Disaster Medicine: Access Block in the ED

In Commentary, Opinion by George MastorasLeave a Comment

Bed pressure: anyone who has worked in the Emergency Department has felt it. I make a routine practice to come in for my shifts 15 minutes early and find a dark corner of the ED where I can “take the temperature of the department” and get a sense of the day’s pressures. On a day with heavy bed pressure there’s a frenetic buzz in the air, a tension that is almost palpable – everyone knows we are working in a crisis situation, and you can feel it.

Recently, I worked a shift where we had 3 available beds in our 20-bed module within the ED, and about 8 available beds out of 60 department-wide. That’s serious bed pressure. In my corner before my shift starts, I see the charge nurse pass by and he looks just a bit more harried than usual. The department board has an overall look resembling a highway at rush hour. The Emergency Physician on the outgoing shift mentions to me that she is “trying to tidy up” and handover might be delayed, because she doesn’t want to burden me with risky follow-ups when she already knows the state of the place and what I’m going to be facing over the next nine hours. On this particular day, our nurse manager even had 5 admitted patients waiting in the departmental boardroom to try to free up space.

This kind of pressure makes you sweat. It makes you worry about the patients you can’t get to. It makes you wonder when the paramedic phone is going to ring with a critical patient that will upset the house of cards – Where will we put them? Who will we pull to treat them? How will that affect the rest of the department? It acts as a catalyst for efficiency: you try everything you can to get patients moving through – and out of – the department safely. Unfortunately, it is also a major threat to patient safety: delays to diagnosis, delays to therapy, and delays to disposition all abound. And we all know that it’s only a matter of time before the unrecognized septic patient on the EMS runway decompensates, the undiagnosed man with a AAA who presented to triage with “abdominal pain” bleeds, or the lady with the missed MI in ambulance offload suffers a cardiac arrest.

In the Emergency Department, we often practice disaster medicine without any outside declaration of a disaster. A wise Emergency Physician once said to me on a night shift, that if 40 patients in the waiting room and one doctor to care for them isn’t a disaster (when patient demand overwhelms available resources), then he doesn’t know what is. So by that definition this is a disaster. When our hospital was faced with a mass-casualty incident last year, the “Code Orange” Mass Casualty Protocol was initiated and the whole hospital started pulling together: elective operations got cancelled, patients in the ED were decanted upstairs to the wards even if it upset nursing ratios, and ward patients who were considered “good enough” were discharged home a day or two early. Everyone in the hospital, from the medical and surgical inpatient teams, to the nurses, to the lab techs and porters worked with an understanding that we didn’t know what was coming in, and we needed to free up the “three S’s” of disaster preparedness: space, staff, and stuff. But we don’t activate this protocol on an above-average Tuesday, and so we leave the rest of the hospital to operate in the dark, without a full awareness of the realities “on the ground” in the ED.

Back to the busy shift. A couple patients to be seen (in beds), three others with treatment and investigations underway (one in a chair in the corridor), and six in the ambulance offload area. After seeing the patients in beds, I try to get to the offload patients to screen for life-threatening problems and request some initial investigations and treatments. But they are in a back hallway with little privacy, so I know my history-taking and physical exam are going to be inadequate – trying to protect their dignity. I hope to remember this when they move into the department hours later, and go back to repeat my exam more thoroughly. Other docs I work with have a “policy” of not seeing patients in the offload, knowing that beyond taking shortcuts in the H and P, orders may or may not be fulfilled anyway (the nurses at triage are overwhelmed trying to pluck other sick people out of the waiting room crowd).

When we are faced with a situation like this, most Emergency Doctors talk about “finding another gear”: they start to work faster, try to work smarter and more efficiently, and try to motivate their team to do the same. They might skip a test and just call an admitting service, to offload the cognitive burden of trying to manage dozens of active patients in parallel. They might have a frank conversation with the patient or family, weighing the merits of an early discharge against the reality that the patient may have to return if they don’t do well at home. Meanwhile admitting services “come down” to the ED after finishing their ward rounds to check in on their admitted patients. They shrug bashfully and apologize to the family of the elderly man with bilateral SDHs who has been waiting 30 hours for a bed “upstairs” and say that they don’t control the bed situation. They try to “get in and get out” of the ED, zig-zagging to their three or four admitted patients before disappearing, for reasons I don’t quite grasp despite all my rotations with these services. Maybe it’s a fear of getting a curb-side consult, or maybe it’s a discomfort with the general tension of the department, the noise, the crush of patients and families, the irritability of the staff who are thinking “don’t you see how busy I am here?”

What I don’t understand, then, is why we do this in isolation. When the ED is buried on any given Tuesday, we take sole ownership of the surge rather than call it what it is: a (minor) disaster. The bed pressure we feel may translate into more efficient or pragmatic care, or it may end up being a systematic cause of medical error and patient harm – either way, we alone bear that cross. The patients in the waiting room, offload, etc – the people who only have a symptom attached to them, not a diagnosis or any treatment plan – will have to wait because we don’t have enough beds or nurses right now (and we probably never will – it’s like building a wider highway). These “undifferentiated patients” are ticking time bombs, some of them. But if someone gets sent home inappropriately, or someone we haven’t yet seen deteriorates, we as Emergency Physicians and as an Emergency Department will face the tough questions about “why” this happened. 100% of the bed pressure, and the fallout from working in this disaster scenario, is shouldered by those of us working “downstairs”. Upstairs, on the wards, patients are (usually) more stable. They have a diagnosis, or at least a clearer understanding of what is wrong than when they arrived at the triage station. They have an investigative and treatment plan. They have a team of doctors, consultants, nurses, and allied health professionals invested in their care. They have a roadmap towards getting better and getting home. That isn’t to say that there are never bumps or major detours along the way, and occasionally they are on entirely the wrong roadmap, but there’s a more complete understanding of the patient by the time they get upstairs.

So why, then, don’t we shift some of the bed pressure to the ward? This is exactly what we would do in a real disaster situation: decant patients to the wards, where our colleagues in turn start looking to move patients out. Don’t misunderstand – I know that ward managers, attending physicians, and the like are very aware of the overall bed situation in the hospital. They know that their unit is at 98% (or even 105%) capacity. They get phone calls twice a day from bed administration. They know that there are four patients (or two, or ten) waiting to “come up” from the ED once a bed or nursing resources become available. Admitting services lament the days with a “big list” that includes patients “bed-spaced” to other units (e.g. the medicine patient on the surgical ward because that’s where a bed existed) or that require rounding in the ED. But they never feel the same acute pressure, or the same fear that something in the unknown woods of the ED waiting room is about to go badly.

The solution here should be obvious: move patients out of the ED the moment (or soon after) they are admitted. One person in a converted broom closet on the ward might make people “aware” of the bed situation, but it won’t be a catalyst to take action. A “runway” of patients in stretchers or chairs, waiting to come in, adds real bed pressure and underscores the need to decant. Does it respect dignity? No, but not any more than in ambulance offload. Does it raise the risk of patient harm? Yes, but I would argue less so when it’s a patient with a diagnosis and a plan, as compared to an undifferentiated patient who has just arrived to the ED. Does it upset nursing ratios? Big time, but less so when it can be distributed across the hospital rather than concentrated in the ED. Might it be a risk for infection control? Absolutely, but so is sitting in the waiting room beside a coughing patient with a mask over their lower lip and chin.

I’m not saying this solution would be easy to stomach. But while we can’t call a Code Orange every day, perhaps there is a way to facilitate a broader understanding across the hospital of what kind of pressure the ED is facing on that above-average Tuesday. By shifting some of the surge from “downstairs” to “upstairs” on a more routine basis, perhaps we can catalyze more efficiency in patient dispositions from the wards, spread out (and hopefully in turn, diminish) the risks to patients, and encourage our colleagues to “find that other gear” that we all try to find.

George Mastoras

George Mastoras

George Mastoras is a fourth-year Emergency Medicine resident at the University of Ottawa, currently pursuing advanced training in resuscitation medicine. His interests include medical teamwork, human factors, and the use simulation to advance patient care. He de-stresses after long days (or nights) in the ER by playing with his son, praying for the Leafs to just make the playoffs for once, or enjoying a fine scotch.
George Mastoras

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Frontdoor2Healthcare, founded by Dr. Edmund Kwok in 2012, provides editorial and commentary on issues affecting Canadian healthcare from the emergency department’s “front door” perspective. Frontdoor posts allow for open sharing of the diverse opinions and perspectives of emergency physicians from across the country.

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