle and blamed for it all

What modern emergency medicine can deliver is truly amazing, but the system is hamstrung by capacity and manpower shortfalls and now faces unprecedented demands amid Covid-19, writes emergency medicine consultant and former IMO President Dr Peadar Gilligan

The hospital in which I work recently appeared in the press because there were significant numbers of people in the waiting room of our emergency department (ED).

EDs have not historically set a limit on the number of people who can attend. The nature and severity of illness relevant to attendance at an ED has not been dictated to the public.

There is no requirement for a doctor’s referral prior to attending an ED, with the result that patients come in with whatever problem — physical, psychological or social — that is concerning them.

If a family doctor is concerned about a patient, they advise attendance at an ED; when a specialist wants a patient to attend hospital in an unscheduled manner, they send them to the ED. When a hospital doctor is discharging a patient, they often tell them to return to the ED if they have any concerns.

When a pandemic strikes for those who need hospital care, the ED is often the initial point of contact.

When a major incident happens or patients are injured at work or home or in road traffic accidents, they are brought to the ED.

Unlike a bus driver, as an emergency medicine specialist, I cannot say ‘first two only’ or limit the number of seats that can be sat upon. Unlike a GP or another specialist, I cannot only offer scheduled care.

It is therefore not a wonder that a department which cannot dictate the in-flow, and which is dependent on the efficient working of the entire health system for the timely out-flow, becomes dangerously crowded.

Infection control imperatives suggest that if we cannot reduce the attendance of patients, what we must do is move patients through the system in a timely manner.

EDs in Ireland were already crowded as a result of inadequate capacity in the system.

With hospital wards wanting to provide socially-distant care, and as a result, six-bedded ward bays becoming four-bedded and four-bedded bays moving to two-bedded, acute hospital bed numbers will be reduced by 30-to-50 per cent.

In real terms, an acute hospital system that according to the Economic and Social Research Institute needed 5,000 beds, now requires between 6,500 and 7,500 to address the healthcare needs of Ireland’s population. The real challenge of access to healthcare in Ireland, for those who require it based on clinical need, is that we do not have the beds and staff we need with which to provide that care.

The infection control-indicated reduction in available clinical care spaces is happening in a system that did not have enough beds to provide timely acute medical care.

Outpatient appointment waiting lists must increase if less patients can be seen in each clinic to avoid crowding of waiting rooms. Elective procedure waiting lists will be longer if fewer surgeries can be performed in the same time frame. GPs are increasingly offering appointment-only assessments of patients to avoid crowded waiting rooms.

As a result, the patients of Ireland are attending EDs in large numbers to access the care they feel they need. To allow adequate flow, those patients who would more appropriately have their care delivered in an alternate setting must be able to access that.

Patients whose GP knows they need an x-ray, ultrasound, CT scan or MRI scan, must be able to access it on the basis of their GP’s request for the investigation.

Patients whose GP needs a specialist opinion must be able to access it in a timely manner, rather than the patient attending the ED with a non-emergent condition.

The step-down facilities that acute hospitals require to discharge patients in a timely manner must be available. Ireland can no longer continue to have 15-to-20 per cent of its acute hospital capacity occupied by patients who should be cared for at home, in a nursing home or in convalescent or rehabilitative care.

As an emergency medicine specialist, when I see a patient who needs to be on a hospital ward for the delivery of their care needs, I should be able to access that within an hour or two, not 12-to-14 hours after the patient arrives to my department.

As an emergency medicine consultant, if I know the numbers attending are going to overwhelm the medical and nursing staff I have available to see them, I should be able to access the doctors, nurses, porters, radiographers, healthcare assistants, security staff and administrative support I need to deliver the emergency care our patients require.

What modern emergency medicine can deliver is truly amazing, but our ability to do any of that important work is compromised by a lack of flow of patients through the entire system. If we want our EDs to be available to provide timely care when we need it, we have to ensure they are never again allowed to become crowded with patients who need to be moved to the ward, or with patients who could have their care delivered in alternate settings.