Emergency Doctor: Don’t Expect ED To Handle Everything

An emergency medicine doctor suggests a multidisciplinary approach to start plans for patients entering the emergency department, instead of leaving it to the ED alone to manage a surge of patients.

KUALA LUMPUR, Dec 22 — An emergency medicine doctor from a public hospital in the Klang Valley has called for collective plans across departments for patients to be started when they enter the emergency room.

Dr Avicen (pseudonym) stated that currently, stabilisation and treatment — based on patient plans from the primary team — is executed in the emergency department (ED).

However, with the near constant inflow of patients and the lack of beds affecting the level of care that patients receive, Dr Avicen proposed that a collective plan consisting of input from various doctors in other departments be put in place.

“Whenever there is a surge capacity issue, it becomes a hospital response and should not be left to a department to stand alone to solve it. This multidisciplinary involvement is essential to ensure care of a patient is not delayed in every aspect of care,” Dr Avicen told CodeBlue in an interview, requesting anonymity as civil servants are prohibited from speaking to the press.

“The goal here is to ensure that whatever plans that are made for the patient are a collective plan together with the primary team. And to start off treatment as early as possible so that by the time the patient goes into the ward, the care is already started, the treatment started.

“So hoping that by the time the patient goes to ward, one-tenth of the treatment has started, therefore less time spent in the hospital to stabilise the patient.”

The ED has traditionally been a transit zone where patients are rushed in for a sudden illness or injury, resuscitated or stabilised, and whisked out to be immediately admitted into their respective inpatient wards.

However, emergency rooms in public hospitals in Malaysia are undergoing a metamorphosis, as bed shortages and rising patient arrivals force doctors to treat patients in the ED itself.

“Basically, we do start treatment for patients in the emergency department. Let’s say, for example, the patient comes in, so the emergency component is started until the patient is relatively stabilised,” Dr Avicen explained.

“When the patient is not stable – let’s say the patient has difficulty breathing – so we give oxygen. If patients are asthmatic, we start on the nebuliser. Because of the condition, he still needs to be admitted, so maybe he needs a two-hourly or four-hourly nebuliser, for example.

“So, that component, we start off at ED. That means the definitive care is started. Now, we do not just plan for admission, but also we start off the plan of the primary team. What they want us to do – start antibiotics for the patient etc.”

Dr Avicen informed CodeBlue that this trend of treating patients in the ED is something that has been going on for “quite some time”, as emergency doctors have seen their colleagues struggling to manage patients.

In Dr Avicen’ opinion, it is “only fair that we start the definitive plan in ED”.

“Many departments and hospitals have changed their mindset, where for some certain medication that is only given in the wards, we can also start in ED.”

CodeBlue reported last week that critically ill patients, including ventilated cases, are stranded for up to six days in the Red Zone of Raja Permaisuri Bainun Hospital’s (HRPB) emergency department due to insufficient critical care beds and staff.

Doctors from the general hospital in Ipoh said the situation this year has worsened from pre-pandemic days, when patients waited one and a half days at the most back then for beds in a ward.

Overcrowded, understaffed, and underfunded emergency and trauma departments (ETD) in government hospitals first came to light in the Auditor-General’s 2018 report.

Dr Avicen held that all hospitals ought to have a contingency plan in place that “should encompass all aspects required to ensure care is given as best as possible.”

“All hospitals should, by now, have contingency plans to deal with staff shortage to support the extra patient load, pooling of staff, and assigning new duties for care of patients when warranted, whether on standby or on-call basis, that should already be in the planning. This is planned for all levels of staff that are involved in patient care,” he suggested.

“[For] example, 24-hour roster for staff to come down to ETD or medical ward to help with the sudden surge of patients.

“Medically trained staff (doctors, staff nurses, assistant medical officers) in administrative positions such as quality, infection control, day care, specialist clinics etc. can be mobilised to cater for the increase in patient load, especially in areas that have been created to put patients temporarily while waiting for admission to the wards.

“For example, they can help with discharges, sending patients for radiological investigations, monitoring patients, and administering treatment planned by primary teams etc.”

Once the above plan is in action and patients are being tended to, the next area to look into would be the discharging of patients.

According to Dr Avicen, doctors today treat patients till they are completely cured.

Using severe asthma as an example, he explained that in the past, once the patient has been treated and can talk, the next line of action would be to discharge the patient with the appropriate medication and instructions to go to the nearest general practitioner (GP) and continue medication.

Today, however, some doctors keep patients in the hospital till the rhonchi (sound in the lungs) stops; this holding of patients takes up valuable bed space.

“Last time when I was in HKL (Kuala Lumpur Hospital), when you have severe asthma, they come to the department, we give them medication, we try to stabilise them. They still have difficulty breathing. So now, they’re planned for four hourly nebulisers. They get admitted.

“Once in the ward, because our colleagues in medical know that tomorrow will be another active day, so once this person [after three doses of nebuliser every four hours] can talk, a little bit of rhonchi, [then] discharge. Advice: give medication, say, ‘Go to the nearest GP and continue medication’.”

However, some doctors now, said Dr Avicen, will only discharge patients when they no longer have rhonchi in their lungs.

“Now, they expect no rhonchi. They want to treat the patient until they suspect the patient no rhonchi. So there’s no more rhonchi in the lung, and the patient can walk and talk as normal.

“That’s the recommendation now, but the problem is they don’t want to discharge the patient when the patient still has rhonchi because they are scared that if the patient comes back severe, they have to answer.

“In certain situations, the teams managing patients need to exercise discretion when it comes to discharging patients. For example, some patients can continue monitoring at home with the help of family members. This will help free up beds earlier to cater for awaiting patients that may need further care.”

While these are the steps that public hospitals can take to free up beds and avoid overcrowded emergency rooms and wards, congestion can still occur because patients’ families are unable or unwilling to pick them up from the hospital when they are discharged.

“They prefer to pick up the patient after office hours – easier,” Dr Avicen said.

“So again, this also will delay beds to be emptied for new patients to come in. These are the challenges that we face in the hospital. Family members should be responsible enough to pick up patients as soon as allowed discharge so that beds can be freed and utilised as soon as possible.”

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