World Emergency Medicine Day 2021: lessons learnt from Covid-19 and roadmap for future

The Covid-19 pandemic resulted in health and economic disruptions across the world. In India particularly, our healthcare system’s vulnerabilities have been greatly exposed. Despite the numerous strides taken by government bodies, the scientific community, and healthcare providers, our healthcare delivery system struggled to cope with the exigencies.

Emergency Medicine and Critical Care departments within our country were not immune, and were impacted significantly. But the lessons learnt so far are good enough to help us build strong Emergency Medicine departments and disaster management systems in hospitals, especially to tackle future outbreaks, and offer support during calamities of such great magnitude.

Role of emergency care in combating the pandemic

One of the foremost lessons learnt from this pandemic is that the emergency care system is a crucial component of the larger social safety net system of any nation. As such, it is subject to many forces far beyond its direct control. Also, critical environmental factors are difficult to address but the Emergency Department (ED) should be the most efficient and responsible division within hospitals. Having said that, emergency medical care can play a significant role in designing and implementing an effective approach against Covid-19.

The pandemic has highlighted all across the nation how quickly emergency medicine and critical care infrastructures can be challenged to provide adequate care. However, recognizing the importance of managing patient flow to address ED crowding is a must.

The ED plays following pivotal roles in such case:

1. Triage – Separating suspected Covid and non- Covid cases in defined care areas of ED
2. Recognizing the deceptive presentations
3. Resuscitation, patient stabilization & making accurate diagnosis
4. Making further patient care plan and delivering golden hour care
5. Prevention of cross-infection
6. Disposing the patient in appropriate patient care areas of hospital as per the plan of care

Focused history-taking, astute evaluation, and rational imaging helps pick up the Covid-19 cases early and they can be treated in Emergency Isolation areas. This approach helps segregate patients into Covid-19 positive and non-Covid-19 areas of the hospital; thereby preventing patients with Covid-19 from going into non-Covid-19 allocated areas, which could pose a huge risk to the other patients as well as their caregivers. Therefore, accurate diagnosis, prompt emergency care and transfer of patients to proper patient care areas from the Emergency Department becomes crucial, and the emergency caregivers play a very crucial role in enabling this.

Need for understanding patient flow management

In the last few months, we have witnessed very challenging situations in EDs of all hospitals across the country. For instance, inadequate resources for maintaining an efficient triage, sick people scattering all over the place, nurses and paramedics gasping for breath amid rising workload, instances of violence by relatives of patients against the hospital staff and many other cases. The situation has been absolutely overwhelming everywhere in both government and private hospitals.

We must remember that crowding within EDs pose a serious threat to the quality, safety, and timeliness of emergency care. While many factors contributing to crowding are outside the immediate control of the hospital, some can be due to the result of operational inefficiencies in the management of patient flow. If a patient arriving by ambulance cannot be transferred quickly to an ED stretcher, efficiently triaged and directed in appropriate care areas for rapid evaluation, resuscitation, stabilization, and disposed to appropriate areas of the hospital after making a plan of care; ED crowding is bound to happen, and patient care will be compromised.

Hospital administrators and government bodies have at their disposal a number of promising options for identifying and resolving patient inflow problems that contribute to ED crowding. Three things are most important for maintaining this: proper queueing system, efficient supply-chain management, and statistical process control. The ED should be efficient enough to quickly analyze, diagnose, stabilize and transfer the patient.

Here are some inputs which can improve efficiency within EDs and hospitals in these difficult times;

• EDs should be manned round the clock by doctors & nurses who are trained in Emergency Medicine
• EDs must have adequate manpower i.e. doctors and nurses with good and mature communication skills to help counsel patients and their relatives
• Emergency Departments of hospitals should have adequate area and infrastructure for patient care
• Emergency Department should have high quality equipments handy, such as ventilators - invasive & non invasive, point-of-care diagnostic equipments and advanced airway management equipments
• Extremely effective triage system
• Set protocols for distinction between Covid and non-Covid patients
• Set protocols for managing every emergency medical condition and training of all doctors and nurses on the same
• Negative isolation rooms in Emergency Departments
• Separate areas for Covid and non-Covid patients in ED
• Ensure that COVID antigen testing unit is available 24x7
• Recognize the significance of patient-flow management to curb crowding
• Remove in-patient admission bottlenecks
• Ensure there is no delays in ancillary services
• Have a coordinated bed management system for available beds within the hospital or make sure the hospitals are well connected with other hospitals in the vicinity or with government hospitals to help patients arrange beds elsewhere
• Do not encourage emergency services for non-emergency care. Emergency Departments are meant for Emergency Care only.
• Use ergonomic designs and infrastructure for space management within the department

In the end, the Covid & non-Covid related success of any hospital lies in its efficient emergency medical care; and we can only build on our emergency medical preparedness by nurturing emergency care talent.

The author, Dr. Sandeep B Gore is a Director with the Emergency Medicine department of Fortis Hospital in Mulund, Mumbai. Dr Gore is also the Vice President of Society for Emergency Medicine in India.