COVID-19 has brought significant disruption to the way medical care is delivered across all areas of clinical practice including Emergency Medicine (EM). Change has occurred rapidly, much of it challenging for patients and staff, but some of it is undoubtedly good. Emergency Medicine has been dynamic in adapting to care for both COVID and non-COVID patients without ceasing services to incoming patients. As we move from a pandemic to an endemic state, the Irish Association for Emergency Medicine is setting out its position on how care in Irish Emergency Departments (EDs) and hospitals must be reset to allow EM continue to care for those patients that need EM expertise in a way that is safe for patients and staff. The response of the Irish public has been instrumental in allowing the healthcare system cope during this pandemic. Patients must continue to feel that EDs are safe places to attend and staff must be safe working there. Three important principles need to be at the heart of what happens now:
1. Emergency Departments cannot be allowed to become reservoirs of nosocomial (hospital- or healthcare-acquired) infection for patients.
ED infrastructure must be upgraded to allow social distancing for staff and patients and allow segregation/ isolation of those with infectious disease. Staffing in ED must be adequate to compensate for the extra time required in certain patient encounters in safely putting on and taking off personal protective equipment (PPE). There must be rapid access to the supports necessary (e.g. diagnostics) for rapid and effective decision making so that patients spend as short a time as possible in the ED.
2. Emergency Departments (or hospitals) cannot be allowed to become crowded again.
Unoccupied beds must be always available so that once a decision is made that a patient needs to be admitted to a hospital bed (25-30% of those who attend ED), this can occur immediately. There must be adequate isolation areas on wards so that patients are not kept in the ED simply because of infection control concerns – this is completely unacceptable. The HSE Key Performance Indicator, Patient Experience Time (PET), sets a standard that 95% of patients should spend less than 6 hours in the ED from arrival to departure (either by being discharged or admitted to a hospital bed). This must be implemented transparently. Measured performance against this target has been running at about 60% for years but increased to about 80% during the pandemic as beds were available for admitted patients. This proves that ‘trolley waits’ are the result of there being insufficient beds for the numbers of patient requiring admission.
3. Pathways to treat patients outside the hospital setting should be consolidated and significantly enhanced.
The risk of nosocomial infection will always be greater in the congregated setting of the acute hospital than in more dispersed community settings. This is particularly the case in the ED, which sees undifferentiated patients in whom the
diagnosis may not be clear. Large numbers of patients must not be expected to gather in ED waiting rooms with long delays to see a clinician.
The Association re-emphasises the need for patients with severe illness or injury to feel safe in attending an ED. However, some patients with certain less urgent conditions should be able to avail of other care pathways. ED must be the best place to deliver the right care at the right time to the right patient, rather than the only place available. EDs must not be the part of our healthcare system that picks up the pieces when community and other specialty care fails to provide the necessary service. System reform must be universal, not sporadic. EM must return to its core purpose which is the rapid assessment and emergency stabilisation of seriously ill and injured patients.
Finally, the Association wishes to thank all of those who work in healthcare: in the community, in pre-hospital care and hospital care for their efforts during the COVID-19 pandemic. We also remember all those who have died during this difficult time, both healthcare providers and patients alike.