The care crisis facing hospital emergency departments

Dr Cliff Connell remembers when he was an emergency nurse working in a Victorian hospital emergency department (ED) in the late 1990s and early 2000s, when he and the ED consultant would routinely walk the floor during a practice called “rounding reviewing” each patient.

Those days are gone, he says, “because there is simply not enough time for the ED nurse and doctor in charge of the department to review each person face-to-face”.

These days, staff in charge during ED shifts rely largely on monitoring their patients using electronic health records and physiological parameters such as blood pressure or oxygen saturation on centralised computer screens, as well as updates from the ED team.

Read more: Ambulance ramping shows the health system is floundering, and solutions need to extend beyond EDs

Adding to the strain of the ED staff is the number of electronic records each patient has when they’re admitted to the ED – health records, pathology records, x-rays, and so on, “with none of these in a one, easy-to-access and compare system”, Dr Connell says.

Recognising and responding to a deteriorating patient in a prompt and effective way is known to prevent serious adverse events such as cardiac arrest and unexpected death.

Across Victoria, a rapid response call is activated about every 15 minutes, according to Safer Care Victoria.

In the past decade, the number of hospital emergency department presentations has increased between 23% and 49% globally.

Those who attend the ED are diverse – suffering from cardiac, orthopaedic or respiratory diseases, young, old, frail, or seemingly healthy. “There’s no other area in any hospital that deals with such complex and diverse patient problems and illnesses,” Dr Connell says.

As Deputy Director of Graduate Research at Monash’s School of Nursing and Midwifery, Dr Connell studies ways EDs can best manage not only this variety of sick people, but how to manage the approximately 11% who rapidly deteriorate.

“The goal is to know which patients are likely to deteriorate so we can intervene and prevent that from happening,” he says.

Dr Connell was recognised as a Sigma 2023 Emerging Nurse Researcher/Scholar for the Pacific Region at the 34th International Nursing Research Congress in Abu Dhabi in July – one of only six awarded globally in 2023.

In the ED, signs a patient is deteriorating become apparent when they start showing abnormal vital signs or show change in consciousness. When this happens, the rapid response system (RRS) triggers a review of the patient by the emergency nurse and physician in charge of the shift.

But, according to Dr Connell, the rise in people coming into the ED, even before the COVID-19 pandemic, and overcrowding due in part to the lack of available inpatient ward beds to take patients who have been diagnosed and treated in the ED, means staff are faced with overwhelming increases in workload, often exacerbating known ED safety concerns such as frequent interruptions, cognitive overload, and can impact on clinical reasoning and good decision-making, he says.

Dr Connell’s area of research, and for which he received the Sigma award, aims to give the nurses and doctors in the ED the ability “to work out where the hotspots are, to determine, early, who needs more intense monitoring or escalating to intervention”, he says.

In 2021, Dr Connell was lead author on a research paper published in the journal Australasian Emergency Care, looking at the prevalence and management of deteriorating patients in the ED.

The research team looked at a major Victorian hospital ED that served both adult and paediatric patients. In 2018, this ED saw just under 70,000 patients.

The ED also has an RRS or medical emergency team (MET) criteria to manage those patients who are deteriorating.

Triggering a MET alert involves a nurse conducting physiological signs to verbally inform the ED nurse and the doctor in charge, who are then required to review the patient within two minutes and then supervise the patient’s management.

The study found one in 10 patients exhibited signs of deterioration.

Concerningly, almost 50% were not escalated, according to the hospital’s mandatory alert criteria.

This was not impacted by workload or staffing levels; however, there were significant associations between “the experience and expertise of the person documenting signs of deterioration, the area within the ED where the patient was being cared for, and whether their care was appropriately escalated”, Dr Connell said.

While EDs have continued to improve the safety and quality of care in the intervening years, there remains “still much that needs to be done”.

According to Dr Connell, by modifying current ED-specific rapid response systems that use synthesised health data from all electronic health data systems in real time, clinicians will be better-positioned to provide equitable access to safer and higher-quality care in the ED.