tag:theconversation.com,2011:/id/topics/emergency-departments-1184/articlesEmergency departments – The Conversation2024-01-15T20:46:57Ztag:theconversation.com,2011:article/2209802024-01-15T20:46:57Z2024-01-15T20:46:57ZRSV, flu and COVID: demystifying the triple epidemic of respiratory viruses<figure><img src="https://images.theconversation.com/files/568892/original/file-20240110-27-k3w5hm.jpg?ixlib=rb-1.1.0&rect=0%2C2%2C995%2C663&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The influenza virus, which causes seasonal flu, is back at its usual rate after a hiatus due to health measures.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Since 2022, a triple epidemic of respiratory viruses — RSV, influenza and SARS-CoV-2 — has been disrupting our daily lives. In addition, the media constantly reminds us of how this is straining emergency departments.</p>
<p>How does the present respiratory virus season differ from seasons during the pre-COVID era?</p>
<p>As a specialist in virus-host interaction, I would like to shed some light on the new dynamics of the respiratory virus season.</p>
<h2>The infamous SARS-CoV-2</h2>
<p>SARS-CoV-2, the instigator of the COVID-19 pandemic, is still with us. Despite limited access to screening tests, analysis of the number of hospital admissions shows that the virus is still going strong.</p>
<p>Québec’s Institut National de Santé Publique counted more than 33,000 hospitalizations in Québec in 2023 affecting all age categories, <a href="https://www.inspq.qc.ca/en/node/29197">including 648 children under the age of nine</a>.</p>
<p>The virus is not seasonal. It has a strikingly efficient capacity to spread through aerosols, especially as we take refuge indoors to escape the cold. The virus currently circulating is actually a mixture of different viruses, known as variants, each of which has the potential to partially evade the immunity an individual has acquired through a previous infection or vaccination.</p>
<h2>Resurgence of seasonal flu</h2>
<p>After a hiatus due to health measures, the influenza virus, which causes seasonal flu, has returned with the same force. It is once again circulating <a href="https://www.cdc.gov/flu/about/viruses/types.htm">in different variants belonging to Types (strains) A and B</a>, although scientists believe that one Type B strain, the <a href="http://doi.org/10.2807/1560-7917.ES.2022.27.39.2200753">Yamagata lineage, has disappeared</a>.</p>
<p>A variant of H1N1 Type A, different from the viruses that caused the 1918 and 2009 pandemics, is now dominant in North America where it is causing an increase in hospital admissions, <a href="https://www.canada.ca/en/public-health/services/publications/diseases-conditions/fluwatch/2023-2024/week-49-december-3-december-9-2023.html">especially among the elderly and young children</a>.</p>
<p>However, we must remain vigilant, as the strain may change within the same season. What could this mean? The target population could change, <a href="https://www.canada.ca/en/public-health/services/publications/diseases-conditions/fluwatch/2018-2019/annual-report.html">as it did in the 2018-2019 season</a>.</p>
<h2>And what about RSV?</h2>
<p>The respiratory syncytial virus (RSV) also appears to be <a href="https://www.canada.ca/en/public-health/services/surveillance/respiratory-virus-detections-canada/2023-2024/week-50-ending-december-16-2023.html">resuming its pre-pandemic transmission levels</a>.</p>
<p>RSV causes bronchiolitis and pneumonia. <a href="https://cps.ca/en/documents/position/bronchiolitis">Bronchiolitis is characterized by the obstruction of the small airways, which can progress to wheezing or respiratory distress</a>.</p>
<p>Virtually all children are infected with RSV before the age of 2, and RSV infection is one of the main causes of hospitalization in young children.</p>
<p>Before the COVID-19 pandemic, there was an average of 2,523 hospitalizations per year in Canada, <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2810133">half of them in children under six months of age and more than a quarter requiring admission to intensive care</a>.</p>
<p>But RSV also severely affects the elderly and adults who are immunocompromised or have existing chronic conditions. RSV shows high levels of severe illness, hospital admissions and in hospital deaths in adults, <a href="https://doi.org/10.1093/infdis/jiad559">figures which are comparable to those for influenza</a>.</p>
<p>Admittedly, although these three viruses are attracting attention, other less publicized respiratory viruses are also circulating, <a href="https://www.canada.ca/en/public-health/services/surveillance/respiratory-virus-detections-canada/2023-2024/week-50-ending-december-16-2023.html">demonstrating a diverse viral environment</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/568438/original/file-20240109-27-z61q6c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="woman in hospital" src="https://images.theconversation.com/files/568438/original/file-20240109-27-z61q6c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/568438/original/file-20240109-27-z61q6c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/568438/original/file-20240109-27-z61q6c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/568438/original/file-20240109-27-z61q6c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/568438/original/file-20240109-27-z61q6c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/568438/original/file-20240109-27-z61q6c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/568438/original/file-20240109-27-z61q6c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The continued presence of SARS-CoV-2 means our hospitals can’t catch their breath.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<h2>SARS-CoV-2 has turned everything upside down</h2>
<p>The presence of SARS-CoV-2 marks the principal difference from the pre-pandemic era, since it is augmenting the burden on an already weakened health-care system. The challenge is amplified by the extremely high transmission capacity of SARS-CoV-2 compared with influenza and RSV, which makes seasonal management much more complex.</p>
<p>Until the SARS-CoV-2 pandemic, the respiratory virus season had a fairly predictable beginning and end that was determined by virus surveillance over the years. Our systems were already struggling to absorb this seasonal increase in patients. But today, the picture has become even more complex with the continuing presence of SARS-CoV-2. And our hospitals, with no time to catch their breath, are struggling to keep up.</p>
<h2>Beyond infection</h2>
<p>The second major difference that should not be overlooked is SARS-CoV-2’s ability to cause widespread health problems well beyond the respiratory system. In addition, it causes long-term consequences after infection, such as post-COVID syndrome (also known as long COVID), which affects millions of people.</p>
<p>The extent of the consequences of infection and reinfection on human health remains uncertain, as does the effectiveness of vaccines in limiting these effects. The SARS-CoV-2 pandemic – with its exceptional transmission levels – has produced a large number of patients available for research. Coupled with unprecedented funding, this has made it possible to undertake research that has never been possible before on a post-viral syndrome.</p>
<p>Of course, the number of people infected with RSV or influenza globally each year does not even come close to the number infected with SARS-CoV-2, even at this stage of the pandemic. However, there is considerable evidence that, in addition to the acute symptoms and mortality associated with influenza and RSV, <a href="https://doi.org/10.1038/s41591-022-01810-6">post-viral conditions also exist</a>, as they do with SARS-CoV-2.</p>
<h2>The importance of vaccines</h2>
<p>The final distinction from the pre-pandemic period is the arrival of RSV vaccines. In Canada, the Arexvy vaccine has been approved for people over 60, and the Abrysvo vaccine was also approved for pregnant women, providing immunity to children from birth. However, these two vaccines have not yet been officially recommended. We are still waiting for a vaccine to be made available for children. The trio of vaccines against COVID-19, influenza and RSV will certainly help to reduce the severe symptoms associated with respiratory virus infections in the coming seasons.</p>
<p>However, our primary objective must be to reduce the incidence of respiratory virus infections. Despite vaccination, we can expect the mortality and morbidity associated with these infections to increase as the population ages.</p>
<p>All three viruses share a common trait — they spread through the air. Their transmission could be reduced by implementing passive strategies aimed at reducing the concentration of aerosols in indoor air.</p><img src="https://counter.theconversation.com/content/220980/count.gif" alt="La Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nathalie Grandvaux received research funding from the Canadian Institutes of Health Research (CIHR), the Natural Sciences and Engineering Research Council of Canada (NSERC), the Fonds de recherche du Québec - Santé (FRQS), the Canada Foundation for Innovation (CFI), the Fondation du centre hospitalier de l'Université de Montréal, and the Ministère de l'économie et de l'innovation du Québec.</span></em></p>The current triple epidemic of respiratory viruses is affecting all age groups, prompting comparisons with the pre-COVID-19 era.Nathalie Grandvaux, Professeure en biochimie des interactions hôte-virus, Université de MontréalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2158702023-10-27T12:18:30Z2023-10-27T12:18:30ZWhite patients are more likely than Black patients to be given opioid medication for pain in US emergency departments<figure><img src="https://images.theconversation.com/files/556165/original/file-20231026-19-8q0th6.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5499%2C3663&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Doctors have struggled to find the balance between effective pain management and the very real addiction risks that come with prescription pain medication.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/macro-of-oxycodone-opioid-tablets-with-prescription-royalty-free-image/1162845770?phrase=pain+treatment&adppopup=true">BackyardProduction/iStock via Getty Images Plus</a></span></figcaption></figure><p>White people who visit hospital emergency departments with pain are 26% more likely than Black people to be given opioid pain medications such as morphine. This was a key finding from <a href="https://doi.org/10.1007/s11606-023-08401-2">our recent study</a>, published in the Journal of General Internal Medicine. We also found that Black patients were 25% more likely than white patients to be given only non-opioid painkillers such as ibuprofen, which are typically available over the counter. </p>
<p>We examined more than 200,000 visit records of patients treated for pain, taken from a representative sample of U.S. emergency departments from 1999 to 2020. Although white patients were far more likely to be prescribed opioid medication for their pain, we found no significant differences across race in either the type or severity of patients’ pain. Furthermore, racial disparities in pain medication remained even after we adjusted for any differences in insurance status, patient age, census region or other potentially important factors.</p>
<p>Our analysis of prescribing trends spanning over two decades’ worth of records found that opioid prescribing rates rose and fell, reflecting changing attitudes in clinical practice toward the use of opioid drugs. Notably, however, there appeared to be little change over time in the prescribing disparity across race.</p>
<p><iframe id="G0M5M" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/G0M5M/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>Why it matters</h2>
<p>These findings are important because they suggest that efforts to promote equitable health care in the U.S. over the past two decades, such as <a href="https://www.hhs.gov/healthcare/about-the-aca/index.html">the Affordable Care Act</a>, or “Obamacare,” do not appear to have translated to clinical practice – at least with regards to pain management in hospital emergency departments.</p>
<p>There’s no question that as the <a href="https://www.nytimes.com/2023/02/20/nyregion/sudden-deaths-overdoses-fentanyl-nyc.html">ongoing opioid crisis</a> <a href="https://www.npr.org/2023/08/30/1196343448/fentanyl-deaths-teens-schools-overdose">continues to escalate</a>, a careful balance must be struck between the risks and benefits of prescribing opioids. But their appropriate use is an essential component of pain control in the emergency department, and they typically provide superior relief to non-opioids for short-term moderate to severe pain. </p>
<p>Undertreated pain produces unnecessary suffering and can result in a range of negative outcomes, even including a <a href="https://doi.org/10.1111/j.1526-4637.2010.00983.x">greater likelihood of developing long-term pain</a>. There are over <a href="https://doi.org/10.1007/s11606-023-08401-2">40 million pain-related emergency department visits annually</a>, so it is clear that equitable pain treatment is a fundamental component of a fair health care system. </p>
<h2>What still isn’t known</h2>
<p>We do not know why such marked racial disparities exist. Some researchers <a href="https://doi.org/10.1056%2FNEJMsa2034159">have argued</a> that prescribing fewer opioids may be beneficial for Black patients as it reduces the risk of addiction. But this argument doesn’t square with the data, which show that overdose rates have traditionally been <a href="https://doi.org/10.1111/add.15233">lower in Black populations compared with white people</a>. However, this trend has <a href="https://doi.org/10.1111/add.15233">started to change in recent years</a>. </p>
<p>In addition, some evidence suggests that clinicians <a href="https://doi.org/10.1073/pnas.1516047113">may hold unconscious biases</a>, incorrectly believing Black patients to be less sensitive to pain or that certain racial groups are <a href="https://doi.org/10.1371/journal.pmed.1001411">less willing to accept pain medication</a>. </p>
<p>While there is preliminary evidence that these factors may be important, there is not enough research that examines the degree to which they influence clinical practice. Researchers like us also know very little about whether promising remedial strategies based on these factors – such as educational training during medical school that challenges stereotypical beliefs – are effective, or indeed even implemented, in the real world. </p>
<h2>What’s next?</h2>
<p>The need for tackling racial disparities in health was brought into focus once more in February 2023, when the <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2023/02/16/fact-sheet-president-biden-signs-executive-order-to-strengthen-racial-equity-and-support-for-underserved-communities-across-the-federal-government/">Biden-Harris administration</a> signed an executive order on further advancing racial equity. Given the long history of these issues, it is clear that more research is needed to help develop better strategies for tackling health inequalities.</p>
<p>The most effective strategies for addressing racial disparities in pain treatment are likely to be those that target the underlying causes. We are currently undertaking research to try to better understand these causes, how they contribute to disparities in real-world clinical practice and whether strategies designed to address them are actually effective.</p><img src="https://counter.theconversation.com/content/215870/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Undertreated pain can result in unnecessary suffering and a greater likelihood of long-term chronic pain.Trevor Thompson, Associate Professor of Clinical Research, University of GreenwichSofia Stathi, Professor of Social Psychology, University of GreenwichLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2002292023-03-09T23:52:16Z2023-03-09T23:52:16ZSuicide attempts rose among children and adolescents during the COVID-19 pandemic, especially for girls<p>Will the kids be alright? There was hope that children and adolescents would “bounce back” as the pandemic progressed, but sadly, the data suggest otherwise. </p>
<p>Twenty-five percent of children and adolescents reported that they have <a href="https://doi.org/10.1001/jamapediatrics.2021.2482">experienced significant depression</a>. The incidence and hospitalization rates for new onset eating disorders <a href="https://doi.org/10.1001/jamanetworkopen.2021.37395">increased by 60</a> per cent during the COVID-19 pandemic.</p>
<p>Precipitants of mental illness have also increased dramatically for children and adolescents in the pandemic. Screen time <a href="https://doi.org/10.1001/jamapediatrics.2022.4116">increased by 50 per cent</a>, physical activity <a href="https://doi.org/10.1001/jamapediatrics.2022.2313">decreased by 20</a> per cent, <a href="https://doi.org/10.3390/children10020279">loneliness increased</a>, family violence <a href="https://doi.org/10.1016/j.eclinm.2022.101634">increased</a>, and parent <a href="https://doi.org/10.1016/S2215-0366(21)00074-2">depression and anxiety doubled</a>. </p>
<p>Many of the experiences and opportunities that help children and teens build identity, friendships, supports and personal growth were also <a href="https://doi.org/10.1001/jamapediatrics.2022.0791">stripped away during the pandemic</a>.</p>
<h2>Child and adolescent suicide attempts</h2>
<p>An unfortunate, but commonly used, indicator of the state of children’s and adolescents’ mental health is suicide attempts. There has been repeated discussion as to whether suicide attempts were within historic trends, or have increased during the pandemic among children and adolescents. </p>
<p>To inform this discussion, our research team conducted a systematic review, published in <a href="https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(23)00036-6/fulltext"><em>Lancet Psychiatry</em></a>, of the literature on 11.1 million children’s and adolescents’ emergency department visits in 18 countries.</p>
<figure class="align-center ">
<img alt="A teen girl with green hair talking to a school counsellor" src="https://images.theconversation.com/files/514525/original/file-20230309-729-1am03b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/514525/original/file-20230309-729-1am03b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/514525/original/file-20230309-729-1am03b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/514525/original/file-20230309-729-1am03b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/514525/original/file-20230309-729-1am03b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/514525/original/file-20230309-729-1am03b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/514525/original/file-20230309-729-1am03b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Girls may be more comfortable than boys talking with a health-care professional about their feelings.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>In our study, we compared the rate of children’s and adolescents’ emergency department visits for suicide attempts that occurred before the pandemic, to the rate that occurred during the pandemic. In doing so, we provide the most rigorous test to date of whether the number of children and adolescents presenting to the emergency department for suicide attempts has increased, decreased or stayed the same during the pandemic.</p>
<p>We found that the rate of suicide attempts for children and adolescents increased by 22 per cent during the pandemic compared to before the pandemic. Specifically, we found that on average, in any given emergency department setting, there were 102 child and adolescent visits per month for suicide attempts before the pandemic, which increased to 125 during the months of the pandemic.</p>
<p>The pandemic has been difficult for many, and the results of our study highlight just how difficult, and potentially fatal, it has been for children and adolescents.</p>
<h2>Girls attempt suicide more than boys</h2>
<p>When we looked deeper into who was more likely to show increases in suicidal behaviour, we found that the rate of emergency department visits during the pandemic increased by 39 per cent for girls, and by six per cent for boys. </p>
<p>This finding is consistent with previous data on teen suicide, which shows that while girls are more likely to attempt suicide and seek mental health care for their distress, boys are <a href="https://doi.org/10.1001/jamapsychiatry.2020.0596">more likely to die by suicide</a>.</p>
<p>There are several factors that may be contributing to these gender differences. First, girls are more likely than boys to seek <a href="https://doi.org/10.1177/070674371305800504">help when they are distressed</a>, even when that distress is severe and <a href="https://doi.org/10.1177/07067437211058602">potentially life-threatening</a>.</p>
<p>Second, girls are also more likely to have, and sought care for, underlying mental health disorders, such as depression or anxiety, which are more common <a href="https://doi.org/10.1001/jamapsychiatry.2019.3523">among adolescent girls than adolescent boys</a>.</p>
<p>Third, girls may be more comfortable talking with a health-care professional about their feelings. As a society we may also, either intentionally or unintentionally, encourage girls to think and talk about their feelings more than we do for boys. This may lead boys to think or feel that it’s not okay to admit to thoughts of hopelessness, death and suicide, or seek help <a href="https://doi.org/10.1016/j.jadohealth.2017.07.024">when they occur</a>.</p>
<h2>Prevention is key to fostering well-being</h2>
<p>Our research allows us to say more conclusively that the frequent and prolonged exposure to pandemic stressors (such as repeated school closures, social distancing, online learning), combined with limited access to protective supports (for example, extracurriculars, sports, community centres, school counsellors), have likely led to a mental health crisis, the likes of which children and teens have never experienced before. </p>
<figure class="align-center ">
<img alt="A group of boys on a soccer field, talking with their coach" src="https://images.theconversation.com/files/514527/original/file-20230309-24-yxpscj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/514527/original/file-20230309-24-yxpscj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/514527/original/file-20230309-24-yxpscj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/514527/original/file-20230309-24-yxpscj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/514527/original/file-20230309-24-yxpscj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/514527/original/file-20230309-24-yxpscj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/514527/original/file-20230309-24-yxpscj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pandemic stressors like school closures, social distancing and online learning, combined with limited access to protective supports like sports, extracurriculars, community centres and school counsellors, have likely led to a mental health crisis.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>This crisis requires immediate attention from governments and policymakers. The needs of children and adolescents must be central in health care decision making.</p>
<p>The mental health crisis can be de-escalated through the creation and implementation of prevention strategies and supports. There is very good evidence that it’s better to create <a href="https://cehd.uchicago.edu/?page_id=237">upstream solutions to prevent mental illness</a>, than costly downstream interventions to mitigate mental illness in individuals once it’s established.</p>
<p>Prevention strategies should be implemented early in development, to help children and adolescents gain greater comfort in identifying and expressing their emotions. Mental health care needs to be accessible, convenient and cost effective, spanning “<a href="http://dx.doi.org/10.1139/facets-2021-0078">promotion, prevention, early intervention and treatment</a>.”</p>
<p>Prevention strategies should be mindful of the gender differences in suicidal behaviour among girls and boys, and tailor their initiatives accordingly. Strategies for girls should focus on bolstering supports in health-care settings since girls are likely to engage in help-seeking. Strategies for boys should focus on reducing stigma related to mental distress to increase boys’ comfort in reaching out, and engaging with, adults that they trust and mental health services.</p>
<p>It is important that countries and governments prioritize the mental health of children and adolescents to help reduce the burden of mental illness and improve overall health and well-being. There is no better investment than in the lives of children and adolescents, as they are the next generation of societal contributors and citizens.</p>
<p><em>Information on suicide prevention <a href="https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/suicide">can be found here</a>. Distress lines in Canada are open 24 hours a day. Kids Help Phone: 1-800-668-6868. <a href="https://talksuicide.ca/">Talk Suicide Canada</a>: 1-833-456-4566 or text 45645. Québec residents: 1-866-277-3553. If you live outside of Canada, please look up a suicide help line in your geographical location.</em></p><img src="https://counter.theconversation.com/content/200229/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sheri Madigan receives funding from the Social Sciences and Humanities Research Council, the Canadian Institutes of Health Research, the Alberta Children's Hospital Foundation, an anonymous donor, and the Canada Research Chairs program.</span></em></p><p class="fine-print"><em><span>Daphne Korczak receives funding from Canadian Institutes of Health Research, the SickKids Research Institute, and the SickKids Foundation. Dr. Korczak is the Chair of the Mental Health Task Force of the Canadian Pediatric Society.
</span></em></p><p class="fine-print"><em><span>Jackson Hewitt receives funding from the Social Sciences and Humanities Research Council.</span></em></p><p class="fine-print"><em><span>Nicole Racine receives funding from the Social Science and Humanities Research Council, the Canadian Institues of Health Research, the CHEO foundation, and uOttawa Faculty of Social Sciences. She is affiliated with Strong Minds Strong Kids Psychology Canada. </span></em></p><p class="fine-print"><em><span>Tracy Vaillancourt receives funding from Canadian Institutes of Health Research, the Social Sciences and Humanities Research Council of Canada, and the Canada Research Chairs program. Vaillancourt is the chair of the Royal Society of Canada (RSC) COVID-19 Task-Force and was the chair of the RSC Children and Schools working group.</span></em></p>The rate of suicide attempts in children and adolescents increased by 22 per cent during the pandemic compared to before the pandemic.Sheri Madigan, Professor, Canada Research Chair in Determinants of Child Development, Owerko Centre at the Alberta Children’s Hospital Research Institute, University of CalgaryDaphne Korczak, Child and Adolescent Psychiatrist, SickKids' Chair in Child and Youth Medical Psychiatry, Associate Professor, University of TorontoJackson Hewitt, Graduate Student, Clinical Psychology, University of CalgaryNicole Racine, Assistant professor, School of Psychology, L’Université d’Ottawa/University of OttawaTracy Vaillancourt, Tier 1 Canada Research Chair in School-Based Mental Health and Violence Prevention, L’Université d’Ottawa/University of OttawaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2004202023-02-27T21:26:52Z2023-02-27T21:26:52ZEmergency department crowding has gone beyond hallways onto ambulance ramps. Now there’s nowhere left to wait.<iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/emergency-department-crowding-has-gone-beyond-hallways-onto-ambulance-ramps--now-there-s-nowhere-left-to-wait-" width="100%" height="400"></iframe>
<p>A hospital’s emergency department (ED) has long been considered the canary in the coal mine for the health-care system: when it’s congested, the whole hospital is congested. </p>
<p>Routine and prolonged ED congestion has since led to declarations that patients waiting in an ambulance outside the ED are the new <a href="https://theconversation.com/ambulance-ramping-is-a-signal-the-health-system-is-floundering-solutions-need-to-extend-beyond-eds-187270">canaries in the coal mine</a>. </p>
<p>But when ambulances waiting outside the ED become routine and prolonged, another new canary appears: patients at home waiting for an ambulance. They may represent the truest analogy for the canary in the coal mine because they are <a href="https://www.wsws.org/en/articles/2022/10/21/gebn-o21.html">literally dying</a> and are a clear indicator that the health-care system is congested at a dangerous level.</p>
<h2>Pinch points</h2>
<p>Delayed handovers of patients arriving by ambulance is a <a href="https://theconversation.com/bad-for-patients-bad-for-paramedics-ambulance-ramping-is-a-symptom-of-a-health-system-in-distress-169528">decades-old problem</a> challenging health-care systems around the world. In the United Kingdom, the National Health Service has made eliminating handover delays one of its three priorty reforms for pre-hospital urgent care in its 10-year <a href="https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf">Long Term Plan</a>. </p>
<p>In <a href="https://www.paramedicchiefs.ca/wp-content/uploads/2022/07/PCCStatementonOffloadDelaysJuly2022Final.pdf">Canada</a>, where health care is provided by provinces, <a href="https://www.mcmasterforum.org/docs/default-source/product-documents/rapid-responses/identifying-approaches-for-optimal-management-of-ambulance-to-hospital-offload-processes.pdf?sfvrsn=9d809fdb_7">British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, Québec, New Brunswick and Nova Scotia</a> have all experienced challenges handing over patients in a timely manner. </p>
<p>Australia has <a href="https://theconversation.com/bad-for-patients-bad-for-paramedics-ambulance-ramping-is-a-symptom-of-a-health-system-in-distress-169528">likewise</a> seen long lineups of ambulances queueing at hospitals, and has committed to hiring thousands of paramedics in an effort to combat <a href="https://www.ama.com.au/articles/ama-ambulance-ramping-report-card">year-on-year increases</a> in patient handover times.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/ambulance-ramping-is-a-signal-the-health-system-is-floundering-solutions-need-to-extend-beyond-eds-187270">Ambulance ramping is a signal the health system is floundering. Solutions need to extend beyond EDs</a>
</strong>
</em>
</p>
<hr>
<p>Beyond ambulance handovers, delays and congestion also occur at other areas: the ED, wards and long-term care are some of the pinch points common in health-care systems around the world. </p>
<p>As an industrial engineer researching and working in health-care patient flow, this raises the question: where’s the next pinch point? </p>
<h2>Code zero</h2>
<p>We know hospital congestion is routinely caused by <a href="https://doi.org/10.1186/s12245-020-00312-x">access block</a>, which occurs when patients are blocked from flowing through the system by a lack of downstream capacity. This is often rooted in an inability to discharge patients from the hospital, which is often due to lack of space in long-term care.</p>
<p>Naturally, this stalls the flow of patients, causing them to wait in ward beds to be discharged from the hospital, in ED hallways waiting for ward beds, in ambulances waiting for ED beds, and eventually at home waiting for an ambulance. </p>
<p>This last group represents a new pinch point. Although ambulances not meeting targeted response times is not new, it is a relatively new phenomenon that there are <em>no</em> ambulances available to respond to calls in a timely manner — a situation known as “code zero.”</p>
<p>This new pinch point however, is substantially different from the others. The patients affected have not yet been seen by health-care providers, are not within meters of health-care services, and their urgencies are not known. These patients are at home, in unknown duress, waiting. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/BDzhN14OFuA?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Acute care director of the National Health Service in the U.K. discusses ambulance delays, and a family tells how delays led to tragedy.</span></figcaption>
</figure>
<p>Patients waiting with an ambulance on the “ramp” (known as “ramping”) or in a hallway between the ED and the ward are known to be at <a href="https://www.theguardian.com/society/2023/jan/25/record-exposure-to-severe-harm-from-england-ambulance-delays">higher risk</a> for adverse outcomes. Patients with hospital stays prolonged by delay are likewise at <a href="https://www.england.nhs.uk/urgent-emergency-care/reducing-length-of-stay/">higher risk</a> for hospital-borne infections and adverse outcomes. </p>
<p>Less is known about patients waiting at home for an ambulance, but given their precarious circumstance, it is logical to assume they are also at high risk.</p>
<h2>Patients at risk</h2>
<p>Many emergency services system evaluations in <a href="https://www.ama.com.au/articles/ama-ambulance-ramping-report-card">Australia</a>, <a href="https://www.niagararegion.ca/government/departments/health/ems-response-times.aspx">Canada</a> and the <a href="https://www.health.org.uk/publications/long-reads/why-have-ambulance-waiting-times-been-getting-worse">U.K.</a> have reported waiting times longer than performance targets. But the extent to which they are waiting is new. </p>
<p>It has become all too common to read about code zero situations, in which there are no ambulances available. Again there are reports from <a href="https://www.sbs.com.au/news/article/code-red-ambulance-and-triple-zero-systems-are-in-crisis-across-australia/nxf8kw7hc">Australia</a>, the <a href="https://www.mirror.co.uk/news/uk-news/nhs-crisis-brits-who-died-28897334">U.K.</a> and <a href="https://www.saltwire.com/atlantic-canada/news/paramedic-level-zeroes-more-than-doubled-in-2022-during-a-horrendous-year-for-ambulance-delays-100824629/">Canada</a>. People are dying while waiting. </p>
<p>In Australia, ambulance ramping and call delays were recently linked to <a href="https://www.wsws.org/en/articles/2022/10/21/gebn-o21.html">33 deaths over 18 months</a>. </p>
<p>In three examples from the U.K., a woman <a href="https://www.dailymail.co.uk/health/article-11594743/National-Hell-Service-Wife-dies-16-HOUR-ambulance-wait.html">died following a 16-hour wait for an ambulance</a>, a man <a href="https://www.youtube.com/watch?v=BDzhN14OFuA">died when no ambulance was available</a> to take him to the hospital, and an 87-year-old <a href="https://www.independent.co.uk/news/health/ambulance-delays-wait-nhs-glangwili-hospital-b2260228.html">died after waiting 17 hours</a> for an ambulance and then 13 hours in the ambulance at the hospital. </p>
<p>In all three U.K. cases, long handover delays and ambulance ramping were identified as the cause of ambulance unavailability.</p>
<h2>System failures spilling over</h2>
<p>In Canada, the frequency of zero ambulances available <a href="https://www.cbc.ca/news/canada/ottawa/paramedic-level-zero-incidents-2022-availability-numbers-1.6746551">doubled in Ottawa in 2022</a>, with offload delays identified as the number one cause. Code zeros are reported to be daily occurrences, with prolonged frequencies and durations <a href="https://www.thespec.com/news/hamilton-region/2022/10/17/hamilton-paramedics-ambulance-code-zero.html">in Hamilton, Ont</a>. A woman in <a href="https://globalnews.ca/news/8980799/urgences-sante-condolences-91-year-old-dies-waiting-hours-ambulance/">Montréal</a> died after waiting seven hours for an ambulance. </p>
<p>A “canary in the coal mine” is an early indicator of potential danger or failure. The response was insufficient when the ED’s canary died, and the failure spilled over to the ambulance service. Now, with prolonged offload delays routinely causing zero ambulances to be available, the ambulance ramping canary isn’t long for this world either. </p>
<p>This time when the failure spills over, the “canary” at risk is not a metaphorical bird, but is instead a patient waiting at home for an ambulance.</p><img src="https://counter.theconversation.com/content/200420/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Vanberkel receives funding from NSERC. </span></em></p>Ambulance response times have not always met targets, but the alarming new pinch point in our health-care system is that there are no ambulances at all available to respond to calls.Peter Vanberkel, Professor, Department of Industrial Engineering, Dalhousie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1952922022-11-27T13:09:07Z2022-11-27T13:09:07ZRSV FAQ: What is RSV? Who is at risk? When should I seek emergency care for my child?<figure><img src="https://images.theconversation.com/files/497240/original/file-20221124-14-7r3k7l.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5100%2C2868&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">RSV is the leading cause for hospital stays in infants in developed countries.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><h2>What is RSV?</h2>
<p>Respiratory syncytial virus (RSV) is <a href="https://doi.org/10.1093/cid/ciaa1719">one of many viruses that causes infection of the ear, nose, throat and lungs</a>. It <a href="https://doi.org/10.7150/ijbs.64762">infects people of all ages</a> and can be found worldwide.</p>
<h2>Who is at risk of RSV?</h2>
<p>RSV is an important cause of lung infections in children under two years of age, and is the leading reason for <a href="https://doi.org/10.1155/2017/4521302">hospital stays in children under one year of age (infants) in developed countries</a>. Premature infants, adults above 65 years of age and those with chronic heart and lung conditions are at <a href="https://doi.org/10.1056/nejmoa043951">higher risk for severe disease and hospitalization</a>.</p>
<h2>Why is RSV so prevalent this season?</h2>
<p>Infections due to RSV occur throughout the year, with higher numbers of infections in the late fall to early spring in North America. The start and end of RSV season changes slightly each year, <a href="http://dx.doi.org/10.15585/mmwr.mm6702a4">and infections peak in January and February</a>. Typically, RSV infections occur in two-year cycles — <a href="https://doi.org/10.1001/jamanetworkopen.2021.24650">a year of increased numbers and higher severity of illness alternating with a milder year</a>.</p>
<p>Most children will have had one RSV infection by two years of age, and some may have had more than one infection. Unfortunately, having been infected by RSV does not provide long lasting immunity, although re-infections are usually milder. Although antibodies (proteins made by the immune system in response to infection) are made against RSV, they only last six to 12 months and <a href="https://doi.org/10.1093/infdis/jiac192">require repeated exposure to keep high antibody levels</a>. </p>
<p>This likely explains why RSV infections have an alternating severe-mild cycle: in a bad year, patients develop high levels of antibodies that help protect against infection or a bad infection in the subsequent year.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/rsv-experts-explain-why-rates-of-this-virus-are-surging-this-year-194403">RSV: experts explain why rates of this virus are surging this year</a>
</strong>
</em>
</p>
<hr>
<h2>How does RSV spread?</h2>
<p>RSV is spread through two ways:</p>
<ul>
<li><p>Contact with an object that has been sneezed on, coughed on, drooled on, touched or been in the mouth of a person who is sick with RSV. That person, who now has germs on their hands, becomes sick when he/she touches their nose or mouth.</p></li>
<li><p>Breathing in the virus when the infected person coughs or sneezes, within one metre of others, without covering their nose or mouth.</p></li>
</ul>
<h2>What are the symptoms of RSV?</h2>
<p>In general, approximately three to seven days after being infected, people will develop symptoms of a common cold including fever, runny or stuffy nose, sore throat, cough and decreased energy. Patients may complain of muscle aches and their appetite may decrease. Some may have difficulty breathing. The symptoms of infection due to RSV are identical to the symptoms of other respiratory viruses.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/KlHjKaGiWFY?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">CBC covers the surge in children needing treatment for respiratory viruses.</span></figcaption>
</figure>
<p>Some patients develop pneumonia (infection of the lungs). Infants may develop bronchiolitis — inflammation (swelling) of the very small tubes that deliver air (oxygen) to the lungs. Infants with bronchiolitis commonly have wheezing — a whistling sound when they breathe out. This whistling sound sometimes is only heard using a stethoscope, but sometimes can be heard even without one. </p>
<p>Bronchiolitis and pneumonia can lead to lower oxygen levels in the blood in some patients. It is important to remember that other respiratory viruses can also lead to pneumonia and bronchiolitis.</p>
<h2>How is RSV treated?</h2>
<p>Since RSV is a virus, use of antibiotics will not lead to shortening of the illness nor will it lead to shortening the period that sick people are infectious to others. There are no antivirals for treatment of RSV infections. Most patients can be managed at home:</p>
<ul>
<li><p>Antipyretics (medications to lower fever) if fever is present. Lowering the fever does not lead to shortening of the illness, but will also treat any muscle aches and the general feeling of being unwell.</p></li>
<li><p>Saline sprays or drops help with nasal congestion, and can be used often without the risk of overdose.</p></li>
<li><p>Commercially available nasal aspirators can be used to help infants and children breathe easier </p></li>
<li><p>Encourage fluids to reduce the risk of dehydration — offer small amounts, but offer often. Fluids for infants should be breastmilk or formula. Older children can be offered a variety of fluids including oral rehydration fluids like <a href="https://www.webmd.com/drugs/2/drug-11147/pedialyte-oral/details">Pedialyte</a>, chicken broth, popsicles, ice cream and jello. Extended periods of only water should be avoided, as should relying on soda. A few days without solid food is not harmful.</p></li>
</ul>
<h2>When should I seek emergency care for my child for RSV?</h2>
<p>Although most patients can be managed at home, there are several reasons to seek medical care. They include:</p>
<ul>
<li>Breathing too hard to sleep or feed properly even when fever is not present;</li>
<li>For infants, feeding has been significantly reduced below normal; </li>
<li>Being excessively sleepy or difficult to wake;</li>
<li>Not urinating in 12 hours.</li>
</ul>
<p>Patients with RSV infections will need to be hospitalized if they need:</p>
<ul>
<li>extra oxygen;</li>
<li>intravenous fluids if they are dehydrated.</li>
</ul>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/497244/original/file-20221124-7159-xc0qpb.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="a hospital sign directing people to EMERGENCY CHILDREN / URGENCE ENFANTS" src="https://images.theconversation.com/files/497244/original/file-20221124-7159-xc0qpb.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/497244/original/file-20221124-7159-xc0qpb.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=349&fit=crop&dpr=1 600w, https://images.theconversation.com/files/497244/original/file-20221124-7159-xc0qpb.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=349&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/497244/original/file-20221124-7159-xc0qpb.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=349&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/497244/original/file-20221124-7159-xc0qpb.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=439&fit=crop&dpr=1 754w, https://images.theconversation.com/files/497244/original/file-20221124-7159-xc0qpb.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=439&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/497244/original/file-20221124-7159-xc0qpb.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=439&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Ontario has asked thousands of family health-care workers to work evenings and weekends to help ease the burden on overwhelmed children’s hospitals.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Adrian Wyld</span></span>
</figcaption>
</figure>
<h2>How do I protect myself and my family from RSV?</h2>
<p>Although there are no vaccines against RSV, a scientifically prepared antibody, palivizumab, <a href="https://doi.org/10.14745/ccdr.v48i78a08">is recommended to reduce the risk of complications of RSV infection in premature infants and children with chronic lung or heart disease who meet certain criteria</a>. Palivizumab is given as monthly injections during RSV season.</p>
<p>The same general measures that protect against COVID-19 and other respiratory viruses lead to reduced risk of getting infected with RSV:</p>
<ul>
<li>Wash your hands well and often;</li>
<li>Stay two meters from others when in public places — patients with RSV may be infected and capable of infecting others before they have symptoms;</li>
<li>Wear a mask when in enclosed public places.</li>
</ul>
<p>Be a good neighbour and reduce the risk that others will get sick:</p>
<ul>
<li>Stay home from school or work if you are sick;</li>
<li>Cough etiquette — cough into your elbow or a tissue. This reduces the chance that viruses are on your hands, which can then be passed onto others or objects that others may handle.</li>
</ul><img src="https://counter.theconversation.com/content/195292/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Athena McConnell is affiliated with Sanofi as a member of an advisory board related to the development of nirsevimab, an alternate monoclonal antibody against RSV. </span></em></p>As visits to emergency departments surge — and in some cases overwhelm hospitals — here are answers to frequently asked questions about Respiratory syncytial virus (RSV).Athena McConnell, Associate Professor, Pediatric Infectious Diseases, University of SaskatchewanLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1887122022-09-14T19:21:29Z2022-09-14T19:21:29ZHow improving COPD treatment in primary care could reduce demand on hospitals and emergency departments<figure><img src="https://images.theconversation.com/files/484673/original/file-20220914-19-lq6phg.jpg?ixlib=rb-1.1.0&rect=0%2C22%2C4715%2C3295&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Because of the difficulty in managing their care, patients with COPD have hospitalization rates 63 per cent higher than the general population, as well as 85 per cent more emergency department visits and 48 per cent more ambulatory care visits.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>In Ontario, <a href="https://www.publichealthontario.ca/-/media/documents/c/2019/cdburden-report.pdf?sc_lang=en">nearly 900,000 people</a> live with chronic obstructive pulmonary disease (COPD). <a href="https://doi.org/10.1164/rccm.201211-2044OC">People with this condition account for 24 per cent of hospitalizations, 24 per cent of emergency department visits and 21 per cent of ambulatory care visits</a>. </p>
<p>Because of difficulty in managing care, patients with COPD have hospitalization rates that are <a href="https://doi.org/10.1164/rccm.201211-2044OC">63 per cent higher than the general population, as well as rates of emergency department and ambulatory care visits that are, respectively, 85 per cent and 48 per cent higher than the general population</a>, all of which contribute <a href="https://doi.org/10.1016/j.rmed.2007.10.010">significant financial costs</a> to Ontario’s health-care system. </p>
<p>Health-care sustainability has made headlines as emergency rooms around Ontario have closed due to <a href="https://www.cbc.ca/news/canada/toronto/ont-er-closures-1.6545119">staffing shortages, COVID-19 infections and burnout of frontline workers</a>. Ontario’s Health Minister Sylvia Jones has said that the province should <a href="https://toronto.citynews.ca/2022/08/11/ontario-health-minister-pushes-back-against-privatization/">embrace innovation</a> to help solve challenges within the health-care system. </p>
<p>Arguably, one of the most effective solutions would be to divert patients away from the emergency room and hospital in favour of more cost-effective primary care. Innovations in treatment of patients with COPD in primary care has the potential to alleviate a significant strain on the health system by reducing emergency department visits and hospitalizations.</p>
<p>Fortunately, there is an existing program in primary care, called Best Care, that has been demonstrated to be <a href="https://doi.org/10.1186/s12962-022-00377-w">cost-effective</a>, <a href="https://doi.org/10.1186/s12913-022-07785-x">improve patient and provider experience</a> and <a href="https://doi.org/10.2147/COPD.S338851">reduce emergency department visits and hospitalizations</a>.</p>
<h2>The opportunity for Best Care</h2>
<p>Best Care is an innovative integrated disease management program (IDM) for managing high-risk, exacerbation-prone patients with COPD in a primary care setting. It was designed by a collaborative team of frontline health-care providers and administrators, supported by Ontario Health.</p>
<figure class="align-center ">
<img alt="A young woman behind a desk in a white coat with stethoscope watching an older woman use an inhaler" src="https://images.theconversation.com/files/484703/original/file-20220914-9486-zb8574.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/484703/original/file-20220914-9486-zb8574.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/484703/original/file-20220914-9486-zb8574.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/484703/original/file-20220914-9486-zb8574.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/484703/original/file-20220914-9486-zb8574.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/484703/original/file-20220914-9486-zb8574.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/484703/original/file-20220914-9486-zb8574.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">People in the Best Care program become active partners in their care, taking back control over their lives.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>The <a href="https://doi.org/10.1038/s41533-019-0119-9">Best Care IDM program</a> involves <a href="https://www.argi.on.ca/copd-patient">embedding a certified respiratory educator</a>, who is also a case manager, within the primary care practice where the patient normally receives care. In collaboration with the patient’s primary care provider, the certified respiratory educator delivers or supports access to all 14 of <a href="https://www.hqontario.ca/Portals/0/documents/evidence/quality-standards/qs-chronic-obstructive-pulmonary-disease-quality-standard-en.pdf">Ontario Health’s COPD quality standards</a>, including diagnosis, assessment, care planning, patient education, medication management and specialized respiratory care.</p>
<p>People in the Best Care program become active partners in their care, taking back control over their lives. The efficacy of Best Care has been empirically <a href="https://doi.org/10.1038/s41533-019-0119-9">demonstrated to improve patients’ quality of life and to help avoid emergency department visits</a> and <a href="https://doi.org/10.2147/COPD.S338851">reduce hospitalizations</a>. </p>
<p>Over the past three years, 7,000 Ontarians affected by severe COPD have benefited from the program. Three Ontario health regions implementing Best Care have shown dramatic reductions in COPD-related emergency department visits and hospitalizations.</p>
<h2>Evaluating cost-effectiveness</h2>
<p>Recently, with a team of health economists from the University of Ottawa, we <a href="https://doi.org/10.1186/s12962-022-00377-w">evaluated the cost-effectiveness</a> of the Best Care integrated disease management program for high-risk, exacerbation-prone patients in a primary care setting. In this research we used data from our earlier clinical study and the best available evidence to evaluate if investment in the Best Care program was cost-effective from the perspective of the Ontario health system. </p>
<p>Our results show that Best Care is not just cost-effective, but is dominant in comparison to standard care in Ontario. Best Care integrated disease management program was cost-effective in 85.3 per cent of our simulations.</p>
<p>When evaluating programs in terms of health economics, a program is <a href="https://doi.org/10.1016%2Fj.jacc.2008.09.018">dominant</a> when it improves patient outcomes and costs less than the alternative standard of care: in other words, better care at a lower cost. </p>
<figure class="align-center ">
<img alt="A man breathing into a white tube through his mouth, with a blue nose clip on his nose." src="https://images.theconversation.com/files/484714/original/file-20220914-8999-jfq04p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/484714/original/file-20220914-8999-jfq04p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/484714/original/file-20220914-8999-jfq04p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/484714/original/file-20220914-8999-jfq04p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/484714/original/file-20220914-8999-jfq04p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/484714/original/file-20220914-8999-jfq04p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/484714/original/file-20220914-8999-jfq04p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">One of the ways COPD patients are assessed is spirometry, a test of lung function.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>With a modest up-front investment in primary care, the Best Care program is expected to dramatically reduce demand for acute health services. In fact, our modelling anticipates a 1.5-fold return on investment in the first year of implementation. Continued health system savings are expected for at least 10 years by reducing the number of urgent care and emergency room visits and the frequency of hospitalization.</p>
<p>We also ran several different scenarios to test the assumptions we made within our economic analysis. The results consistently demonstrated that Best Care integrated disease management program was cost-effective and dominant in comparison to the usual standard of care. When we assume that a patient’s quality of life should only improve with access to a certified respiratory educator/ case-manager (i.e., the patient’s quality of life should remain the same or increase, but not decrease), the probability that Best Care IDM is cost-effective increases to over 96 per cent. </p>
<h2>Sustainable health-care investment</h2>
<p>The <a href="https://www.ontario.ca/document/healthy-ontario-building-sustainable-health-care-system/chapter-2-vision-health-care-ontario">Ontario health system</a> seeks to invest in sustainable, innovative solutions that will maximize health-care capacity. This includes reducing avoidable hospitalizations and emergency department visits; improving patient, caregiver and provider experience; and enhancing patient outcomes while containing costs. </p>
<p><a href="https://doi.org/10.1038/s41533-019-0119-9">Prior peer-reviewed publications</a> and health system data have confirmed that the Best Care integrated disease management program improves patient outcomes as well as patient, caregiver and provider experience. Our robust health economic analysis confirms that Best Care is economically attractive compared to the current provincial care standard. </p>
<p>Best Care in COPD is a <a href="https://www.hqontario.ca/Portals/0/documents/health-quality/quality-matters-print-en.pdf">sustainable health-care investment</a> and delivers on all of the goals of the <a href="https://doi.org/10.1370%2Fafm.1713">quadruple aim approach to health care</a>: optimizing patient experience, improving health at the population level, reducing costs and supporting the well-being of health-care providers.</p>
<p><em>Madonna Ferrone, Director of Operations, Asthma Research Group Windsor-Essex County Inc., co-authored this article.</em></p><img src="https://counter.theconversation.com/content/188712/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew D. Scarffe (he/him) received funding from the Asthma Research Group Windsor-Essex County Inc. in the form of a doctoral student stipend. He also receives funding from Mitacs Inc. through the Mitacs e-Accelerate scholarship. Andrew is a two time recipient of the Queen Elizabeth II Graduate Scholarship for Science and Technology and is a one time recipient of the Ontario Graduate Scholarship. He also receives funding from the Telfer School of Management and the University of Ottawa in the form of a graduate student scholarship and excellence (admission) scholarship. Publication of this article was not contingent on approval and/or censorship from any of the funding sources listed above.</span></em></p><p class="fine-print"><em><span>Dr. Licskai has received salary support from Western University as Professor of Health System Innovation and is the Medical Director of the Best Care in Primary Care program related to this work. Outside of the submitted work Dr. Licskai reports personal fees and / or research grants from AstraZeneca, GlaxoSmithKline, Novartis, Teva, and Sanofi Genzyme.</span></em></p><p class="fine-print"><em><span>Doug Coyle, Kednapa Thavorn, and Kevin Peter Brand do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Innovation in primary care for COPD patients has the potential to alleviate a significant strain on the health system by reducing emergency department visits and hospitalizations.Andrew Scarffe, PhD Candidate in Management (concentration in Health Systems), L’Université d’Ottawa/University of OttawaChristopher Licskai, Associate Professor of Medicine, Professor of Health System Innovation, Division of Respiratory Medicine, Western UniversityDoug Coyle, Professor, School of Epidemiology and Public Health, L’Université d’Ottawa/University of OttawaKednapa Thavorn, Senior scientist, L’Université d’Ottawa/University of OttawaKevin Peter Brand, Associate professor, Health Systems, L’Université d’Ottawa/University of OttawaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1891992022-09-08T20:14:32Z2022-09-08T20:14:32ZWith family doctors heading for the exits, addressing the crisis in primary care is key to easing pressure on emergency rooms<figure><img src="https://images.theconversation.com/files/482397/original/file-20220901-14792-k5pnkl.JPG?ixlib=rb-1.1.0&rect=410%2C506%2C5418%2C3382&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Until the government acknowledges the critical role family physicians have in population health and on easing the burden on acute hospital care, pressures will only be relieved temporarily.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Justin Tang</span></span></figcaption></figure><p>The Ford government’s recently released plan to ease pressure on Ontario emergency rooms makes no mention of the <a href="https://ottawacitizen.com/opinion/abdulla-you-want-a-family-doctor-in-ontario-sorry-its-not-going-to-be-easy">mass exodus of physicians from family practice</a>. With that omission, the province’s <a href="https://files.ontario.ca/moh-plan-to-stay-open-en-2022-08-18.pdf">Plan to Stay Open</a> ignores the central role of family doctors in the health-care system, and sets itself up for failure.</p>
<p>A strong primary care system, identified as <a href="http://doi.org/10.1001/jama.1993.03500190088041">the cornerstone of health care</a>, keeps patients <a href="https://doi.org/10.1186/s12913-015-0705-7">away from emergency rooms</a> and plays a huge role in encouraging <a href="https://doi.org/10.9778/cmajo.20170007">self-management of illness and prevention of disease</a>.</p>
<h2>Critical role of primary care</h2>
<p>Focusing mainly on hospitals to fix the problem is akin to closing the barn door after the horses have fled. We must look upstream to primary care where about <a href="https://www150.statcan.gc.ca/n1/pub/82-625-x/2020001/article/00004-eng.htm">86 per cent of Canadians trust family doctors</a> to assist them in staying healthy. </p>
<p>In my ongoing research on integrated health-care systems — including <a href="https://health.gov.on.ca/en/pro/programs/connectedcare/oht/">Ontario Health Teams</a> and the capacity for family physicians to inform system change — I see a high degree of skepticism among family physicians about influencing system reform, since many have previously seen their input not heeded or not even sought. Time also limits their participation in health system research.</p>
<figure class="align-center ">
<img alt="A woman in a white coat is examining a little girl using a stethoscope, while another woman stands behind the girl." src="https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/483575/original/file-20220908-9311-ypbwpr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Ontario’s plan ignores the central role of family doctors in the health-care system, and sets itself up for failure.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Until the government acknowledges the critical role family physicians have in population health and on easing the burden on acute hospital care, pressures will only be relieved temporarily. At the same time, family physicians are fed up. No wonder that some are <a href="https://ottawacitizen.com/news/local-news/burned-out-closing-practices-family-doctors-warn-health-care-situation-will-likely-get-worse">walking away because they “can’t take it anymore</a>.” </p>
<h2>Increasing challenges in family medicine</h2>
<p>Family physicians are dealing with significant burnout, ever-increasing workloads, unrealistic patient demands and <a href="https://www.cfp.ca/content/57/9/983.long">lack of respect from other specialties</a>. In addition to having a passion for providing continuous, comprehensive care, family physicians also need to acquire business acumen to manage overhead costs, performance management skills to hire, fire and coach office staff, and administrative prowess to deal with the mounds of paperwork that is done after the patient leaves (and is mostly non-billable). </p>
<p>Despite the value that most of us place on having a family doctor that we trust with our cradle-to-grave health issues, they are among the <a href="https://nationalpost.com/opinion/why-five-million-canadians-have-no-hope-of-getting-a-family-doctor">lowest paid and the least respected physicians, yet they have the most knowledge about the inefficiencies</a> in a health-care system that is coming apart more each day. </p>
<p>To make matters worse, supply is decreasing. This year’s residency applications through the <a href="https://www.carms.ca/the-match/">Canadian Resident Matching Service</a> (CaRMS) indicates that <a href="https://www.cbc.ca/news/canada/ottawa/fewer-medical-students-are-pursuing-family-practices-and-these-doctors-are-worried-1.6516261">the number of medical school graduates choosing family medicine as their top choice for training spots is declining steadily</a>. </p>
<p>This should be worrying for all of us as patients. More exploration into why family medicine is no longer seen as a worthy profession is sorely needed as more and more patients will be unable to access the continuous, comprehensive care they require. </p>
<h2>More Canadians without a family doctor</h2>
<p>News headlines continue to highlight that <a href="https://www.thestar.com/opinion/editorials/2022/07/30/an-unhealthy-shortage-of-family-doctor.html">more patients across the country are without a family doctor</a> and fewer doctors want to enter, or stay, in family practice. </p>
<p>In addition to diminished supply of new family doctors, many are heading for the exits earlier than anticipated. Family physicians are choosing to retire early, and in some cases <a href="https://ottawacitizen.com/news/local-news/burned-out-closing-practices-family-doctors-warn-health-care-situation-will-likely-get-worse">walking away from large and long-standing practices</a> leaving more and more patients without a family physician and having no other option but to visit the emergency department for their health concerns. </p>
<figure class="align-center ">
<img alt="A stethoscope on a desk in the foreground, with a doctor out of focus sitting at the desk with his hands to his face" src="https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/483576/original/file-20220908-9292-p13ez5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Family physicians are dealing with significant burnout and ever-increasing workloads.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Increasing the number of family physicians is important but retaining those that we already have should be viewed as absolutely critical. With the <a href="https://www.cma.ca/news-releases-and-statements/critical-family-physician-shortage-must-be-addressed-cma">average age of a family doctor in Canada at 49</a>, it’s not hard to predict that more retirements (planned or otherwise) will have a detrimental impact on the health of Canadians. </p>
<h2>Primary care challenges</h2>
<p>Primary care is not without its own challenges. For those that are lucky enough to have a family doctor, the time to see them varies, and <a href="https://healthydebate.ca/2015/11/topic/what-does-access-to-primary-care-really-mean/">access issues</a> are a common theme in patient complaints. Different physician offices use different appointment booking practices and scheduling rules, which can impact patient access ratings. </p>
<p>There are inequities between family physicians with solo practices in comparison to those who are attached to a family health team — health-care organizations that provide primary health care to communities and include various health professionals such as nurses, dietitians, social workers and others who share aspects of patient care with doctors. </p>
<p>Ontario has done better than most areas of Canada with the <a href="https://www.health.gov.on.ca/en/pro/programs/fht/">introduction of family health teams in 2005</a>, with team-based primary care reporting <a href="https://doi.org/10.1016/j.mayocp.2019.01.038">better outcomes for both patients and providers</a>. </p>
<p>But no new family health teams have been funded since 2012, which is a problem. Ontario Health Teams were introduced in 2019, and offer potential to influence what is currently a cadre of services (including primary care, hospitals, long-term care, home care, health support services) to function better as an integrated health system covering a geographic region. </p>
<p>Ontario Health Teams do not provide direct care, but are tasked with building a better system of care, working to break down silos between health-care providers and organizations to function better for patients. Primary care must be a major player in these. </p>
<p>Political will is required to invest in the entire health-care system and not ignore the fact that primary care represents a very large part of this system. We have a capacity crisis for certain — but cannot fix only one flat tire when all the tires are flat!</p><img src="https://counter.theconversation.com/content/189199/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Colleen Grady does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A strong primary care system keeps patients away from emergency departments and helps patients self-manage illnesses. But Ontario’s plan to ease pressure on emergency rooms ignores family medicine.Colleen Grady, Associate Professor, Family Medicine, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1892202022-08-24T16:19:30Z2022-08-24T16:19:30ZPreventing delirium protects seniors in hospital, but could also ease overcrowding and emergency room backlogs<figure><img src="https://images.theconversation.com/files/480629/original/file-20220823-26-mhqlqw.jpg?ixlib=rb-1.1.0&rect=0%2C137%2C4345%2C3265&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Delirium is a preventable condition often caused by hospital practices.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/preventing-delirium-protects-seniors-in-hospital--but-could-also-ease-overcrowding-and-emergency-room-backlogs" width="100%" height="400"></iframe>
<p>Imagine a health condition that <a href="https://doi.org/10.1056/nejmp1910499">leads to the death of up to one-quarter of those hospitalized with it</a>. </p>
<p>It’s a condition that can convert a independent older person into one stuck in hospital awaiting a bed in a long-term care home. A condition that affects up to 25 per cent of older persons presenting to hospital, and is acquired by a further 25 per cent while in hospital. A condition that prolongs hospital stays, ties up beds and backs up emergency rooms. </p>
<p>The costs of this condition <a href="https://doi.org/10.1056/nejmp1910499">exceeded $160 billion in the United States alone</a> in 2011. Finally, consider how this condition occurs in almost every hospital around the world, essentially making it a pandemic.</p>
<p>No, this is not COVID-19, monkeypox or influenza.</p>
<p>This is delirium. A condition we’ve known about for decades. A condition that often goes unrecognized. A condition often caused by hospital practices. A condition that we can prevent, but usually don’t. </p>
<h2>Delirium in hospitals</h2>
<p>Delirium usually occurs <a href="https://doi.org/10.1016/j.cger.2019.11.001">during an acute illness and causes a rapid decline in cognition</a>. Older persons, particularly those with pre-existing changes in cognition, are at risk. </p>
<p>Delirium is often triggered in hospital by enforced bed rest, misplaced or lost hearing and visual aids, sleep disruption from noisy and brightly lit wards at night, over-prescription of unnecessary and often sedating medications or overuse of “tethers” like bladder tubes or intravenous lines. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/480537/original/file-20220823-27-o24mux.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A health-care worker in PPE pushing a patient on a gurney, seen through a window" src="https://images.theconversation.com/files/480537/original/file-20220823-27-o24mux.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/480537/original/file-20220823-27-o24mux.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/480537/original/file-20220823-27-o24mux.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/480537/original/file-20220823-27-o24mux.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/480537/original/file-20220823-27-o24mux.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/480537/original/file-20220823-27-o24mux.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/480537/original/file-20220823-27-o24mux.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The downstream effects of delirium on the health-care system include high ‘alternate level of care’ rates, hospital overcrowding and emergency room backlogs.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Graham Hughes</span></span>
</figcaption>
</figure>
<p>People with delirium can experience disorientation, agitation or paranoia, and may become a risk to themselves or to others. As a result, many are restrained physically or chemically with drugs such as <a href="https://doi.org/10.1002/14651858.CD005594.pub3">antipsychotics</a>, which can cause injury, reduced mobility or death. </p>
<p>Delirium often leaves patients too disabled or confused to return home. Some eventually do so after a period of rehabilitation, but many others never fully regain their independence and are placed on wait lists for long-term care homes. Adding insult to injury, because these patients are stable enough to not require acute hospital care, they are designated “<a href="https://www.cihi.ca/en/guidelines-to-support-alc-designation">alternate level of care (ALC)</a>” and are <a href="https://www.health.gov.on.ca/en/public/publications/chronic/chronic.aspx">charged a daily co-payment</a>. </p>
<h2>Downstream complications</h2>
<p>An emerging and dangerous infectious disease, a drug with unacceptable side-effects or a faulty medical device would trigger a major public outcry and prompt regulatory action. Yet, something as widespread and harmful as delirium — <a href="https://doi.org/10.1503%2Fcmaj.109-4069">an injury clearly linked to hospital practices</a> — rarely comes to attention. </p>
<p>Instead, we focus on its downstream complications: high ALC rates, hospital overcrowding and emergency room backlogs. In what amounts to systemic gas-lighting, <a href="https://www.thestar.com/politics/provincial/2022/08/17/sylvia-jones-warns-status-quo-in-ontario-health-care-is-not-sustainable.html">blame is directed at those elderly “bed-blockers</a>” and pressure builds on governments to act. Pundits and <a href="https://www.cbc.ca/news/politics/moncton-health-care-summit-1.6558745">politicians debate the merits of private health care</a> but ultimately, the same solution — one that does nothing to make hospitals safer for older persons — is reapplied: more long-term care. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/enabling-better-aging-the-4-things-seniors-need-and-the-4-things-that-need-to-change-151191">Enabling better aging: The 4 things seniors need, and the 4 things that need to change</a>
</strong>
</em>
</p>
<hr>
<p>More long-term care homes are then built, into which ALC patients are “decanted” (a system planning term). ALC rates come down, challenges with “access and flow” (another system planning term) are reduced and hospital pressures eased. The issue goes away — at least, until the long-term care homes become full again and the entire cycle is repeated, like a bad sequel to the movie <em>Groundhog Day</em>.</p>
<h2>Preventing delirium and its downstream effects</h2>
<p>Delirium can be prevented. The <a href="https://doi.org/10.1016%2Fj.jagp.2018.06.007">Hospital Elder Life Program</a> (HELP) was developed in the 1990s and has been shown to <a href="https://doi.org/10.1016/j.psc.2017.10.001">substantially reduce the odds of hospital-acquired delirium by over 50 per cent</a>, reduce in-hospital falls by 42 per cent, prevent hospital-acquired disability, and reduce costs, both in-hospital and by avoiding long-term care. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/480930/original/file-20220824-12096-zngofk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An older man lies in a hospital bed with an older woman standing by his side, and two health-care workers" src="https://images.theconversation.com/files/480930/original/file-20220824-12096-zngofk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/480930/original/file-20220824-12096-zngofk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/480930/original/file-20220824-12096-zngofk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/480930/original/file-20220824-12096-zngofk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/480930/original/file-20220824-12096-zngofk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/480930/original/file-20220824-12096-zngofk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/480930/original/file-20220824-12096-zngofk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Hospital Elder Life Program is characterized as a</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Characterized as a “low-tech and high-touch” intervention and supported by specialized staff and volunteers, HELP identifies older adults at risk of delirium upon hospital admission and immediately implements an array of senior-friendly measures. </p>
<p>These measures include regular exercise; elimination of unnecessary tethers; cognitive stimulation; attention to vision, hearing and hydration needs; and sleep protocols such as noise reduction (no more jarring “CODE BLUE!” blasting over the intercom at 3 a.m.), back rubs, relaxation tapes and music, and herbal tea or warm milk. It’s low-tech. And it works.</p>
<p>Yet, over two decades after the publication of a <a href="https://doi.org/10.1056/NEJM199903043400901">landmark clinical trial</a>, and despite ample supporting evidence, the implementation of HELP remains the exception, rather than the rule. Hospitals in Canada are simply not mandated to provide senior-friendly care. It is time they were. </p>
<p>Hospitals must also be required to measure and publicly report on rates of hospital-acquired delirium and functional decline. This type of mandatory, standardized and publicly available information collection is how long-term care homes in Canada were able to compare their performance, learn from one another and <a href="https://doi.org/10.1016/j.jamda.2020.04.004">reduce unnecessary antipsychotic use</a>.</p>
<p>Rather than remaining stuck in this <em>Groundhog Day</em> scenario, it is only through structured and mandatory senior-friendly quality improvement that our health-care system will eventually escape an ALC loop that ultimately affects us all.</p><img src="https://counter.theconversation.com/content/189220/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>George A Heckman is affiliated with interRAI, a not-for-profit scientific organization that develops assessment systems for vulnerable populations in various health care sectors. He would like to acknowledge Dr. Amy Miles and Ms. Michelle Klosch who provided feedback on earlier drafts of this article.</span></em></p>Delirium doesn’t just harm vulnerable seniors. It prolongs hospital stays, ties up beds and clogs emergency rooms. Mandating senior-friendly hospital care protects patients and the health-care system.George A Heckman, Schlegel Research Chair in Geriatric Medicine, Associate Professor, University of WaterlooLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1842422022-06-03T03:33:17Z2022-06-03T03:33:17ZEmergency departments are clogged and patients are waiting for hours or giving up. What’s going on?<figure><img src="https://images.theconversation.com/files/466875/original/file-20220603-18-8dxkiz.jpg?ixlib=rb-1.1.0&rect=56%2C69%2C3948%2C2420&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/sydney-nsw-australia-january-26-600w-1916848787.jpg">Shutterstock</a></span></figcaption></figure><p>Around <a href="https://www.aihw.gov.au/reports-data/myhospitals/intersection/activity/ed">25,000 people</a> visit hospital emergency departments across Australia every day. Many of them are reporting waiting for hours to be seen. Some <a href="https://www.abc.net.au/news/2022-06-01/victorian-hospitals-emergency-department-crisis/101111452">give up</a> and leave, only to have their condition deteriorate. </p>
<p>“Ambulance ramping” – where ambulances queue outside hospitals to hand over patients – has become more common and means some people wait long periods before they even arrive at emergency. </p>
<p>Of the <a href="https://www.aihw.gov.au/reports-data/myhospitals/sectors/emergency-department-care">8.8 million</a> presentations at emergency departments each year, one in three people wait more than four hours to be treated and admitted to a ward for further care, or to be discharged.</p>
<p>Our fragile public health system and its staff need urgent attention before emergency departments can recover.</p>
<h2>Not a new problem</h2>
<p>Demand for urgent hospital care is increasing Australia-wide, placing prolonged strain on the acute care services provided by emergency departments. But demand has been building over decades, not months.</p>
<p>According to the <a href="https://www.aihw.gov.au/reports-data/myhospitals/intersection/activity/ed">Australian Institute of Health and Welfare</a>, the number of people presenting at public emergency departments increased by 3.2% on average each year from 2014–2019, mostly due to an ageing population that is experiencing more complex health issues. </p>
<p>Perhaps surprisingly – and despite ups and downs in some cities over shorter periods – overall demand on emergency departments <a href="https://www.aihw.gov.au/reports-data/myhospitals/intersection/activity/ed">decreased</a> during the peak COVID period as people chose to stay home or were in lockdown. Volumes have only recently recovered to normal levels. </p>
<p>Two key issues stand in the way of people getting emergency care. </p>
<p>First, the public health system is already at capacity, so even small increases in demand send it into gridlock. </p>
<p>Second, with more and more staff unable to work due to illness, including COVID infection, burnout and now influenza, there are not enough staff to look after patients. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1525278391796396032"}"></div></p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/hospital-emergency-departments-are-under-intense-pressure-what-to-know-before-you-go-169098">Hospital emergency departments are under intense pressure. What to know before you go</a>
</strong>
</em>
</p>
<hr>
<h2>No slack in the system</h2>
<p>Emergency departments are in the business of preparing for the unexpected, whether it’s a surge in COVID infections or mass injuries from natural disasters, large-scale accidents or a terrorist attack.</p>
<p>The surge becomes magnified when the event also affects health-care staff or facilities, taking away care capacity as demand increases. We are currently facing an early influenza surge, with rates around what’s typically seen in late <a href="https://www1.health.gov.au/internet/main/publishing.nsf/Content/cda-surveil-ozflu-flucurr.htm/$File/flu-04-2022.pdf">June</a>. </p>
<p>Systems can cope with unexpected events by allowing “slack” or holding excess capacity in normal times. Unfortunately, our health-care systems have been stripped of excess capacity. <a href="https://theconversation.com/remind-me-how-are-hospitals-funded-in-australia-177915">Cuts</a> in the name of efficiency have been implemented by successive governments, without fully appreciating the implications on health-care supply in times of need. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1529809106533588992"}"></div></p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-private-health-insurance-rebate-has-cost-taxpayers-100-billion-and-only-benefits-some-should-we-scrap-it-181264">The private health insurance rebate has cost taxpayers $100 billion and only benefits some. Should we scrap it?</a>
</strong>
</em>
</p>
<hr>
<h2>Working harder comes at a cost</h2>
<p>During COVID, extra capacity was created by ambulance and hospital staff working faster and longer. Longer term, this results in burnout. </p>
<p>Because burnout is harder to see than ramped ambulances, it’s less likely to make the evening news – but it’s a more critical and complex problem.</p>
<p>Around <a href="https://9now.nine.com.au/today/more-than-twenty-thousand-critical-care-nurses-quit-amid-pandemic-stress/87af0657-b43b-4be7-975b-8ff418234397">20,000 Australian nurses</a> left the profession in 2021, many citing <a href="https://www.acn.edu.au/post/we-need-to-urgently-address-the-nursing-crisis-in-australia">stress and abuse</a> suffered on the job. </p>
<p>Around 8% of <a href="https://theconversation.com/paramedics-have-one-of-australias-most-dangerous-jobs-and-not-just-because-of-the-trauma-they-witness-149540#:%7E:text=A%20national%20Australian%20study%20of,have%20anxiety%20and%2027%25%20depression">paramedics</a> suffer post-traumatic stress disorder, twice the average for Australian workers. Almost one third are diagnosed with depression. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/bad-for-patients-bad-for-paramedics-ambulance-ramping-is-a-symptom-of-a-health-system-in-distress-169528">Bad for patients, bad for paramedics: ambulance ramping is a symptom of a health system in distress</a>
</strong>
</em>
</p>
<hr>
<h2>Just add beds?</h2>
<p>The addition of “more beds” sounds like a practical solution – but hospital beds rely on staff (particularly nurses) to take care of the patients in them.</p>
<p>Addressing hospital staff shortages is less straightforward. There is a long lead time to train additional nurses and we can’t rely solely on importing them from overseas. New Zealand is already concerned we’re going to take many of its nurses to help our <a href="https://www.abc.net.au/news/2022-04-12/new-zealand-aged-care-labor-election-opposition-nurses/100983882">aged care sector</a> and other countries are competing for skilled hospital staff.</p>
<p>In an attempt to relieve pressure, governments want to divert those with less severe illnesses or injury away from emergency departments to urgent care centres or 24-hour GPs. This may improve access to care for some patients, but it may not substantially reduce emergency demand. <a href="https://www.bhi.nsw.gov.au/data-portal">New South Wales data</a> shows surprisingly few people went to emergency when they could have gone to a GP. </p>
<h2>Improving flow</h2>
<p>The long-term solution to emergency department blockages is to increase throughput. </p>
<p>Imagine the hospital as a bathtub, and the patients as the water streaming into the bath. Increasing the bath size is a temporary fix. If you can’t turn off the tap, it will quickly fill. We need to work on the drainage system – increasing the size of the drain and unblocking any pipes that are clogged. </p>
<p>Hospitals have a duty of care to discharge patients to a safe environment. To quicken hospital discharges, we need more community capacity to house people with disability, people with mental health conditions who need supported care, older people who can no longer live alone without assistance, and homeless people. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/466876/original/file-20220603-12-aoc3q5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="hospital staff at busy work station" src="https://images.theconversation.com/files/466876/original/file-20220603-12-aoc3q5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/466876/original/file-20220603-12-aoc3q5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/466876/original/file-20220603-12-aoc3q5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/466876/original/file-20220603-12-aoc3q5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/466876/original/file-20220603-12-aoc3q5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/466876/original/file-20220603-12-aoc3q5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/466876/original/file-20220603-12-aoc3q5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Addressing the shortage of health-care workers is a complex process.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com.au/detail/news-photo/india-wells-rn-and-ed-opnum-and-ed-mcgregor-ed-registrar-news-photo/1359053648?adppopup=true">Getty/Lisa Maree Williams</a></span>
</figcaption>
</figure>
<h2>Working with patients</h2>
<p>Processes often follow a “one size fits all” model, yet patients are diverse in their preferences and needs. Some groups have more complex needs, which mean they may spend longer in the emergency department. </p>
<p>We know, for example, emergency departments perform worse for older adults with multiple health conditions, people who have a disability or mental health condition, people who are Aboriginal and/or Torres Strait Islander, or who come from a culturally and linguistically diverse background.</p>
<p>We are about to embark on a <a href="https://thepulse.org.au/2022/05/04/2-8-million-to-reduce-emergency-wait-times-in-western-sydney-hospitals/">project</a> with three large Sydney hospitals. We will work with patients, clinicians and community groups to co-design emergency care improvements and reduce wait times. Examples might include strengthening connections between GPs and the emergency department, and greater use of technology to streamline care pathways and help patients navigate the journey. </p>
<p>For now, everyone can help alleviate stress on emergency departments by taking better care of their health, addressing problems early with their GP, and taking advantage of immunisation programs such as for COVID and influenza.</p><img src="https://counter.theconversation.com/content/184242/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robyn Clay-Williams receives funding from the Medical Research Future Fund and the Australian Research Council.</span></em></p><p class="fine-print"><em><span>Henry Cutler receives funding from the Medical Research Future Fund, National Health and Medical Research Council and the Australian Healthcare and Hospitals Association</span></em></p>Adding more beds won’t fix emergency department pressures. Neither will one-size-fits-all processes. But improving patient flow and addressing staff shortages might.Robyn Clay-Williams, Associate Professor, Macquarie UniversityHenry Cutler, Professor and Director, Macquarie University Centre for the Health Economy, Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1762422022-02-23T21:19:51Z2022-02-23T21:19:51ZTips for navigating an emergency department visit: Who you’ll see, what to ask and why it matters<figure><img src="https://images.theconversation.com/files/445346/original/file-20220209-15-iayomf.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C3967%2C2967&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Paramedics and ambulances spill out of the Emergency ramp at Michael Garron Hospital in Toronto.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Frank Gunn</span></span></figcaption></figure><p>The emergency department (ED) can be a stressful and confusing place for individuals who are sick or injured. During the pandemic, with many hospitals not permitting friends or family to accompany ED patients, being alone may exacerbate the uncertainty, fear and anxiety patients may experience about things like waiting times, undergoing tests or medical prognoses.</p>
<p>Research shows that <a href="http://doi.org/10.1136/emermed-2011-200451">almost half of all patients leave the hospital with a poor understanding of their ED visit</a>. As doctors who see the consequences of poor communication, let us break down what is going on in the ED and give you the knowledge and tools to empower you to have a smoother experience. </p>
<h2>The emergency department explained</h2>
<p>In the ED, some patients arrive by themselves (or get dropped off by family), some disembark from an ambulance and some are transferred from other hospitals. To decide the order of patient care, clinicians use a decision-making tool called the <a href="https://ctas-phctas.ca/">Canadian Emergency Department Triage and Acuity Scale</a> (CTAS). The CTAS is used instead of a first-come, first-served system. </p>
<p>The CTAS sorts patients based on severity of the illness or injury. A score of 1 suggests an imminent risk of dying or severe disability within minutes without treatment (for example, serious car accident or stroke). A score of 5 suggests that the outcome of the medical issue will not change whether treatment is delivered now or in a few hours. </p>
<p>A patient’s movement around the ED, from waiting location to treatment room to investigation area, is based on the presenting illness and CTAS. Patients wait for the room with the best resources for their condition. For example, a plaster room is the best place to make a cast for a broken ankle, but does not have the heart monitor equipment for diagnosing or treating a heart attack. </p>
<p>These factors help explain why certain patients seem to leave the waiting room faster than others. </p>
<h2>People in the ED</h2>
<p>The people working in the ED include clinicians such as doctors, nurses and social workers, and non-clinical staff such as clerks, porters and housekeepers. The number and types of staff will depend on the size of hospital. Each team member has a defined role and scope of practice, resulting in a roughly predictable sequence in which patients will see each staff member. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/447239/original/file-20220218-17-t26q1y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Medical staff wearing gowns, caps and face masks with two figures in the foreground seen from behind" src="https://images.theconversation.com/files/447239/original/file-20220218-17-t26q1y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/447239/original/file-20220218-17-t26q1y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/447239/original/file-20220218-17-t26q1y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/447239/original/file-20220218-17-t26q1y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/447239/original/file-20220218-17-t26q1y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/447239/original/file-20220218-17-t26q1y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/447239/original/file-20220218-17-t26q1y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A patient is brought into a resuscitation bay in the emergency department at the Health Sciences Centre in Winnipeg. Patients are brought to the treatment area best suited for their health issue.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Mikaela MacKenzie</span></span>
</figcaption>
</figure>
<p>A patient entering the ED usually has their information collected by a clerk first, followed by a preliminary assessment by the triage paramedic or nurse. They may then be seen by another professional for a test or procedure like an X-ray. They may be monitored and treated by a nurse through much of this time, and seen by a physician. Before leaving the ED, a social worker or patient navigator may be seen as well.</p>
<p>Sometimes clinicians come and go over time, depending on whether they are waiting for results of tests or responses to treatment, so visits can differ in length. Recognizing the different roles of each employee, and different timelines, can help patients understand the process of diagnosis and treatment. </p>
<h2>Why understanding your ED visit matters</h2>
<p>To minimize feelings of being overwhelmed, and improve overall quality of care, patients should understand what happens in the ED. Patients may understand their diagnosis, but often have less comprehension of the <a href="https://doi.org/10.1016/j.annemergmed.2008.05.016">followup plan</a>. For example, approximately five to 10 per cent of patients do not fill their ED medications as <a href="https://doi.org/10.1016/j.annemergmed.2013.02.002">prescribed</a> and many do not follow up with recommended <a href="http://doi.org/10.1017/S1481803500012410">medical appointments</a>. </p>
<figure class="align-center ">
<img alt="Paramedics wheeling a patient on a gurney draped in orange in a crowded hospital corridor" src="https://images.theconversation.com/files/447241/original/file-20220218-27-yyuwmm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/447241/original/file-20220218-27-yyuwmm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=427&fit=crop&dpr=1 600w, https://images.theconversation.com/files/447241/original/file-20220218-27-yyuwmm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=427&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/447241/original/file-20220218-27-yyuwmm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=427&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/447241/original/file-20220218-27-yyuwmm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=537&fit=crop&dpr=1 754w, https://images.theconversation.com/files/447241/original/file-20220218-27-yyuwmm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=537&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/447241/original/file-20220218-27-yyuwmm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=537&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In the emergency department, some patients arrive by themselves, some disembark by ambulance and some are transferred from other hospitals.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette</span></span>
</figcaption>
</figure>
<p>This is partially due to a lack of understanding of their ED visit, and results in more returns to the ED and greater likelihood of hospitalization, <a href="http://doi.org/10.1097/PTS.0b013e31820c7678">especially for older adults</a>.</p>
<p>Certain factors put patients at higher risk for leaving the ED without sufficient knowledge. These include hearing or vision challenges, cognitive impairment or altered cognition (for example, from intoxication or severe illness), <a href="https://doi.org/10.1016/j.annemergmed.2011.10.023">speaking a primary language different than the one spoken in the ED, as well as having difficulty reading or a lack of knowledge about the health-care system or health issues</a>.</p>
<h2>What you can do</h2>
<p>While the health care system needs to do its part to improve the ED experience and clearly communicate, there are evidence-based strategies that can empower patients in their own care. </p>
<ul>
<li>Have a list of your medications, allergies and medical conditions on hand, saved on a phone or in a wallet. It is beneficial to be as prepared as possible. Think about the questions you want to ask: What is the goal of the visit? Who will help you keep track of the recommendations? Preparing in advance can speed up the process and provide information to the health-care team. </li>
</ul>
<figure class="align-center ">
<img alt="A hospital worker is seen through the glass entrance doors of an emergency department" src="https://images.theconversation.com/files/447243/original/file-20220218-21-i4xr96.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/447243/original/file-20220218-21-i4xr96.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=391&fit=crop&dpr=1 600w, https://images.theconversation.com/files/447243/original/file-20220218-21-i4xr96.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=391&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/447243/original/file-20220218-21-i4xr96.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=391&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/447243/original/file-20220218-21-i4xr96.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=492&fit=crop&dpr=1 754w, https://images.theconversation.com/files/447243/original/file-20220218-21-i4xr96.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=492&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/447243/original/file-20220218-21-i4xr96.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=492&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Being knowledgeable and prepared to advocate for yourself can make the next emergency department visit easier and less stressful.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Jonathan Hayward</span></span>
</figcaption>
</figure>
<ul>
<li><p>For older people, those with mobility or sensory challenges and those who are very unwell, a family member of caregiver may call the hospital and ask to speak to a nurse or doctor to relay or receive this information if their loved one is unable to do so. </p></li>
<li><p>On discharge, the patient should ask for clear written instructions. <a href="https://doi.org/10.1016/S0196-0644(95)70112-5">Short, concise</a> and in plain language is preferred over long medical summaries. <a href="http://doi.org/10.1002/14651858.CD003716">Written is generally better than verbal instructions</a>. </p></li>
<li><p>Repeat the discharge and followup instructions with the nurse or physician to check for accuracy. If the information and next steps are overwhelming, ask to speak to a discharge planning nurse or care navigator who can help smooth the transition from ED to home. </p></li>
<li><p>If the patient and/or loved ones see barriers to being able to follow through with a suggested care plan (such as an inability to afford medication, get to a pharmacy or swallow pills), these barriers should be brought to the ED team’s attention. It is better to address these proactively than to leave a condition under-treated. </p></li>
<li><p>If you are not feeling better, or are getting worse, return to the ED. Ask about return precautions: symptoms to watch for that should prompt a return to the ED. Going back may give ED staff a chance to see your symptoms at a different stage, which may result in a different course of action.</p></li>
</ul>
<p>In terms of what to ask, <a href="http://doi.org/10.1136/bmjoq-2021-001419">research has shown that it’s helpful</a> for patients to record a few important points:</p>
<ul>
<li> Date of ED visit and main diagnosis</li>
<li> Medication details (dose, purpose and how long to take)</li>
<li> Any doctors to follow up with, when and how to contact</li>
<li> Symptoms that should lead to immediate return to the ED</li>
</ul>
<p>Being knowledgeable and prepared to self-advocate can not only make the next ED visit easier and less stressful for you or your loved one, but can also help ensure you leave with the information you need.</p><img src="https://counter.theconversation.com/content/176242/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jasmine Mah is an Internal Medicine resident with Nova Scotia Health and receives scholarships supporting her PhD research from the Department of Medicine at Dalhousie University, Dalhousie Medical Research Foundation, Dr. Patrick Madore Foundation, Alzheimer Society of Nova Scotia and the Pierre Elliott Trudeau Foundation. She is part of the Canadian Consortium on Neurodegeneration in Aging (CCNA) Team 14, which investigates how multi-morbidity, frailty and social context modify risk of dementia and patterns of disease expression. The CCNA receives funding from the Canadian Institutes of Health Research (CNA-137794) and partner organizations (<a href="http://www.ccna-ccnv.ca">www.ccna-ccnv.ca</a>). The affiliations/funders had no input into any aspect of this subject or article.
</span></em></p><p class="fine-print"><em><span>Melissa Andrew has received funding from Sanofi, GSK, Merck, Pfizer, Seqirus, Public Health Agency of Canada, Canadian Institutes of Health Research, and the Canadian Frailty Network, unrelated to the present article. She serves as a member of the Alzheimer Society of Nova Scotia Board of Directors and is part of the Canadian Consortium on Neurodegeneration in Aging (CCNA) Team 14, which investigates how multi-morbidity, frailty and social context modify risk of dementia and patterns of disease expression. The CCNA receives funding from the Canadian Institutes of Health Research (CNA-137794) and partner organizations (<a href="http://www.ccna-ccnv.ca">www.ccna-ccnv.ca</a>).</span></em></p>Almost half of patients have poor understanding of their emergency department visit. Being aware of how the emergency department works can give patients the tools to have a smoother experience.Jasmine Mah, MD (Internal Medicine Resident) & PhD candidate (Focus on Geriatrics), Dalhousie UniversityMelissa K. Andrew, Professor of Geriatric Medicine, Dalhousie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1690982021-10-05T00:26:20Z2021-10-05T00:26:20ZHospital emergency departments are under intense pressure. What to know before you go<p>Emergency departments around Australia have experienced COVID in a variety of ways. </p>
<p>From the first quarter of 2020, most if not all have worked hard to plan for an influx of very unwell, highly infectious patients. In the less fortunate of jurisdictions, those apprehensions are being realised — though thankfully not yet to the magnitude seen in some overseas cities. </p>
<p><a href="https://www.healthdirect.gov.au/hospital-emergency-departments">Hospital emergency departments</a> (EDs) are under <a href="https://www.abc.net.au/7.30/hospitals-put-under-pressure-from-covid-outbreak-%E2%80%93/13529812">intense pressure</a> and there have been calls for the public to carefully weigh up need before presenting there. Don’t come if you don’t need to, they’ve been <a href="https://www.nhsgrampian.org/news/2021/april/public-urged-to-stop-avoidable-hospital-admissions-as-lockdown-eases/">told</a>. But equally, don’t wait if you need treatment, <a href="https://www.theguardian.com/australia-news/2021/sep/27/more-than-half-of-the-covid-cases-who-died-at-home-in-nsw-were-unknown-to-health-authorities">especially for COVID</a>. </p>
<h2>Less staff, more pressure</h2>
<p>For all hospitals, COVID planning has involved creating streams of patient flow, to ensure those infected can be treated in addition to and at the same time as those who are not — while preventing the former infecting the latter. This is labour-intensive work, often duplicating patient pathways but without a doubling of staff. </p>
<p>In fact, staff numbers in many EDs are down in Australia, for a variety of reasons. Many smaller rural departments rely on fly-in-fly-out locums, now locked out by lockdowns. At times, doctors and nurses have been <a href="https://www.abc.net.au/news/2021-08-23/vic-furloughed-healthcare-workers-brace-impact-covid-19/100397820">furloughed</a> because they have been infected at work or elsewhere, or because they have been close contacts. </p>
<p>Understaffed EDs push on, with the greater burden being <a href="https://www.publish.csiro.au/ah/AH21014">carried by fewer health workers</a>, resulting in their subsequent burnout. To that, add the task of working in <a href="https://www.abc.net.au/news/2020-08-03/nurses-do-not-want-public-to-complain-about-coronavirus-masks/12512436">full personal protective equipment</a>, often for many hours at a time. It is physically demanding, uncomfortable, unpleasant work, in an environment in which both high levels of vigilance to keep staff safe and cognitive skills to manage often complex and rapidly deteriorating patients are required.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-workers-are-among-the-covid-vaccine-hesitant-heres-how-we-can-support-them-safely-168838">Health workers are among the COVID vaccine hesitant. Here's how we can support them safely</a>
</strong>
</em>
</p>
<hr>
<h2>Not just COVID patients</h2>
<p>Much of the focus in the media on health care in a time of pandemic has understandably been on COVID hospitalisations and subsequent intensive care unit admissions. Less has been said about the impact of COVID on the treatment of other illnesses or injuries. </p>
<p>We are very fortunate in Australia there is still more of “the other” in our EDs than there is COVID. That might change in the run up to Christmas.</p>
<p>The ED is most obviously a place of treatment for acute injuries and illnesses. In addition to that, we treat people with chronic illnesses. The ED can act as a safety net for those who have no one else to turn to and reassure many without affliction. For patients in each of these categories, the experience of ED has changed significantly. </p>
<p>There are great concerns many of those who need immediate medical care are deferring seeking it. They may fear catching COVID or being a burden on a strained system. Many in the latter category are elderly patients and those with probably the most reasonable indications for using our services.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/heres-what-happens-when-youre-hospitalised-with-covid-167544">Here's what happens when you’re hospitalised with COVID</a>
</strong>
</em>
</p>
<hr>
<h2>First off, it’s your emergency</h2>
<p>So how should we, as a resource-constrained civil society, in the middle of a pandemic, use our EDs?</p>
<p>The first and overriding principle is that any medical emergency is YOUR emergency. If you think you are experiencing a medical emergency — one you cannot see yourself addressing with the resources available to you, at the time you are experiencing it — you should come to ED. It doesn’t matter if it seems trivial to others, it’s your emergency. And we are your emergency department.</p>
<p>If you don’t feel too unwell, and are uncertain where you should go for medical care, there are alternatives to the ED where excellent medical advice and treatment can be found. </p>
<p>Telehealth has been a godsend to both patients and our GP colleagues. There are now also numerous <a href="https://www.health.gov.au/contacts/healthdirect-hotline">health lines</a> to call. Pharmacists can provide excellent information about medication, as well as now providing COVID vaccinations.</p>
<p>The ED is not the best place to go to have a COVID test. If you are otherwise well, there are many testing locations where you will wait a far shorter time for a test and the results. </p>
<p>Similarly, many concerns about the very rare side effects of COVID vaccination can be addressed with a telehealth consultation and a blood test if required.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1443374265718358017"}"></div></p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-covid-affects-the-heart-according-to-a-cardiologist-165446">How COVID affects the heart, according to a cardiologist</a>
</strong>
</em>
</p>
<hr>
<h2>Extra precautions, longer waits</h2>
<p>If you do come to the ED, try and be patient. There are extra measures in place to keep you safe. </p>
<p>You’ll need to wear a mask and check in with a QR code, use hand sanitiser and physically distance. There are increasingly strict rules about the numbers of visitors. </p>
<p>If that’s a problem, you’re probably going to be asked to leave. It’s nothing personal — we have a duty of responsibility to all our patients. </p>
<p>You might wait longer than expected despite the efforts of medical staff to see everyone as quickly as possible. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-contagious-is-delta-how-long-are-you-infectious-is-it-more-deadly-a-quick-guide-to-the-latest-science-165538">How contagious is Delta? How long are you infectious? Is it more deadly? A quick guide to the latest science</a>
</strong>
</em>
</p>
<hr>
<h2>EDs treat all comers</h2>
<p>Finally, if you’re worried about the consequences of catching COVID, get vaccinated. We treat all comers, with a variety of beliefs about their medical care — all as long as they agree to abide by the rules of “The House”: to be respectful and abide by hospital procedures. </p>
<p>But vaccination will reduce your chance of needing ED attention as a consequence of COVID — and protect you from catching it if you come to ED for another reason.</p>
<p>Working in the ED at the moment isn’t much fun for anyone. We’re all really tired and, for many, that’s even before the ED where we work has become COVID-dominant. We’re looking forward to moving out of this phase of the pandemic, safely. Then we can get back to treating the mishaps of more normal human lifestyles, led to the fullest.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-well-do-covid-vaccines-work-in-the-real-world-162926">How well do COVID vaccines work in the real world?</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/169098/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Caldicott does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>If you feel like you’re having a medical emergency then you should still go to hospital. Expect longer waits and extra precautions.David Caldicott, Senior lecturer, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1589612021-04-15T07:15:07Z2021-04-15T07:15:07ZThere’s a mental health emergency happening in South Australia. We need a radical overhaul<p>While all eyes are on Australia’s severely faltering vaccine rollout, in South Australia the public health system is in a state of turmoil.</p>
<p>Former Central Adelaide Local Health Network mental health director John Mendoza — effectively the state’s mental health boss until he resigned last week — <a href="https://indaily.com.au/news/2021/04/08/its-a-joke-exiting-mental-health-chief-maintains-rage-over-sa-health-failures/">has blasted</a> the South Australian government, alleging a series of failures, budget cuts, and lack of commitment to reforming the state’s mental health system.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1381528759229030402"}"></div></p>
<p>So what’s the problem, and how can it be fixed?</p>
<h2>Over capacity</h2>
<p>Demand for mental health services <a href="https://www.abs.gov.au/statistics/people/people-and-communities/household-impacts-covid-19-survey/6-10-july-2020#mental-health-and-related-services">has increased</a> over the past year because of the COVID pandemic. </p>
<p>While this is true across Australia, the demand for mental health support is now overwhelming South Australian emergency departments. Mendoza noted close to <a href="https://indaily.com.au/news/2021/04/08/its-a-joke-exiting-mental-health-chief-maintains-rage-over-sa-health-failures/">a 40% increase</a> in mental health presentations to the Royal Adelaide Hospital between February 2019 and February 2021. </p>
<p>According to <a href="https://www.aihw.gov.au/reports-data/indicators/australias-health-performance-framework/national/all-australia/access/accessibility">Australian Institute of Health and Welfare</a> data, South Australia falls below the national average when it comes to treating patients who present to emergency departments in a timely manner.</p>
<p>Through no fault of their own, people in mental health crisis are creating a backlog in emergency departments, contributing to overcrowding, long wait times for admission, and therefore ramping — where patients are left waiting in ambulances at the hospital entrance. </p>
<p>Ambulance services in South Australia are reportedly at <a href="https://www.theaustralian.com.au/breaking-news/sa-ambos-at-breaking-point-union-calls-for-more-funding-to-better-protect-staff-and-patients/news-story/cf0b062c3a25501269eb7f9d2edbba99">breaking point</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/waiting-for-better-care-why-australias-hospitals-and-health-care-are-failing-104862">Waiting for better care: why Australia’s hospitals and health care are failing</a>
</strong>
</em>
</p>
<hr>
<h2>Ramping</h2>
<p>The issue of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700606/">ramping</a> is emblematic of the crisis in emergency department access.</p>
<p>An <a href="https://s3-ap-southeast-2.amazonaws.com/sahealth-ocp-assets/general-downloads/Delays-in-Transfer-of-Care-for-Mental-Health-Consumers-at-SA-EDs.pdf">investigation</a> into ramping at South Australian hospitals conducted before the pandemic found more than <a href="https://indaily.com.au/news/2021/04/01/truly-demoralising-bombshell-report-reveals-children-elderly-at-mercy-of-ambulance-ramping/">34% of mental health patients</a> brought by ambulance to South Australian emergency departments experienced ramping. </p>
<p>These delays in receiving care, sometimes lasting several hours, can exacerbate psychological trauma and even <a href="https://www.abc.net.au/news/2019-02-27/patient-harm-caused-by-rah-ramping-revealed-new-documents/10851770">cause harm</a> for patients. </p>
<p>The problem of ramping affects patients with physical illnesses too. And because paramedics need to stay with patients for longer, ramping also diverts paramedics from other jobs.</p>
<figure class="align-center ">
<img alt="Two health-care workers move a patient through a hospital corridor." src="https://images.theconversation.com/files/395180/original/file-20210415-23-19llbn4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/395180/original/file-20210415-23-19llbn4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/395180/original/file-20210415-23-19llbn4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/395180/original/file-20210415-23-19llbn4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/395180/original/file-20210415-23-19llbn4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/395180/original/file-20210415-23-19llbn4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/395180/original/file-20210415-23-19llbn4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">When emergency departments struggle to keep up, it can lead to ramping.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>While <a href="https://indaily.com.au/news/2021/04/07/not-going-to-waste-my-time-mental-health-chief-blasts-sa-health-on-way-out-door/">John Mendoza’s controversial exit</a> has lifted the lid on the crisis in South Australia’s public health system, other states and territories face <a href="https://pubmed.ncbi.nlm.nih.gov/30014624/#:%7E:text=Results%3A%20After%20the%20implementation%20of,to%205%20post%2DCDU%20implementation.">similar problems</a> in emergency mental health care. And for other jurisdictions, too, the pandemic might exacerbate these challenges.</p>
<h2>The ED should be a last resort</h2>
<p>In a responsive, modern mental health-care system, the emergency department should be the <a href="https://www.linkedin.com/pulse/new-models-care-mental-health-offer-hope-australian-hundertmark/?articleId=6714873080080166912">last resort</a> for access to care. </p>
<p>The <a href="https://grattan.edu.au/wp-content/uploads/2020/01/Grattan-Inst-sub-mental-health.pdf">Grattan Institute</a> has suggested there’s a “a yawning gap for people who need intensive community support but not inpatient care”. In a report published in 2020, it said federal and state governments need to work more closely to provide appropriate resources for mental health care.</p>
<p>The focus should be on health promotion and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5330334/">prevention</a> through mental health programs and services in the community rather than waiting for a crisis to occur. We need accurate surveillance of demand for mental health care, and services must be well-resourced to prevent the system becoming overwhelmed. </p>
<p>Upon his resignation, <a href="https://www.adelaidenow.com.au/news/south-australia/mendoza-this-is-what-is-needed-right-here-right-now-to-save-lives-and-prevent-an-exodus-of-clinicians/news-story/e3f334c1418c6b9aaccc14ecc00776aa">Mendoza sounded alarm bells</a> that this was not happening. He warned that South Australia’s mental health system is approaching crisis unless the government allocates additional resources urgently.</p>
<p>Mendoza has been supported by senior mental health staff and the <a href="https://www.ranzcp.org/news-policy/news/%E2%80%9Csouth-australians-deserve-better%E2%80%9D-mental-health-s">Royal Australian and New Zealand College of Psychiatrists</a>, who argued South Australians deserve better.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-cant-ignore-mental-illness-prevention-in-a-covid-19-world-145686">We can't ignore mental illness prevention in a COVID-19 world</a>
</strong>
</em>
</p>
<hr>
<h2>A radical overhaul</h2>
<p>Mendoza outlined a <a href="https://www.adelaidenow.com.au/news/south-australia/mendoza-this-is-what-is-needed-right-here-right-now-to-save-lives-and-prevent-an-exodus-of-clinicians/news-story/e3f334c1418c6b9aaccc14ecc00776aa">ten-point plan</a> to radically overhaul South Australia’s mental health system.</p>
<p>Among the recommendations is recruiting more mental health staff. Chronic under-resourcing in <a href="https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/community-mental-health-care-services">community</a> teams at present means the remaining staff are overworked and stressed attempting to fill the gaps. This inevitably leads to consumer needs not being met, resulting in increased emergency department presentations.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1381929235124613124"}"></div></p>
<p>Meanwhile, he’s called for upskilling of first responders. This involves providing specialised training for emergency personnel, such as police and ambulance staff, around supporting people in a mental health crisis.</p>
<p>Mendoza also flagged the importance of non-ambulance transfers for mental health patients — so having dedicated vehicles to transport mental health patients. South Australia is the <a href="https://www.adelaidenow.com.au/news/south-australia/mendoza-this-is-what-is-needed-right-here-right-now-to-save-lives-and-prevent-an-exodus-of-clinicians/news-story/e3f334c1418c6b9aaccc14ecc00776aa">only jurisdiction</a> still exclusively using stretcher-based transport for all mental health patients, meaning they’re strapped in inside the ambulance. This restrictive practice is unnecessary, traumatising, and contributes <a href="https://www.abc.net.au/news/2021-03-23/regional-sa-paramedics-call-for-more-resources-staff/100023896">to ramping</a>.</p>
<p>Further, Mendoza recommended upscaling current prevention programs. These include programs providing mental health expertise to support local general practitioners, and increasing support in people’s homes.</p>
<p>He also suggested providing emergency accommodation for <a href="http://www.lawfoundation.net.au/ljf/site/templates/resources/$file/Homelessness_SA.pdf">people experiencing homelessness</a> with mental health issues, recognising homelessness is a key cause of social stress.</p>
<p>Importantly, Mendoza strongly advocated that forensic patients (people with a mental disorder who have committed a crime) shouldn’t be housed in general hospitals while waiting for a mental health bed. This means providing an adequate number of beds for forensic mental health admissions (the target is 80, up from the <a href="https://indaily.com.au/news/2021/04/14/hospital-patients-under-guard-as-govt-misses-key-mental-health-target/?fbclid=IwAR13hpGUCdw8YN2-bbnQRPOEveIndp6ob0tf1m1EKBnk71RCTeqJ6UH3DeI">60 we have now</a>). </p>
<p>Currently, patients unable to access care in a specialist forensic psychiatric facility are reportedly <a href="https://indaily.com.au/news/2021/04/14/hospital-patients-under-guard-as-govt-misses-key-mental-health-target/?fbclid=IwAR13hpGUCdw8YN2-bbnQRPOEveIndp6ob0tf1m1EKBnk71RCTeqJ6UH3DeI">restrained with handcuffs</a> and surrounded by security guards in the emergency department.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/from-asylums-to-gp-clinics-the-missing-middle-in-mental-health-care-46345">From asylums to GP clinics: the missing middle in mental health care</a>
</strong>
</em>
</p>
<hr>
<p>The ten-point plan offers insightful recommendations from someone who has a deep understanding and experience of the inner workings of the current mental health system, available resources, and areas of weakness. And while it’s designed to fix South Australia’s crisis, there are some recommendations other states would do well to consider.</p>
<p>For South Australia moving forward, the most critical aspect will be easing the pressure on emergency departments by providing targeted staffing resources within community care networks. The second is changing the way mental health patients are transported to hospital.</p><img src="https://counter.theconversation.com/content/158961/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Musker does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The COVID pandemic has increased the strain on an already troubled mental health system in South Australia. Now, the state’s outgoing mental health boss is calling for accountability and change.Michael Musker, Senior Research Fellow, South Australian Health & Medical Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1440712020-08-11T06:58:25Z2020-08-11T06:58:25ZVictorian emergency departments during COVID-19: overall presentations down but assault, DIY injuries up<figure><img src="https://images.theconversation.com/files/352104/original/file-20200811-20-1vymxs6.jpg?ixlib=rb-1.1.0&rect=50%2C0%2C5627%2C3748&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>COVID-19 restrictions in Victoria have had a marked effect on how and where we spend our time. For many people, home has become the workplace, and for most school-aged children, home is also the classroom.</p>
<p>We compared <a href="https://www.monash.edu/__data/assets/pdf_file/0009/2294919/COVID-19-VISU-May-Bulletin-3.pdf">Victorian emergency department presentations</a> in May 2020 to those in May 2019 and found this extra time at home has affected the rates at which people are presenting to hospital with injuries — and the types of injuries they’re presenting with.</p>
<p>Importantly, overall presentations to the emergency department were down. But some categories saw notable increases, including the number of “unintentional home injuries”, which grew by 21%, and the number of injuries caused by “assault in the home”, which was 48% greater than the same time last year.</p>
<p>Although motor vehicle related injuries decreased, there was an increase in bicycle injuries, particularly among children.</p>
<h2>What we did</h2>
<p>At Monash University’s <a href="https://www.monash.edu/muarc/research/research-areas/home-and-community/visu">Victorian Injury Surveillance Unit</a>, we’ve been tracking injury rates throughout the pandemic.</p>
<p>We get our data from the <a href="https://www2.health.vic.gov.au/hospitals-and-health-services/data-reporting/health-data-standards-systems/data-collections/vemd">Victorian Emergency Minimum Dataset</a>, which holds deidentified clinical records of presentations at Victorian public hospitals with 24-hour emergency departments (currently 38 hospitals).</p>
<figure class="align-center ">
<img alt="The outside of a hospital with large red " src="https://images.theconversation.com/files/352109/original/file-20200811-16-1sr22k8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/352109/original/file-20200811-16-1sr22k8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/352109/original/file-20200811-16-1sr22k8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/352109/original/file-20200811-16-1sr22k8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/352109/original/file-20200811-16-1sr22k8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/352109/original/file-20200811-16-1sr22k8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/352109/original/file-20200811-16-1sr22k8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Fewer Victorians are presenting to emergency departments during the pandemic.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>We’re also tracking emergency department presentations overall, to determine how much more common different types of injuries are becoming as a proportion of usual emergency department presentations. We call this measure “relative to emergency department caseload”.</p>
<p>So for example, in our <a href="https://www.monash.edu/__data/assets/pdf_file/0009/2294919/COVID-19-VISU-May-Bulletin-3.pdf">most recent bulletin</a>, we took the total emergency department presentations during May 2020. But because we’re looking for the proportion of usual emergency department presentations — that is, outside a pandemic — we excluded presentations directly or indirectly related to the pandemic from the total.</p>
<p>To calculate “relative to emergency department caseload”, we worked out the injuries as a proportion of this total.</p>
<h2>Illness</h2>
<p>Emergency presentations in Victoria were 24% lower in May 2020 than in May 2019 (118,793 versus 156,708 respectively). This decrease should be considered in the context of <a href="https://www.aihw.gov.au/reports-data/myhospitals/sectors/emergency-department-care">steady growth in emergency department presentations</a> in Victoria in recent years. It’s difficult to deny the COVID-19 pandemic is deterring people from presenting to hospital.</p>
<p>Respiratory illness-related presentations (such as asthma or pneumonia) in particular saw a steep reduction. Some 4,748 people presented to Victorian emergency departments with respiratory issues in May — 63% fewer than in May last year, when there were 12,847 such presentations.</p>
<p>Even people with potentially life-threatening conditions were less likely to present to hospital. Heart attack presentations were down 15% compared with the same period one year prior (721 versus 613), and stroke presentations were down 19% (858 versus 693). </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/even-in-a-pandemic-continue-with-routine-health-care-and-dont-ignore-a-medical-emergency-136246">Even in a pandemic, continue with routine health care and don't ignore a medical emergency</a>
</strong>
</em>
</p>
<hr>
<h2>Injuries</h2>
<p>The overall number of injury presentations to Victorian emergency departments was actually 26% lower in May 2020 than in May 2019 (26,991 versus 36,293). </p>
<p>But breaking this down by the place where the injury occurred shows a marked reduction in injuries that took place in sporting venues and schools, and an increase in injuries that occurred in the home and on farms. </p>
<p>Unintentional home injuries, including DIY injuries, increased from 10,105 to 12,265 (21%) from May 2019 to May 2020. Relative to emergency department caseload, this was a 56% increase. At both timepoints, falls were the most common cause of unintentional home injuries.</p>
<hr>
<p><iframe id="aVAbY" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/aVAbY/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<hr>
<p>Self-harm injuries did not increase in May 2020 versus May 2019 in terms of the raw numbers (719 versus 773). But relative to emergency department caseload, self-harm injury presentations increased by 20%. </p>
<p>This can be taken with more recent data outside of our research which showed <a href="https://www.theage.com.au/national/victoria/victoria-records-394-new-covid-19-case-17-deaths-20200809-p55jz4.html">a 9.5% rise</a> in the number of overall Victorian hospital admissions for self-harm in the past six weeks.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/its-not-only-teenage-girls-and-its-rarely-attention-seeking-debunking-the-myths-around-self-injury-120214">It's not only teenage girls, and it's rarely attention-seeking: debunking the myths around self-injury</a>
</strong>
</em>
</p>
<hr>
<p>According to our data, assault in the home increased from 118 presentations in May 2019 to 175 in May 2020: a 48% increase in frequency and a 91% increase relative to emergency department caseload. </p>
<p>Finally, transport injuries overall were not much different in May 2020 compared to May 2019 (1,669 versus 1,766). This was, however, a 22% increase when considered relative to emergency department caseload. While motor vehicle injuries decreased by 30% (833 to 581), bicycle injuries increased 55% from 371 to 576.</p>
<p>For children under 15 years, the rate of transport-related injury presentations to emergency departments increased 78% from May 2019 to May 2020.</p>
<hr>
<p><iframe id="qm16y" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/qm16y/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<hr>
<h2>Staying safe at home</h2>
<p>The bulletins we previously released for <a href="https://www.monash.edu/__data/assets/pdf_file/0005/2224283/COVID-19-VISU-Bulletin-1-03JUN2020.pdf">March</a> and <a href="https://www.monash.edu/__data/assets/pdf_file/0006/2246604/COVID-19-VISU-Bulletin-2.pdf">April</a>, and the data we’re now collating for June, reflect similar trends in the rates and types of emergency department presentations, as compared to the same time points last year.</p>
<p>Our findings have a few different implications.</p>
<p>First, we should encourage people who are sick and need hospital care to present to hospital — not to stay home for fear of contracting COVID-19.</p>
<figure class="align-center ">
<img alt="Young girl riding her bike." src="https://images.theconversation.com/files/352111/original/file-20200811-17-ow8avo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/352111/original/file-20200811-17-ow8avo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/352111/original/file-20200811-17-ow8avo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/352111/original/file-20200811-17-ow8avo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/352111/original/file-20200811-17-ow8avo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/352111/original/file-20200811-17-ow8avo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/352111/original/file-20200811-17-ow8avo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Children were disproportionately represented in transport-related injuries.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Second, alongside the messaging we’re receiving to “stay home” and “stay safe” from coronavirus, public health messaging should include advice on staying safe at home. </p>
<p>With reduced face-to-face contact with health practitioners, some injury prevention messaging, such as the information provided through child-maternal health services, general practitioners and nurses, should be made available through other channels. These could include social media, radio, television, and telephone consultations. </p>
<p>Improving awareness of cycling safety, including messaging around <a href="https://www.monash.edu/__data/assets/pdf_file/0010/2186956/Hazard87-FINAL.pdf">cycling road rules</a>, would also be pertinent at this time. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/there-are-ways-to-reduce-injuries-in-kids-that-dont-involve-wrapping-them-in-cotton-wool-79408">There are ways to reduce injuries in kids that don't involve wrapping them in cotton wool</a>
</strong>
</em>
</p>
<hr>
<p>Finally, trends in self-harm and assault in the home need to be closely monitored, particularly during stage 4 restrictions in Victoria. </p>
<p>The stricter lockdown conditions may result in further increases in violence in the home and compound the effects on mental health, and we need to provide support accordingly.</p><img src="https://counter.theconversation.com/content/144071/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The Victorian Injury Surveillance Unit is funded by the Victorian Government</span></em></p>Comparing presentations to Victorian hospital emergency departments in May 2020 to those in May 2019 reveals some important differences.Janneke Berecki-Gisolf, Associate Professor, Accident Research Centre, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1363142020-04-29T12:12:26Z2020-04-29T12:12:26ZWait times remain stubbornly long in hospital emergency rooms<figure><img src="https://images.theconversation.com/files/329804/original/file-20200422-47784-16wqp2s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">How long will you wait?</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/sliding-doors-of-emergency-room-in-hospital-royalty-free-image/601797385?adppopup=true">Getty Images</a></span></figcaption></figure><p>Each year, there are well over 100 million hospital emergency department visits in the U.S. In 2017, there were about <a href="https://www.cdc.gov/nchs/fastats/emergency-department.htm">139 million</a>, or 43 visits for every 100 Americans.</p>
<p>While wait times have declined in the last decade – now averaging about 40 minutes – they remain stubbornly long. Millions of patients still wait at least two hours to see a provider – <a href="https://www.cdc.gov/nchs/data/nhamcs/web_tables/2017_ed_web_tables-508.pdf">7 million did</a> in 2017 – and that is no guarantee they won’t have to wait even longer for treatment. In California, <a href="https://www.sacbee.com/news/local/health-and-medicine/article230552184.html">hundreds of thousands of patients that same year</a> left after getting an emergency department bed but before their care was complete.</p>
<p>How long people have to wait can have a lot to do with the outcome of those visits, <a href="https://doi.org/10.1016/j.rmclc.2017.04.008">sometimes with serious consequences</a> that include longer hospital stays, increased medical errors and higher death rates. </p>
<p><a href="https://www.bu.edu/sph/profile/paul-shafer/">One of us</a> studies how people enroll in and use health insurance, including how often they go to the emergency room and why, while the <a href="https://www.bu.edu/sph/profile/alex-woodruff/">other is a policy analyst</a> who is focused on access to care for vulnerable populations, in particular those with opioid use disorder. We decided to take a deeper look at what we know about the drivers of emergency department wait times and crowding, especially as the COVID-19 pandemic shows just how important a well-functioning emergency medicine system is.</p>
<p>We studied the literature on emergency wait times and identified several reasons why they remain high. One surprise finding is that many <a href="https://journals.sagepub.com/doi/full/10.1177/1062860617700721?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed">patients likely without true emergencies are told to go</a> to the emergency room by physicians out in the community, which contributes to high emergency department volume.</p>
<h2>An obligation to treat everyone</h2>
<p>Every day, hospital emergency departments serve as the entry point into health care for Americans who don’t feel right and have nowhere else to go, or have an emergency, like a car accident. This also includes millions of patients seeking <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4156292/">routine medical care</a> that is available elsewhere: While the estimates vary widely from <a href="https://pubmed.ncbi.nlm.nih.gov/28992158/">study</a> to <a href="https://pubmed.ncbi.nlm.nih.gov/26763823">study</a>, upwards of a third of all emergency department visits could be considered “nonurgent.”</p>
<p>Emergency rooms face a Herculean task. They are asked to be prepared for anything and everything, keep wait times down and costs low. They are <a href="https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/">mandated by law</a> to treat and stabilize anyone who walks in the door regardless of their ability to pay, a burden that no other part of the health care system faces.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/330066/original/file-20200423-47841-xyv0nc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/330066/original/file-20200423-47841-xyv0nc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/330066/original/file-20200423-47841-xyv0nc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/330066/original/file-20200423-47841-xyv0nc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/330066/original/file-20200423-47841-xyv0nc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/330066/original/file-20200423-47841-xyv0nc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/330066/original/file-20200423-47841-xyv0nc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Patients forced to wait for treatment in the hallways of an Atlanta Hospital in 2006 due to lack of space and overcrowding.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/at-grady-memorial-hospital-emergency-department-where-many-news-photo/98618601?adppopup=true">Jonathan Torgovnik/Getty Images)</a></span>
</figcaption>
</figure>
<p>The average wait time to see a health care provider in the emergency department in 2017, the most recent national data available, was <a href="https://www.cdc.gov/nchs/data/nhamcs/web_tables/2017_ed_web_tables-508.pdf">37.5 minutes</a>, down from <a href="https://www.cdc.gov/nchs/products/databriefs/db102.htm">58.1 minutes</a> a decade earlier.</p>
<h2>Why the wait?</h2>
<p>An obvious driver of crowding and high wait times is how many patients show up for treatment.</p>
<p>A large number of patients who don’t <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4156292/">have what rises to the level of a true emergency</a> are referred to the emergency department by outside physicians. These referrals could be because the physician is not sure if they can provide complete care, or because their schedule is too tight to see patients quickly. One <a href="https://pubmed.ncbi.nlm.nih.gov/28693337/">study</a> found that about half of “nonemergent” patients contacted another physician first, and 70% of them were told to go to the emergency room.</p>
<p>One of us experienced this firsthand recently. Paul’s rambunctious three-year-old launched herself off the couch head first into the coffee table. There was lots of blood, crying and an immediate trip to urgent care. It was a small wound that the doctor probably could have stitched up himself, but he recommended that Paul go to the emergency room because his daughter might need a plastic surgeon. She ended up not needing stitches and was instead patched up with surgical glue. From her leap off the couch until arriving back home, we probably spent a few minutes with doctors and a couple of hours waiting.</p>
<p>Also adding to the emergency department load is that outside physicians often lack admitting privileges to hospitals. When a patient needs to be admitted as an inpatient but the provider can’t admit them directly, they send the patient to the emergency room for admission instead. <a href="https://www.acepnow.com/article/latest-data-reveal-the-eds-role-as-hospital-admission-gatekeeper/?singlepage=1&theme=print-friendly">A report from the American College of Emergency Physicians</a> suggests that 70% of hospital admissions come through the emergency room, and it is increasing.</p>
<p>For patients who choose to go on their own to the emergency room, it might be exactly the right thing to do. Chest pain can be indigestion or a sign of a heart attack. Playing Monday morning quarterback after the fact, <a href="https://epmonthly.com/article/prudent-layperson-meet-imprudent-payer/">which insurers sometimes do</a>, makes it easy to point fingers at patients for “avoidable” visits, but it is <a href="https://pubmed.ncbi.nlm.nih.gov/23512061/">unfair</a>.</p>
<h2>Solutions exist</h2>
<p>There are several options for hospitals and communities to reduce the demand for emergency department services. </p>
<p>Urgent care centers and retail clinics <a href="https://pubmed.ncbi.nlm.nih.gov/30193357/">can care for simpler cases</a> that otherwise might have showed up to the emergency room, but the evidence <a href="https://www.annemergmed.com/article/S0196-0644(16)30998-2/abstract">isn’t clear</a> on how much volume they absorb. There is some evidence that retail clinics, like CVS Minute Clinics, may actually <a href="https://www.healthaffairs.org/doi/10.1377/hlthaff.2015.0995">increase health care use and spending</a>.</p>
<p>Over half of emergency department visits (57.2%) come <a href="https://www.cdc.gov/nchs/data/nhamcs/web_tables/2017_ed_web_tables-508.pdf">outside of business hours</a>, when many retail clinics, along with more traditional options like community health centers and primary care offices, are often closed. </p>
<p>Many urgent care centers are open later and on weekends, but not everyone has easy access to one. Many lower-income neighborhoods do not have <a href="https://www.bostonglobe.com/metro/2019/01/12/urgent-care-centers-proliferate-mass-but-fewer-low-income-patients-have-access/FATkqt7OtDc0sHFupk7eSJ/story.html">access to urgent care</a>. Not surprisingly, when urgent care centers close at night, <a href="https://www.nber.org/papers/w25428">nonemergent emergency room visits increase</a>. </p>
<h2>No beds to be had</h2>
<p>No one really knows what the “right” average wait time is. It will always be too long for someone. One of the biggest challenges to reducing wait times is crowding that occurs because the emergency room has no beds available because patients are waiting to be released or moved. </p>
<p>If a patient needs to be admitted but there are no unit beds available, the emergency department often “boards” the patient for hours. The emergency physicians association calls this “<a href="https://www.acep.org/globalassets/sites/acep/media/crowding/empc_crowding-ip_092016.pdf">a primary contributor to crowding</a>” and notes that over 90% of hospitals routinely report crowded conditions in their emergency rooms.</p>
<p>The situation is even worse when it comes to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3408670/">psychiatric</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2396562/">substance use</a> patients, where limited availability of specialized treatment beds means even longer waits. Space in homeless shelters can matter too. There are many nights when it isn’t safe to send someone back out into the cold with nowhere to go.</p>
<p>Boarding and crowding are <a href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2011.0786">not new problems</a>, yet policymakers and health care leaders have struggled to find and implement solutions. Improving this system will require pushing on several levers to connect patients with the right level of care. This effort can help ensure that when true emergencies happen, people can get the care they need quickly.</p>
<p>[<em>Like what you’ve read? Want more?</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=likethis">Sign up for The Conversation’s daily newsletter</a>.]</p><img src="https://counter.theconversation.com/content/136314/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Shafer has received funding in the past three years from the Kate B. Reynolds Charitable Trust, Robert Wood Johnson Foundation, Horowitz Foundation for Social Policy, and the North Carolina Translational and Clinical Sciences Institute.</span></em></p><p class="fine-print"><em><span>Alex Woodruff does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In a well-functioning health care system, the emergency room would be able to meet the needs of all of its patients in a timely manner.Paul Shafer, Assistant Professor, Health Law, Policy and Management, Boston UniversityAlex Woodruff, Policy Analyst, Boston UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1325992020-03-08T19:07:41Z2020-03-08T19:07:41Z‘Fever clinics’ are opening in Australia for people who think they’re infected with the coronavirus. Why?<figure><img src="https://images.theconversation.com/files/318800/original/file-20200305-127872-1e4h1oi.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C1000%2C664&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/many-people-waiting-room-see-doctor-778331905">Shutterstock</a></span></figcaption></figure><p>The Western Australian health minister <a href="https://www.watoday.com.au/national/western-australia/wa-fever-clinics-to-open-next-week-ahead-of-anticipated-rise-in-coronavirus-cases-20200304-p546s5.html">has announced</a> “fever clinics” are to open this week for people who think they have coronavirus symptoms.</p>
<p>And <a href="https://www.news.com.au/lifestyle/health/health-problems/rpa-coronavirus-clinic-swamped-by-hundreds-of-suspected-cases/news-story/33d656c4ad84896477ea1f630c12d0fd">in NSW</a>, the chief health officer <a href="https://www.abc.net.au/news/2020-03-02/coronavirus-spread-means-nsw-government-could-divert-ed-patients/12015958">has advised</a> hospitals set up “respiratory clinics” to deal with a potential spike in COVID-19 cases.</p>
<p><a href="https://www.theguardian.com/world/2020/mar/06/coronavirus-palaszczuk-says-federal-government-too-slow-to-act">Other</a> <a href="https://www.abc.net.au/news/2020-03-07/coronavirus-infects-melbourne-doctor/12023438">states</a> are set to open their own versions, particularly if transmission of the virus from person to person becomes more established in the community.</p>
<p>So what are these clinics? And why are people being advised to use them rather than seeing their GP or going straight to the emergency department?</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/its-now-a-matter-of-when-not-if-for-australia-this-is-how-were-preparing-for-a-jump-in-coronavirus-cases-132448">It's now a matter of when, not if, for Australia. This is how we're preparing for a jump in coronavirus cases</a>
</strong>
</em>
</p>
<hr>
<h2>What are ‘fever clinics’?</h2>
<p>Fever clinics are dedicated facilities to assess, test, treat and reassure people, and where necessary, to triage them through the healthcare system.</p>
<p>In the absence of substantial community transmission of the virus in Australia, it’s expected most people who’ll use these clinics will be:</p>
<ul>
<li><p>people worried they’re sick but aren’t showing symptoms (the “worried well”) </p></li>
<li><p>people who think they may have been in contact with an infected person</p></li>
<li><p>people with other illnesses who want reassurance.</p></li>
</ul>
<p>The idea is to divert people concerned they may be infected away from emergency departments and general practices.</p>
<p>Not only does this reduce demand for these traditional services, it potentially limits the spread of disease among vulnerable populations, such as the sick and elderly.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-do-we-detect-if-coronavirus-is-spreading-in-the-community-132349">How do we detect if coronavirus is spreading in the community?</a>
</strong>
</em>
</p>
<hr>
<p>General practices have open waiting rooms and while they can ramp up their infection control measures, not all practices can do this effectively.</p>
<p>Similarly, emergency departments are not well structured to isolate large numbers of potentially infectious patients.</p>
<p>By contrast, fever clinics can assess and treat potentially large numbers of people with appropriate levels of infection control. They’re also staffed by people dedicated to this one task. So expertise is concentrated in one location.</p>
<p>Fever clinics are part of a broader <a href="https://www.health.gov.au/sites/default/files/documents/2020/02/australian-health-sector-emergency-response-plan-for-novel-coronavirus-covid-19_2.pdf">emergency health response</a> to the coronavirus. And different states give them different names. For instance, in NSW their <a href="https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=2ahUKEwjrlJuGoILoAhWQwzgGHVZ8AQkQFjAAegQIBBAB&url=https%3A%2F%2Fwww1.health.nsw.gov.au%2Fpds%2FActivePDSDocuments%2FPD2016_016.pdf&usg=AOvVaw3tBn1Pm9ISu4MdNFrIboHu">official name</a> is “pandemic assessment centres”.</p>
<h2>Where are these clinics?</h2>
<p>Fever clinics <a href="https://www.racgp.org.au/running-a-practice/practice-management/managing-emergencies-and-pandemics/managing-pandemics/managing-pandemic-influenza-in-general-practic-1">may be set up</a> in new facilities or by repurposing existing ones, such as community health centres or dedicated general practices.</p>
<p>They need to be somewhere with good public access (and parking), preferably away from existing crowded major health facilities to avoid congestion. </p>
<p>They may be possible in heavily populated areas but less so in rural areas as they require enough patient numbers (to make them viable) and access to enough staff.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/318802/original/file-20200305-127918-19yfq45.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/318802/original/file-20200305-127918-19yfq45.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/318802/original/file-20200305-127918-19yfq45.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/318802/original/file-20200305-127918-19yfq45.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/318802/original/file-20200305-127918-19yfq45.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/318802/original/file-20200305-127918-19yfq45.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/318802/original/file-20200305-127918-19yfq45.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/318802/original/file-20200305-127918-19yfq45.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Existing healthcare staff will work in these new fever clinics, stretching regular services.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/medical-staff-looking-digital-tablet-hospital-361329464">Shutterstock</a></span>
</figcaption>
</figure>
<p>Staff – such as doctors, nurses and laboratory staff – will generally come from the existing health service, potentially leaving these services short. And staffing may be an issue in rural and remote areas that are already under-resourced.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/worried-about-your-child-getting-coronavirus-heres-what-you-need-to-know-131909">Worried about your child getting coronavirus? Here's what you need to know</a>
</strong>
</em>
</p>
<hr>
<p>People who attend these fever clinics, who require higher levels of care, will need to be referred to specific health facilities. So arrangements for referral and safe transfer are needed.</p>
<p>Fever clinics are also only part of a broader health system response and can never replace other sources of care.</p>
<p>Severely ill patients will still call for an ambulance and need to be in hospital. Many patients will choose to see their regular GP.</p>
<p>So the broader health system needs to be supported if we are to mount an effective health response against the coronavirus.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/theres-no-evidence-the-new-coronavirus-spreads-through-the-air-but-its-still-possible-131653">There's no evidence the new coronavirus spreads through the air – but it's still possible</a>
</strong>
</em>
</p>
<hr>
<h2>Do fever clinics work?</h2>
<p>There is surprisingly little published research about people’s experience with fever clinics. Few outbreaks have had enough patient numbers to justify setting them up.</p>
<p>During the <a href="https://www.who.int/csr/disease/swineflu/frequently_asked_questions/about_disease/en/">swine flu pandemic of 2009</a>, Australians <a href="https://www.sciencedirect.com/science/article/abs/pii/S1574626710000066">were keen to use one</a> clinic when it was located within an emergency department. More than 1,000 people with flu-like symptoms attended in one month.</p>
<p>However, it is difficult to find any evaluation of how well fever clinics work across health systems, either in improving health outcomes or reducing costs.</p>
<h2>What’s the take-home message?</h2>
<p>People have a right to be concerned, but not unduly alarmed, about the outbreak of COVID-19. </p>
<p>Recent data <a href="https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf">suggest</a> the disease is highly infectious although 80% of people have a mild-to-moderate disease, 20% a severe/critical illness and 2-3% die.</p>
<p>People who are at greater risk are those who are older or have other illnesses.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-hand-washing-really-is-as-important-as-doctors-say-132840">Why hand-washing really is as important as doctors say</a>
</strong>
</em>
</p>
<hr>
<p>The best thing people can do is to take reasonable precautions: avoid crowded places, wash your hands regularly and avoid touching your eyes and mouth.</p>
<p>Fever clinics may well have a role in providing a single source of assessment, advice and treatment. However, we still need enhanced infection control procedures across the healthcare system and to access other sources of medical care.</p><img src="https://counter.theconversation.com/content/132599/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gerard Fitzgerald has previously received funding from the NHMRC to examine the impact of Swine flu on emergency departments.
He is a Member of the Board of Medic Alert Foundation Australia.</span></em></p>We’re likely to see more ‘fever clinics’ opening as coronavirus transmission takes hold in the community. But what are they? And do you need a fever to attend one?Gerard Fitzgerald, Emeritus Professor, School of Public Health, Queensland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1313862020-02-17T01:06:39Z2020-02-17T01:06:39ZAussie Rules players risk injuring hands and wrists too<p>When people think about Australian Rules Football injuries, they tend to think about head injuries and the long-term effects of <a href="https://www.abc.net.au/news/2019-03-19/john-barnes-ex-afl-ruckman-joins-planned-concussion-class-action/10915086">concussion</a>. Or they might think of the potentially lengthy recoveries after <a href="http://www.aflcommunityclub.com.au/index.php?id=342">hamstring</a>, shoulder or ankle injuries.</p>
<p>But our <a href="https://www.jsams.org/article/S1440-2440(19)31347-7/fulltext">recently published research</a> found another leading cause of injury serious enough to take players to the emergency department – injuries to the hand or wrist. </p>
<p>These cost one Victorian public health network <a href="https://bridges.monash.edu/articles/Individual_community_and_societal_burden_following_acute_hand_and_wrist_injury/11635335">between</a> about A$250 (for a single emergency department consultation) and about A$5,300 (for surgery and rehabilitation) each time. And many of these injuries can be prevented or better managed.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/aussie-rules-rules-thanks-to-the-eight-hour-working-day-27630">Aussie Rules rules thanks to the eight-hour working day</a>
</strong>
</em>
</p>
<hr>
<h2>What causes these injuries?</h2>
<p>Australian Rules Football or Aussie Rules involves a mix of physical endurance, high-speed running, frequent changes of direction, jumping, sudden and forceful collisions, aggressive tackling, as well as kicking and ball-handling skills. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/XMZYZcoAcU0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">How does Aussie Rules differ from other types of football?</span></figcaption>
</figure>
<p>The sport’s distinctive rules and physical demands exposes players to both unique and uncommon injuries compared to those sustained in other football codes, for instance in <a href="https://www.ncbi.nlm.nih.gov/pubmed/16247262">gridiron football</a> played in the United States and Canada or <a href="https://www.ncbi.nlm.nih.gov/pubmed/22879401">Gaelic football</a> played in Ireland. </p>
<p>Put simply, the 360-degree nature of the game (unlike rugby which is played mainly in straight lines up and down the pitch), can result in fingers, hands and wrists to be pulled, jarred, kicked and crushed. </p>
<p>Players’ hands and wrists can also be injured by other players, when falling on the grass pitch or when in contact with the hard leather ball. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-traumatic-brain-injury-and-how-is-it-treated-34697">Explainer: what is traumatic brain injury and how is it treated?</a>
</strong>
</em>
</p>
<hr>
<h2>More and more people playing around the country</h2>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/8665278">Research published in the 1990s</a> found hand fractures were the second most frequent injury, behind concussion, for amateur Aussie Rules players. </p>
<p>Since then, the game has become much more popular. Nationally, it’s the <a href="https://www.clearinghouseforsport.gov.au/__data/assets/pdf_file/0012/796827/AusPlay_focus_Children_Participation.pdf">third most popular</a> organised sport for children (behind swimming and soccer). </p>
<p>And the number of women playing the amateur game <a href="https://www.theage.com.au/sport/afl/number-of-women-playing-footy-surges-post-aflw-20190429-p51i5j.html">has increased</a> since the introduction of the women’s professional league, <a href="https://womens.afl/">the AFLW</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/growth-of-womens-football-has-been-a-100-year-revolution-it-didnt-happen-overnight-71989">Growth of women’s football has been a 100-year revolution – it didn't happen overnight</a>
</strong>
</em>
</p>
<hr>
<p>This rise in participation at an amateur level is likely to have impacts on the number of injuries presenting to emergency departments.</p>
<p>We weren’t aware of Australian data looking at people with sports and exercise-related hand and wrist injuries who presented to the emergency department. So we decided to establish baseline data so that we could track patterns over time. </p>
<h2>What we found</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/314657/original/file-20200211-146708-17zxie6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/314657/original/file-20200211-146708-17zxie6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=702&fit=crop&dpr=1 600w, https://images.theconversation.com/files/314657/original/file-20200211-146708-17zxie6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=702&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/314657/original/file-20200211-146708-17zxie6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=702&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/314657/original/file-20200211-146708-17zxie6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=883&fit=crop&dpr=1 754w, https://images.theconversation.com/files/314657/original/file-20200211-146708-17zxie6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=883&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/314657/original/file-20200211-146708-17zxie6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=883&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">This x-ray shows a complex finger joint injury from a player who came to the emergency department after playing Aussie Rules.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Our study used diagnostic codes and billing records at one Victorian public health network. Over a year, we identified and tracked 692 people with a sport and exercise-related admission to the emergency department following a hand or wrist injury.</p>
<p>People playing amateur Aussie Rules were the largest group (20.2%) followed by cyclists (15.9%). </p>
<p>The most common injuries were finger dislocations, with or without fractures, to the <a href="https://www.sciencedirect.com/topics/medicine-and-dentistry/proximal-interphalangeal-joint">proximal interphalangeal joint</a> (the middle joint on the x-ray shown) of the little and ring fingers. Next came <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3928373/">metacarpal fractures</a> (in the bone below the knuckles).</p>
<p>The total cost of all sport and exercise-related injuries during the year for the health network was A$790,325, with Aussie Rules accounting for close to <a href="https://bridges.monash.edu/articles/Individual_community_and_societal_burden_following_acute_hand_and_wrist_injury/11635335">A$167,000</a> alone.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/get-a-grip-the-twist-in-the-wrist-that-can-ruin-tennis-careers-90318">Get a grip: the twist in the wrist that can ruin tennis careers</a>
</strong>
</em>
</p>
<hr>
<p>As Australia’s national injury database does not capture specific hand and wrist injury data, we cannot compare injury patterns from sports and exercise across states and territories.</p>
<p>But if our study was repeated in New South Wales, for example, where other football codes are more popular, we’d expect to see a different injury profile.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/rugby-world-cup-injuries-thats-gotta-hurt-3101">Rugby World Cup injuries: That's gotta hurt</a>
</strong>
</em>
</p>
<hr>
<h2>Could we prevent or better manage these injuries?</h2>
<p>Nevertheless, our finding that Aussie Rules accounts for one in five sport and exercise-related hand and wrist injuries highlights the need for further action.</p>
<p>Preventing these injuries would be challenging for a number of reasons. These include the fast pace of the game, the number of players on the pitch, and the unpredictable bounces that come with using an oval shaped ball. </p>
<p>Yet several strategies might help reduce the frequency and impact of these injuries, as well as their health-care costs.</p>
<p>These include training players from junior grassroots level the <a href="https://doi.org/10.1097/JSM.0b013e31829aa3e8">correct way to tackle, handball and mark</a>. </p>
<p>For example, when tackling, players need to avoid catching their fingers in another player’s clothing as it could lead to dislocation; players can avoid handballing with the thumb in the palm; and they can hold their fingers to the sky and their body behind their hands when <a href="https://www.youtube.com/watch?v=I9Rk7r0V_HI">marking</a> where possible.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/I9Rk7r0V_HI?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">How to mark in Aussie Rules.</span></figcaption>
</figure>
<p>Clubs could ensure ground conditions are safe, for instance by providing padding on goal posts and avoiding playing on hard, concrete cricket pitches.</p>
<p>And, on the ground, we could ensure there are enough club trainers or health professionals experienced in diagnosing and managing these types of hand injuries. This would reduce the risk of misdiagnosis and exposure to further injury. </p>
<p>Both of us have treated injuries made worse by a well-meaning trainer who has, for example, treated a fracture as a dislocation, leading to further displacement of the bone fragments.</p><img src="https://counter.theconversation.com/content/131386/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Running, jumping, tackling, not to mention handling the ball, means Aussie Rules players risk injuries to their hands and wrists serious enough to send them to the emergency department.Luke Robinson, Lecturer, Department of Occupational Therapy, Monash UniversityLisa O'Brien, Associate Professor, Occupational Therapy, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1270202019-12-19T19:06:42Z2019-12-19T19:06:42ZHow a rethink of emergency care is closing the gap, one person at a time<figure><img src="https://images.theconversation.com/files/307569/original/file-20191218-11919-1epy5bl.JPG?ixlib=rb-1.1.0&rect=2%2C10%2C987%2C722&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Walpiri Transient Camp, Katherine: Western medicine can't be expected to work for disadvantaged Indigenous Australians unless housing and social disadvantage are also addressed.</span> <span class="attribution"><span class="license">Author provided</span></span></figcaption></figure><p><em>This is one of our occasional <a href="https://theconversation.com/au/topics/essays-on-health-32828">Essays on Health</a>, about one community’s attempt at closing the gap between Indigenous and non-Indigenous health in the Northern Territory. It’s a long read.</em></p>
<p>You can see <a href="https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/BriefingBook44p/ClosingGap">the gap</a> driving through the main street of Katherine in the Northern Territory.</p>
<p>The broken shop windows, the dust, the wheelchairs and crutches and bandaged bodies sing out poor health and inequity.</p>
<p>Overcrowding and homelessness are pervasive, and there is very little reprieve from the oppressive heat.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1204986670711558144"}"></div></p>
<p>Like many towns of its size, Katherine has its own hospital. Here, social and environmental determinants drive hospital attendance. </p>
<p>For instance, the town has <a href="https://www.katherinetimes.com.au/story/6419712/in-the-top-league-of-homelessness-rates-katherine-needs-a-plan/">some of the highest rates of homelessness</a> in Australia, in a jurisdiction with the <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4517.0%7E2018%7EMain%20Features%7ENorthern%20Territory%7E27">highest incarceration rates</a>, <a href="https://digitallibrary.health.nt.gov.au/prodjspui/bitstream/10137/572/1/Mortality_in_the_NT_1967_2006_web.pdf">lowest life expectancy</a> and the <a href="https://nap.edu.au/docs/default-source/resources/2018-naplan-national-report.pdf?sfvrsn=2">poorest educational outcomes</a>. The gap in Katherine is a chasm.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/three-reasons-why-the-gaps-between-indigenous-and-non-indigenous-australians-arent-closing-91561">Three reasons why the gaps between Indigenous and non-Indigenous Australians aren't closing</a>
</strong>
</em>
</p>
<hr>
<h2>Who’s who in the emergency department?</h2>
<p>The hospital is a busy place, made even more so by the <a href="https://www.mja.com.au/journal/2008/189/10/frequent-attenders-emergency-departments-linked-data-population-study-adult">emergency department frequent attenders</a> who come and go through a constantly revolving door of admission and discharge. </p>
<p>Frequent attenders fall into two broad categories.</p>
<p>Roughly one-third are very sick, wracked by illness or chronic conditions, almost all underpinned by great social challenges. Despite stereotypes, this is a group that rarely drinks alcohol. </p>
<p>By contrast, grog is a driving force for the other two-thirds, often as a direct result of alcohol and its complications. Once again, illness and social exclusion are pervasive.</p>
<p>Most frequent attenders <a href="https://www.mja.com.au/journal/2016/204/3/factors-contributing-frequent-attendance-emergency-department-remote-northern#tbox1">are Indigenous</a>. They come from <a href="https://www.mdpi.com/1660-4601/16/22/4306/htm">around 30 different tribal nations</a>, each with unique language. Most are just three or four generations away from the first wave of colonisation.</p>
<p>Just over two-thirds are homeless, a situation shaped by subtle and ongoing forces of colonisation and subsequent displacement.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/making-space-how-designing-hospitals-for-indigenous-people-might-benefit-everyone-122550">Making space: how designing hospitals for Indigenous people might benefit everyone</a>
</strong>
</em>
</p>
<hr>
<p>Only one-fifth of frequent attenders have access to a car in a town with no public transport (other than school buses). This affects people’s health in the tropics where it’s a long, hot walk from where most Indigenous people live to the pharmacy. </p>
<p>It is really no wonder more than half of frequent attenders have not taken their medicines, contributing to their presentation to the emergency department.</p>
<p>For frequent presenters to Katherine Hospital, poverty and illness go hand in hand. When you are living in an over-crowded house, and the <a href="https://www.jacanaenergy.com.au/residential/metering/prepaid_meters">A$20 power card</a> feeding the air conditioner expires on a 43°C tropical day, when your heart, lungs and kidneys are chronically malfunctioning and the insulin in the fridge slowly warms, the only free number you can call for help is “000” for an ambulance trip to hospital.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1206693515377467392"}"></div></p>
<p>These are some of the real-world challenges of closing the gap in Indigenous health. But these challenges can be overcome. </p>
<h2>Here’s what worked</h2>
<p>We have <a href="https://www.mdpi.com/1660-4601/16/22/4306/htm">recently published evidence</a> of how a locally driven program can make a difference.</p>
<p>When some of the town’s most vulnerable people attend the emergency department, the program connects them to primary care and other supports. It also tackles underlying drivers of hospitalisation such as homelessness or inadequate housing.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=797&fit=crop&dpr=1 600w, https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=797&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=797&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1001&fit=crop&dpr=1 754w, https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1001&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1001&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">At the emergency department, people are supported to move away from inadequate housing, as well as being treated for their physical or mental illness.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>The referral point taps into a critical moment when people choose to turn up to hospital, asking for help.</p>
<p>This is an opportunity to do things differently. As such, the program re-defines “help” beyond the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5750953/">biomedical paradigm</a>, to both improve health and use limited resources more efficiently. </p>
<p>This contrasts with past approaches grounded in <a href="https://www.abc.net.au/news/2017-04-21/nt-mandatory-alcohol-rehab-has-little-health-impact-report-finds/8459998">discipline and law</a> that have failed to meaningfully help people who suffer the combined disharmony of sickness, homelessness and alcohol. </p>
<p>Among the 109 people supported in the first ten months of the program, there was a 23% reduction in emergency department presentations.</p>
<h2>More GP visits</h2>
<p>A <a href="https://grattan.edu.au/wp-content/uploads/2018/07/906-Mapping-primary-care.pdf">Grattan Institute report</a> found the most disadvantaged people living in the remotest areas are the least likely to see or have access to a GP.</p>
<p>In Katherine, many of the people presenting frequently to the emergency department with chronic diseases would benefit from being managed by their GP or other primary care provider.</p>
<p>As a result of the program, there was a 90% increase in GP attendance.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-the-housing-shortage-exacerbates-scabies-in-indigenous-communities-71337">Why the housing shortage exacerbates scabies in Indigenous communities</a>
</strong>
</em>
</p>
<hr>
<h2>Community support is vital</h2>
<p>The program has been developed gradually over the past five years, first with an understanding of <a href="https://www.mja.com.au/journal/2016/204/3/factors-contributing-frequent-attendance-emergency-department-remote-northern">who the hospital’s frequent attenders are</a>, and then getting the community on board. </p>
<p>Central to the program’s success is this community support. The four main partners include the hospital, the <a href="https://www.wurli.org.au/">Wurli-wurlinjang</a> local Aboriginal health service, the <a href="http://kalano.org.au/">local Aboriginal housing organisation</a> and <a href="http://www.krahrs.org.au/">Katherine Regional Aboriginal Health and Related Services</a>. </p>
<p>Other partners including the <a href="https://www.shelterme.org.au/katherine-doorways-hub">first ever homeless hub in Katherine</a> (a drop-in centre and community space for homeless people), as well as St John Ambulance, Mission Australia, Red Cross and the territory housing department.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/refugees-in-their-own-land-how-indigenous-people-are-still-homeless-in-modern-australia-55183">Refugees in their own land: how Indigenous people are still homeless in modern Australia</a>
</strong>
</em>
</p>
<hr>
<h2>The harsh reality of the town camp</h2>
<p>Just off Katherine’s main drag is a patch of thick scrub that shields visitors from seeing the harsh realities of <a href="https://theconversation.com/refugees-in-their-own-land-how-indigenous-people-are-still-homeless-in-modern-australia-55183">Warlpiri Transient Camp</a>. This is where many people who frequently present to the emergency department live.</p>
<p>This <a href="https://dlghcd.nt.gov.au/town-camps/about-town-camps">“temporary” camp</a>, set up over 40 years ago, houses some of the sickest people in what is one of the sickest towns in Australia. </p>
<p>Up to 20 people live in small dwellings bursting at the seams. These structures often provide meagre refuge to people on dialysis, with failing hearts from rheumatic heart disease, and to the elderly and frail.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/307573/original/file-20191218-11924-ux1kcq.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/307573/original/file-20191218-11924-ux1kcq.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=640&fit=crop&dpr=1 600w, https://images.theconversation.com/files/307573/original/file-20191218-11924-ux1kcq.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=640&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/307573/original/file-20191218-11924-ux1kcq.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=640&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/307573/original/file-20191218-11924-ux1kcq.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=804&fit=crop&dpr=1 754w, https://images.theconversation.com/files/307573/original/file-20191218-11924-ux1kcq.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=804&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/307573/original/file-20191218-11924-ux1kcq.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=804&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Up to 20 people live in small dwellings bursting at the seams, some without electricity never mind air-conditioning.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Only a handful of these dwellings are air conditioned; some don’t even have electricity. Often it is sickness that drives people from ancestral lands into bigger towns like Katherine to access health services like kidney dialysis.</p>
<p>But <a href="https://www.katherinetimes.com.au/story/6434194/dialysis-patients-forced-onto-housing-waiting-list/">housing is less available than dialysis</a>. And the camp is not a destination of choice.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/want-to-improve-the-nations-health-start-by-reducing-inequalities-and-improving-living-conditions-64434">Want to improve the nation's health? Start by reducing inequalities and improving living conditions</a>
</strong>
</em>
</p>
<hr>
<p><a href="https://www.mdpi.com/1660-4601/16/22/4306/htm">Our analysis of the program</a> demonstrates some striking features of people who live in the camp and who frequently attend the emergency department.</p>
<p>First, they are very sick. Almost 10% had died before the end of the first year of the program. Participants had an average of 2.8 significant health problems, many fold higher than the <a href="https://www.aihw.gov.au/getmedia/666de2ad-1c92-4db3-9c01-1368ba3c8c98/ah16-3-3-chronic-disease-comorbidities.pdf.aspx">Australian average</a>.</p>
<p>Three out of five didn’t have reliable access to enough affordable, nutritious food. Almost one-third had chronic kidney disease, and 10% were on dialysis. Of the 11 people needing dialysis three times a week, eight met the <a href="https://www.abs.gov.au/websitedbs/censushome.nsf/home/factsheetsh">Australian Bureau of Statistics’ definition of homelessness</a>; three were living in a tent.</p>
<p>Needless to say, nowhere else in Australia is it imaginable that someone sick enough to require dialysis has to live in a tent in temperatures <a href="https://www.katherinetimes.com.au/story/6548992/tuesday-was-australias-hottest-day-ever/?cs=9397">regularly above 40°C</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-chronic-kidney-disease-and-why-are-one-in-three-at-risk-of-this-silent-killer-81942">Explainer: what is chronic kidney disease and why are one in three at risk of this silent killer?</a>
</strong>
</em>
</p>
<hr>
<h2>A safe home, a working fridge and a good education</h2>
<p>Modern western medicine is the icing on the cake of a healthy and meaningful life. For people who do not have even the most fundamental building blocks of a normal urban existence, like the vast majority of people in this trial, applying western medicine is like icing a cake that has not yet been baked.</p>
<p>A safe home, a fridge that remains powered and relatively stocked, access to transport, and a good education, are ingredients that need to be slowly and systematically put together over a lifetime for western medicine to be an appropriate first step in resolving an individual health problem. </p>
<p>Applying a biomedical model of emergency care is nothing more than a very expensive band aid. But emergency departments can be structured in innovative ways to make a much bigger difference.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/to-close-the-health-gap-we-need-programs-that-work-here-are-three-of-them-91482">To close the health gap, we need programs that work. Here are three of them</a>
</strong>
</em>
</p>
<hr>
<img src="https://counter.theconversation.com/content/127020/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Quilty set up and designed the project mentioned in the article.</span></em></p><p class="fine-print"><em><span>Lisa Wood evaluated the program mentioned in the article.</span></em></p>A safe home, a working fridge and access to transport are all needed before western medicine has a chance of working in the long term. But a new way of providing care can help.Simon Quilty, Senior Staff Specialist, Alice Springs Hospital. Honorary, Australian National UniversityLisa Wood, Associate Professor, School of Population and Global Health, The University of Western AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1216372019-08-14T05:07:59Z2019-08-14T05:07:59ZPatients have rights. Here’s how to use yours<figure><img src="https://images.theconversation.com/files/287949/original/file-20190814-136203-jkg1tg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">What rights do you have when discussing medical treatments or test results with your doctor?</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/professional-treatment-nice-smart-pleasant-man-750044245?src=7aaC6FBe4ldDNXdnqzhvig-1-24">from www.shutterstock.com</a></span></figcaption></figure><p>Working your way around the health-care system can be overwhelming. This is especially hard when care takes place in health systems <a href="https://theconversation.com/waiting-for-better-care-why-australias-hospitals-and-health-care-are-failing-104862">under stress</a>.</p>
<p>However as a patient, you have rights about how you’re treated. This includes not just your actual therapy, but how you’re spoken to, how your records are handled and even whether you wish to be treated at all.</p>
<p>Now, the Australian Commission on Safety and Quality in Health Care <a href="https://www.safetyandquality.gov.au/national-priorities/charter-of-healthcare-rights/review-of-the-charter-of-healthcare-rights-second-edition">has updated</a> its <a href="https://www.safetyandquality.gov.au/sites/default/files/2019-06/Charter%20of%20Healthcare%20Rights%20A4%20poster%20ACCESSIBLE%20pdf.pdf">charter of patient rights</a>.</p>
<p>The idea is to promote a more active role in health care for patients (and their carers) by reminding them of their seven rights: access to health care, safety, respect, partnership, information, privacy and giving feedback. </p>
<p>But what do these rights really mean when it comes to day-to-day issues you or your family might face with your GP, in hospital or in a nursing home?</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-an-australian-charter-of-rights-is-a-matter-of-national-urgency-121411">Why an Australian charter of rights is a matter of national urgency</a>
</strong>
</em>
</p>
<hr>
<h2>Example 1: leaving hospital early</h2>
<p>Imagine an elderly patient who has been hospitalised with an infection. After a couple of days of treatment, she <a href="https://jamanetwork.com/journals/jama/article-abstract/203118">wants to go home</a> to live alone. The patient’s doctors are worried she won’t be able to take care of herself and try to convince her to move into a rehabilitation facility. She refuses.</p>
<p><em>Respect</em> means the patient has the right to make her own choices, even if they could result in harm. But this doesn’t mean just abandoning the patient to her rights. A first step is the right to <em>information</em>, to ensure she understands the risks of going home. <em>Partnership</em> requires communication with the patient herself as well as other people she chooses, like family members and friends. This helps <a href="https://www.sciencedirect.com/science/article/pii/S0738399113004722">support the patient</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/hospital-discharges-to-no-fixed-address-heres-a-much-better-way-106602">Hospital discharges to ‘no fixed address’ – here's a much better way</a>
</strong>
</em>
</p>
<hr>
<h2>Example 2: dementia restraints</h2>
<p><a href="https://www.aihw.gov.au/reports-data/health-conditions-disability-deaths/dementia/overview">More than half</a> of all people in permanent residential aged care have dementia. </p>
<p>Sometimes patients become physically aggressive, becoming a danger to themselves and others. Physical and chemical restraints for these people has been widespread, and is being considered by the <a href="https://agedcare.royalcommission.gov.au/Pages/Terms-of-reference.aspx">Royal Commission into Aged Care Quality and Safety</a>.</p>
<p>Restraints won’t be the right thing <a href="https://ama.com.au/position-statement/restraint-care-people-residential-aged-care-facilities-2015">in all cases</a>. Whether it’s right for a particular person requires balancing <em>respect</em> for the patient’s own views and dignity, with other people’s rights to <em>safety</em>. <em>Respect</em> can be facilitated by working in <em>partnership</em> with the patient and their family to identify safe options other than restraint.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/physical-restraint-doesnt-protect-patients-there-are-better-alternatives-111060">Physical restraint doesn't protect patients – there are better alternatives</a>
</strong>
</em>
</p>
<hr>
<h2>Example 3: health information disclosure</h2>
<p>Trips to the emergency department are often scary and sensitive. The visit can be even worse if you feel others can overhear your conversations with doctors or nurses.</p>
<p><a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1742-6723.2005.00702.x">More than one in ten</a> people who went to the emergency department of a major Melbourne hospital reported this experience. These people felt the loss of their <em>privacy</em>. It also might fail to show respect, dignity and consideration, as required in the right to <em>respect</em>.</p>
<p>But not every unwanted disclosure of health information will be wrong. Some might even be necessary to meet other health-care rights. </p>
<p>For instance, an emergency department with curtains instead of walled rooms to help people or equipment move more freely might meet the <em>safety</em> right even though it risks a patient’s right to <em>privacy</em>. But the charter at least means hospitals and treating teams have to justify any unwanted disclosure of health information. It also means patients who feel uncomfortable can <em>give feedback</em>, another of their rights.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/paper-tsunami-how-the-move-to-digital-medical-records-is-leaving-us-drowning-in-old-paper-files-119534">Paper tsunami: how the move to digital medical records is leaving us drowning in old paper files</a>
</strong>
</em>
</p>
<hr>
<h2>How does Australia stack up?</h2>
<p>Other countries have created similar lists of patients’ rights, including <a href="https://www.hdc.org.nz/your-rights/the-code-and-your-rights/">New Zealand</a> and <a href="https://www2.gov.scot/Resource/0039/00390989.pdf">Scotland</a>.</p>
<p>The most valuable part of the Australian charter is improving patient and carer understanding of existing health-care rights. This makes it easier to know when to complain to a state or territory <a href="https://www.ahpra.gov.au/Notifications/Further-information/Health-complaints-organisations.aspx">complaints commission</a>, or the <a href="https://www.ahpra.gov.au/Notifications/Raise-a-concern.aspx">Australian Health Practitioner Regulation Agency</a>.</p>
<p>Although the Australian Commission on Safety and Quality in Health Care is releasing <a href="https://www.safetyandquality.gov.au/our-work/partnering-consumers/australian-charter-healthcare-rights/supportive-resources-second-edition-charter">more resources</a> for patients, its charter may not go far enough in protecting groups who <a href="https://www.abc.net.au/news/2019-07-29/naomi-williams-tumut-sepsis-death-inquest-findings/11355244">experience systemic bias</a> in their health-care interactions. This includes many Aboriginal and Torres Strait Islander people.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/ms-dhu-coronial-findings-show-importance-of-teaching-doctors-and-nurses-about-unconscious-bias-60319">Ms Dhu coronial findings show importance of teaching doctors and nurses about unconscious bias</a>
</strong>
</em>
</p>
<hr>
<p>Another pitfall of the charter is its non-binding nature. It describes the rights patients should expect but it does little to enforce them. This can leave the charter as something of a toothless tiger, an issue also discussed <a href="http://www.cmaj.ca/content/182/13/E641.short">internationally</a>. </p>
<p>The charter also doesn’t deal with potential <a href="https://www.bmj.com/content/bmj/335/7631/1187.full.pdf">patient responsibilities</a>. These are the obligations consumers have for their own health, like treating staff considerately and keeping medical appointments. </p>
<p>It’s hard to see how one can exist without the other.</p><img src="https://counter.theconversation.com/content/121637/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lisa Eckstein is an investigator on two current Australian Research Council Discovery Program Grants - Genomic Data Sharing: Shaping an Optimal Regulatory Framework and Reforming the Regulatory Environment for Innovative Health Technologies: Identifying Congestion and Filling Gaps.</span></em></p><p class="fine-print"><em><span>Rebekah McWhirter is on the board of Women’s Health Tasmania and has been supported by NHMRC and ARC grants.</span></em></p>It’s all very well having rights. But what do these rights really mean when you’re with your GP, in hospital or in a nursing home?Lisa Eckstein, Senior Lecturer in Law and Medicine, University of TasmaniaRebekah McWhirter, Research Fellow, Centre for Law and Genetics, University of TasmaniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1048622018-10-30T02:58:44Z2018-10-30T02:58:44ZWaiting for better care: why Australia’s hospitals and health care are failing<figure><img src="https://images.theconversation.com/files/242387/original/file-20181025-71038-17bngcx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Health is the largest single component of state government expenditure.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/245905492?src=jhlWisgjKa449M1gf5-h5A-1-61&size=huge_jpg">Shutterstock/hxdbzxy</a></span></figcaption></figure><p><em>This week we’re exploring nine different policy areas across Australia’s states, as detailed in Grattan Institute’s State Orange Book 2018. Read the other articles in the series <a href="https://theconversation.com/au/topics/state-of-the-states-2018-61464">here</a></em>.</p>
<hr>
<p>Australia has a good health system by international standards, but it has to get better. Half of all patients across Australia wait more than a month for an elective hospital procedure, such as a hip replacement. This is in addition to waiting for an outpatient visit so they can be added to the elective procedure wait list. </p>
<p>“Elective” here doesn’t mean the patient can do without the procedure – they may be in pain or having trouble moving around while waiting. Elective simply means it doesn’t have to be done immediately and can be scheduled.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/to-keep-patients-safe-in-hospitals-the-accreditation-system-needs-an-overhaul-101513">To keep patients safe in hospitals, the accreditation system needs an overhaul</a>
</strong>
</em>
</p>
<hr>
<p>About 9% of people in New South Wales and about 25% in South Australia wait more than a year for public dental services, such as fillings, extractions and root canals. </p>
<p>Physicians report nearly one-third of patients with an acute mental illness wait more than eight hours in hospital emergency departments.</p>
<p>The Grattan Institute’s <a href="https://grattan.edu.au/report/state-orange-book-2018/">State Orange Book 2018</a> charts the performance, maps a route to improvement, and recommends penalties for states that fail to meet waiting list targets. </p>
<h2>Why hospitals are always key state election issues</h2>
<p>Health is the largest single component of state government expenditure in every state of Australia, and <a href="https://grattan.edu.au/report/budget-pressures-on-australian-governments-2014/">has been growing rapidly</a>. About two-thirds of <a href="https://www.aihw.gov.au/reports/health-welfare-expenditure/health-expenditure-australia-2015-16/contents/summary">state government health spending</a> – excluding transfers from the Commonwealth – is on public hospitals. </p>
<p>Just over half the population does not have health insurance and so relies on public hospitals for all their care. Even for people with private insurance, public hospitals are their principal source of emergency care. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/242391/original/file-20181025-71017-1e527cl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/242391/original/file-20181025-71017-1e527cl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=449&fit=crop&dpr=1 600w, https://images.theconversation.com/files/242391/original/file-20181025-71017-1e527cl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=449&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/242391/original/file-20181025-71017-1e527cl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=449&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/242391/original/file-20181025-71017-1e527cl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=565&fit=crop&dpr=1 754w, https://images.theconversation.com/files/242391/original/file-20181025-71017-1e527cl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=565&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/242391/original/file-20181025-71017-1e527cl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=565&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Even Australians with private health insurance use public emergency departments.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/270431723?src=CRCnZ-2UKKWBIUb0mQBTmg-1-12&size=huge_jpg">Annette Shaff/Shutterstock</a></span>
</figcaption>
</figure>
<p>State governments are responsible for public hospitals, so hospital care is always a key issue in state elections. It is therefore no surprise state governments love to tell us how much they are doing for public hospitals, and election campaigns are often jam-packed with promises of new or expanded hospitals.</p>
<p>The politicians, at least in states with growing populations, are right that more beds are needed. What matters for the public, though, is not how many beds there are, but whether there are enough. One way of measuring that is waiting times, and here the picture isn’t as rosy as campaigning politicians would like us to believe.</p>
<h2>Waiting for elective hospital procedures</h2>
<p>It’s bad enough half of all patients across Australia wait more than a month for an elective procedure from the time they were booked. What’s worse is that about 10% wait more than six months. </p>
<p>In our smallest state, Tasmania, 10% of patients wait about a year. In the biggest state, NSW, the situation is almost as bad. </p>
<p><strong>This graph shows the waiting time (days) for elective procedures, 2012-13 to 2016-17, for the 10% of patients who wait longest (orange) and the median (maroon):</strong></p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/242860/original/file-20181030-76384-o3lxkt.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/242860/original/file-20181030-76384-o3lxkt.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/242860/original/file-20181030-76384-o3lxkt.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=393&fit=crop&dpr=1 600w, https://images.theconversation.com/files/242860/original/file-20181030-76384-o3lxkt.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=393&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/242860/original/file-20181030-76384-o3lxkt.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=393&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/242860/original/file-20181030-76384-o3lxkt.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=494&fit=crop&dpr=1 754w, https://images.theconversation.com/files/242860/original/file-20181030-76384-o3lxkt.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=494&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/242860/original/file-20181030-76384-o3lxkt.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=494&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Grattan Institute/Australian Institute of Health and Welfare</span></span>
</figcaption>
</figure>
<p>Publicly reported data focus on elective procedure or elective surgery waiting times, but there is another important wait: from the time a patient is referred to the hospital to the time they are seen in an outpatient clinic. This is sometimes called the <a href="https://theconversation.com/getting-an-initial-specialists-appointment-is-the-hidden-waitlist-99507">“hidden waiting list”</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/getting-an-initial-specialists-appointment-is-the-hidden-waitlist-99507">Getting an initial specialists' appointment is the hidden waitlist</a>
</strong>
</em>
</p>
<hr>
<p>For the patient, the wait for an appointment with an outpatient clinic matters – it delays diagnosis and treatment. Yet these waits are not publicly reported in NSW, Western Australia, the Australian Capital Territory or the Northern Territory. And the states that do report outpatient clinic wait times do not use consistent measures. </p>
<p>Our state and territory governments should strengthen hospital accountability to reduce combined outpatient and inpatient waiting times. There should be clear consequences and penalties for failure to meet targets.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/242392/original/file-20181025-71026-19w3hop.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/242392/original/file-20181025-71026-19w3hop.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/242392/original/file-20181025-71026-19w3hop.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/242392/original/file-20181025-71026-19w3hop.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/242392/original/file-20181025-71026-19w3hop.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/242392/original/file-20181025-71026-19w3hop.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/242392/original/file-20181025-71026-19w3hop.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">First you have to wait to get on the waiting list. Then you get booked in for your procedure.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/counting-down-days-calendar-110130863?src=e7fmSXAl-CJ1LfyBpfMKeg-1-2">Shutterstock/cvm</a></span>
</figcaption>
</figure>
<h2>Waiting for public dental care</h2>
<p>The <a href="http://www.coaghealthcouncil.gov.au/Portals/0/Australia%27s%20National%20Oral%20Health%20Plan%202015-2024_uploaded%20170216.pdf">COAG Health Council</a> (made up of Commonwealth, state and territory health officials) says current funding for public dental services allows for treatment of only about 20% of the eligible population. </p>
<p>The remaining 80% have to wait for long periods, pay for relatively expensive care in the private sector, or go without care entirely.</p>
<p>Waiting times vary significantly among states. And in several states, notably Vic and SA, <a href="https://www.pc.gov.au/research/ongoing/report-on-government-services/2018/health/primary-and-community-health">waiting times have got longer in recent years</a>.</p>
<p>Boosting public dental services will improve people’s health and reduce the strain on hospitals. </p>
<p>In 2015-16, there were <a href="https://www.aihw.gov.au/getmedia/acee86da-d98e-4286-85a4-52840836706f/aihw-hse-201.pdf.aspx?inline=true">67,266 hospital admissions for potentially preventable dental conditions</a> – more than one-fifth of all hospital admissions for potentially preventable acute conditions.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/poor-and-elderly-australians-let-down-by-ailing-primary-health-system-100586">Poor and elderly Australians let down by ailing primary health system</a>
</strong>
</em>
</p>
<hr>
<p>Unforgivably, our state governments have not delivered on a 2012 commitment to monitor waiting times for public dental care through a National Healthcare Agreement performance indicator. Data inconsistencies mean it is <a href="https://www.aihw.gov.au/getmedia/df234a9a-5c47-4483-9cf7-15ce162d3461/aihw-den-230.pdf.aspx?inline=true">not possible to reliably compare public dental waiting lists</a> across states and territories. </p>
<p>NSW does not provide data on public dental waiting lists at all, citing concerns about the potential for misleading comparisons. The only comparable data we have is from an Australian Bureau of Statistics sample survey, which shows more than 10% of patients across the country wait more than a year for public dental care. </p>
<p><strong>This graph shows the proportion of people who waited more than a year for public dental services:</strong></p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/242862/original/file-20181030-76402-11wzj6r.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/242862/original/file-20181030-76402-11wzj6r.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/242862/original/file-20181030-76402-11wzj6r.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=391&fit=crop&dpr=1 600w, https://images.theconversation.com/files/242862/original/file-20181030-76402-11wzj6r.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=391&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/242862/original/file-20181030-76402-11wzj6r.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=391&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/242862/original/file-20181030-76402-11wzj6r.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=491&fit=crop&dpr=1 754w, https://images.theconversation.com/files/242862/original/file-20181030-76402-11wzj6r.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=491&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/242862/original/file-20181030-76402-11wzj6r.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=491&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Notes: The figures in smaller states should be regarded as approximate; the percentages are of those who have been seen, and do not include those still waiting at the time of the survey.</span>
<span class="attribution"><span class="source">Grattan Institute/Australian Bureau of Statistics</span></span>
</figcaption>
</figure>
<h2>Waiting for mental health care</h2>
<p>Campaigners say Australia has reached a “tipping point” on access to mental health care. Physicians report nearly one-third of patients with an acute mental illness wait more than eight hours in emergency departments. </p>
<p>We know this does damage: long waits for access to community mental health services can result in poorer outcomes for patients, as a condition may be harder to control the longer it persists. Long waits may also place additional pressure on families or friends who face the consequences of their friend or family member’s behaviour. </p>
<p>Yet there is no information about the adequacy of community mental health services in Australia. The 2017 <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/mental-fifth-national-mental-health-plan">National Mental Health and Suicide Prevention Plan</a> only tracks the use of services, not their adequacy. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/more-australians-can-stay-healthier-and-out-of-hospital-heres-how-55746">More Australians can stay healthier and out of hospital – here's how</a>
</strong>
</em>
</p>
<hr>
<p>In contrast, Canadian governments have agreed that a <a href="http://www.highperforminghealthcaresystems.com/content/25550">wide range of mental health and addictions indicators</a> will be collected and reported from 2019. </p>
<p>Australian voters should demand their state governments do the same thing. We should wait no longer for a better health system.</p><img src="https://counter.theconversation.com/content/104862/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and contribute to funding Grattan Institute's activities. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities as disclosed on its website. The State Orange Book 2018, from which this article draws, was supported by a grant from the Susan McKinnon Foundation.</span></em></p>Australians are waiting too long for elective surgery, dental care and treatment for mental health. It’s no wonder health is a vote-changer.Stephen Duckett, Director, Health Program, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/961702018-05-14T21:57:50Z2018-05-14T21:57:50ZHow to solve Canada’s wait time problem<figure><img src="https://images.theconversation.com/files/218635/original/file-20180511-34027-1r1tz5n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nearly every Canadian family has a wait time story. This is because our system is not designed to provide optimal care for patients with multiple chronic diseases. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Canadians are <a href="https://www.theglobeandmail.com/opinion/article-bc-where-access-to-a-wait-list-is-considered-access-to-health-care/">fed up with long wait times</a> for <a href="http://www.cbc.ca/news/health/hip-knee-replacement-wait-times-1.4615531">health-care services</a>. </p>
<p>A new <a href="http://waittimes.cihi.ca">analysis from the Canadian Institute for Health Information (CIHI)</a> shows wait times for hip and knee replacements and also cataract surgeries have increased across Canada since 2015.</p>
<p>But we love our health care system. In particular, we take pride in the principle that care should be provided on the basis of need, rather than ability to pay. </p>
<p>Our system and its virtues have become part of our collective identity. We even named Tommy Douglas, the architect of medicare, “<a href="http://www.cbc.ca/archives/entry/and-the-greatest-canadian-of-all-time-is">The Greatest Canadian of all time</a>.” </p>
<p>Are long wait times simply the price we must pay in order to uphold our Canadian values of equity and fairness?</p>
<p>As a doctor of medicine and professor who has spent a career in health policy and advocacy, I disagree. Our health system — designed in the 1960s — is in dire need of an overhaul. Canadians and their health needs have changed, but the system hasn’t changed with them. Wait times are not the core problem. They are a <em>symptom</em> of the problem. </p>
<p>And, like every doctor, I would rather cure the problem than just treat the symptoms.</p>
<h2>A nation of perpetual pilot projects</h2>
<p>It can be difficult to challenge the status quo, particularly when the health system has become so iconic. </p>
<p>Critics argue, however, that our “system” is not really a system at all — our public investment is largely confined to doctors and hospitals while home and community care, drugs, rehabilitation, long term care, dentistry and many other important health services are paid for from a mixed bag of public, private and out-of-pocket sources. </p>
<p>Our federated model has created provincial and territorial silos, and our attempts at integration and reform have largely fallen flat. Monique Bégin famously said that we are a <a href="http://www.cmaj.ca/content/180/12/1185">country of perpetual pilot projects</a>, lamenting our inability to scale-up and spread new ways of doing things. </p>
<p>The highly respected Commonwealth Fund has consistently <a href="http://www.commonwealthfund.org/publications/fund-reports/2017/may/international-profiles">ranked our system either ninth or 10th out of 11 peer countries</a> for many years now. </p>
<p>On one issue in particular — wait times — we rank dead last.</p>
<h2>The ‘wait time problem’</h2>
<p>Nearly every Canadian family has a wait-time story. We wait in emergency departments. We wait to see family physicians. We wait for tests, procedures and surgeries. We wait to see specialists. We even wait to get <em>out</em> of hospital — an increasing number of Canadian seniors find themselves in acute care hospital beds not because they are sick, but because they cannot live independently and have nowhere else to go.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/218903/original/file-20180514-100722-m2s73x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/218903/original/file-20180514-100722-m2s73x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/218903/original/file-20180514-100722-m2s73x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/218903/original/file-20180514-100722-m2s73x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/218903/original/file-20180514-100722-m2s73x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/218903/original/file-20180514-100722-m2s73x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/218903/original/file-20180514-100722-m2s73x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A ‘national seniors’ strategy’ could help fix the system to reduce wait times.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Successive provincial, territorial and federal governments have all acknowledged and addressed the wait-time problem. In 2004, Prime Minister Paul Martin announced a 10-year health accord with the provinces, touting it as the <a href="http://policyoptions.irpp.org/magazines/the-2004-federal-election/a-fix-for-a-generation/">fix for a generation</a>. </p>
<p><a href="http://www.waittimealliance.ca/">The Wait Time Alliance (WTA)</a>, a national federation of medical specialty societies and the Canadian Medical Association, developed a <a href="http://www.waittimealliance.ca/benchmarks/">list of evidence-based wait-time benchmarks</a> for nearly 1,000 health services so that progress could be measured. </p>
<p>A total of <a href="https://www.theglobeandmail.com/opinion/editorials/a-retrospective-on-the-fix-for-a-generation/article4096807/">$41.3 billion was spent by the federal government over 10 years</a>, including $5.5 billion to specifically address wait times in five key areas: Cancer, cardiac, sight restoration, medical imaging (CT and MRIs) and joint replacement.</p>
<p>Some provinces, notably Ontario, saw improvement. Annual report cards from the WTA and Canadian Institutes for Health Information (CIHI) showed modest improvements across the country. </p>
<h2>A landscape of chronic disease</h2>
<p>But now were are seeing slippage. Performance on wait times is <a href="https://www.cihi.ca/en/wait-times-for-priority-procedures-in-canada-2017">holding steady at best</a>. It’s increasingly clear that all this money bought us time, but did not fix the problem.</p>
<p>And no wonder. Because the problem is not a lack of investment. Canada has the fifth most expensive health-care system in the world. <a href="https://www.cihi.ca/en/health-spending">In 2017, we spent around 11.5 per cent of our GDP on health care</a>. </p>
<p>Spending more is not the solution. Spending smarter is.</p>
<p>The underlying problem is the system itself (or, rather, the lack of a system). The hodgepodge of bureaucracies, budgets, facilities and providers that collectively carry out the business of health care in this country are more disconnected than ever before. </p>
<p>At the same time, patients’ health-care experiences are changing. No longer is the health-care landscape dominated by acute illness — where you get sick, you get treated and then you get better. </p>
<p>Increasingly, the landscape is dominated by chronic disease. In fact, most patients with chronic disease actually have <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60240-2/fulltext"><em>multiple</em> chronic diseases</a>. </p>
<h2>How to fix the system</h2>
<p>Our system is not designed to provide optimal care for these patients and, as a result, everything slows down. Patients with complex needs who are not really acutely ill wind up in emergency departments and hospitals. </p>
<p>Emergency departments and hospitals, in turn, experience overcrowding and can’t do what they are designed to do. Surgeries and procedures get cancelled, wait times increase and everyone gets delayed care.</p>
<p>Fixing the <em>system</em> is the only way we will ever get wait times to come down. History has shown that spending more money doing the same things over and over does not work. </p>
<p>A great place to start would be to develop and implement a <a href="https://www.demandaplan.ca/">national seniors’ strategy</a>. Such a strategy would acknowledge that the new health-care landscape is one of multiple chronic diseases driven by our aging population. It would work to develop a properly integrated, transdisciplinary model of care in the community. </p>
<p>Doing so would free up hospitals to do what they are supposed to be doing — looking after acutely ill people and performing procedures and surgeries. Budgets that align with patient trajectories, wherever they are in the system, rather than with institutions or programs, will allow smarter, more efficient spending. </p>
<p>And building in incentives for better patient outcomes, shorter waits and enhanced satisfaction will help realign our primary accountability — to the patients we serve rather than to the institutions where we work.</p><img src="https://counter.theconversation.com/content/96170/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chris Simpson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>To improve wait times for surgery, Canada needs to fix its health-care system. Developing a national seniors’ strategy would be a good place to start.Chris Simpson, Acting Dean, Faculty of Health Sciences, Queen's University, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/920402018-02-20T00:20:15Z2018-02-20T00:20:15ZGrey’s Anatomy is unrealistic, but it might make junior doctors more compassionate<figure><img src="https://images.theconversation.com/files/207031/original/file-20180219-116351-1pwovei.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Grey's Anatomy's portrayal of trauma experiences is far more dramatic than in real life.</span> <span class="attribution"><a class="source" href="http://www.imdb.com/title/tt0413573/mediaviewer/rm2607778304">IMDb/Shondaland, The Mark Gordon Company, Touchstone Television (2005-2007), ABC Studios</a></span></figcaption></figure><p>Patient experiences in the TV drama Grey’s Anatomy are, unsurprisingly, portrayed inaccurately when compared with real-life trauma cases, according to a new study.</p>
<p>The US-based medical team of researchers wanted to see if the long-running program, now in its fourteenth season, was realistic in showing what happens to patients when they are rushed to hospital after experiencing a major injury. They reviewed 269 episodes of the program and compared the fictional patients’ treatment and outcomes with those from a database of nearly 5,000 real patients collected in their hospital.</p>
<p>The study, published today in the journal <a href="http://tsaco.bmj.com/content/3/1/e000137">Trauma Surgery & Acute Care Open</a>, found most of the fictional patients (71%) were transferred from emergency directly to the operating theatre. This happened to only one in four of the real patients. </p>
<p>The fictional patients also died three times more frequently than the real patients. But if they survived their injury, they were more likely to recover quickly, without further surgeries – and be discharged early.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/aoeouk2UezY?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Fictional patients in Grey’s Anatomy died around three times more frequently than the real patients.</span></figcaption>
</figure>
<p>Writing from the perspective of health-care providers working in trauma medicine, the researchers advised fans of Grey’s Anatomy who found themselves or their family members in emergency departments after traumatic injury, that they could hold unrealistic expectations of their care and recovery. But they also noted that it was difficult to know how much credence lay people placed on fictional portrayals of medical care. </p>
<p>Given the enduring popularity of television medical dramas, other researchers have wondered about the accuracy of depictions of medical care and illness in these programs, and what key messages viewers might take away from watching them. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/friday-essay-tvs-troubling-storylines-for-characters-with-a-mental-illness-81456">Friday essay: TV's troubling storylines for characters with a mental illness</a>
</strong>
</em>
</p>
<hr>
<p>For example, several research teams have criticised medical dramas showing heart resuscitation techniques for conveying misinformation about their effectiveness, such as <a href="http://www.nejm.org/doi/full/10.1056/nejm199606133342406">far higher survival rates</a> from a heart attack, or <a href="http://www.resuscitationjournal.com/article/S0300-9572(09)00403-1/abstract">more younger people experiencing attacks</a> than in real life. </p>
<p>Numerous studies have found that such portrayals could have an effect on perceptions, but their findings are often contradictory. <a href="https://academic.oup.com/her/article-abstract/32/2/107/3069890?redirectedFrom=fulltext">A review of several such studies</a> found that viewing fictional medical TV programs had a negative influence on viewers’ health-related knowledge, perceptions or behaviour in 11% of studies, a positive influence in 32% of studies, and mixed influence in 58%.</p>
<p>The mixed results are indicative of what <a href="https://books.google.com.au/books?hl=en&lr=&id=Osf-AwAAQBAJ&oi=fnd&pg=PA366&dq=active+audience&ots=HeHyxt3bVm&sig=7CGug_LKO340Xy2q0nYTka05T0Q#v=onepage&q=active%20audience&f=false">media studies researchers have long argued</a>: that television viewers don’t passively absorb what they see on their screens. They are active audiences, drawing on other sources of information such as their own experiences, talking to others, and other forms of media to interpret what they see on television. </p>
<h2>From god-like to human</h2>
<p>Medical dramas have long been a staple of television, from the days of Dr Kildare and Marcus Welby in the 1960s, to the more recent ER, Casualty, Cardiac Arrest, Scrubs, House, and Grey’s Anatomy. In Australia, the likes of The Young Doctors, A Country Practice, GP and All Saints have received high ratings and long runs.</p>
<p>Over these decades, <a href="http://www.tandfonline.com/doi/abs/10.1080/08998280.2010.11928659">the portrayal of doctors has changed dramatically</a>. The first generation of TV doctors were typically white, male, kindly and paternalistic – the “doctor knows best” archetype. Recent medical dramas, in contrast, feature both men and women in doctor roles, with a range of ages and ethnic and racial backgrounds. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/abIbAFxNizw?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Television portrayals of doctors have changed with the times.</span></figcaption>
</figure>
<p>Doctors are no longer depicted as god-like creatures, but instead as regular humans who may be dedicated to their craft but suffer from insecurities. They make mistakes, succumb to stress, and have relationship problems. Some even struggle with drug addictions or personality disorders. </p>
<p>The eponymous House, for example, is a brilliant doctor in his diagnostic abilities. However, he is addicted to pain medication, clashes constantly with other staff members, and lacks personal interest in his patients.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/I4o9U5QJeHA?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Dr House is addicted to pain medication and has serious problems with his communication style.</span></figcaption>
</figure>
<h2>Influence on medical students</h2>
<p>Medical shows might not just affect patients, but also aspiring or current doctors. Viewers may be inspired to become doctors by watching their favourite television characters, or develop ideas about how doctors should behave and present themselves to patients. </p>
<p><a href="https://bmcmededuc.biomedcentral.com/articles/10.1186/1472-6920-11-50">An Australian study</a> of undergraduate medical students training in Sydney in 2011 found that most students had seen the series House and Scrubs, and to a lesser extent Grey’s Anatomy. Students were asked which characters on Grey’s Anatomy and House (the two major medical dramas at the time) they would most and least want to be like in their professional careers.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/gn--7WFOlx8?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Some TV shows could actually teach medical students empathy.</span></figcaption>
</figure>
<p>Derek Shepherd and Miranda Bailey from Grey’s Anatomy were viewed as the most positive role models. The characters viewed as most negative were Christina Yang and Meredith Grey from Grey’s Anatomy, and House himself. </p>
<p>Many students said they recalled the ethical issues raised in the shows. Of these, the most frequently recalled were medical mistakes (96.6%), death and dying (94.6%), professional misconduct (92%), and quality or value of life or personhood (91.1%). Many discussed these issues with their friends and family after watching the programs.</p>
<p>The authors suggested their research had implications for medical education and that there may be “benefit in using the shows in tutorials or lectures as case studies or examples for students”.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/scrubs-house-greys-anatomy-are-medical-students-learning-bad-habits-2627">Scrubs, House, Grey's Anatomy: Are medical students learning bad habits?</a>
</strong>
</em>
</p>
<hr>
<p>Television medical drama, it seems, is still an important avenue for portraying the medical profession and medical care. In this digital age, future researchers should broaden the focus to investigate how doctors and patients alike present videos and images of themselves and medical procedures in online forums and social media, such as <a href="https://simplysociology.wordpress.com/2016/07/14/digitised-dissection-medical-procedures-on-the-internet/">YouTube, Instagram, Pinterest and Snapchat</a>.</p><img src="https://counter.theconversation.com/content/92040/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Deborah Lupton has received funding from the Australian Research Council to conduct research on how doctors are portrayed in the news media. She is a board member of the Australian Privacy Foundation.</span></em></p>A new study compared fictional patient experiences in Grey’s Anatomy with real trauma cases. It concluded patients who are fans of the show might have unrealistic expectations of medical care.Deborah Lupton, Centenary Research Professor, University of CanberraLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/698792017-07-05T01:03:32Z2017-07-05T01:03:32ZDoctors and nurses can’t always tell if someone’s drunk or on drugs, and misdiagnosis can be dangerous<figure><img src="https://images.theconversation.com/files/171991/original/file-20170602-22797-icl539.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Even emergency department staff can have trouble telling if someone's intoxicated as clinical clues can mislead.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/159380372?src=OWQQcAH0BbqI0JnY4UHWWQ-2-85&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>Bob has arrived at the emergency department at 10am on a Tuesday after breaking several fingers slamming his hand in a car door. Bob is quite anxious; he speaks quickly and paces around. When asked to sit and explain what has happened, he provides an articulate account of events. A look at past medical records indicates Bob has recently been admitted to hospital for alcohol withdrawal. Bob’s blood alcohol concentration is 0.35% (or 0.35 grams per decilitre). For the average person, this could be fatal. But Bob is sitting upright with little outward cues he has been drinking heavily.</p>
<p>Now we turn to Bruce. Bruce stumbles up the street at 1am on a dark Saturday night. He loses his footing more than once and pauses multiple times as it seems he is struggling to avoid throwing up. Bruce’s speech is slurred and incoherent. Suddenly, he collapses in the street. When passers by check on him, they notice considerable cuts and bruises to his head. The man isn’t drunk; he was in a fight earlier that night and has a head injury.</p>
<p>These examples demonstrate “common sense” doesn’t always tell you who’s drunk and who’s sober. While slurred speech or lack of coordination might help, we cannot apply these cues in all circumstances.</p>
<p>These cues can be masked in people with high levels of tolerance to alcohol, or displayed by people who are not under the influence but have medical conditions with similar symptoms. For instance, both head injuries and <a href="https://www.diabetesaustralia.com.au/ketoacidosis">diabetic ketoacidosis</a> (when people have very high blood sugar levels in type 1 diabetes) have symptoms that mimic being drunk.</p>
<p>So what if Bruce, who seems drunk but is completely sober, turns up to emergency? Would staff have made the right diagnosis?</p>
<h2>Mistakes could be deadly</h2>
<p>Many of the issues surrounding correctly diagnosing someone with alcohol intoxication apply to correctly diagnosing someone who’s taken other drugs; mistakes could lead to illness and death.</p>
<p>The consequences of falsely identifying someone as intoxicated when they really have a life-threatening condition can be severe; they can receive the wrong treatment, or not receive treatment at all.</p>
<p>It is equally important to correctly identify intoxication with alcohol or other drugs, especially identifying the exact substance taken as some drugs can produce seemingly similar effects. Again, correctly identifying intoxication avoids giving medications incompatible with what the person’s taken.</p>
<p>While alcohol and drug testing (for instance blood or urine tests) is useful to determine intoxication objectively, their cost and time constraints may sometimes mean this is impractical. So, health care staff must accurately pick up on visual and verbal cues to tell if someone’s intoxicated or not.</p>
<p>But clinical suspicion alone may lead to missing a significant proportion of people who are intoxicated. In one study, trauma surgeons <a href="http://journals.lww.com/jtrauma/Abstract/1999/12000/Detection_of_Acute_Alcohol_Intoxication_and.27.aspx">failed to identify 23%</a> of patients who were acutely alcohol intoxicated.</p>
<h2>Why intoxication might be missed</h2>
<p>In one study that assessed emergency doctors’ and nurses’ knowledge of and attitudes to intoxication, <a href="http://www.sciencedirect.com/science/article/pii/S1755599X08000967">most (73.8%)</a> had not received specific training about drug and alcohol issues.</p>
<p>And as many people go to the emergency department with drug and alcohol related issues <a href="https://www.ncbi.nlm.nih.gov/pubmed/19378442">over the weekend or after hours</a> staff may not have enough time to interact sufficiently with each patient to pick up intoxication cues. </p>
<p>In some cases it may not be whether someone is intoxicated, but what they are intoxicated with that’s the issue. For instance, someone may have taken a <a href="https://www.ncbi.nlm.nih.gov/pubmed/25588018">novel psychoactive substance</a> (a designer drug) or more than one substance at once. These make it particularly difficult to spot and so provide the right treatment. </p>
<p>Bias may also play a role. In the <a href="http://journals.lww.com/jtrauma/Abstract/1999/12000/Detection_of_Acute_Alcohol_Intoxication_and.27.aspx">trauma surgeon study</a>, patients who the surgeons thought were dishevelled or of low socio-economic status were more likely to be falsely suspected of being drunk. And men were twice as likely as women to be falsely suspected of being drunk. But doctors were more likely to miss intoxication if patients were “well groomed”. </p>
<p>These issues are also relevant for first-responders as the ability for police, ambulance staff, and firefighters to correctly identify alcohol (and other drug) intoxication will influence how they approach and interact with people.</p>
<h2>How about the rest of us?</h2>
<p>So with these experienced and trained health workers potentially missing or misinterpreting the signs of intoxication, what chances do the rest of us have?</p>
<p>We might tell if friends and family are drunk because we know them sober so can compare their behaviours. If we try to tell if a stranger’s drunk, the context (such as a bar) might help, or it might be deceptive.</p>
<p>For drugs other than alcohol, we might know what our friends or family have taken. This information is vital for health professionals to know, so tell paramedics or other health workers so they can make the right treatment choices, even if this makes you feel uncomfortable. In the majority of drug overdoses police <a href="http://www.nuaa.org.au/wp-content/uploads/2014/03/police-overdose.pdf">will not get involved</a>.</p>
<h2>What we need to do</h2>
<p>It is astonishing how little research has been devoted to the topic of accurate detection of whether or not someone’s drunk or on drugs. We still can’t be certain people are receiving adequate training in this area, not only for individual substances but also if they have taken more than one substance.</p>
<p>How much someone’s taken and individual differences in how people respond to these substances also complicate the picture.</p>
<p>As there are a range of potential reasons why clinical suspicion may not be sufficient to detect intoxication (or rule out conditions that mimic intoxication), this suggests objective alcohol and drug testing may need to be more widely applied.</p>
<p>Knowing how to reliably assess intoxication will benefit the health services (correct diagnoses), first responders in general, and ultimately the community.</p><img src="https://counter.theconversation.com/content/69879/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lauren Monds is affiliated with NSW Health. </span></em></p><p class="fine-print"><em><span>Celine van Golde does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>We all know what a drunk person looks like, right? Wrong. Even health care workers can be confused.Lauren Monds, Research Fellow in Addiction Medicine, Research Officer in Forensic Psychology, University of SydneyCeline van Golde, Associate Lecturer in Forensic Psychology, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/794302017-06-19T01:04:46Z2017-06-19T01:04:46ZEmergency doctors are using acupuncture to treat pain, now here’s the evidence<figure><img src="https://images.theconversation.com/files/174109/original/file-20170616-519-1v70ply.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Doctors with special training in acupuncture and practitioners of traditional Chinese medicine worked together in emergency departments.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/467699921?src=UHqdQ2DUj9poIUxTG_8Haw-1-36&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>Emergency medicine is not all about life and death situations and high-tech solutions. Our study, the largest of its kind in the world, shows using acupuncture in the emergency department can relieve acute pain.</p>
<p>The study, published today in the <a href="https://www.mja.com.au/journal/2017/206/11/acupuncture-analgesia-emergency-department-multicentre-randomised-equivalence">Medical Journal of Australia</a>, finds acupuncture is as effective as medication in treating pain for lower back pain and ankle sprain. But it took more than an hour for either to provide adequate pain relief.</p>
<p>Our study builds on previous research to show the effectiveness of acupuncture to treat <a href="http://www.bmj.com/content/338/bmj.a3115">chronic</a> (long-term) <a href="https://www.ncbi.nlm.nih.gov/pubmed/20070551">pain</a>.</p>
<p>Yet, there are several barriers to using acupuncture routinely in emergency departments.</p>
<h2>What is acupuncture and who practices it?</h2>
<p>Using acupuncture to relieve pain involves placing needles in various parts of the body to stimulate the release of endorphins and other neurochemicals, which can act as the body’s naturally occurring pain relievers.</p>
<p>For generations <a href="https://theconversation.com/modern-acupuncture-panacea-or-placebo-8102?sa=google&sq=acupuncture&sr=1">various cultures</a> around the world have used acupuncture to treat multiple conditions, including providing pain relief. And in Australia, it is reimbursed through the <a href="http://www9.health.gov.au/mbs/search.cfm?q=173-195&sopt=I">Medicare Benefits Schedule</a> when administered by a medical doctor.</p>
<hr>
<p><em>Further reading: <a href="https://theconversation.com/modern-acupuncture-panacea-or-placebo-8102?sa=google&sq=acupuncture&sr=1">Modern acupuncture: panacea or placebo?</a></em></p>
<hr>
<p>Acupuncture is one of the <a href="http://online.liebertpub.com/doi/abs/10.1089/acm.2005.11.995">most accepted</a> forms of complementary medicine among Australian general practitioners. It also appears in treatment guidelines for doctors in <a href="https://tgldcdp.tg.org.au/guideLine?guidelinePage=Analgesic&frompage=etgcomplete">how to manage</a> pain. </p>
<h2>Why we ran the study and what we did</h2>
<p>Anecdotally, we were aware that several emergency department doctors, in both public and private hospitals in Australia, were treating patients’ pain with acupuncture. But until this large federally-funded study, no-one had set up a trial like it to show how effective it was.</p>
<p>Our trial was an “equivalence” study, which means we aimed to see if the different treatments were equivalent rather than seeing if they were better than <a href="https://theconversation.com/explainer-what-is-the-placebo-effect-and-are-doctors-allowed-to-prescribe-them-55219?sa=google&sq=placebo&sr=1">placebo</a>. We did this as it would not be ethical to give a placebo to people coming to an emergency department for pain relief.</p>
<p>So, we randomly assigned more than 500 patients to receive standard painkillers, standard painkillers plus acupuncture, or acupuncture alone when they presented with back pain, migraine or ankle sprain at four Melbourne hospitals (some private, some public). While the patients knew which treatment they had, the researchers involved in assessing their pain didn’t (known as a single-blind study).</p>
<p>The type of acupuncture we used included applying needles at specific points on the body for each condition, as well as along points chosen by the treating acupuncturist. This was to reflect what would happen during regular clinical practice.</p>
<p>Doctors who were also qualified medical acupuncturists and practitioners of traditional Chinese medicine (registered in Victoria with the <a href="http://www.chinesemedicineboard.gov.au/">Chinese Medicine Registration Board of Australia</a>) performed the acupuncture.</p>
<p>After treatment, we assessed patients’ pain after an hour, and every hour until discharge. We also rang them for an update 24-48 hours after being discharged.</p>
<h2>What we found</h2>
<p>We found acupuncture, either alone or with painkillers, was equivalent to drugs-alone in providing pain relief for lower back pain, ankle sprain, but not for migraine.</p>
<p>When patients looked back on their treatment, the vast majority (around 80%) were satisfied with their treatment regardless of which treatment they had.</p>
<p>However, no treatment provided good pain relief until after the first hour.</p>
<h2>What are the implications?</h2>
<p>Our findings suggest acupuncture may be a viable option for patients who come to the emergency department for pain relief. This is especially important for those who cannot or choose not to have analgesic drugs. </p>
<p>This is also an important finding in light of the potential for side effects and abuse with opioid analgesics, which might otherwise be used to relieve pain in the emergency department.</p>
<p><a href="http://www.iama.edu/OtherArticles/acupuncture_WHO_full_report.pdf">Previous research</a> shows using acupuncture to treat chronic pain is comparable to morphine, is safer and doesn’t lead to dependence. Our findings suggest acupuncture also has a role in treating acute pain.</p>
<p>However, our research raises several issues, not only about conducting such research but also in implementing our findings in practice.</p>
<p>We had to overcome many ethical, policy and regulatory issues before we started. These included issues around the qualifications of medical and non-medical acupuncturists and employing traditional Chinese medicine practitioners to deliver acupuncture in a western medical hospital.</p>
<p>And to more widely implement our findings, we need to discuss the type of practitioners best placed to deliver acupuncture in hospital, what type of training they need to work in the emergency department and what type of conditions they should treat.</p>
<p>Hopefully, our study will spark further research to address these issues and lead to the development of safe and effective protocols for acute pain relief that may involve combining both modern and ancient forms of medicine to achieve rapid and effective analgesia for all emergency department patients.</p><img src="https://counter.theconversation.com/content/79430/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marc Cohen received funding from the NHMRC. </span></em></p>Some emergency doctors are already using acupuncture to relieve patients’ pain. Now a new study shows when it works, when it doesn’t and how emergency departments of the future might use it.Marc Cohen, Professor of Health Sciences, RMIT UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/774622017-05-31T20:18:05Z2017-05-31T20:18:05ZAfter-hours GP home visits strain the budget (and don’t help emergency departments)<figure><img src="https://images.theconversation.com/files/170483/original/file-20170523-8883-1flsbdr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">After-hours home medical services are offered with bulk billing. But are they the best use of taxpayers' money?</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/520263562?src=aD11o6aSl2O2l414Kw3a-A-1-1&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>After-hours home medical services are a burden on our health budget and don’t ease the strain on emergency departments after all, new research shows.</p>
<p>The roll out of after-hours GP-type home visits is linked with as much as a ten-fold increase in Medicare claims in one jurisdiction. And rather than reducing the need to visit the emergency department, their rise in popularity has been accompanied by a slight <em>increase</em> in visits.</p>
<p>Our findings, published today in the <a href="http://www.racgp.org.au/afp/">Australian Family Physician</a> journal, question whether these convenient house calls are really the best use of taxpayers’ money.</p>
<h2>What are after-hours home medical services?</h2>
<p>The way people access GP-type services after their regular doctor’s surgery has closed for the day, or at weekends, has changed considerably in recent years. </p>
<p>In the past, if you called your GP after hours, you might hear a recorded message with the phone number of an after-hours medical service to attend. Alternatively, the message would recommend you go to the local emergency department.</p>
<p>But over the past five years, there has been a proliferation of after-hours medical services that come to you. These services advertise 100% bulk-billed consultations by GPs and other doctors in the home.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/170270/original/file-20170522-4471-4cqy65.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/170270/original/file-20170522-4471-4cqy65.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/170270/original/file-20170522-4471-4cqy65.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=301&fit=crop&dpr=1 600w, https://images.theconversation.com/files/170270/original/file-20170522-4471-4cqy65.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=301&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/170270/original/file-20170522-4471-4cqy65.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=301&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/170270/original/file-20170522-4471-4cqy65.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=379&fit=crop&dpr=1 754w, https://images.theconversation.com/files/170270/original/file-20170522-4471-4cqy65.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=379&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/170270/original/file-20170522-4471-4cqy65.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=379&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">After-hours medical services like this one offer bulk-billed home visits in the comfort of your own home.</span>
<span class="attribution"><a class="source" href="https://www.homedoctor.com.au/">Screen shot/National Home Doctor Service</a></span>
</figcaption>
</figure>
<h2>A blow-out in Medicare claims</h2>
<p>Doctors can claim one of several Medicare items to reimburse them for providing care <a href="https://www.humanservices.gov.au/health-professionals/enablers/after-hours-incentive">after hours</a>. The precise item number depends on whether the service they provide is urgent, where they provide that service and the length of the consultation.</p>
<p>There’s been a <a href="https://theconversation.com/is-medicare-facing-a-cost-blowout-from-urgent-after-hours-care-rebates-60785">rapid growth</a> in claims <a href="http://www.smh.com.au/national/health/boom-in-afterhours-gps-raises-concerns-about-medicare-cost-blowout-20160511-gosr95.html">reported</a> for all after-hours Medicare items. And since 2014, claims for these items increased <a href="http://www.aph.gov.au/%7E/media/Committees/clac_ctte/estimates/add_1617/Health/Answers/SQ17_000203.pdf">five times</a> faster than the rate of standard GP consultations.</p>
<p><a href="https://theconversation.com/is-medicare-facing-a-cost-blowout-from-urgent-after-hours-care-rebates-60785">Attention has focused</a> on Medicare <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/mbsprimarycare-changes-to-medicare-primary-care-items-qanda">item 597</a>, the key item number for such, “urgent” after-hours consultations.</p>
<p>We reviewed the <a href="http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp">Medicare statistics website</a> from 2010/11, when these after-hours services started to be launched. In the period since then until 2015/16 the number of claims for item 597 increased by 170%.</p>
<p>This growth has naturally affected Medicare expenditure. In the five years before 2010/11, <a href="http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp">annual expenditure</a> on item 597 increased from A$55 million to A$72 million, a 29% increase. But in the next five years, expenditure increased to A$197 million, a 136% increase.</p>
<h2>What’s driving this increase?</h2>
<p>So what’s driving this increase, not only in the number of Medicare claims, but how much they cost the taxpayer?</p>
<p>We examined whether there was any truth in <a href="http://www.smh.com.au/national/health/boom-in-afterhours-gps-raises-concerns-about-medicare-cost-blowout-20160511-gosr95.html">media reports</a> suggesting the emergence of after-hours home medical services was largely responsible.</p>
<p>We identified key dates when the services were set up or expanded in Western Australia (WA), Tasmania, Australian Capital Territory (ACT) and Northern Territory (NT). Then we tracked changes in quarterly Medicare rebates against item 597 in each jurisdiction.</p>
<p>All jurisdictions had rapid and substantial increases in claims for item 597 after services in their area were set up or expanded.</p>
<p>To illustrate this, we charted the growth in claims from the quarter before the services were established up to the second quarter of 2016.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/170458/original/file-20170523-7354-rmd704.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/170458/original/file-20170523-7354-rmd704.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/170458/original/file-20170523-7354-rmd704.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=311&fit=crop&dpr=1 600w, https://images.theconversation.com/files/170458/original/file-20170523-7354-rmd704.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=311&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/170458/original/file-20170523-7354-rmd704.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=311&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/170458/original/file-20170523-7354-rmd704.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=391&fit=crop&dpr=1 754w, https://images.theconversation.com/files/170458/original/file-20170523-7354-rmd704.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=391&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/170458/original/file-20170523-7354-rmd704.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=391&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">All jurisdictions had rapid and substantial increases in claims for item 597 after services in their area were set up or expanded.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>In the ACT, there was a 1,057% increase in claims since the second quarter of 2014; Tasmania saw a 521% increase since the fourth quarter of 2014; in WA there was a 348% increase since the second quarter of 2012; and for the NT, a 219% increase since the first quarter of 2015 was reported.</p>
<h2>Impact on emergency department visits</h2>
<p>Supporters of after-hours home medical services <a href="http://www.namds.com/wp-content/uploads/2017/01/NAMDS-Medicare-Benefits.pdf">say</a> the growth in Medicare claims associated with these services <em>reduces</em> government expenditure. This is because
fewer people use emergency departments.</p>
<p>A recent <a href="http://www.namds.com/wp-content/uploads/2017/01/Deloitte-Report-Analysis-of-after-hours-primary-care-pathways-1.pdf">report</a> by Deloitte Access Economics, commissioned by the National After-Hours Medical Deputising Service, estimated A$724 million in savings over four-years due to reduced emergency department presentations. This estimate was based on the assumption that 25% of “avoidable GP-type” emergency department presentations would receive care through after-hours home visiting medical services instead. However, there is no evidence to support this assumption.</p>
<p>According to the latest <a href="http://www.aihw.gov.au/publication-detail/?id=60129557372">report</a> from the Australian Institute of Health and Welfare, emergency department presentations in all states <em>increased</em> between 2011/12 and 2015/16 by 2.7%.</p>
<p>Indeed, both emergency presentations and, as we have shown, Medicare claims for item 597 are increasing.</p>
<p>Recently released <a href="http://www.aph.gov.au/%7E/media/Committees/clac_ctte/estimates/add_1617/Health/Answers/SQ17_000203.pdf">Senate Estimates documents</a> provide interesting reading. An estimated 180,000 people received three or more “urgent” consultations from an after-hours home visiting medical service between 2014 and 2016. Of these, more than 10,000 had no contact with a regular GP.</p>
<p>If these services are truly meeting previously unmet demand for urgent medical care, then we should see a decrease in emergency department presentations. However, this is not occurring.</p>
<h2>What’s behind these figures?</h2>
<p>What we are likely observing is clever marketing, using multiple channels – like web-based advertising, YouTube videos, flyers in pharmacies – to fuel demand for these new services.</p>
<p>Another potential reason for the increased claims for item 597 relates to reimbursement. As the rate for urgent after-hours consultations is higher than non-urgent consultations, some doctors or businesses may be tempted to claim an urgent consultation.</p>
<h2>What needs to happen next?</h2>
<p>There is no definition of “urgent” in the Medicare Benefits Schedule as doctors are well-placed to decide what’s urgent. However, greater scrutiny of claims against item numbers for urgent consultations, such as regular audits, may be warranted.</p>
<p>As part of wider Medicare reforms, the federal health department and Royal Australian College of General Practitioners are <a href="http://health.gov.au/internet/main/publishing.nsf/Content/98C1ED2053EF2A8CCA25811B002759EC/$File/Agreement%20RACGP.pdf">aiming to</a> set up a new after-hours rebate structure and will also review after-hours billing practices.</p>
<p>The <a href="http://www.health.gov.au/internet/main/publishing.nsf/content/mbsreviewtaskforce">Medicare Benefits Schedule review</a> is also expected to publish its recommendations about after-hours medical care soon.</p><img src="https://counter.theconversation.com/content/77462/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Barbara de Graaff receives funding from Primary Health Tasmania to evaluate primary health care in the after-hours.. </span></em></p><p class="fine-print"><em><span>Mark Nelson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>After-hours home medical services cost the taxpayer dearly and don’t reduce emergency department visits, according to new research.Barbara de Graaff, Postdoctoral Research Fellow, Health Economics, University of TasmaniaMark Nelson, Head, Discipline of General Practice, University of TasmaniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/763082017-04-19T04:29:35Z2017-04-19T04:29:35ZIf a croc bite doesn’t get you, infection will<figure><img src="https://images.theconversation.com/files/165748/original/image-20170419-32700-mceytd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Open wide ... the mouths of crocodiles like this contain bacteria that cause potentially lethal infections in people they bite.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/269526644?src=FpjaBKKNSjPO5jVUrnr_PQ-1-18&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>Most people assume if you’re unlucky enough to be bitten by a crocodile, then a severed limb or other severe trauma is all you have to worry about. But new research is emerging about serious infections you can catch from a bite that might kill you instead.</p>
<p>Our study, published <a href="https://www.mja.com.au/journal/2017/206/7/microbiology-crocodile-attacks-far-north-queensland-implications-empirical">earlier this week</a>, showed the range of bacteria crocodiles can transfer to their human victims. The good news is they can be cured with a much simpler antibiotic treatment than we realised.</p>
<p>Since crocodiles were granted <a href="http://www.environment.gov.au/cgi-bin/sprat/public/publicspecies.pl?taxon_id=1774">protected species</a> status in the 1970s in Australia, they have attacked <a href="http://www.crocodile-attack.info/">more than 100 humans</a>.</p>
<p>For those lucky to survive, their injuries often become infected. Bacteria can enter the body via the deep cuts from a crocodile’s teeth or from wounds occurring when people try to escape.</p>
<p>Bacteria living in crocodiles’ mouths can come from the intestines of other animals they eat or from the water in which they live.</p>
<p>When people are trying to escape a crocodile attack, bacteria living in the soil and mud also pose a risk. And bacteria commonly living on our skin without causing problems can cause infection when the skin’s protective barrier is lost. </p>
<p>If untreated, bacteria can cause severe wound infections. Without treating these infections properly, the victim’s tissues die and their arms and legs may need to be amputated. Infection can also enter the bloodstream and spread to the rest of the body causing multiple organ failure and death.</p>
<h2>How do we treat croc bite infections?</h2>
<p><a href="https://tgldcdp.tg.org.au/guideLine?guidelinePage=Antibiotic&frompage=etgcomplete">Australian guidelines</a> recommend how to treat infections after bites from animals in general. But until recently we didn’t know much about which antibiotic is best for people who have been attacked by a crocodile.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/165739/original/image-20170418-32689-mij7lb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/165739/original/image-20170418-32689-mij7lb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=868&fit=crop&dpr=1 600w, https://images.theconversation.com/files/165739/original/image-20170418-32689-mij7lb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=868&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/165739/original/image-20170418-32689-mij7lb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=868&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/165739/original/image-20170418-32689-mij7lb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1090&fit=crop&dpr=1 754w, https://images.theconversation.com/files/165739/original/image-20170418-32689-mij7lb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1090&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/165739/original/image-20170418-32689-mij7lb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1090&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Crocodiles make the front page across Australia’s Top End.</span>
<span class="attribution"><a class="source" href="http://www.bandt.com.au/information/uploads/2016/07/croc_03_custom-f2ec6b20d09f44d5cae4485128053ff664983800.jpg">NT News</a></span>
</figcaption>
</figure>
<p>Some 25 years ago, a <a href="http://europepmc.org/abstract/med/1453999">study</a> in the Northern Territory found over half of people who had been attacked by a crocodile had infected wounds.</p>
<p>Researchers found a wide variety of bacteria you would expect to find in the water, the soil, the intestines of animals and on the skin of humans. To kill all of these potential infection causing bacteria, they recommended a complex treatment of four different antibiotics which would mean up to 14 injections a day. With so many antibiotics, this increases the risk of potential side effects and the cost of patient care.</p>
<p>So, we <a href="https://www.mja.com.au/journal/2017/206/7/microbiology-crocodile-attacks-far-north-queensland-implications-empirical">reviewed</a> all cases of people who had been treated for a crocodile attack in Far North Queensland and attended the Cairns Hospital over a 25-year period. </p>
<p>A total of 15 people needed medical attention after a crocodile attack over this time, including several crocodile handlers. Four people were clearly infected by the time they reached hospital. A further two had bacteria in their wounds and almost all needed surgery. </p>
<p>Surgery is essential to prevent new or worsening infection after any bite as surgeons can remove already-infected tissue and help flush out any bacteria hiding in the wounds.</p>
<p>Despite finding lots of different bacteria, we discovered antibiotics given orally (amoxycillin-clavulanate) in mild infections or intravenously (piperacillin-tazobactam) for severe infections would be suitable to kill almost all of the bacteria found after a crocodile attack.</p>
<p>Although all of these patients were treated at Cairns Hospital, the results of the study will likely influence national guidelines for the management of crocodile attacks. The results may even help doctors in other countries. </p>
<h2>Prevention is your best bet</h2>
<p>Although we did not find it in our study, another important thing to remember is tetanus – an infection that can be contracted through dirty wounds – may also develop after a crocodile attack and this can be prevented by <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-tetanus">vaccination</a>.</p>
<p>When it comes to crocodile attacks, like most things in health, prevention is better than cure. People should take care when visiting areas where crocodiles live. If people are attacked and lucky enough to survive, they are likely to require surgery and have a high chance of developing an infection. </p>
<p>A crocodile is a beautiful creature to observe from a distance, but in the <a href="https://genius.com/Frank-churchill-never-smile-at-a-crocodile-from-peter-pan-soundtrack-version-lyrics">words</a> of American composer Frank Churchill:</p>
<blockquote>
<p>Don’t be taken in by his welcome grin.</p>
</blockquote><img src="https://counter.theconversation.com/content/76308/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Smith does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Until recently we didn’t know much about which antibiotic is best for people who have been attacked by a crocodile.Simon Smith, Adjunct Lecturer (Clinical), Medicine, James Cook UniversityLicensed as Creative Commons – attribution, no derivatives.