Introduction by Croakey: The traumatic impacts of the COVID-19 pandemic upon global health systems and especially staff in emergency departments has been a key theme at an international medical conference.
Emergency medicine delegates have gathered in Naarm/Melbourne this week at the 21st International Conference on Emergency Medicine to discuss the challenges and learnings from the past few years.
Staff burnout is a common theme, and the conference also heard that addressing social disadvantage and inequity was “fundamental” to the pandemic response, reports Dr Amy Coopes for the Croakey Conference News Service.
Coopes writes below about some experiences during the pandemic in emergency departments, highlighting stories from Sri Lanka, Uganda, South Korea and Singapore. Bookmark this link for ongoing reports from the Congress.
Amy Coopes writes:
Social and structural disadvantage has been a central driver of COVID-19 within and between countries, and addressing inequity is the only way to truly make a difference to this and future pandemics, a global emergency medicine conference heard this week in Australia.
The 21st annual International Conference on Emergency Medicine (ICEM) conference kicked off in earnest in Melbourne on Thursday with a strong focus on international experiences from the COVID-19 frontlines, ranging from higher-income countries to resource-limited lower- and middle-income (LMIC) settings.
The conference, which is themed Better Care for a Better World and centred around global healthcare, equity, sustainability and innovation, is the first time the world’s emergency doctors have been able to come together in a substantive way since the pandemic began.
Some 1,500 delegates from more than 65 countries registered for the hybrid event, with a roughly even split between in-person and online attendees.
Though challenges varied, there were some common themes to experiences of emergency care at the coalface of the outbreak, referred to by a number of speakers as the ‘four S model’ of systems, staffing, structures and stuff.
The personal toll on emergency staff, who found themselves thrust into an unprecedented and unpredictable global crisis, has been immense, the conference heard. Burnout was significant – one study in the Philippines found that 97 percent of emergency doctors had experienced moral injury during the pandemic and more than half had been depressed.
In Sri Lanka, doctors spent months isolated from their families, their children growing up without them, almost constantly on call. A field hospital was constructed in Borneo in the space of six days and in 106 days of operation saw more than 330,000 patients.
Ugandan emergency doctors were forced to build a response capacity from scratch, writing protocols and training up staff on the run.
Singapore’s government pulled out all stops to keep patients flowing through the system, even bringing in Uber drivers to help transport low-acuity patients to care.
Deaths from out-of-hospital cardiac arrest and mortality in the ED increased, along with intentional injury and hangings in South Korea, as ambulance workloads ballooned 35 percent.
In Britain, ambulances ground to a halt, heart attack and stroke patients waiting an average of four to six hours. Dr Katherine Henderson, president of the Royal College of Emergency, described this as a fundamental breach of medicine’s social contract to provide timely emergency care.
Rather than create new problems, Henderson said COVID-19 had merely exposed fragilities in the system that had been for many years papered over by the slimmest of buffer zones, a margin for error that had been “annihilated” by the pandemic.
Indeed, part of the problem had been that emergency medicine prided itself on efficiency, explained Dr Ng Yih Yng, chief medical officer for the Singapore Government.
Emergency departments worldwide tended to run close to capacity and with little resource redundancy, meaning there was little room to manoeuvre to the scale that was required when COVID-19 hit, requiring a surge capacity in some locations in the order to 60-100 percent.
Ongoing disruption and some silver linings
Rather than getting a reprieve and returning to some semblance of business as usual like most other parts of the health system, Professor Lee Wallis from the World Health Organization (WHO) told ICEM delegates that emergency medicine was coming under increasing disruption, despite the diversion of significant resources to assist.
Globally, 38 percent of countries reported impacts to their emergency care systems during the pandemic, and Wallis said this was more pronounced in LMICs, where the burden of excess mortality due to conditions amenable to emergency interventions was also highest.
IFEM President Professor Sally McCarthy put this figure at 75 percent, and said it highlighted the value of emergency care as increasingly recognised by the WHO in these settings. She also told delegates poor-quality care (60 percent) now outstripped access barriers (40 percent) in terms of preventable death in LMICs.
Wallis and his WHO colleague Dr Teri Reynolds both shared data showing that significant disruptions had been seen across a range of health settings globally due to COVID-19, with 59 percent of countries reporting disturbances in elective surgery, 54 percent in community care, 53 percent in primary care, 52 percent in rehabilitation and palliative medicine and 38 percent in the emergency space.
Wallis said it was important to note that many of these sectors were scaled back or mothballed to allow for diversion of resources to the COVID effort, including to emergency services, making the 38 percent figure – in spite of this – even more significant.
As the pandemic stretched into its third year, most areas of health are starting to see a normalisation of their work, but emergency services continued to come under sustained pressure, including ambulance operations, which Wallis said was perhaps the most disturbing trend.
According to the WHO data, the number of countries reporting ambulance service disruptions doubled across the course of 2021, and Wallis said mortality from both COVID-19 and a range of other time-sensitive conditions had likely substantially increased in the near-term as a result.
Both supply and demand factors were at play, he added, with reporting countries dividing evenly across three major themes: lack of resources, policies mandating the suspension or scaling back of services, and decreased care-seeking.
In Britain, RCEM’s Henderson said the latter had been significant, with government messaging urging people to ‘flatten the curve’ and stay at home to ‘protect the NHS’ resulting in deferred and delayed care that was now flooding back into the system at overwhelming volume and acuity.
The WHO had identified six bottlenecks to scaling up countries’ COVID-19 response, which Wallis said also overlapped with almost entirely perennial issues in emergency care: funding, workforce, supplies and equipment, distribution capacity, data and information, and strategy, guidance and protocols.
While the impacts had obviously been significant, there were some surprising silver linings, particularly for developing nations.
Delegates from Sri Lanka and Fiji described the pandemic as something of a blessing, drawing attention to and resources for their nascent field and fast-tracking infrastructure and development of emergency care capacity in their country that would outlast COVID-19.
Health inequities exposed
Though the pandemic exposed systemic shortcomings, it also underscored the interconnectedness and interdependence of people’s lives, as well as the importance – and sometimes expendability – of our shared humanity, delegates heard.
Within countries, the pandemic had laid bare class and cultural divides, with a clear social gradient to disease transmission and mortality.
Henderson highlighted that the majority of physicians who had died on the COVID-19 frontlines in Britain were from culturally and linguistically diverse backgrounds. While the NHS had health equity as its core mission, in practice it failed to deliver, with marginalised groups bearing the brunt of the pandemic.
This was also seen in Australia, where renowned field epidemiologist Professor Kamalini Lokuge said the Federal Government – despite warnings from herself and others on their advisory group – dismissed and even seemed surprised by the suggestion that disadvantage would be a key driver of the pandemic.
Lokuge is a veteran of infectious disease outbreaks including Ebola, working for Medicins Sans Frontieres and the International Committee of the Red Cross for decades in low-resource settings, and she said the likely demographic trajectory of SARS-CoV-2 had been known well before it came to pass.
Experiences with Ebola and other large-scale outbreaks had shown that disadvantage was a major factor in transmission and COVID-19 had been no different, “finding its way” to the most marginalised groups in society through insecure work and housing, underlying mental and physical disease, experiences of trauma and marginalisation – particularly in the health setting, as well as language and cultural barriers, she said. This was seen clearly in the epidemiology of COVID-19 in Sydney and Melbourne.
It was also known, from earlier outbreaks, that top-down, post-hoc, surveillance-driven responses divorced from the usual paradigms and infrastructure of public health were less effective than decentralising power and control to affected communities, she said, urging delegates to embrace a broader mandate to advocate for their patients.
“With the power you have, an essential part of doing the right thing by your patients is to use that power to not just provide care but to work to identify and address the drivers (of their ill health),” she argued.
Trust and community engagement
Lokuge said trust, and upholding of the social contract, were so critical in pandemic management, and this was echoed by Dr Kerry Chant, chief health officer of NSW and something of a household name after years of fronting sometimes daily press conferences on the populous state’s COVID-19 response.
Chant said the importance of trust, community engagement and addressing social disadvantage had been key lessons in NSW from the pandemic, which she said had passed its acute phase but was still very much ongoing and would continue to pose challenges around management and messaging.
“Pandemics are a long game with much uncertainty, and focus has to be on overall health outcomes,” Chant said. “COVID-19 has shown us that we need to expect the unexpected, and that we will continue to confront significant challenges.”
She credited “incredible public health and social measures” and vaccine uptake, as well as the recent addition of antivirals to the treatment matrix with Australia’s relative successes, as illustrated by global and local excess mortality data.
Chant said what the Australian experience had shown, with comprehensive and swift government intervention to protect people’s incomes and enable isolation without financial penalty, is that addressing social disadvantage and inequity was “fundamental” to the pandemic response.
Communications had also been crucial, and many lessons had been learned, Chant said, including keeping messaging simple and consistent, flagging changes early, and understanding and addressing barriers to compliance, particularly those related to income and time off work.
While Australia’s COVID-19 deaths and excess mortality are lower compared to many other countries, it is important to keep in mind the current and ongoing impact of COVID-19 where “COVID is currently on track to be one of the leading causes of death in Australia this year,” Professor Nancy Baxter and Professor Nicholas Talley reported last month.
The pandemic has disproportionately impacted Aboriginal and Torres Strait Islander people who, according to recent research from OzSage, are two-to-three times more likely to end up in ICU or to die from COVID than non-Aboriginal Australians of the same age.
Bringing a fatigued community on the sustained journey of pandemic management was a real challenge, Chant added, particularly in an environment where information was rapidly evolving in real time and the goal posts had and would continue to shift.
Echoing comments from others, including Victorian Health Minister Martin Foley, who formally welcomed delegates to Melbourne on behalf of the State Government, Chant said a resilient, strong and most importantly well-connected health system had to be at the heart of readiness for future pandemics.
Foley said COVID-19 had demonstrated the fragmentation and siloing of health in federated Australia, where we had a collective of services in series instead of an integrated health system. It was time to “reimagine and reconceive” of what such a system could and should look like, he said.
“COVID-19, it’s impact, and potential relations to climate change and the global environment in which we live have shown that this pandemic is, sadly, not going to be a one-off event,” Foley said.
He described the past few years as among the most traumatic in living memory for global health systems, particularly emergency staff, who he said had withstood unprecedented and unforeseen pressures and demands beyond what could reasonably expected of any individual or profession.
“Your commitment and compassion has inspired, and saved no doubt countless lives,” he said.
This message was echoed by Dr Takeshi Kasai, regional director for the WHO’s Western Pacific regional office, who sent a video tribute thanking those gathered for their lifesaving efforts during COVID-19, a moment when he said “the future has arrived on our doorstep”.
Speaking in welcome on behalf of the Australasian College for Emergency Medicine, President Clare Skinner said better care – the central conference theme – went far beyond the emergency department’s doors, and was about values, ethics, the social determinants and a shared humanity fostered through connection and inspiration.
Read Coopes’ threads from Day One of #ICEM22: Opening plenary, sessions on GEC development: challenges and opportunities for emerging emergency care systems and COVID and ED thread from across the globe.
Dr Amy Coopes was in virtual attendance at the International Conference for Emergency Medicine for the Croakey Conference News Service. Follow her at @coopesdetat for her Tweets from the conference, with additional coverage via @croakeynews and @wepublichealth.
Join the conversation and tag #ICEM22 on Twitter, Facebook or Linkedin. Follow this Twitter list of #ICEM22 presenters and participants, and bookmark this link to track coverage by Croakey Conference News Service.