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Editor—Fatovich highlights the important international problem of overcrowding in emergency departments, a common cause of this being the decreased availability of inpatients beds.1 The risk of waits is proportional to the average bed occupancy. In the United Kingdom it is now recognised that excessively high bed occupancy (over 85%2) is a sign not of efficient management but of failure to plan.
MICHAEL DONNE/SPL
Fatovich suggests only two long term measures to address overcrowding. Although increasing the number of beds should decrease overcrowding, it has to be combined with a bed management system, working across elective and emergency components, to ensure that average bed occupancy is kept at 82-85% (this may require an extra 10 000 beds in England).
Overcrowding in emergency departments can be solved only by measures across the whole health community. In the prehospital phase, systems must be in place to avoid unnecessary attendance at the emergency department (for example, easy availability of urgent primary care, protocols for ambulance services to discharge patients to a variety of destinations, access to urgent specialist clinics). Some, however, have suggested that it is better to adapt the emergency department system and that creating new routes may increase total workload.3
In the emergency department patient flows must be optimised to avoid delay (for example, by streaming of patients). Adequate staff of appropriate seniority and training must be available, staff must be used to maximum benefit (for example, by matching staffing levels and workload by the hour, autonomous practice by nurse practitioners), and diagnostics must be available at all times. Early senior input decreases unnecessary admissions.
Various community link schemes—for example, for deep vein thrombosis and chronic obstructive pulmonary disease—have reduced numbers of patients needing a hospital bed. In the hospital, teams must ensure regular review of all patients, with processes to avoid delays in investigations and discharge. Social care and primary care must be adequately funded and designed to permit safe early discharge.
If a motorway becomes a car park at rush hour the solution is not just to add more lanes but to look at flows on and off the motorway and at the whole transport infrastructure. The principles are the same in overcrowded emergency departments and are part of the government's strategy in the United Kingdom.4
2.Bagust A. Place M, Posnett JW. Dynamics of bed use in accommodating emergency admissions: stochastic simulation model. BMJ. 1999;319:155–158. doi: 10.1136/bmj.319.7203.155. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.New Zealand Health Technology Assessment Clearing House. Christchurch: New Zealand Health Technology Assessment; 1998. Emergency department attendance: a critical appraisal of the literature; p. 35. [Google Scholar]
Editor—We are concerned about the resuscitation algorithm displayed in Fatovich's review on emergency medicine.1-1 The legend below the algorithm indicates that it was adapted from the Resuscitation Council (UK) website. We wish to make it very clear that these modifications are not consistent with the Resuscitation Council (UK) and European Resuscitation Council (ERC) guidelines for advanced life support (ALS), and the changes to the algorithm were made without approval by either of these organisations. The publication of this modified algorithm in a prominent British journal will confuse European healthcare professionals and detracts from the consistent educational approach we strive to achieve on the Resuscitation Council (UK) and European Resuscitation Council course I advanced life support.
The algorithm displayed in Fatovich's review is the one published in the International Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.1-2 The correct European Resuscitation Council and Resuscitation Council (UK) universal algorithm for advanced life support is displayed at www.resus.org.uk/pages/alsalgo.pdf. Vasopressin is not included in the European Resuscitation Council and Resuscitation Council (UK) guidelines.1-3 This decision was made by the advanced life support working group of the European Resuscitation Council after careful consideration of the scientific evidence and economic consequences of including vasopressin in the guidelines. A recent randomised controlled trial showing no benefit from vasopressin after cardiac arrest in hospital provides further support for this decision.1-4 The results of a European multicentre prospective randomised trial comparing vasopressin with adrenaline in prehospital cardiac arrest will be available soon (V Wenzel, personal communication). Any role for vasopressin in the European Resuscitation Council and Resuscitation Council (UK) guidelines for advanced life support will be reconsidered at this stage.
Other adaptations to the algorithm include changes to the list of potentially reversible causes and to the wording of the interventions to be considered during cardiopulmonary resuscitation.
1-2.American Heart Association in collaboration with the International Liaison Committee on Resuscitation (ILCOR) International guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care—a consensus on science. Resuscitation. 2000;46:1–448. [Google Scholar]
1-3.De Latorre F, Nolan J, Robertson C, Chamberlain D, Baskett P. European Resuscitation Council guidelines 2000 for adult advanced life support. A statement from the advanced life support working group and approved by the executive committee of the European Resuscitation Council. Resuscitation. 2001;48:211–221. doi: 10.1016/s0300-9572(00)00379-8. [DOI] [PubMed] [Google Scholar]
1-4.Stiell IG, Hebert PC, Wells GA, Vandemheen KL, Tang AS, Higginson LA, et al. Vasopressin versus epinephrine for inhospital cardiac arrest: a randomised controlled trial. Lancet. 2001;358:105–109. doi: 10.1016/S0140-6736(01)05328-4. [DOI] [PubMed] [Google Scholar]
Editor—Fatovich's clinical review of emergency medicine does not address several initiatives to resolve the situation of inappropriate referral and access block.2-1 The author has suggested expanding existing systems, such as increasing the number of beds and enlarging emergency departments, which may only partially relieve the problem.
Several other strategies to improve the situation have undergone trials in south west Sydney, Australia. These systems work as complementary services to the emergency department and are based on improving communication with general practitioners and other healthcare workers and providing a range of alternative paths for patients with acute conditions.
These strategies include a general practice run after hours on the hospital site, with experienced general practitioners working on a rota system every evening, and direct referral from general practitioners or the emergency department to an ambulatory care service with a specialist on call seven days (24 hours) a week.2-2 Patients may be referred to these services and offered an alternative to hospital admission. A responsive primary health nursing service is also available to target patients attending emergency departments who are at risk of presenting again.
This approach, involving multidisciplinary and multifaceted community care, improved communication between the general practitioner and hospital, and integration with the emergency department, provides many care options. It also results in better use of the emergency department's stretched resources.
2-2.Wison S, Chapman C, Nancarrow L, Collins J. Macarthur model for ambulatory services. Aust Health Review. 2001;24:187–193. doi: 10.1071/ah010187. [DOI] [PubMed] [Google Scholar]
Editor—Cooke reinforces the international nature of the problem of emergency department overcrowding. I support the comment by Cooke, that excessively high bed occupancy (over 85%) is not a sign of efficient management but a sign of failure to plan. Derlet has said that, should there be a major epidemic of infectious disease or national catastrophe, emergency departments and hospitals could not accommodate the demand.3-1
Cooke is correct in saying that the solutions require a response of the whole system but incorrect in saying that I suggested only two long term measures to address overcrowding. The text clearly states that all the causes of overcrowding outlined in box B1 need to be addressed. As said in the methods, because of space restrictions it is simply not possible to provide a comprehensive review.
Cooke also says that an extra 10 000 beds are required in England to help decrease overcrowding, with the aim of keeping bed occupancy at 82-85%. This reinforces the finding that overcrowding in emergency departments is due to increased demand and decreased capacity.3-1 The data from Poolman et al on the prolonged times required for organising admission of patients highlight the congestion of the acute hospital system. They also reinforce the loss of clinical productivity and effectiveness for doctors participating in disposing patients.3-2
Wilson suggests several strategies, including a general practice after hours on the hospital site. This sends a clear message to the community to attend the hospital with their problem, thus potentially aggravating the situation. The focus should be to use community based resources as much as possible.
I agree with the comments of Nolan et al. The reference for the algorithm came from reference 6 in the paper, and this is what was originally submitted. The reference to the Resuscitation Council (UK) website was an editorial mistake. The adaptations reflect the American Heart Association algorithm.3-3 I agree with their comments on vasopressin, and the reference they quote to support this is the same as reference 7 in my paper. Although I do not use vasopressin in my practice, the comments in my paper that vasopressin is included as an option in the (American Heart Association) algorithm nevertheless reflects that algorithm.
References
3-1.Derlet RW. Overcrowding in emergency departments: increased demand and decreased capacity. Ann Emerg Med. 2002;39:430–432. doi: 10.1067/mem.2002.122707. [DOI] [PubMed] [Google Scholar]
