HiQuiPs: Resource Issues in the Emergency Department

Emergency departments are busy and are getting busier^{1, 2}. Emergency physicians are faced with issues of overcrowding, departmental closures, and insufficient staffing. These issues are exacerbated by both the Covid pandemic³ and pressures found in the post-Covid “return to normal”⁴. Physicians are still expected to provide safe medical care in the face of these challenges. But what does that look like when your emergency department lacks appropriate resources? And how can physicians minimize their medico-legal risk when providing care in under-resourced emergency departments?

Case vignette:

A 41-year-old patient presents at a busy community emergency department (ED) during the evening with severe back pain that has persisted for 3 days. He is given analgesics at triage and placed in the hallway. There is a significant wait-time to see patients, due to the high volume and acuity of patients in the ED. In addition, part of the ED has been closed due to nurse staffing shortages.

On examination the patient appears in significant discomfort and has difficulty getting up onto the stretcher. His vital signs are BP 105/58, Pulse 110, Respiratory rate 18 and Temperature 37.1 Celsius. On history, he endorses difficulty with initiating urination and bowel movements, which is new. He denies any episodes of incontinence, bloody diarrhea, or upper respiratory tract infection symptoms. There is no history of acute trauma. His past medical history is significant for advanced Crohn’s disease treated with infliximab and methotrexate.

Resource issues in the emergency department

Emergency departments are feeling the effects of a lack of resources in a number of areas. Physicians are treating patients who have been unable to access timely treatment elsewhere, and these patients are often sicker and have greater mortality⁵. Emergency department closures have recently occurred in a number of provinces due to a lack of human healthcare resources⁶. ED closures place greater strain on other hospital emergency departments and may increase patient harm incidents². Some hospitals may also attempt to relieve the problem by relying on the work of contract health care providers who may not be familiar with the facility/processes. Physicians in these situations may have to make difficult decisions in order to provide the best care for their patients in challenging circumstances – such as negotiating a transfer to another hospital, finding appropriate space for personal exams, or accessing care resources – while still respecting patient privacy, confidentiality, and dignity.

The emergency physician asks the nurse to move the patient to a room so that she can do a more thorough history and physical examination. She is advised that there are no rooms available due to bed-block. Just then, a critically ill patient with acute coronary syndrome arrives and the physician quickly attends to the new patient.

Advocating on behalf of your patient

Emergency physicians should advocate for their patients due to the unique role they play in the healthcare system. Due to a lack of access to primary care providers, emergency physicians play a significant role in providing patients access to needed treatments and care⁷. Emergency physicians may need to advocate quickly in order to help their patients receive the best care. This role is increasingly important when resources are scarce.

Physicians can advocate for their patients in different ways. They can advocate for individual patients by requesting appropriate care or testing; they can advocate for groups of patients by requesting services that would be helpful for the community at large; and they can advocate at a systems level by pushing for change in their hospital, province/territory, or larger healthcare system⁸. At an individual level, advocating on behalf of your patient helps them to navigate these complex systems⁹.

A few hours later, the physician reassesses the patient with back pain as they have now been placed in a room. She notes on examination that the patient has decreased rectal tone, signs of urinary retention, and decreased reflexes to his lower extremities. She is concerned regarding acute cauda equina and initiates IV antibiotics because of a suspected spinal abscess. She notifies radiology to arrange for an urgent MRI and consults neurosurgery.

Communicating and collaborating with your team

Emergency departments rely on complex and dynamic relationships between team members in order to treat a wide variety of patient presentations and characteristics. In addition, communication breakdowns within healthcare teams can occur due to interruptions or delays in care, resulting in potential patient harm¹⁰.

When communicating with your team, particularly when working with new or unfamiliar team members, ensure you are explicit in your communications¹¹, particularly when working with an unfamiliar team. For example, in our case study, the physician does not initially provide an explanation to the nurse or describe the patient’s situation when they request a private room or space. Clear communication of their concerns would help their teammate to understand the potential urgency of the situation.

When lacking appropriate space due to ED overcrowding, teams need to work together to find solutions in sensitive or urgent patient situations. By communicating clearly about patient needs, it is vital for teams to work together to adapt to changes in patient status, should a patient’s condition worsen or deteriorate.

Providing safe care when your department is under-resourced:

Canadian emergency departments are overburdened. This can take the form of a shortage of healthcare providers, a lack of beds, or a lack of specialists for consultations. These circumstances exacerbate the stress that emergency physicians already face in their demanding work. For those who are concerned regarding their potential increased medico-legal risk, it is important to note that courts and medical regulatory authorities (Colleges) will consider the context of your care and the availability of resources when reviewing complaints. These bodies recognize that care cannot be provided with “resources that do not exist”¹². The concept of “reasonableness” is used by Colleges and courts based on how a physician of similar practice and experience would act under similar circumstances with the same availability of resources¹³. Nevertheless, physicians are expected, within those resource constraints, to do the best they can for patients, and to act reasonably in such circumstances. Physicians should document any efforts to obtain the required resources for their patients (e.g. referrals) along with any deviations from the norm for resource considerations, as well as justifications for doing so.

When working in an overcrowded or under-resourced emergency department, remember that your work helps others. If you are interested in advocating within systems or larger institutions, CMPA has some recommendations that may be of use in your clinical (or work) setting: CMPA – Advocacy for change: An important role to undertake with care (cmpa-acpm.ca).

We know that the overburdened system weighs heavily on physicians. While our article addressed the stress this can have on patient care, we cannot ignore the impact it has on the well-being of physicians overall. Emergency care can be difficult in the best of times and the current status of healthcare in Canada can be challenging. We want you to know that we are here for you. If you are experiencing difficulty at work, we have several resources in our “Physician Wellness” hub related to work stress, fatigue, and anxiety that may be of value: CMPA – Physician wellness (cmpa-acpm.ca).

The Bottom Line:

Even under difficult circumstances, physicians aim to provide the best care possible. Follow your normal patterns of care when you can (history, physical exam, etc.).
Advocate on behalf of your patient – speak up and speak out if your patient’s status changes, or if your patient requires care they are not currently receiving.
Work together with your team; communicate clearly and see what short-term solutions can be found when space and resources are limited

CMPA Resources:

This post was copyedited by Zeina El karsh

Senior Editor: Ahmed Taher

References

1.
Miller A, Bamaniya P. Why ERs are under intense pressure across Canada — and how to help fix them. CBC. Published June 24, 2023. https://www.cbc.ca/news/health/canada-er-pressure-health-care-system-solutions-1.6885257
2.
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CMPA. Advocacy for change: An important role to undertake with care. Canadian Medical Protective Association. Published June 2014. https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2014/advocacy-for-change-an-important-role-to-undertake-with-care
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Ahmadpour S, Bayramzadeh S, Aghaei P. Efficiency and Teamwork in Emergency Departments: Perception of Staff on Design Interventions. HERD. Published online June 15, 2021:310-323. doi:10.1177/19375867211023156
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Victorian Department of Health. Teamwork and Communication: Effective Communication. Victorian State Trauma System. Published October 5, 2023. https://trauma.reach.vic.gov.au/guidelines/teamwork-and-communication/effective-communication
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CMPA. Wait times when resources are limited. Canadian Medical Protective Association. Published May 2022. https://www.cmpa-acpm.ca/en/education-events/good-practices/the-healthcare-system/wait-times-when-resources-are-limited
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