Lorna Rothery spoke to Jim Connolly, President of the European Society for Emergency Medicine about how long-established issues in the health system are being reflected in emergency care, and the bold actions needed to address this.
No area of healthcare is exempt from the ongoing effects of societal-wide challenges such as the COVID-19 pandemic and the cost-of-living crisis. In recent years, the rising demand for hospital inpatient care coupled with unprecedented workforce shortages have put a continuous strain on hospitals and, most acutely, emergency care. Prolonged wait times within A&E departments – often used as a barometer for how the health and social care system is performing – not only impact patient outcomes but the physical and emotional wellbeing of staff working within high-stress environments. According to the UK’s Royal College of Emergency Medicine (RCEM), in the first four months of 2022 alone, there was a total of 79,610 12-hour decision to admit (DTA) waits; nearly as many as the cumulative total of the 11 years since data collection began.
While COVID helped to increase awareness of the challenges faced by emergency medicine personnel, it is equally not a major facilitator of the pressures the system is buckling under today. Lorna Rothery spoke to Jim Connolly, President of the European Society for Emergency Medicine, about the complex needs faced by emergency medicine and why a whole systems approach is paramount to ensure emergency medicine is made safer for both healthcare professionals and patients.
Emergency medicine has faced unprecedented challenges over the past few years with ambulance offload delays, treatment delays and staff shortages. Would you say emergency medicine is being suitably prioritised as part of the EU’s public health agenda?
Prior to the COVID-19 pandemic, emergency medicine (EM) was facing significant challenges, mainly due to changing demographics and the increased need of services, allied to a lack of investment in social care. Winter has been difficult for a number of years. Last winter, we experienced a major respiratory outbreak along with high staff absence which further exacerbated the situation, and the reality started to dawn that emergency services were facing a real crisis. Emergency services have become completely overcrowded, leading to increased stress, workforce pressures, and poorer patient outcomes; it is a perfect storm.
Planning and workforce retention is a real priority now and must be one of the highest priorities across medicine in general, especially ‘front door’ medicine. Emergency medicine, as well as respiratory physicians and ICU, bore the brunt of COVID, and those groupings are still trying to recover from the impact of the pandemic while facing significant and continued pressures.
What are some barriers to a more homogeneous approach and definition of emergency medicine?
People often discuss the differences between Anglo-American and Franco-German health systems, for example, one historically developing around hospitals and the other around delivering emergency physicians, doctors, and anaesthetists to the scene. But now, these approaches are beginning to coalesce; in the UK, for example, there are more pre-hospital services for the acutely ill in order to alleviate hospital admissions. Similarly, throughout Europe, there are efforts to establish more emergency departments. Over the last decade, there has also been a rapid change in countries recognising the structure works best if there is an emergency facility. There are many positives for each approach that can be shared between regions, and Europe is slowly moving towards a more unified approach.
Equally, we need to start seeing a level playing field of what an emergency specialist is across Europe. That unification will help us tackle issues such as staff retention and recruitment. One of the EU’s strengths is encouraging the movement of skills throughout the region.
How does working in a high-pressured and sometimes unpredictable environment impact clinical decision-making?
We are seeing a lot of campaigning from bodies and associations of emergency medicine to put an end to corridor care and overcrowding. As part of that, we have to prioritise staff welfare and recruitment over the next few years. There has to be a political will to say corridor care is never acceptable; we know this contributes not only to patients’ lack of privacy and dignity, but it also blocks up the whole system. At the same time, there is a lack of output from the ED. The department is trying to exist as an emergency facility for patients arriving while still looking after a ward full of – often very ill – patients who just cannot move on. This pressure then that backs into the community.
There have been some strong voices out there that have raised the reality that departments in other areas of the hospital would not accept this. Emergency medicine has been called the barometer of the health system or the ‘canary in the mine’ as it is the first part of the system that alerts us that things are not as they should be. We must listen to the warning signs. This emergency system, as it stands, is creaking and there are concerning signs. The process then almost becomes self-serving, and staff who work in that environment get burnt out more quickly and face more moral injury. As a consequence, we risk seeing results that were unimaginable a few years ago in terms of outcomes.
The reason many healthcare professionals work in EM is the ability to instantly and significantly impact on people’s lives not just clinically but in a wider caring sense. If they are in a position where their ability to do this is decreased, then this can be very demoralising for staff. We know burnout is rife, with figures showing that up to 60% of EM workers experience some form of burnout.
How has dependence on emergency care and the nature of conditions treated there changed in recent years? What are some of the reasons why patients might visit the ED department for non-urgent concerns instead of seeking care elsewhere?
We have realised that it does not take much to destabilise an emergency system. In the UK, for example, even though primary care physicians are working harder than ever before in terms of the number of consultations per day, even a small change in the ability to service increased demands can overload emergency departments.
EUSEM and other bodies are highlighting the need to preserve EM systems for those who need it, but recognise that often, patients may attend emergency care because they feel they have no other alternative and expecting patients to decide if their ailment is an emergency is not always as easy as it seems.
There would appear to be an increased demand for healthcare, especially face-to-face consultations. This is likely for many reasons, not just COVID. Going forwards we need to recognise that increased demand is not going to go away. It is important however that we do not see this increased attendance as the major factor because it is not. Lack of flow and capacity remain the biggest current challenge the service is facing. Though there are more people and departments are overcrowded, this element is fixable.
What is needed is a whole systems approach to address the major challenges we are seeing, including investment in social care, and ensuring there are facilities for people to go to when they leave the EM; this should be a high priority for local and national health systems.
We also need to continue to develop better pathways which acknowledge the reality that EM is not necessarily always the best place for unscheduled care to happen. An amount of this ‘unscheduled care’ is however predictable, so it is important to build systems that understand EM’s remit but also acknowledge that sometimes, with effective planning, patients could be seen outside of the ED, as opposed to relying on ED as the only portal during a crisis/complication.
Can you share any examples of best practices and/or technologies that are helping to improve the delivery of emergency care?
COVID allowed the rapid development of systems and changes in practice because we needed to adapt quickly. It was a lot easier during COVID to institute change and to innovate, and there was a genuine willingness to do so. We currently hear a lot about the ‘virtual ward’. This is not new as during the pandemic, patients were sent home from the hospital with oximeters and specific guidance as to when to call for help. Such technology will fundamentally change the interface between patients and hospital.
Emergency systems and hospitals have not stood still. We have been open to systems that can streamline processes, whether walk-in centres (WIC) or same-day emergency care (SDEC) or rapid assessment and treatment (RAT) emergency care is almost unrecognisable from the systems we had in place twenty years ago. Ensuring we get patients the right care at the right time in the right place benefits both the health system and the patient.
Last year’s Emergency Medicine Day campaign highlighted guidance on minimal standards for EM in Europe. It pointed out simple but effective measures, such as ensuring staff are adequately trained and have the right equipment as well as ensuring their environment is fit for purpose. It also highlighted the importance of ensuring staff are supported in every way, from how they work to supporting their psychological wellbeing. Part of this was the need for recognition from other specialities that emergency medicine is different at times and those working in the emergency system experience different pressures.
COVID helped to shine a light on EM as a speciality across Europe and highlighted how appropriately trained EM specialists could adapt and deliver high quality care in the most challenging of situations. It is critical in this time of unprecedented pressures on the emergency system that we remember our staff are our most valued asset.
This article is from issue 25 of Health Europa Quarterly. Click here to get your free subscription today.