Why it's so chaotic at our hospital emergency departments

If you go to any emergency department at government hospitals, there are always large crowds waiting inside and outside. — Photos: Filepic

Delays at hospital emergency departments (ED) is a global issue.

As long ago as 2006, the United States based American nonprofit organisation Institute of Medicine described American EDs as ‘nearing breaking point’ due to longer waiting times and crowding.

The issue waxes and wanes according to the political news cycle, but is worth taking note of – and doing something about.

The situation has been exacerbated by the aftermath of the pandemic and made worse by an increasingly ageing society with a more complex casemix of patients.

The risk with delays

ED functions primarily to provide healthcare services for critical and time-sensitive medical conditions e.g. heart attacks, strokes, breathing difficulties, trauma and severe infections.

Congestion can lead to a delay in diagnosis, recognition of severity and treatment of disease.

Multiple studies have demonstrated that longer lengths of stay in EDs are associated with worse outcomes.

A recent one from January 2022 looked at the increased risk of death resulting from delays in ward admissions from major EDs in United Kingdom.

The study, published in the Emergency Medicine Journal, showed that delays to hospital ward admission for patients in excess of five hours from time of arrival at the ED are associated with an increase in mortality rates.

For every 82 admitted patients whose time to ward bed transfer is delayed beyond six to eight hours from time of arrival at the ED, there is one extra death.

Delays also have significant physical and psychological impact on caregivers and healthcare workers.

Dr Zaliha Mustafa, our Health Minister, recently visited the ED at Hospital Tengku Ampuan Rahimah Klang incognito.

Besides witnessing the challenges faced by healthcare staff firsthand, conversations we had with various patients and their next-of-kin highlighted the frustrations some face when waiting for admission.

Why the delay?

A 2010 report by McKinsey on fixing ED congestion highlighted a very key point: “Many of the factors that contribute to ED overcrowding occur in other parts of the hospital and thus are beyond the department’s control. Hospitals are complex, high-stress systems that require significant cross-departmental and cross-role coordination at all times.

“Even something as seemingly simple as transferring a patient can require the involvement of six to 10 clinical and nonclinical staff members.Even in outpatient departments, elderly patients wait from as early as 6am for the doors to be open.Even in outpatient departments, elderly patients wait from as early as 6am for the doors to be open.

“Therefore, the only way to make substantial operational improvements in one part of a hospital is to implement corresponding changes in other areas.”

This is particularly true when there is a lack of bed availability in the hospital.

A 2019 study covering all major EDs in the UK showed that higher proportions of patients waited for over four hours in ED when hospital ward bed occupancy levels were higher, especially when it was above 92% occupied.

There are also other factors at play – lack of resources (human, equipment, infrastructure and space) can be particularly evident during peak hours as can the high numbers of patients.

But oftentimes solving the problem requires a far more comprehensive and subtle approach than throwing money at it.

Reducing delays

ED waiting times vary depending on time of day, time of year and location.

Consequently, solutions will need to be individualised depending on the nature of the problem for a given ED.

From an organisational standpoint this means that sufficient authority should be decentralised to hospital directors to act in a manner they see fit in order to reduce ED congestion.

This should include the ability to override department heads in the placement of patients in the wards, creating discharge units and short-term stay wards as well as redirecting resources depending on need.

Other measures that will be looked into include increasing primary care services either by greater public-private partnerships or by extending working hours in order to reduce congestion caused by non-critical conditions.

The latter can only be done in tandem with efforts to increase healthcare providers.

“The need to get more manpower including doctors, nurses, assistant medical officers, pharmacy officers, allied science professions, support staff and others would continue to be done,” Dr Zaliha said.

Contrary to popular belief, decisions regarding healthcare staff appointments are not the sole prerogative of the Health Ministry, but are made together with the Finance Ministry and the Public Service Department (JPA).

The Health Ministry will also inculcate the Lean Healthcare Approach in more hospitals in an attempt to improve bed management flow.

The concept is not dissimilar to how the manufacturing industry creates efficiencies.

For example, a coordinator can allocate beds to patients in ED based on real time information of patient discharges.

Efforts can be made to ensure that patients who are meant to go home are out of their bed by noon in order to prevent congestion in the afternoon.

This lean approach has been shown to reduce time to discharge, waiting time for beds and duration of stay in 36 hospitals across the country.

In the longer term, we must develop an information and communication technology (ICT) platform that allows for ED and hospital systems to “speak” to each other and thus allow for better allocation of resources.

Transparency of such data may also allow patients to determine which EDs to attend and when.

The public must also be given more education and options regarding non-critical conditions that can be treated outside of EDs.

It is obvious that many things can, and will, be done in order to alleviate the congestion at our EDs.

All of us may one day be on the receiving end of ED services, if we haven’t done so already, and it is imperative that stakeholders work together in order to deliver a better service for the rakyat.

Dr Helmy Haja Mydin is a specialist in respiratory medicine and a special advisor to the Malaysian Health Minister. For further information, email starhealth@thestar.com.my. The information provided is for educational and communication purposes only. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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Emergency Department , Hospital , Trauma


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