Emergency Department (ED) crowding and access block are among the most significant issues affecting access to emergency care. This is a reality not only for North America but also the vast majority of emergency care systems in the world.
Fundamentally, crowding refers to a situation in which the supply for emergency care is outpaced by the demand; access block refers to the delay in transferring a patient out of the ED and into an inpatient bed. Access block has been frequently identified as one of the most significant contributors to ED crowding worldwide.
The cumulative global experience with COVID-19 has produced early insights that can be applied to tackle these issues.
Input, throughput, and output
During the early stages of COVID-19, the ED system in Canada underwent significant changes. In the span of a few short weeks, ED crowding seemed to disappear overnight. The input-throughput-output model proposed in 2003 can be one framework to understanding crowding. In simple terms, input factors are those related to patients arriving at the ED. Throughput factors are related to a patient’s journey through the ED, including diagnostic tests, treatments, etc. Output has to do to a patient leaving the ED, either through discharge or hospital admission. Access block belongs in the output category.
From an input point of view, patient volumes in the ED decreased precipitously. Various factors have contributed to this, including public fear of contracting COVID-19 in the ED as well as a sense of public responsibility to not overwhelm the health system. The rapid expansion of telemedicine capabilities has also provided meaningful alternatives and modalities that patients can easily access.
There have also been remarkable changes in output factors. At the hospital level, we’ve cleared out backlogs of patients, reduced scheduled/elective surgeries and freed up significant inpatient capacity. Collectively, these changes have virtually eliminated access block (temporarily, at least). These changes and the subsequent results speak to a key policy point that many healthcare planners and emergency physicians have been proposing for decades: Canada could address its crowding issue by addressing its acute care capacity and primary care access issues. In other words, ED crowding is often a misnomer; it is not a problem restricted to the ED but often a symptom of a systems-wide issue.
Of course, it would be difficult for some of these changes to be sustainable. We cannot realistically expect reduced ED volumes indefinitely and cannot have reduced volumes of scheduled surgeries without suffering significant population-wide morbidity and mortality. Thus, in the long term, an investment in significantly increased acute care capacity is required to maintain the current access performance.
Telemedicine and virtual care
Improvement of our primary care systems through acceleration of widespread telemedicine usage, however, is a meaningful and sustainable change that we can maintain in the post-COVID era. There has been enough significant innovation in this space that it can survive past the pandemic. Telemedicine can even play a relatively nuanced role in preventing return visits. Sometimes, patients have no other way of clarifying issues related to their discharge instructions or their post-discharge course other than to return to the ED. Scheduling a phone call or video visit instead could be very effective. Ultimately, the expansion of telemedicine capabilities can act as one means of sustainably reducing input to ED, thereby reducing crowding.
Crowding and challenges with human resources are the two biggest issues facing emergency medicine in Canada that have seen little sustained success. ED crowding, a systems-issue, inherently requires systems solutions that are enacted from higher levels and then trickle down. Chronic national shortages of adequately trained emergency physicians are also an important challenge to maintaining public access to emergency services. Many emergency medicine physicians are in key leadership positions in healthcare. However, leadership on its own may not be enough. The complexities of medical politics can be challenging to navigate. Often, emergency medicine groups have had difficulties agreeing with colleagues in other disciplines over issues such as relative compensation levels or size of training programs.
Implementing changes in one part of the system that could alleviate crowding or access block may introduce complexities or inconveniences in another part of the system. A recent example of these conflicting results can be seen with time-based targets. These targets, such as the United Kingdom’s four-hour standard, aim to have a certain proportion (e.g., 95 per cent) of emergency patients admitted or discharged within pre-defined time. While the implementation of these targets have resulted in improvements in metrics such as ED length of stay and a reduction in access block, they are also controversial as they have been associated with inappropriate admissions and increased inpatient length of stay. Solutions to ED crowding inherently will have impacts on other parts of the health system. Recognizing this and coming to consensus with our colleagues in other disciplines is essential to implementing change. COVID-19 highlights this well – a reduction in elective surgeries may reduce access block but at what cost to patients who require surgical care? “Elective” after all is another word for medically necessary but not urgent or immediately life-threatening (which is why some have taken to calling them “scheduled” surgeries instead).
From every crisis comes an opportunity to learn, adapt and improve. Our experience with COVID-19 has affirmed many of the root causes of ED crowding and access block, has helped identify some key long-term sustainable solutions that can address crowding, and has reminded us of the importance of collaborating with our colleagues in other disciplines in approaching systems-level change.
SARS left a deep scar in Toronto but it wasn’t broadly felt in Canada. COVID-19 is different. We hope that lessons learned from our experience with it will stick more broadly and durably.