KEY POINTS:
The problems of long waits in the emergency department reported at North Shore Hospital emergency care centre over a recent few days will be familiar to most staff working in large emergency departments across New Zealand.
Similar problems are also occurring in many other countries, such as the United States, Australia and Britain.
Gridlock usually occurs when the occupancy of a hospital is too high, and patients cannot be moved out of the emergency department to the in-patient beds within the normal time period.
Specifically, when more than 95 per cent of resourced hospital beds are full, a hospital will find it virtually impossible to cope with a surge in admissions or an increase in the length of stay.
This often occurs at the start of the cold weather because of the increase in cardiac and respiratory conditions affecting vulnerable elderly patients.
Once past a critical point, the resources of the emergency department are exceeded and there are no more spaces, no more nurses and no more doctors. Queues then form in waiting rooms, corridors and ambulance bays.
It is imperative not to be complacent about the consequences of this problem. Once an emergency department becomes overloaded, it is not just a matter of patients suffering inconvenience, lack of privacy, and discomfort, though this clearly happens when they wait for many hours to be seen or are cared for on trolleys in corridors for days on end. It may also affect their chances of survival.
Research in Australia strongly links "bed block" episodes with additional mortality among emergency admissions - perhaps up to 13 additional deaths a year in larger departments.
By definition, gridlocked departments in which resources have been overwhelmed have insufficient staff to carry out all of the care a patient requires. This leads to drug errors, inadequate monitoring, delays in tests and critical treatments.
Vicious circles are also often created: if there are no rooms to examine patients, and no treatments instituted to hasten recovery, the length of stay in hospital further increases and worsens the problem.
Staff have to spend more time defusing angry relatives, answering complaints and shuffling trolleys around and less time on patient care.
They become tired and demoralised, and finally refuse to work overtime, leaving even fewer staff to deal with the workload.
Costs also spiral - the earlier that treatment is administered in many diseases, such as severe infection, heart attack, pneumonia, and head injury, the shorter (and cheaper) the hospital stay is and the less disabled the patient is at the end of the process.
The solutions are hospital-wide, as they are not just emergency department issues. Broadly, there are two parallel strategies. First, the hospital occupancy needs to be run at the internationally validated level of 85 per cent of maximum to cope with surges.
If this were adopted as a key health policy, the problem of gridlocked emergency departments would largely disappear.
Second, hospitals need to recognise that it is too risky to allow emergency departments to become so overloaded that patients are in the corridors.
The load needs to be spread to the in-patient wards which can admit those waiting for a bed to their side-rooms, dayrooms and treatment rooms to allow the emergency staff space to treat new arrivals who will not have received any care and may be dangerously ill.
This latter policy is successfully employed at Auckland City Hospital, but has been difficult to sustain recently because of the persistently high levels of occupancy.
Patients in overloaded emergency departments do not just suffer discomfort, indignity and frustration. They are also at risk of significant preventable harm.
An acceptance of this risk by everyone may make gridlock less common, and less tediously predictable.
* Dr Tim Parke is clinical director, adult emergency department, Auckland City Hospital.
