Introduction by Croakey: Emergency departments are often thought of as the canary in the coalmine, but what do we do when the canary is clearly in distress?
Dr Simon Judkins, President of the Australasian College for Emergency Medicine (ACEM), started a much-needed conversation about Australia’s overburdened emergency departments back in September with a post to coincide with national RUOK Day.
In response, an anonymous emergency clinician penned this searing, heartfelt account of the very real pressures ED workers face every day. If you haven’t yet read it, we’d very much encourage you to do so.
While only one person’s story, it resonated with and captured the experience of many, reflecting a system underresourced and overwhelmed, according to Judkins, who wrote an open letter in reply — below — calling for courageous reform.
Simon Judkins writes:
You are not anonymous to me; I know you.
You are the registrar I met in Logan Hospital last year who became tearful when talking with me about how hard it was to turn up to work each day or night. Facing a full waiting room with patients being treated in chairs, in hallways, in the waiting room, exposing their personal stories to everyone around them, others pretending not to hear, being as polite as they could be, while also hoping they would be the next to be seen by you..
You are the Emergency Physician I met in Liverpool Hospital, who showed me through your ED, with 11 patients who needed mental health beds, flanked by 11 security guards, many of whom had been there for more than a day. You were trying to put on a brave face, but were seething that your pleas to have better care for your patients had been ignored time and time again.
@acemonline Great to meet such a great bunch of EPs at Liverpool ED today. There is something special about EPs who can stay positive despite the challenges of overcrowding and understaffing. Mental health capacity a critical problem and ACEM is taking this on.. pic.twitter.com/rNCnTHUZxR
— ACEM President (@JudkinsSimon) July 12, 2018
You are the trainee I met in an ED in Tasmania, struggling with your choice of career. While you love ED and love your work, your new knowledge and skills, your team, you struggle to see how you can work in a hospital which is deteriorating month after month, and has senior clinicians in powerful positions actively resisting changes to hospital processes to improve patient access; something you cannot fathom. Clinicians without any apparent motivation except to maintain their own interests over those of the system they work in, but not for.
You are the emergency physician in Fiona Stanley who called me and asked what you can do to make your Minister understand that your department isn’t OK; the physician in Rockhampton Hospital, Cairns Hospital, Westmead, Flinders, Darwin and The Northern hospitals who did the same. All concerned, stretched, stressed and feeling powerless to change a system which seems broken, but unchangeable.
Keeping the hounds at bay
You are the frustrated Director in countless EDs who gets hauled over the coals for not meeting impossible performance targets in a department which is constantly full, constantly under pressure and perennially understaffed. You try to keep your ED staff up and motivated, but are bullied and harassed on a daily basis by managers with their own short-term goals.
You go home and lie awake, wondering how you can ensure your patients and staff are safe, while you try to keep the hounds at bay.
You are the incredible nurses working in EDs across Australia and New Zealand, trying to care, show compassion and empathy in a system which does as much as it can to ensure that this is a challenge in itself.
You are the ambulance officer waiting, ramped out the front of an overcrowded ED in South Australia, who cries “SHIT!” as, after over an hour waiting, your patient’s blood pressure drops and she loses consciousness, never to regain it.
You are the patient who spent 13 days in an ED in regional Victoria recently because no-one — no service, no inpatient team — could provide the support you needed.
You are every patient, and their relatives, who wait frustrated, in pain and at risk of poor outcomes the longer you sit in triage, getting angry at the ED staff. You know that it’s not their fault, but are helpless to do anything else, leaving doctors, nurses and paramedics to bear the brunt of your rage and frustration.
This. @JudkinsSimon @acemonline the harder we work, seeing people in waiting rooms on chairs and ambulance trolleys, we strive to keep patients safe, minimise harm, soak up the dissatisfaction from patients,families,ambulance bosses-while the hospitals continues to fail us all https://t.co/SumJcSu1uw
— anne creaton (@annecreaton) October 16, 2019
As I write this, seeing my reflection on the screen, a shadow over the words I have written, I realise that you are also me, worn down after hearing about the constant abuses, the seemingly unsolvable problems, the mounting pressure and sleepless nights; but more determined than ever to see a change.
You are every doctor and nurse working in a system which is failing on so many levels.
A system where errors are common, but left unfixed as “no one died” — although many do — hidden in layers of Riskman reports and committee meetings, which achieve little outside of the bureaucratic maze of KPIs.
A system where, from where I sit, every gap a patient falls through — and there are many — seems to mean they end up in the ED.
A system where we see the latest in a line of policy failures playing out right now, in real time, with emergency departments picking up the pieces of a struggling National Disability Insurance Scheme (NDIS). We are daily seeing anxious and stressed parents bringing their children with special needs to the ED, as they can’t access community care anymore. Kids who need a secure, controlled environment thrust into the chaos of the ED, only to be told that the Paeds team can’t or won’t help, mental health admission isn’t appropriate, and we have no access to experts who can assist in care provision.
These are the faces of a system where we haven’t addressed overcrowding in Emergency Departments to the detriment of all patients, despite having clear evidence of increasing morbidity, adverse outcomes due to significant delays to acute care, medical error due to fatigue, burnout and multi-tasking, and of increased patient deaths.
This is a system where those in charge — our minsters, health department leaders, our Treasurers — are so far removed from the coalface that they remain completely unaware of the data fudging, the creative accounting, the layers of administration that allow them to insist that it’s all fine, nothing to see here, while patients present, day in day out in ever-increasing numbers and you witness a desperate deterioration in care.
Hospital systems should be patient centred. A ‘patient journey’ is not served by silos, tribalism, shifting cost and risk. I recommend a look at the ethnographic ED work of Peter Nugus. Healthcare should be a team sport with patients and their needs the main focus. @JudkinsSimon https://t.co/tuAUiy9t9O
— Clare Skinner (@claski) October 18, 2019
Time to be brave
Outdated models of care ensure that nothing will change, particularly where many in the system have no desire to do anything differently, and where doctors — many in positions of significant power — are more interested in maintaining their own empires, their own incomes, their own interests, than improving care for patients, and for our communities. This was highlighted in Stephen Duckett’s 2016 report ‘Targeting Zero‘ by a rural hospital CEO who said:
There’s an imbalance of power … The further out you go, the harder it is to replace staff. Smaller towns’ hospital boards can be held to ransom by their doctors
We have had the same models of care in many places for decades; I believe that it is well past the time for change in our public hospitals. What other business would survive by employing a group of staff who are pivotal to its operations on a part-time basis, allowing them to come and go when they please, and not when the business needs them? How, in such conditions, could any business expect to run effectively and safely?
So, let’s take a bold step and appoint many more full time specialists — not just one or two, but dozens — across our big, busy and complex hospitals, to be there seven days a week (yes, gasp, all seven). This way we can ensure that the right decisions are made, that our doctors-in-training feel supported, and that patients can be discharged home on Friday, Saturday or even Sunday at 6pm, because they don’t need to be in hospital anymore.
The same applies in our EDs; we can’t run these frontline departments, the place of highest risk in the hospital, without enough senior staff, enough time to think, or enough capacity. The Visiting Medical Officer (VMO) zero-hours models, which administrators are addicted to, will not support process change, quality care, staff morale, career satisfaction or most importantly, a decrease in patient risk.
Get the right people, value them, and you will be paid back in spades.
You know what makes me really mad? Senior docs (I’m looking at you, FACEMs) who, on learning of brutal, inhumane sleep deprivation of registrars, say things like, “they chose to do this job” and “no one’s forcing them”. Some of the hrs worked in Oz are frankly criminal.
— Kristin Boyle (@KristinJBoyle) October 15, 2019
There is so much more we can do that we haven’t been brave enough to try. This is one thing we can do tomorrow, to make a difference immediately.
Let’s be brave. Let’s call this out. What is happening in Australian EDs, due to the failings of the system we are truly embedded in, is a crisis.
It’s a crisis because our hospital systems desperately need reform. We need to move away from traditional employment structures which are outdated and ineffective, improve medical leadership, and address a culture which promotes tribalism, a constant battle of us vs them, and which is far removed from patients. That reform needs to start yesterday.
There are many other things we need to fix. I’m happy to sit with any health minister, departmental planner, hospital administrator, and share my views on what we need to do. But, first and foremost, we need to be brave and take a big step, and make a big commitment.
If we don’t, we will continue to betray all those who bear the brunt of a system which is failing: our patients, our communities, and thousands of ED staff.
Simon Judkins is President of ACEM, the Australasian College for Emergency Medicine
ACEM’s annual scientific meeting #ACEM19 will be held in Hobart next month, and Amy Coopes will be there for the Croakey Conference News Service.
This year’s meeting is themed ‘The Changing Climate of Emergency Medicine’. Read our previous ACEM ASM coverage here and here
Whilst I greatly sympathise with my colleagues working under stress in ED, all the solutions presented are around demand management – more resources, more staff, etc. Adequate staffing is certainly a reasonable aim we all support.
However, there was not one mention of looking to reduce that demand. As a GP, it is my patients who end up in ED, for various reasons. Many of these are preventable, with the right systems in place. And I take my responsibility to keep patients out of ED seriously. So part of the solution Is to resource and empower GP. Adequate rebates for the longer consults these people require, access to allied health staff, systems to support quality care etc. Give me too the support I need and some of these patients won’t end up overloading your ED. The time has come to stop looking at these problems in isolation and having a narrow, siloed approach to solving them. Having more hospital specialists alone won’t solve the problem, it is only one part of the solution.
A local issue we have is the lack of real time transparency for GP referrals to outpatients. There is no acknowledgement of the referral and no expected time frame (eg up to a year for neurology for example). Then the GP gets frustrated, doesn’t know if referral is received then sends the patient to ED. Where we often then contact the specialist and get the advice. Then it becomes “well going to ED worked better than outpatients, May as well do that”
This ‘cri de coeur’ invites the highest attention to resourcing primary health care. There is no doubt that a significant percentage of presentations to these swamped EDs arise because of the maldistribution of GPs and the fraying of primary health care as a co-ordinated, evidence-based system to keep people away from hospital. If there is a shortfall in capacity in the primary health care system, where else do people go?? A primary health care plan is being developed and should address the shortcomings of the previous national primary health care plan, otherwise it’s just more ‘ground hog day’ for everyone. No more short-term programs. Fund primary health care to its full potential. Then staff in ED departments will be able to breathe.
I’m an ED consultant in a regional hospital. I have a lot of respect for Simon’s position on these issues and I thank him for his advocacy over the last couple of years as ACEM president. I think that both the article and the comments afterwards are in danger of obscuring the real issues that plague EDs across the country.
To me the basic problem in emergency departments is not outdated models of care or the employment conditions of senior doctors, although I agree with Simon’s points. I also don’t think the issue is a lack of access to primary care. Good primary care can improve people’s chronic disease and quality of life. It can prevent some hospital admissions, but the biggest increase in hospital admissions I’ve seen in the last five years is in category 2 patients – those who are quite unwell and need to be seen in ten minutes – in the over 85 age group. A good GP can’t stop the ageing process and sooner or later all of us will get old and sick, and many of us will come to ED, no matter how good our primary care is.
The patients who clog up my ED every single day need a hospital bed, or a mental health bed, but we are constantly told that the solution is to work smarter, to do more with less, to divert people from hospital. Patients are told not to go to the emergency department for minor illnesses, after hours services are put in place, we’ve got nurse navigators and discharge planners and GEDI aged care nurses. It seems like government and hospital administrators will do literally anything to convince people that it’s a crisis that we can think and design our way out of.
In reality the solution to the problems in emergency departments could not be simpler. We need more physical beds and more doctors and nurses to staff them. We need them every day of the year. There are very few major problems in my ED that would not be solved by opening 40 new medical beds, and very few major problems that could be solved by anything else.
I know beds are boring. They represent bug chunks of recurrent spending that gets maybe one news headline and is then forgotten. They aren’t smart and innovative. But we don’t need smart and innovative, we need boring and expensive.