Patients not to blame for overcrowded emergency departments - study

Overcrowding in New Zealand hospital emergency departments (EDs) is not being driven by patients who should have gone elsewhere, a new study shows.

However hospital-based inpatient teams and EDs needed to be adequately resourced to reduce pressure in the system, one of the study's authors told First Up.

The study, published in today's New Zealand Medical Journal, found 95 percent of people were visiting EDs when that was the appropriate care.

The pervasive narrative that overcrowding in EDs was being driven by people accessing emergency care unnecessarily was nothing new, said University of Auckland Associate Professor - Medical Surgery Peter Jones.

"There's been lots of reports through the years - and I'm talking back down to the 1800s - of people complaining that people come to the emergency departments without good reason and should have gone elsewhere."

However the biggest cause of ED overcrowding was something Jones termed "access block".

"That's getting patients who should be admitted to hospital into the hospital and that's very important because access block is associated with worse outcomes for patients."

Those system blockages affected more than just the patients who were not immediately able to be admitted to hospital, he said.

"Everyone coming to the ED is at increased risk of harm when we have high levels of access block and that's what causes things like ambulance ramping, it causes big delays in patients waiting to be seen, people get angry, violence towards staff increases - it's all because we can't get patients through the ED into the hospital when they should be."

Jones believed part of the reason the narrative about people accessing EDs when they did not need to had persisted was because "we always remember the exceptions".

"It's sort of human nature to remember the things that stand out to us and so those that obviously came without good reason and maybe should've gone to their GP do stand out a bit and it becomes the narrative, when the majority of people are actually seeking care appropriately."

The study also found that visits to EDs in New Zealand were low by world standards, and there was little room to further reduce them.

There were no "quick fixes" to the overcrowding problem, which Jones said had been exacerbated during the pandemic.

"Our health system relies heavily on people from overseas, both doctors and nurses, and when we restricted the number of people coming in - with good reason - for our Covid protections, we had this inadvertent effect of not replenishing our healthcare staff."

However there was a "blueprint" to begin working on the issues.

"Back in 2009, when we introduced our health target for ED length of stay, we slowly over a period of about three years, worked slowly towards that target.

"We never quite got there, but what we did was improve our systems and improve our processes, invest in the right things and hospital staff and resources, and that led to better outcomes for patients," he said.

"We've done it before, we just need to do it again."

A lot had been learnt during that previous period of trying to address wait times in EDs, Jones said.

"We learnt how to avoid some of the perverse outcomes that can happen around targets ... we learnt how to do it right."

But he said investing more in the community, alongside any changes made in hospitals, would also be necessary.

"We've got to support general practice and urgent care ... we also have to support aged residential care and getting people out the other end of the hospital, 'cause the root cause of this is the hospitals are too full," he said.

"We've got to run our hospitals at less that 90 percent occupancy, which we're not doing at the moment. If we do that, with adequate staffing in the hospital, we won't have ED crowding."

'We need to unblock the drains'

New Zealand chair of the Australasian College of Emergency Medicine, Dr Kate Allan, agreed a system-wide approach was needed to address ED overcrowding.

She told Morning Report that while "a proportion" of patients did seek ED care when they could have received more appropriate care in the community, that was not the case for most presentations.

"The real cause of ED overcrowding is bed block, which is caused by the lack of capacity in our hospitals."

The issue was complex, she said.

"There's a number of patients who come through the emergency departments who are unwell enough that they require admission into hospital ... and if our hospitals are occupied, these patients can't move out of the emergency department so these people form a queue, which is effectively like a bed queue.

"And the impact of that is that patients coming into the ED who need a bed have nowhere to go and end up queuing in spaces that are not designed for patient care."

She said there were a number of reasons patients were not being discharged from hospital in a more timely manner.

New Zealand had an ageing population and older people tended to have more complex medical problems and to stay in hospital for longer.

"It's also been difficult to get people out into the community who may need wrap-around services like aged residential care."

She said some patients needed to be in hospital, but some were there "because of the lack of capacity within the community".

"Those patients need to be in another place that is not the acute hospital."

There was a need for long-term investment in infrastructure and planning for capacity increases as the country's population - and particularly its ageing population - grew, Allan said, but that was only part of the puzzle.

"We need to actually be doing more in the community so patients don't need to be in hospital, and that means preventing them coming in at one side but also enabling them to get out at the other end."

More outreach services and home visits could form part of the solution, she said.

"We need to unblock the drains and that effectively means looking at solutions that help us move patients through the system."