This appeared in yesterday’s West: “Urgent ED cases walk out before treatment”
More than three patients needing urgent attention leave the busy emergency departments of Perth’s major hospitals every day without being treated, new figures show. Documents obtained through Freedom of Information laws show that last year, 7215 patients across all levels of urgency attended the emergency departments at Royal Perth, Sir Charles Gairdner, Fremantle and Princess Margaret hospitals but left without being seen by a doctor.
They included 48 category 2 or “emergency” patients, typically including suspected heart attacks, and 1184 category 3 or “urgent” cases, which can include head injuries and major bleeding or fractures. Twenty of these patients were children.
This article looks at some important questions, but it fails to illuminate us on what the answers might be – and the information presented is a little misleading.
First, the author makes a point of saying that the information was “obtained under Freedom of Information” laws, which usually implies that the Government was making efforts to keep the information as quiet as possible. However, Emergency Department (ED) performance statistics are typically not particularly secret or obscure.
Western Australian public hospitals now have ED attendance, admission, waiting times, and ambulance diversion and ramping times publicly available in real time on the WA Public Hospital Activity website. Here’s a snapshot of what to expect at the time of writing – from no wait for category 4 patients at King Edward (OB/GYN hospital with only 2 people waiting), to 72 minutes for cat 4s at Rockingham. It is recommended by the Australasian College for Emergency Medicine (ACEM) that 70% of category 4 patients are seen within 60 minutes. Median waiting times in the 24 hours leading up to writing have been within target in all categories across the metro area.
This real-time site probably picks out Triage Category 4 to show waiting time to the public because Cat 4s are likely to need some sort of help, but also to have a choice about what to do and where to go.
You can read about the Australian Triage Scale at Medeserv. This is a standardised way of categorising people presenting to emergency departments by the urgency of their problem. Triage Category 4 includes conditions like lacerations without major bleeding, migraine, earache, limb injuries that could be sprains of non-urgent fractures, vomiting or diarrhoea without dehydration, and mental health problems without immediate risk. So Category 4 patients accessing this waiting-times website have the opportunity make an informed decision about whether they’re better off attending a general practitioner for assessment and treatment of their problem, or perhaps travelling a little further than the nearest emergency department to a further one if their local is very backed up.
The West’s article about Did Not Waits (DNWs) focusses on Category 2 and 3 patients. As they identify, Category 3 includes head injuries with transient loss of consciousness (now alert), and moderately severe blood loss. However, it does not include “major fractures”, as implied by the “major bleeding or fractures” construction – major fractures would be Category 2.
But that’s not all that goes into Cat 3. It can also include chest pain that’s likely to be non-cardiac, dehydration, and abdominal pain without high-risk features. So your heartburn or costochondritis or even a bad case of mittelschmerz (ovulation pain) might be put in this category. Any “moderately severe pain” goes into category 3. Folks who have had a seizure but are now alert go into this category also – so the “Did Not Wait” (DNW) group can also include your friendly neighbourhood person with known epilepsy who was shipped to the ED by helpful bystanders after a straightforward fit, woke up on the way, and chose not to wait; or a person with a migraine who decided to deal with it at home rather than in a brightly-lit ED, or any of a variety of other people. People who have been assessed as “potentially aggressive” but not an immediate threat also are put into Category 3, which could include various stroppy drunk youths with minor injuries. Over 50% of patients originally triaged to category 3 require no followup after discharge from the emergency department. Not all Cat 3s are seriously ill or injured. State AMA president Gary Geelhoed identifies this as one possible cause of DNWs in the West’s article.
Or we could have people routinely walking out of EDs with moderately severe untreated asthma, acute psychosis, diabetic ketoacidosis, chemotherapy- or AIDS-related fever, and appendicitis. They could be abused women or children dragged home by their abusers. Unfortunately, raw figures tell us nothing about which types of people are in that “DNW”.
The 48 Category 2 walkouts are more worrying, but these are a tiny percentage of the total; again, we need a lot more research before being certain that these weren’t mis-triaged, or chose freely to walk out. And we need to know more about the specifics in order to figure out how to reduce the chances of a walkout by someone who desperately needs and wants help. The most obvious categories of possible Cat 2 walkouts that stand out to me are “drowsiness or decreased responsiveness of any cause”, “violent or aggressive”, and “fever with signs of lethargy”. Drunk or drug-affected people who are presented drowsy or violent regularly disappear from medical care, and not all lethargic people with fever have meningitis – it is entirely possible for someone to improve and decide that they’re rather keep having their nasty flu at home.
Waiting times are a problem. Western Australian EDs are not meeting ACEM targets consistently right now, and waiting times for category 3 patients have been outside of ACEM recommended times for a long time. Page 109 of Performance Indicators Certification Statement 2005 shows the 2000-2005 numbers for the proportion of ED patients seen within recommended times.
Over 99% of Category 1 patients were seen immediately, which is a key performance indicator. ACEM recommends that 75% of Category 3 patients be seen within 30 minutes, but the figures in WA hovered around the high fifties. More recent figures for the Metropolitan Health Service (MHS) are available in its 2008 report, and unfortunately they have dropped away recently, from a peak of 60.6% in 2005-6 to a low of 48.6% in 2007-2008. The only category in which targets are being fully met by MHS Emergency Departments are in category 5, the least urgent minor presentations. Country health services in WA have been performing at a similar level.
We need action on ED waiting times, but putting the burden of that action purely on emergency departments to “perform better” is useless. EDs have been telling us again, and again, and again what they need in order to improve performance: a solution to access block. EDs can’t keep bringing sick people into emergency departments when there’s no way to get the sick people who are already there out. And why are sick people piled up in ED corridors? Because they need admission, but have nowhere to go.
You can’t blame the bottle’s neck for being “inefficient” when the bottle is overflowing.
Read more about access block here at ACEM’s 2004 paper on the issue, “Access Block and Overcrowding in
Emergency Departments“, and in these MJA articles:
“Emergency department overcrowding: dying to get in?” [George Braitberg, MJA 2007; 187 (11/12): 624-625]
Access block: problems and progress [editorial, Peter A Cameron and Donald A Campbell, MJA 2003 178 (3): 99-100]
The access block section of the 3 February 2003 issue
The access block section of the 6 April 2009 issue
(unfortunately most full text articles are now paywalled)
I’ll leave you with the abstract from “Myths versus facts in emergency department overcrowding and hospital access block” [Drew B Richardson and David Mountain, MJA 2009; 190 (7): 369-374], published just two weeks ago. Richardson and Mountain are saying the same things that experts have been saying for over six years now. Is anybody listening?
* Overcrowding occurs when emergency department (ED) function is impeded, primarily by overwhelming of ED staff resources and physical capacity by excessive numbers of patients needing or receiving care. Access block occurs when there is excessive delay in access to appropriate inpatient beds (> 8 hours total time in the ED).
* Access block for admitted patients is the principal cause of overcrowding, and is mainly the result of a systemic lack of capacity throughout health systems, and not of inappropriate presentations by patients who should have attended a general practitioner. Overcrowding is most strongly associated with excessive numbers of admitted patients being kept in the ED.
* Excessive numbers of admitted patients in the ED are associated with diminished quality of care and poor patient outcomes. These include (but are not limited to) adverse events, errors, delayed time-critical care, increased morbidity and excess deaths (estimated as at least 1500 per annum in Australia).
* There is no evidence that telephone advice lines or collocated after-hours GP services assist in reducing ED workloads.
* Changes to ED structure and function do not address the underlying causes or major adverse effects of overcrowding. They are also rapidly overwhelmed by increasing access block.
* The causes of overcrowding, and hence the solutions, lie outside the ED. Solutions will mainly be found in managing hospital bedstock and systemic capacity (including the use of step-down and community resources) so that appropriate inpatient beds remain available for acutely sick patients.