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?
