On my living room wall is a poster – the poster in the photograph – and it perches there, displaying its stupefying complexity to anyone who walks by. I’m not sure why it gets pride of place on my wall when surely an elegant print would do better, but I love to be reminded of the almost hallucinatory sophistication and connectedness of our biologic cellular processes, even in such superficial rendition. It reinforces why trials looking at single interventions in medicine so often fail to show benefit – how do you separate out a single step in a tornado of interplaying factors?
There is another web of similarly convoluted intricacy in health, this one on a scale writ large. Every particle of it is also as interconnected, and altering one does little to change the organism as a whole. It’s a world-wide phenomenon, and I thought this might be an opportunity to share some truths from down-under, where our emergency departments suffer the same plague of overcrowding that others all over the planet do.
The fundamental reason our emergency departments are overcrowded is that there are patients in the ED who do not need to be there. In a perfect world, people who present to ED would have a short episode of ED care and then would either be discharged or swept off to their clean-sheeted, welcoming inpatient bed. Hell, in a perfect world we wouldn’t need EDs at all, such would be the strength of preventative health strategies, care of chronic disease, avoidance of risky health behaviours, things put into place so that nobody would find themselves in need of our services in the first place. Reality, however, has disavowed us of this ideal.
The cause of our overcrowding, certainly in Antipodean land, is as multifactorial as the steps in an inflammatory cascade. There are myriad interlinking pre-hospital, intra-departmental, and post-hospital failings which result in overcrowding, like a clumsy renal failure metaphor.
Once one begins identifying causative elements in society leading to overcrowding in ED, and how they affect each other, one cannot stop. Most somehow reflect the crumbling fabric of society, and which, no matter their root cause, focus like a laser in the Emergency Department, where people end up when there is nowhere else to go. Just to scratch the surface, in Australia, we have: a decreasing distribution of family practitioners, with their undervalued, falling remuneration relative to costs of living, servicing less of our under-represented and disenfranchised populations. GPs are also less likely to visit nursing homes, which themselves are filling with an older, more unwell population. ‘Unwitnessed falls’ in nursing homes find themselves in ambulances stacked outside our bulging EDs waiting to come inside, all for want of a once over in the safety of their own environment. Health literacy in the community is deteriorating, with an antithetical and inversely ratioed rise in health misinformation. Existential unhappiness is also on the inexorable increase, perhaps with the big lie that we should all be happy. This has led to a pandemic of self-medication, trying to blunt away the horrors, to say nothing of the deep psychological wounds of the true pandemic. Where I come from, in Perth, the river runs torrentially with alcohol and methamphetamines.
Ambulances remain ramped outside all the metropolitan EDs, unable to offload the tide – there is no room at any of the city’s Inns.
On the other side of the kidney/emergency department, we suffer from an ever-dwindling bed-stock. Hospital beds are hellishly expensive, so restricting them is an obvious way to keep the ravenous beast of health expenditure at bay. Here in Australia, we have a version of socialised medicine. I appreciate this word is somewhat on the nose for many Americans, and there are good and bad aspects to it (with one of the most poignant being nobody here is ever bankrupted by health care), but it means the beds at the back end of the ED are in precious, short supply, and when they are not available, the log-jam manifests in the ED – cue access block and boarding of inpatients. Those few hospital beds, too, are filled with people with nowhere to go from there, again the end-point of a thousand slings and arrows of an imperfect society.
Of course, our emergency departments have their own inefficiencies, magnified in whole by overcrowding itself. Everything is harder to do when there are patients stacked in corridors, relatives knocking on windows, ambulances ramped out the front, medical and nursing staff wilting with the neglect common to all such overwhelmed systems, sick calls increasing, rosters unfilled, burnout raging like wildfire.
Perhaps the most grievous example of all are the alleys of boarded, formed psych patients. In the most inhumane circumstances we detain these patients, forcing them to wait days for a suitable bed, doubtless worsening their illness.
I wanted to make an elegant diagram, like the one that graces my wall, about how all these societal failings connect like a glorious web, with influence and feedback loops and domino-effect power, but it would not be anywhere near so delightful.
Solutions are not easy to come by, and money thrown at one aspect at the expense of another may barely shift the needle. Where we used to talk about overcrowding being a whole of hospital problem, perhaps it is better described as a whole of societal one, instead.