12 September 2012

An easy solution to the ED 'crisis'

| rescuedg
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I was listening to Ross Solly hammer the Director-General of Health this morning on the radio and some of the feedback from listeners is a clear indication of why the ED in The Canberra Hospital is under such stress. People who cannot be in need of emergency treatment are showing up in droves. The ABC is reporting that an average of 182 people per day are showing up just at the ED in the Canberra hospital.

GPs exist for a reason – to diagnose and treat illness and injury that does not require immediate emergency attention. They are also much much easier to access than people seem to think. I called the GP in O’connor last week, they had spots all that day. The GP in Lyneham is advertising for business. I know that recently Andrew Leigh did a list on his website of all the GPs on the Northside who were taking new bookings and who bulk-bill. When I went to the GP in O’connor they did the medicare rebate on the spot – so only $30 out of pocket for a full appointment where the Dr was in no rush to get me out the door. In the past I have been to the Phillip Medical Centre and always been seen within a couple of hours without an appointment.

I’ve also been to the Walk-in Centre a couple of times and never waited more than half an hour. The nurses there will tell you what is wrong with you and refer you on, if necessary, to a GP or to the ED – if it is something that are not able/allowed to treat.

Tl;DR the ED is for emergencies, if you are not in immediate need there are a lot of other options.

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The comments by @snoopydoc in my experience is pretty much on the mark.

What I find interesting is that the majority of comments here have pretty much spent the best part of a few million dollars extra without coming up with too many ways to pay for it. There’s a real ‘magic pudding’ approach to health – lets have free GPs for all – which would be a rolled gold disaster of many billions.

At the end of the day (and Ive said this many times here on these forums before) – health costs are rising at 8%+, presentations are 5% increase per year, ageing population will inevitably lead to more chronic disease and more presentations. Accept the fact people that we are going to have pay more for the system we have, or we are going to have to accept lower services. Either that or we can just spend more than we earn… I hear that’s worked out well for some nations.

Excellent response Snoopydoc – thanks for the insight and for your hard work.

as for not paying a GP – that is a ridiculous assumption – you can go to medical centres where you also are bulk billed and your wait is generally less.

I heard that there are 120,000 presentations at the ED each year. That’s every Canberran going to the ED once every three years.

I’ve never been once. I think it’s just people going because they don’t want to pay a GP.

our very nearly 2-year old acquired a small nick above his eye one weekday morning, and being in the vicinity of ED, we asked the triage nurse if it would require stitches or gluing, or whether it would just heal itself. They wouldn’t look closely at it, or even be drawn on its severity, so instead put us through the admission process, where we were held up waiting for a bed. Facing a wait of “no idea how long, we haven’t got any free beds”, we disadmitted ourselves after about 30 mins and popped into the walk-in (despite himself not being yet 2 – the minimum age). They were fantastic and on the spot told us not to worry about gluing/stitching, but to keep an eye out for infection/concussion, and we were on our way in less than 5 minutes. I wonder how long we would have had to wait in ED for the same advice?

Surely we could have been one of the (genuine) sub 30 minute patients they so desperately crave? Big props to the walk-in centre, and I’d encourage everyone to think of it first. Now all they need is more in the urban centres…

snoopydoc said :

We are well staffed.

I’m surprised at one comment about being “well-staffed”. The surprise is because every time I’ve been to TCH, all I hear from staff is how understaffed the hospital is and how busy they are.

The hospital is clearly running on stretched resources. The patients are lucky if they have family to come in and assist them go to the toilet/shower or make sure they eat their food, as the staff sometimes don’t get around to doing those things for every patient every day. The patient toilets are often dirty for long periods of time as cleaners aren’t called if the nurses or patients don’t report the mess.

And during weekends and overnight the staffing issue is worse.

I’m not the only one of my friends who knows that if you have to go to hospital it’s best to get there before 5pm on weekdays and avoid weekends – if you have a choice.

Inappropriate “non-emergency” patients presenting to ED are a fact of life, but are actually in the minority. The vast majority of patients we see do indeed have at least moderately urgent problems that either need to be seen in a timely manner (e.g. at least the same day), and while others might not be quite so urgent from a clinical outcome perspective, there are a number of patients seen each day for whom being seen sooner is, for want of a better word, “nicer” (e.g. more convenient logistically for them and/or their family, allowing earlier return to work or at least definite planning in that regard, or more timely access to other medical services that will definitely be necessary on an outpatient basis in their near future).

There are definite gains to be made in efficiency within any emergency department, however, as some commentators have rightly pointed out, the elephant in the room is the phenomenon of access block. Unfortunately, only so much can be achieved by shuffling the deck chairs on the Titanic, when there simply aren’t enough lifeboats to go around.

In the case of emergency department overcrowding and prolonged waiting times, the lifeboats are essentially the acute inpatient hospital beds. There are not enough of them per capita. Indeed, over the last decade or two, the number of acute hospital beds per capita has something like _halved_. For a growing population. A growing, aging population. With more, and more complex, health problems. Problems that require more interaction with the health care system, not less. Problems that require longer stays in hospital, not shorter ones.

Measures such as directing funding and resources into the other end of the blocked pipe – sub-acute services such as aged care, “step-down” beds, rehabilitation beds, community based services and so on – absolutely have merit and will help but, unfortunately, these efforts alone are and will not in the forseeable future be enough to have any significant impact on the current access block problem in anything approaching a timely manner.

There are not enough acute inpatient beds to service the current, let alone the projected, health care needs of the population.

People wait hours to be seen in ED because we are physically full. Our beds are full. The recliner chairs designated for acute care are full. The random spaces in our plaster room, and our corridors are full of the walking (or not quite walking) wounded. The corridors themselves are full of beds with patients who should be somewhere else, either in a proper acute care bed space in the emergency department or, more usually, elsewhere in the hospital.

We are well staffed. We are interested in seeing sick and injured patients. We signed up for it. It’s our job. Some days we even enjoy it. Those are usually the days where we aren’t spending half our work day shuffling patients and beds around in a frenzy of damage control, and apologising to every patient we see about the long wait, or the crappy spot they’ve been plonked in for the past hours. We _want_ to see you. Especially if you are _properly_ sick or broken… because… okay, critical care doctors are just a bit weird that way… but I digress.

We are full because the _hospital_ is full. We have nowhere to send the patients we have already seen, diagnosed, and treated, who need to be admitted to hospital (which as in most large urban hospitals is roughly 30% of the punters who come through the door). These patients continue to occupy beds in the ED. Which means we can’t put new patients, from ambulance stretchers, or the waiting room, into those beds to be assessed, diagnosed and treated in turn.

In the past several years there has been a crescendo of increasingly frenzied activity revolving around increasing the efficiency of patient flow through the ED and the hospital at large, and both clinical and administrative staff currently spend a _lot_ of time and effort trying to optimise these processes within the resource constraints imposed upon us.

But it’s damn hard to keep everyone afloat when you only have half the lifeboats you know you need.

@ pink little birdie:

TCH ED has had a short stay / observation ward for a few years now. Our particular version has 9 beds and is known as the EMU.

Calvary ED has a similar area known as the CDU.

pink little birdie9:44 am 13 Sep 12

This isn’t Canberra example but I think it works well for the maybe need to be admitted cases.

I was very sick and taken to the hospital in Adelaide (6 am boxing day no doctors open). I was straight through to the emergency room (no one in the waiting room and I was sick). Doctors pretty quick on my case. (There was also only a couple other people in the emergency room) After a couple of hours they still weren’t sure if it was gastro or more serious. So they moved me to this “might need to be admitted but we still aren’t sure so we will move you to a short stay room and keep watching you but will free up a emergency bed for us” area It had say 6 beds.
We should get a system like that. Slightly less than accute care.
Making CALMS free might also help (GP After hours service at the hospital)

(and before anyone asks I was admitted and had surgery the next day so I did need to the emergency room)

Having used the Calvary ED twice in the last couple of years for genuine emergencies, I found we were seen to immediately and received excellent care. I like hopefuls idea although that has potential issues to overcome.

I wonder what adding a few doctors to the walk-in clinic might do to the non-emergency presentations at the ED?

But I don’t believe it’s the non-emergency patients who hold up the ED (as they usually end up waiting for many hours outside in the waiting room) I believe it’s the lack of well-trained doctors and nurses available at the hospital that hold up the ED.

I’ve been there many times in the past 12 months and it’s always the same routine – get in quickly due to emergency situation and then wait for hours to see a doctor and then many more hours to get a hospital bed. Every part of our public hospitals is understaffed and underfunded.

The inadequate funding isn’t about current politics – it’s been like this under every colour of political leadership for many years.

The conclusion I’ve reached is that the majority of people assume they’ll never need to go to hospital and see paying extra taxes for healthcare as an imposition. They don’t vote for politicians who promise more funding to health.

Then they find themselves in the ED one night waiting hours to see a doctor and they can’t understand why the situation is so dreadful. They blame the government when the fact is they themselves are to blame.

the news also says that more ED patients are having to be admitted to hospital than ever before, but don’t let the fact worry you.

‘We know year-on-year we’ve seen a 5 to 6 percentage increase in ED presentations over the last three to four years,” Dr Brown said.
”But along with that we’ve had an even higher percentage of people who are being admitted once they present to the ED

Read more: http://www.canberratimes.com.au/act-news/extra-beds-as-patients-surge-20120911-25qxp.html#ixzz26G2YLyjh

Here’s a possible solution – How about a system where the triage nurse gives anyone who presents with a “non-emergency” condition/problem a voucher to go to a doctor. Doctor then gets reimbursment from hospital – $70-$80 well spent. Anecdotal evidence suggests people turn up at the ED because they can’t afford a doctor not because they can’t get in (or haven’t tried!)

unfortunately it’s true.

Maybe if some of these younguns were shown what they look like in the wee small hours a small percentage might change their ways… either way, they often use resources like ambulances, triage staff, nurses and doctors who could be assisting others.

carnardly said :

off their face and have got spew and pi$$ stains all over their pretty going out frocks….

Thanks for that image, canardly! Noice….

Imagine if you could toss all the drunks, smack heads and party pill poppers on a friday or saturday night into the carpark to sleep them sleep themselves off, or cark it… while treating the others. The queue would reduce tremendously.

And unfortunately there are many selfish and thoughtless people that use up critical resources doing the same week after week after week…. It might be fun partying around town, but its not very classy when the hospital rings someone’s mum at 3 am to come and pick up a kid when they’re off their face and have got spew and pi$$ stains all over their pretty going out frocks….

Comic_and_Gamer_Nerd1:02 pm 12 Sep 12

Guarantee that if ED started billing the filthy tight arse scumbags that use it as a free GP, a lot of time would be freed up.

@peitlab, that is a really interesting point. However, it would be interesting to see how many of the 200 presentations on Sunday required hospitalisation or even emergency treatment?

Surely the crush in ED is a direct result of Katie Gallagher’s “South of France Holiday Friend” messing with the wait figures. If the wait times were “lessened”, then of course the hospital honchos charged with planning & strategy would have responded accordingly and not known what the actual emergency department needs were, staffing & response-wise. So Katie’s friend is the cause of the current problems – and it’s squarely Katie Gallagher’s ministerial responsibility. Take the rap, Katie!

Much of the Australian research currently being done on EDs is now saying that GP-type patients are not the major cause of delays in the ED. Overwhelmingly the number one cause is still access block (i.e. access (or not) to an in-patient bed).

Many hospitals around Australia are in the process of redesigning their entire patient flow system to deal with access block. While ACT Health has announced that their redesigning their ED patient flow system (which is an excellent start), does anyone know if they’ve done a whole-of-hospital redesign?

Indeed. I wonder how much the perception of the unavailability/ expense of GP care is simply ingrained now and people just assume they can’t get in, or can’t afford it?

In Gungahlin it was very hard to see a doctor, but in the last year or less at least three new clinics have opened up. I still have to wait if I want to see my particular GP, but if I just need one, anyone, I can generally get in same/ next day. If not, there’s always Gininderra or Phillip and the long wait…..

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