Crunch or cringe By Dr. Peter W. Kujtan, B.Sc., M.D., Ph.D.

Emergency departments can often be viewed as a barometer of hospital activity. Isolating ER overcrowding as an independent entity lacks understanding and solutions based on such views are prone to failure. It seems to be a problem of countries with socialized medicine as I discovered on a recent trip to Ireland. In the USA, solutions come quickly. Some people dismiss overcrowding as a simple result of ER abuse, a definition prone to grayness and confusion.

The ER is an extension of the hospital, and is interdependent with numerous other facets for proper functioning. With the explosion in the hospital management ranks, it is those who have the foresight to view things "outside the box" that seem to be able to implement interesting solutions.

There was a time when I could admit a sick patient directly to a bed, but no more. The ER has now become the entry point for acutely ill patients who require hospitalization. The only exceptions are patients scheduled for surgery and women about to give birth. When there is a heavy burden of illness in the community, patients can occupy emergency spaces for days. ERs are used in spurts, yet policies often depend on smooth averages. In Peel, 70% of patients register between 4 and 11 PM. Seasonal crunches also occur, when various flu's hit the community. There are only a certain number of exam rooms in the ER. When they become full of admitted patients awaiting a hospital bed, it effectively shrinks or closes the ability for anyone else to be seen. There was a time when continuity of care existed. The physician admitting you would also look after you, and saw you in follow-up. This still exists in some small hospitals, but in our area you get assigned at random to the next "available" doctor.

You cannot differentiate hospital overcrowding from ER overcrowding. Gone are the days where I could meet a patient at the ER and quickly provide intervention and arrange follow-up. Trivial parking logistics killed that dinosaur.

Nowadays, when you go to the ER, you will first be seen by a triage nurse who will attempt to rank the severity of your illness in relation to those around you. When an examination room becomes available, you might be escorted there by a volunteer and then will have vital signs measured again by a second nurse. A physician or resident will examine you and may order tests. Blood tests, procedures and x-rays all rely on other parts of the hospital running smoothly and being able to accommodate the requests. Waiting and then re-examining an ill patient is a vital part of the process. Even though the area is crowded, various staff may seem idle at various times, largely due to the inefficiency of the system. The doctors working in the ER need to balance the care of 20 patients or more, a naturally acquired skill. The orchestra conductors are called charge nurses and from their cockpits near the entry, try to oversee the mammoth process.

Another sore point is that doctors are paid by the number of patients seen, while everyone else is on the time clock. There are no bonus systems or other incentives to promote efficiency. One of our local ERs even suffers from "grand non-functional idea syndrome." Flaws, inherent in poor design are replicated and expanded during re-design. Work areas are placed in earshot of everyone, and during times of staff shortages, work breaks are taken with-in earshot of patients and visitors, inciting frustration and promoting burnout. Fortunately, despite the problems there is still an excellent level of care provided by those who work in our local ERs, particularly for the very ill. It is of little use to scream at the people working there when you feel frustrated. They do not set policy, and most problems are ongoing and not new to your visit. If a complaint is warranted, it is best placed in writing and addressed to the chief administrator. Some hospitals even have ombudsmen. The best time to go to the ER is first thing in the morning, but timing is not a factor that can be often influenced.