The healthcare system in Pakistan is broken down system with the Emergency Department being the weakest part because of plenty of reasons, some of which I have explained multiple times in my posts.
Today we will discuss a very important reason and that is crowding. Our healthcare system is broadly divided in Government sector and Private sector hospitals. Most of the private setups don’t have developed emergency departments, and also have very limited capacity. This is mainly because we lack trained emergency doctors and nurses, and so the private institutes feel the poorly trained or untrained doctors stationed in the ED can become a liability. We have seen evidence of bad outcome in cases of untrained doctors working in the ED. In the government or public sector hospitals the situation is different. These public sector hospitals have well placed and properly built emergency departments, but is not managed by trained ED doctors.
This results in public sector hospitals receiving maximum number of patients who require emergency care. As the number of public sector hospitals with defined Emergency Department are quite small in number, they are almost and always packed with patients coming from far and wide. This flux leads to crowding. As defined by the American College of Emergency Physician, crowding occurs when the identified need of emergency services exceeds available resources for patient care in the emergency department(ED), hospital or both. Looking through this lens we see that most of our emergency departments suffer from lack of resources. It includes all kind of resources like space, personnel, competence and material.
Looking in a bit deeper way, the emergency departments across Pakistan are not planned appropriately or not have enough space to adequately take care of the patient numbers coming to those Emergency Department. In the same respect if the ED is not designed appropriately then the crowding can become an issue. This is because the ED design can hamper the patient flow and thus can result in delays.
After the space issues, the material or the equipment is equally important for the ED. As low resource country we can not afford to match the first world when it comes to resources, yet we can provide safe and quality care with less resources. For the quality of care to improve the system needs to have good foot print as well as competent doctors and nurses.
The ED needs to be staffed adequately, otherwise the safety of the patients will be compromised. The staff to patient ratio has been studied by many people and we need to make sure that we are staff atleast by minimal standards initially. The work flow of the ED is very unpredictable, so either we are seen at times as overstaffed and other times as understaffed. A careful planning of the staffing needs makes it easy for the staff as well as patients to have a balance in busy times. Competence of the staff is an issue and it seems that it will continue to be an issue for quite sometime. The doctors and nurses are not in adequate numbers to take care of load of patients in Emergency Department.
In order to deal with crowding, we need to look into possible reasons, so by addressing those reason we will be able to deal with crowding and in turn result in better and quality patient care and ultimately satisfied patients.
In order to improve the quality we need to adjust the balance of ED staff and patient load. Decreasing the load of patients can be done by taking care of patients closer to their homes, so they don’t have to travel far and away to seek emergency help. This will have a direct impact of care and result in good resource utilization. We also need to make sure that the patients healthcare issues are addressed in the clinics by their general practitioners. Another way is to investigate people appropriately and move them out of ED to appropriate hospital floors as soon as possible. This saves precious time and avoid crowding.
In our part of the world the mismatch between the resources and the patient load in any government hospital is too enormous that we all need to think about crowding and work on its solution to improve the quality of care in the emergency department.