A prescription to reboot our hospital emergency departments

A quarter of the population of this country attend local emergency departments (ED) annually, so the question of how to “solve” overcrowding is extraordinarily important to those who manage this State and to the vast numbers who face the possibility of an unexpected visit to hospital. Soon.

Because I have thought long and hard about this perennial congestion and its grim consequences for patients and staff, here is my simple (apolitical) prescription for the kind of “care in a crisis” which we deserve and can afford; the sort which might restore credit to our once-proud medical and nursing traditions.

In no particular order, here are the 20 desiderata (“things greatly to be desired”) which I believe could decongest and renovate our healthcare frontline, and “reboot” the quest for excellence:

1. Agreement that the purpose of the ED is to manage a medical “emergency” (ie a serious, usually unexpected, condition requiring immediate action). Long-stay patients in nursing homes with dementia or patients with back pain for years seldom count as emergencies but they frequently populate our EDs.

2. Provision of enough hospital beds for people who warrant – and receive – “emergency” care. And community beds for those who don’t (eg the elderly patient whose steady deterioration can be envisaged and therefore planned for).

3. Provision of alternatives to referral to the ED: eg acute medical assessment units (AMAUs) for those with chronic disease “flares” or local injury units (LIUs) for minor mishaps. And access to basic “screening” tests (eg X-rays for fractures or tests for blood clots) for GPs.

4. A renewed emphasis on “ambulatory care”: about 80 per cent of ED patients are not admitted but “walk in and walk out” of the facility. It is often forgotten that their care is the core function of the ED, not “corridor care” (which “subverts” the primary purpose of the typical department, meaning people who have had a sudden “mishap” sit for hours in waiting rooms, while those with ancient ailments serve their time on trolleys).

5. Recognition that dedicated ED staff are truly exceptional and should be rewarded accordingly: difficulty in recruitment or “demand exceeding supply” implies that pay, prospects and conditions must be suitably adjusted. It’s obvious: staff shortages trump bed shortages.

6. Locum staffing should become unusual: intrinsically risky, it signifies failed personnel planning.

7. The ED should be designed for comfort, safety and efficiency, with separate areas for children and adults and streaming of the walking, trolley-bound and critically ill.

8. Discipline matters: ED corridors are often full but a “one patient, one companion” must be the rule.

9. Security is paramount: threats to staff, thefts from lockers (and other patients) and unwitnessed deaths in dark corners of any ED should be inconceivable.

10. Patient comfort is the ultimate objective. So every ED should have a Francis Brennan equivalent, committed to making patients comfortable (with “basics” such as a seat, a drink, access to a clean toilet, relative privacy and diversions which make waiting bearable).

11. Advanced nurse practitioners (ANPs) should be regarded as precious autonomous experts, without whom no ED or LIU should operate, and who largely set clinical standards.

12. General practitioners (GPs) should comprise a substantial proportion (eg 10-15 per cent) of the ED’s permanent medical staffing: often dramatically effective, they offer an invaluable bridge to medicine in the community.

13. Every ED should offer a once- or twice-weekly GP rapid access service (GPRAS), which would enable patients whose first ED visit may have been “inconclusive” to be reviewed by a consultant in emergency medicine, by appointment, using confidential email.

14. Resuscitation (the “revival” from near-death of 2-3 per cent of ED patients) should not be unduly emphasised, but delivered calmly by a few ED staff with immediate assistance from in-hospital colleagues, followed by prompt transfer of the patient as necessary, to the scanner, operating theatre, cardiac catheter lab, ICU, etc, rather than its taking place after prolonged waiting in a “resus room”, diverting scarce clinicians away from the majority of patients.

15. Every ED should have a clinical decision unit (CDU) or “short stay ward”, where self-limiting conditions are managed. This avoids unnecessary protracted admissions to non-ED wards.

16. One consultant in emergency medicine should be appointed per 10,000 patient attendances: eg a department which sees 50,000 patients annually would employ five consultants.

17. An audit (cyclical measurement of performance against best practice) should be incorporated routinely into ED activity, with staff specifically employed to collect and collate data. 18. “Best practice” therapeutic policy based on the best available evidence should be instantly accessible online (eg EMed.ie) or on smartphone apps (eg NCHD.ie)

19. Radiology and other tests undertaken in one ED should be immediately accessible to specialist colleagues in other institutions, permitting quick decisions as to whether a patient needs to be transferred or not. 20. One or two medical student “apprentices” should always be present in the ED. They would come from the 20 per cent of their class who would have “signed up” for work in the ED after qualification, in return for a waiving of the Health Professions Admission Test (HPAT) entry requirement to medical school. The students would spend 50 hours in the ED, carrying out tasks that are fundamental to their later effective functioning in the ED.

They would have already spent time in the hospital during their school transition year (after careful vetting for their likely aptitude for medicine) and would be well prepared for the work and surrounded by familiar peers. They would thrive in emergency medicine with its exhilarating diversity, immediate impact and satisfying altruism. In turn, their enthusiasm would sustain older clinicians and maintain a self-perpetuating feel-good virtuous circle.

All of the above things would be supported and co-ordinated by a national emergency medicine programme, a centrally resourced consensual process that would continuously funnel views from the frontline and offer a clearly evolving vista of past, present and ideal emergency care in the country, as well as encouragement for all those who care.

Dr Chris Luke is consultant in emergency medicine, Cork University Hospital/Mercy University Hospital, Cork