The following post in no way represents the opinions, policies or strategies of my employer. Nor does it necessarily represent the opinions or feelings of my colleagues.

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The US is currently experiencing quite a bad influenza season.

Healthcare services and drug supplies are being stretched to the limit in the United States as the authorities warn this year’s flu season is severe.

Official figures indicate that influenza is now “widespread” in 41 states, with high numbers of cases reported in New York, where state governor Andrew Cuomo has declared a public health emergency.

Robert Glatter, an emergency doctor at New York’s Lenox Hill Hospital, said the facility was opening extra work spaces to take care of the influx of patients.

He said medics were almost as worried about the situation as they had been during the swine flu outbreak of H1N1 in 2009.

The severity of this year’s flu is of particular concern, he said, adding many patients are elderly and suffer from severe aches, chills, cough, fevers, dizziness, nausea, vomiting and diarrhoea.
Healthcare Today.

The situation has been compounded with simultaneous spikes in people presenting with pertussis and norovirus, and has placed significant extra demand on hospital wards, and in particular, their emergency departments.

In Australia the influenza season is yet to hit. But looking at the US experience, we should be preparing for a busy one.

I have been working as a nurse in the emergency department for many years now. During the winter season, we see a large increase in demand for hospital in-patient services from our community.

Typically, this quickly overloads our hospital bed capacity. With the hospital full, patients presenting to the emergency department (ED) that require admission have no-where to be sent, and must remain in the ED until a bed becomes available. Sometimes for many days.

This inability to access in-patient beds is known as access block. It leads to a situation known as emergency department overcrowding.

With no-where to place these admitted patients, and a vital need to keep treating new arrivals, inevitably patients are moved into our corridors and other non-clinical areas.

There are now many studies that show these patients, and indeed all patients cared for within this overcrowded environment, are at a significantly increased risk of morbidity and mortality (that is, an increased risk of poorer health outcomes or even death).

An overcrowded, high-stressed emergency department needing to care for its usual workload and the additional workload of patients waiting to access the hospital, quickly becomes demoralised, exhausted and at increased risk of medical errors & accidents.

Perhaps you have visited our department and experienced this situation yourself over the last few years. Perhaps you might experience it during the impending flu season.

We need to prepare for this winter surge in demand for our services now. Once you start reading about overcrowded emergency departments in the newspapers this winter, it is way too late.

The hospital must have a robust and effective strategy for maintaining a flow of patients in and out of our emergency departments so that they can continue to provide quality critical care.

One possible strategy (and there are others) is to move admitted patients up to the corridors outside the ward they are expected to be admitted to. This is by no means a perfect solution, and it is not appropriate in all cases. But what it does do is spread this extra workload evenly throughout the hospital rather then attempting to contain it within the limited space of the ED.

Instead of one area (the ED) having 10–20 admitted patients crowded into their corridors, each ward area can care for an additional 2 or 3 patients. Wards will not like this, but access block is a all-of-hospital problem that requires a shared response.
Patients on their correct specialty ward, with less overcrowding will receive better care, in a safer environment.

I ask you to consider all this and to ensure that our healthcare leaders are developing and implementing strategies such as these now, so that we are ready to meet any demands that the flu-season may bring safely and efficiently.

It is your health system.

 

7 Responses to “An open post to my community.”

  1. I’ve seen this idea of moving patients to the ward corridors to ‘spread the overload’ in other respectable publications, but I can’t remember where, nor find it again. I think it is certainly worth looking into.

    I think the ED is generally the most flexible department to cope with busy days/weeks, but it certainly does have limits, and care for in-patients waiting on ‘beds’ suffers as the ED is over-stretched. The wards are often far more tightly controlled (time organisation wise) and perhaps not as flexible, but with plans in place could surely accomodate more patients in the corridors.

    The idea of utilizing the vacant ICU beds for patients is another good one – those chest pain patients waiting for repeat bloods come to mind as good candidates.

  2. In the UK and particularly in England pressure on emergency departments is not uncommon. However there are two approaches which manage this. Firstly the government have out in an emergency access target of 4 hours from arrival to departure or admission for 95+% of patients. That makes it both a hospital and a system problem. Failure to comply is seems badly and has financial consequences.

    Secondly many organisations have escalation policies whereby all clinicams must review every patient and discharge or more to an appropriate facility. I’m the eventually one gets under seige they can call an internal major incident which pulls in they key operational and clinical leads. Review all non urgent operations and make capacity. Where I work we have opened 3 wards to manage winter pressures.

    While we are a system under strain our reform agenda which are probably more reformed than any other country have thought us to approach this as system flows and manage the probl in different ways. Don’t get me wrong the system here is far from perfect and good will – where doctors and nurses will go out or their way to go the extra mile – is dwindling fast.

    So in wonder is the capacity problem management constipation or true access issues?

    • The institution of financial penalties for failure to meet targets/KPI’s just adds to the problem rather than solving it. It promotes the practice of ‘creative accounting’ with dummy wards… yet fails to solve the real problem of access block and over crowding.

      I think the suggestion of spreading the hurt is a good one, potentially a life saving one, but some ownership and education in the community wouldn’t hurt either. Do you really need to attend the Emergency Department? Can you wait to see your GP or attend a ‘Walk-in-Centre”? Immunisation for at risk communities?

      But it must be said – generally speaking – as individuals we are egocentric.

      • I manage a “walk-in” / urgent care clinic adjacent to a hospital ED. We have 6 gurneys and 10 exam rooms. Even we are holding patients that are awaiting a med surg bed; sometimes for an entire day! We had several yesterday and it’s a big problem because we close at 2200. Because of EMTALA, the ED is not allowed to send non-acute patients to the urgent care, so they have to “evaluate and stabilize” every runny nose and UTI. These non-emergent cases take up precious space in the ED. It’s a hot mess.

        I completely agree that the community has some responsibility here…Most patients didn’t even bother to get their flu shot this year.

  3. Fabulous concept! Wouldn’t it wonderful if the WHOLE hospital took on a shared responsibility for overcrowding in the ED.

    I would also love to see everyone (all hospital staff and general public) get the flu shot – lets get our herd immunity bac on track!

  4. Interesting that you should post this today. At my small hospital we are piloting a program with the ICU and the ER. They ran some analysis and found that the ICU averages about 10 pts in a our 16 bed ward so we are now going to start using 4 ICU rooms as “ER Holding” rooms. The plan is to have an ER trained nurse to bring over the “complex holding” pts, basically anyone who is definitely going to be admitted and will require more than a few hours in the ER. This frees up beds and allows us to isolate more patients who are very sick. It also gives the ER nurse the support of the ICU for patients who are on a ventilator and require more attention.

    There of course is some worry that this will blow up big time, and since I work both areas I know I am going to be knee deep in the experience. I look forward to seeing how this works

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