EMERGENCY MEASURES: Behind and beyond the tide of misery flooding our emergency departments

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EMERGENCY MEASURES: Behind and beyond the tide of misery flooding our emergency departments

Boy in hospital
The Ministry of Health regularly reviews emergency department admissions. From the data collected it appears most people who got to ED need to be there

Liane Topham-Kindley investigates the rising tide of attendance in our hospitals’ emergency departments and asks how it can be pushed back

Waikato Hospital’s emergency department was overwhelmed this winter as patients waited in corridors, hundreds were directed to primary care and nurses quit because of the stress.

“I spent the past three months entirely in ED: Every single day, the ED is busy,” a second-year house surgeon at Waikato Hospital told the South GP CME political session in August, during the mid-season peak.

We’ve just hit a ceiling where we’ve run out of space and everything’s blown out. It’s like we’ve reached a ceiling for capacity, and we can’t make any more efficiencies

The situation was dire, she said. “We have patients waiting in corridors; nurses are leaving all the time – we are not coping.”

According to the chair of the New Zealand faculty of the Australasian College for Emergency Medicine, John Bonning, a tipping point was reached in the Waikato Hospital ED this year.

It’s the point when injured or unwell patients arriving in ambulances cannot be unloaded because there is nowhere for them in the department, says Dr Bonning, until recently the ED’s clinical director.

Termed “ambulance ramping”, the problem of ambulances being unable to transfer patients into EDs because of lack of capacity has been an issue in Australian hospitals for some time, Dr Bonning says. This year was the first time it occurred to any great extent in many New Zealand hospitals.

In Australia, researchers took a “snapshot” of the emergency system on Monday 28 August, in 120 hospitals. They found 21 per cent of patients who needed to be admitted to hospital had to wait more than eight hours for a bed; some waited more than 24 hours.

“These sorts of proportions are now coming to New Zealand,” Dr Bonning says.

In July, presentations to the Waikato ED were up 19 per cent on the same month last year.

“We’ve just hit a ceiling where we’ve run out of space and everything’s blown out. It’s like we’ve reached a ceiling for capacity, and we can’t make any more efficiencies.”

Long waits for a hospital bed are approaching the serious levels seen in Australia, emergency physician John Bonning says
Taumarunui, King Country

The Waikato town of Taumarunui, in the King Country, has a small rural hospital with an inpatient unit and a small ED for a population of about 6000.

All the efforts to prevent ED presentations rising in New Zealand in the last 10 years have not resulted in a significant drop in the numbers going to EDs

Last year, 5886 patients visited the ED. Waikato DHB’s director community and southern rural health services Jill Dibble predicts presentations will be about 6000 this year.

“That’s approximately the entire population for the town and surrounding areas,” Ms Dibble says.

Nelson Marlborough DHB members also have become concerned. They recently agreed to pilot a study redirecting patients from the Nelson Hospital ED to the local after-hours urgent clinic, which is open from 8am to 10pm daily.

“This will explore all reasons why the community present to ED when they could be seen at the Medical and Injury Centre, including the cost barrier,” DHB minutes say.

In neighbouring Blenheim, the DHB has agreed to Marlborough PHO’s business case for an urgent care clinic at the local Wairau Hospital, as it struggles with a shortage of GPs and to address the area’s high ED attendance rate.

Marlborough PHO chief executive Beth Tester says the region has one of the highest rates of ED attendance – almost double the national average, with around 35 to 40 per cent of presentations deemed to be more appropriately treated in primary care.

The scenario in Taumarunui is similar. Ms Dibble says 4920 ED attendees last year had the lowest level of acuity; they could have been seen by their GP.

However, this is not the lesson to learn from the wider capacity crisis now being faced.

Dr Bonning says it’s a myth that patients who would be best cared for in general practice are the problem.

DHBs around the country run annual advertising campaigns, especially throughout the winter, urging the public to “save ED for emergencies”.

But ED overcrowding is not generally due to a glut of patients with minor injuries and illnesses, he says.

“That has been postulated since the time of the Roman Empire. It is just such a broken record that [it] drives us crazy.”

The Ministry of Health regularly reviews emergency department admissions. The most recent data, from 2014/15, show over half of the more than one million ED events that year were extremely serious.

Almost 54 per cent of events were patients presenting to ED with a condition that was immediately to potentially life-threatening (triage

 levels 1–3). A further 39.6 per cent were potentially serious, and 6.7 per cent were classified as less urgent (see table).

Triage levels 4–5 are sometimes referred to as GP-type patients, but Dr Bonning says this is incorrect, and level 5 patients are sometimes best dealt with in EDs.

The ministry data show rates of ED use increased with the level of neighbourhood deprivation. People from the least deprived neighbourhoods turned up in the ED at an annual rate of 8.7 per 100 people; the rate for people from the most deprived neighbourhoods was 21.7 per 100.

Pasifika people had the highest rate of ED use in 2014/15, at 19.3 for every 100 people, followed closely by Māori (18 per 100).

All ethnic groups showed an increase in ED use between 2010/11 and 2014/15. The largest increase was in those of Asian ethnicity (from 8.3 to 9.4 per 100).

Emergency medicine professor Mike Ardagh says it’s too easy to blame the patients for showing up in the ‘wrong place’
The free choice?

It’s often said patients choose to go to the ED because the care is generally free for New Zealand residents, whereas primary care in most cases is not.

Auckland City Hospital emergency medicine specialist Peter Jones and his colleague Vanessa Thornton, former emergency medicine specialist at Middlemore Hospital, undertook a systematic review of New Zealand EDs a few years ago, and considered whether cost actually is the driver.

Their research, published in the New Zealand Medical Journal (2013;126[1387]:15–24) shows the cost of primary care is a factor in under 2 per cent of ED presentations.

They reviewed the literature of 5850 ED patients who were asked a direct question about cost; only 119 cited this as a reason for going to the ED.

The most common reason was a belief the ED was the most appropriate place for them at that time, for reasons of appropriateness and availability.

Almost four years down the track, Dr Jones says the research findings still ring true.

Speaking in his personal capacity, not as a representative of Auckland DHB, he says there is still a prevailing wisdom that many people who turn up in EDs could be looked after elsewhere.

Over the past decade, a lot of effort and money has been spent nationally trying to create other places for people to go.

“The law of diminishing returns suggests that effort trying to reduce a very low rate of ‘inappropriate’ ED presentations in New Zealand is unlikely to have any significant effect overall,” Dr Jones says.

“There may be small gains to be made for a few patients or conditions, but this is unlikely to make a big difference overall.”

That’s why all the efforts to prevent ED presentations rising in New Zealand in the last 10 years have not resulted in a significant drop in the numbers going to EDs, he says.

His view is shared by southern colleague and Canterbury DHB emergency medicine specialist Mike Ardagh. The issue of EDs being overwhelmed by patients who should have gone to their GP is a common perception and an attractive concept, Professor Ardagh says.

It’s attractive because any deficiencies can be deflected on the patients: blame them for going to the wrong place, and doing so simply because it won’t cost them a cent.

The trouble is, no New Zealand evidence to date supports that assumption. It could be an issue, but it’s certainly not the main issue, he says.

Almost 54 per cent of ED events in 2014/15 were for patients presenting with a condition that was immediately to potentially life-threatening (triage levels 1–3)
The number of patients attending Waikato Hospital’s ED grew from 6353 in July 2016 to 7580 in July this year, representing a 19 per cent increase.

Emergency specialist Peter Rodwell says no one knows the size of the problem represented by growing ED attendances or the associated costs.

“The staff, management and media reaction is still much greater than the real problem,” Dr Rodwell says.

“But, nonetheless, the problem is growing alarmingly and starting to impact emergency healthcare delivery.”

Now working part time at Timaru, Gore and Oamaru Hospitals, Dr Rodwell was the first Australasian emergency medical registrar in 1976, working in hospitals in Melbourne, Australia.

He says healthcare costs have grown in comparison to incomes, and personal convenience has become a major factor in people’s decision-making. Expectations are higher.

Demand for an immediate, top-quality service has grown exponentially, and unnecessary ED presentations have grown with it, Dr Rodwell believes.

Urgent care clinics based in the same town, or even when provided within the same hospital facility, have not solved the dilemma, he says.

Professor Ardagh says research to date has shown these actually contribute to demand.

Richard Hulme, a fellow of both the RNZCGP and New Zealand College of Urgent Care, has locumed in the EDs in Taupo and Thames hospitals.

As clinical director of quality for the Nirvana Health Group, Dr Hulme now works at its Mangere clinic in south Auckland. The Nirvana model works on a no-appointment basis, and the clinics see a lot of overflow from patients who can’t see their own GP because they are fully booked.

Many patients end up in EDs because they can’t get an appointment with their GP, he says. “It’s symptomatic of a health system that is under stress.”

The emergency specialists say the reasons behind rising attendances are multifactorial.

An ageing population creates demand. There are increasing numbers of people with comorbidities, Professor Ardagh says.

“There’s a bigger burden of chronic illness because we can mend these things better. A few years ago, these people would have died.”

An innovation by a Waitemata DHB board member suggests convenience is a factor for many turning up to their local ED.

Morris Pita, who describes himself as a social entrepreneur, has developed an app allowing patients to compare waiting times between North Shore Hospital’s ED and the closest urgent care clinic, Shorecare A&M.

People appear to be voting with their feet. Once they know they can be seen sooner at Shorecare, and understand from the app that ED is not the right place for their problem, off they go.

Professor Ardagh also believes people worry much more about illness than they used to. “If you have a pain in your chest, you’re encouraged to call 111. If you have a fever, it could be meningitis. We have a greater fear – which is not always unjustified.”

Strong relationships in the past

“[In the past], you went to your family doctor, whom you not only knew well, but who likely delivered you and your mother and aunts and uncles,” Professor Ardagh says. “If you got unwell, you would see them.

“The relationship was very strong. Now, there is much more episodic, drop-in type care in general practice.”

Even if you have a good relationship with your general practice, as a consequence of episodic care, you are likely to not see your own doctor, he points out. Now it’s a case of people expecting to be able to buy dog food at 2am, so they expect to be able to see a doctor when they want to.

But a good relationship with your own GP reduces ED attendance, Professor Ardagh says. It is here where he and colleagues see hope for reducing demand.

In Canterbury, initiatives have been under way in the past decade that are helping keep people well in the community.

Nationally, on average, 250 people in every 1000 will go to an ED in any one year; in Canterbury, the figure is a lot lower at 180.

Christchurch’s after-hours primary healthcare facility, the long-established 24 Hour Surgery, has helped reduce demand, Professor Ardagh says.

It’s well known in the community that this is the place to go with minor illnesses and injuries, he says. Subsidised by the DHB, it is open 24/7 – a service not offered in many places throughout the country these days.

In some districts, GPs work right in the ED. At Thames Hospital, says Dr Hulme, a GP in the department looks after patients triaged level 4–5. This enables the more acute cases to be seen by emergency specialists.

In Taumarunui, Ms Dibble says the DHB is focusing on providing services to help keep people well so they do not turn up at the ED.

Digging into the reasons for ED attendances and repeat visits revealed some telling data. One child with respiratory issues was living in a house with 13 people. Their caregiver was very ill, and the house they were living in was damp.

The DHB is developing an integrated healthcare model, so various players in primary care work together on helping these children do better.

Dr Rodwell sees many patients who claim they cannot get an appointment to see their GP for a day or more. It would be helpful, as a hospital specialist, to be able to access a practice’s booking system and make the appointment with the person’s GP, he says.

The answers lie in practices making more time available for urgent appointments, he suggests. Large, multidoctor general practices, in particular, could be opening their doors on weekday evenings until at least 8pm and on Saturday mornings.

Ms Dibble says change won’t happen overnight, because habits are entrenched. Over time, a whole-of-system view will provide the answer, she says.

“The hospital ED is always there, it’s always available, it’s a constant in people’s lives.”


Urgency at presentation

All patients who present at ED are assessed by a triage nurse (or doctor). Clinical urgency is assessed, and the patient assigned a triage acuity level, a proxy measure of how long an individual patient can safely wait for a medical screening examination and treatment:

-triage level 1: immediately life-threatening

-triage level 2: imminently life-threatening, or import­ant time-critical

-triage level 3: potentially life-threatening, potential adverse outcomes from delay of more than 30 minutes, or severe discomfort or distress

-triage level 4: potentially serious, or potential ad­verse outcomes from delay of more than 60 minutes, or significant complexity or severity, or discomfort or distress

-triage level 5: less urgent, or dealing with adminis­trative issues only.

Source: Ministry of Health




So one of the drivers for high use of EDs is the persisting mantra of DHBs and Governments of either political shade to push for large GP clinics, call them something flash like an IFHC and think episodic care is true General Practice.  Our DHB openly denigrates the traditional self-employed GP role where people actually have a relationship with a specific GP even though this has been shown to reduce ED attendance, provide better on-going health maintenance and most importantly be the number one predictor of retention in rural areas.