Death in a Crowd

Overcrowded emergency departments kill people and the other departments of our hospitals appear largely ambivalent to this fact. Have we lost the point here or is what happens in emergency departments simply unimportant in the "bigger picture"?

What IS the ultimate goal? Maybe: "Everyone should have a long, productive and happy life with only brief episodes of non-disabling, non-preventable illness or injury, culminating in a dignified pain-free death surrounded by loved ones". To get there, sure, the really big gains are likely to be found in public health with immunisation, screening, and measures to tackle violence, smoking and alcohol. Or in chronic disease management with secondary prevention and early interventions for diabetes for example. Or perhaps most importantly, using social and economic policy to drastically reduce the inequality, relative poverty and social exclusion that drag down the health of entire communities.

Emergency medicine, however, has two vital supporting roles in the fight. Firstly, providing aggressive treatment of bad stuff such as sepsis, trauma and acute coronary syndrome prevents those inevitable blips of acute illness or injury from becoming life-limiting. Secondly, allowing expert evidence-based management of low yield, high risk acute presentations without over-investigation or unnecessary hospitalisation prevents those recurring "groundhog day disasters", such as mis-diagnosing migraine in sub arachnoid haemorrhage, dyspepsia in acute coronary syndrome, intoxication in serious head injury or viral illness in septicaemia.

To do this bit effectively though, there are three required, evidence-based structural components: senior input (for experienced heuristics and "fast thinking"), check lists and protocols (for error trapping and "slow thinking") and the absence of overcrowding.



Overcrowding is the single biggest threat facing emergency departments this winter. Once our departments get overcrowded, all sorts of bad stuff starts to happen. Most bad shifts in the emergency department, like a major accident producing a heavy multiple trauma load, or staff sickness causing crucial roster gaps, are surmountable, mostly, with hard work, multi-tasking, leadership, experience and team work. However, start a shift with patients on trolleys and no prospect of in-patient beds and it will be a shift of frustration, impotence, poor care and staff burn-out, completely resistant to the most talented or heroic of efforts.


In overcrowded departments, treatments get missed or delayed. Errors happen with mixed-up blood samples and wrong medication. Critical incidents occur with patient falls, violence to staff and unnoticed deteriorations. Both patients and staff feel the place they are in is frankly a bit crap. All of these small, and occasionally big, levers operate to produce the eye-watering mortality increases associated with overcrowding: more than 30% additional deaths in admitted patients and more than 70% in discharged patients. It is nearly always an overcrowded hospital that causes emergency departments to become terminally constipated. Overcrowded hospitals have either insufficient beds for their workload, or inappropriately long length of stay due to inefficient work practices.

Ward staff and specialists don't care too much about emergency department overcrowding as it doesn't really affect them. The solution may lie in reversing that through overcapacity protocols. Using these, when the emergency department becomes dangerously overcrowded, the wards share the risk and the pain by also taking patients in their corridors. Where this has been done around the world, the bed fairy has quickly gotten busy with her special magic.

John Snow, the father of epidemiology, would never have tolerated the proven damage caused by ED overcrowding. He would have removed the handle on this particular pump, possibly by personally pushing gridlocked patients into less dangerous areas of the hospital than the corridors of an emergency department. We need systems, seniors and space in our emergency departments to achieve our potential impact in the "bigger picture". Perhaps a little direct action of our own is required this winter to give us some of the latter by using overcapacity protocols. Maybe then "whole of hospital solution" will actually mean something?

Ninjas not Nanas

Ninjas not Nanas

What is the point of Emergency Medicine? Heroic life saving? Round the clock universal medical care? Gatekeepers to hospital beds? Traffic wardens for patients within complex health system? Initial surrogates for expert care? Specialists in vague but risky symptoms? Safety net for a caring society?

Probably all of the above, often in one shift. We are, however, allegedly in “crisis”. Victims of a "failing" NHS acute care system, in a specialty no-one apparently wants to do, trapped, burnt out, powerless at the bottom of the medical heap. We have become pitied, weak, frail and in need of rescue, broken down at the side of the health highway.

However, although sometimes it is quite nice for people to empathise with our difficult job, the big money is now being quietly loaded into trucks to be driven away from the perceived embarrassing train wreck of “A&E” and given to others who confidently declare (without supporting evidence) they have the answer to the acute care problem.

At this point, however, before it is too late, it is time to tell the emperor he is naked and may have received some poor tailoring advice. The truth is that emergency medicine one of the most successful, least dysfunctional part of the entire system. It is simply the visible bulge in the balloon caused by pressure on all sides.

On one side, primary care is seriously hampered by vast variations in practice. Some GPs are outstandingly dedicated, provide excellent patient-centred care and make superb timely referrals. Others appear to be too risk-averse, possibly lacking interest or experience in acute care, or have insufficient access to either simple "rule-out" investigations or chronic care plans for their complex patients to mitigate hospital referrals. As a result, some of the most so-called “inappropriate attenders” at an emergency department are there because the GP sent them in: patients who need a simple blood test like d dimer, or an x-ray or non-urgent scan, or elderly person with a social care crisis. In the absence of community alternatives, the latter group will get admitted for a prolonged hospital stay, perhaps for minimal benefit other than simply accessing services.

On the other side, the in-patient specialists frequently provide the emergency team with a complex array of referral arrangements seemingly designed to protect them from interference with their special interest, elective and sometimes private work. They have layers of junior staff who can be astonishingly dismissive of legitimate emergency referrals through either fear of admitting the “wrong type of patient” and wearing it from the boss on the ward round, or simply through their own inexperience and overwork. “Selling patients” becomes a core skill for the emergency department, with some shifts feeling like a long day cold calling for double-glazing telesales. Furthermore, whatever the bed state of the hospital, the in-patient specialty teams continue to admit electives. Each day seems to bring the same surprise that a number of emergency patients have turned up who also require care. Delays to in-patient review and admission are the major cause of emergency department overcrowding and stress.

So, in addition to emergency medicine doing its own core work of sorting out and resuscitating acute undifferentiated illness and injury, it is picking up the deficiencies of its neighbours. This is undoubtedly straining an otherwise highly successful model of care. Emergency medicine consultants have been shown to improve survival in critical illness and injury and to reduce admission to in-patient beds. An enormous number of patients are still appropriately treated in a very timely manner by international standards to a high level of satisfaction. A&E remains one of the most successful brands ever, in terms of popularity with the public, and local departments are fiercely defended by their communities. Arguably, along with the system of holistic general practice and free-at-point-of-care access, UK emergency medicine plays a major part in keeping the NHS consistently one of the most cost-effective and equitable health care systems in the world. The current “crisis in A&E” is like a highly-functioning airport becoming overloaded during an air traffic dispute. Once the planes take enough passengers away again through departures, the airport works perfectly well.

So, rather than look for alternatives to emergency medicine to solve the current crisis, we should do the exact opposite and give emergency medicine more control of its immediate pressure points:

Telephone advice and support to GPs from emergency medicine consultants backed up with rapid access to community lab, x-ray access and outreach home care teams. Direct admission rights to all in-patient specialty beds without hindrance or delay, together with simple contact arrangements for senior members of duty specialty teams. The emergency department as the hub of operational management for the hospital with the ability to cancel electives during critical occupancy periods and to mandate the redistribution of medical staff from non-urgent duties during activity peaks or critical roster gaps. 

As emergency physicians, we need to stop feeling less like nanas, be more like ninjas, and retake control.