At the beginning of the COVID-19 pandemic restrictions the number of patients attending Ireland’s Emergency Departments (EDs) fell significantly, as did the number of admissions from EDs. A recent ESRI report containing figures to the end of March (and therefore covering just the first few weeks of significant restrictions) confirms this. The experience during April & May has been that patients have begun to attend EDs in numbers comparable to a typical April or May. Unfortunately, this increase in numbers has also seen the return of the phenomenon of EDs being forced to lodge inpatient boarders (i.e. patients whose care in the ED is complete but who are forced to wait on hospital trolleys in EDs until an acute hospital bed is available for them). This is most evident in Limerick and Cork but many other hospitals are on the verge of seeing this scenario return.
At a time when the advice to the public is of the vital need to ensure physical distancing with a minimum separation of 2m between healthy people, it is absolutely indefensible that crowding be allowed to occur in an ED. This is all the more unacceptable as many patients attending EDs are acutely unwell; are often elderly and commonly have comorbidities. These groups are at markedly increased risk of dying from COVID-19 infection.
The ED is a workplace for its staff who are entitled to the same protections from harm that apply in other work environments. Not alone is the return of crowding and inpatient boarders in an on-going COVID pandemic a very significant risk to patients (and magnifies the already well-established risks of ED crowding), it also risks staff contracting COVID-19 with potentially serious consequences for them and for patients due to the consequent shortage of trained personnel.
The public is well aware that many Nursing Homes & long term care facilities became significant reservoirs for COVID-19 infection and many still require significant on-going support to address this. It would be unconscionable that EDs be allowed to become the next major reservoir of COVID-19 infection with catastrophic results for patients and staff alike. It is therefore imperative that the National Public Health Emergency Team (NPHET) and Health Service management recognise this very significant risk and take immediate steps to prevent crowding in EDs occurring in the first place. These steps involve measures to tackle inflow of patients into the ED by the provision of realistic and acceptable options for patients and GPs when a patient’s condition does not require immediate attention; throughput of patients in a space that is adequate for the numbers presenting and supported by prioritised access to the requirements for rapid senior decision making (e.g. Radiology and Laboratory diagnostics, as needed) and egress from EDs (e.g. available beds for those requiring admission and certainty of prioritised access to alternative services for those whose safe discharge depends on it). The Association is currently working on a series of high level recommendations which should inform this significant change in service delivery.
This evolving clinical risk requires the same level of urgency, commitment and sustained effort that has been generally seen in the fight against COVID-19 but not previously in addressing ED crowding in Ireland.