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Consequences of ED crowding need recognition

By Paul Mulholland - 19th Nov 2023


Earlier this month, the Irish Association for Emergency Medicine (IAEM) highlighted a paper published recently in JAMA Internal Medicine.

This was a prospective cohort study of patients 75 years and older who attended emergency departments (EDs) and were admitted between 12-14 December 2022 in hospitals across France. The multi-centre study, which was carried out by researchers at the Sorbonne University in Paris, included 97 hospitals. 

According to the paper, for every 21 older patients kept overnight in an ED awaiting a ward bed, there was one extra death at 30 days. The findings of the study indicate that, for older patients, waiting overnight in the ED for admission to a ward was associated with increased in-hospital mortality and morbidity, particularly in patients with limited autonomy.

According to the IAEM, the findings are “stark”. The Association pointed out medical scientific literature has consistently highlighted that keeping patients in crowded EDs on trolleys is associated with increased deaths.

“Doctors working in emergency departments have been highlighting the harm associated with crowding and prolonged waits on emergency department trolleys for inpatient beds in Ireland for two decades,” according to the IAEM.

“We see first-hand the negative impact that crowded, noisy, brightly lit emergency departments have on sick patients, in particular, on older adults. We see these patients deteriorate before our eyes; emergency medical and nursing personnel are repetitively experiencing moral injury resulting from their witnessing substandard care due to the lack of acute hospital bed capacity.”

The Association pointed to the lack of acute beds in the Irish healthcare system, in addition to insufficient rehabilitation beds, long-term care beds, and community support services.

“This means acute hospital beds, designed for our sickest patients and not designed for the needs of the patient requiring long-term care, are being used as rehabilitation and long-term care beds and as a substitute for homecare packages. Meanwhile, the most acutely sick patients do not have an acute hospital bed to go to and get stuck on a trolley in the emergency department.”

Last month, the Irish Nurses and Midwives Organisation (INMO) again highlighted the chronic problem of crowding in EDs. Over 10,538 patients, including 273 children, waited on trolleys in October, according to the INMO. 

Recent HIQA reports have outlined progress in EDs in Beaumont Hospital, Dublin, and University Hospital Waterford. However, the lack of capacity within the healthcare system continues to be of concern, especially at this time of year. The imposition of the recent recruitment embargo deepens this concern and is likely to exacerbate the situation.

It is easy to become inured to the statistics of ED crowding and long waiting lists, which have been the reality of the Irish health service for decades. But it is important to remember there are people behind these statistics. And it needs to be recognised that a failure to address the lack of capacity within the health system can have devastating, real-world, consequences for patients and their families.

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