At a time of writing articles for Croakey - a Twitter thread
11 October 2021
This article was written as a follow-up piece to an article I wrote with colleagues from ACEM @acemonline in January 2020.
https://www.croakey.org/at-a-time-of-looming-crisis-a-vision-for-health-system-transformation/
Health care has changed in response to the pandemic. There have been many mistakes, but there are a lot of good things that have happened too. We should use what we have learned to drive positive change into the future. We should use this opportunity to build back fairer.
It is impossible to read an old article and not think of things left out, or new angles. I'm going to add some updates for the original article in the rest of this thread.
1. Review the role and function of EDs - Ambulance ramping, ED crowding and access block are worse than ever. It is impossible to practice effective infection control in overcrowded clinical environments. Many direct-to-team referral models (clinic or ward) were successfully implemented to avoid COVID cross-contamination in the ED. These should be reviewed and the effective models maintained as part of business-as-usual. There has also been large scale implementation of virtual care and HITH models to manage COVID. These models must be effectively integrated with ED, and EDs running these models must receive adequate additional resourcing and support.
2. Redesign triage processes - Pre-triage has been successfully used to stream patients according to infection risk, and in some cases to redirect appropriate patients to other services. Infection control considerations should be part of future ED front-of-house process redesign.
3. Improve physical infrastructure - Most EDs are open plan to maximise staff visibility over and access to large numbers of undifferentiated and potentially unstable patients. We need to pandemic-proof ED design - add more single rooms, negative pressure rooms and N class resuscitation rooms for critically ill patients with airborne viral infections. We need separate access points and waiting areas for patients based on their infection risks. This is also likely to improve the patient experience - more privacy, more dignity, less exposure to the sights, smells and sounds of the ED - especially for patients who are disorientated, delirious, at extremes of age, or have experiences of trauma. An ED designed to improve infection control and patient experience will require more staff. We need to stop designing EDs for minimal staffing and design them for maximal care and safety.
4. Transform the ED workforce - the pandemic has highlighted critical workforce shortages in EDs. The most acute shortage is nursing. There is no ED care without highly-skilled, well-trained ED nurses. We need urgent measures to attract, support and retain nurses in ED. Border closures have disrupted international and interstate movement of health care professionals. EDs are highly dependent on overseas-trained staff. We need to review training pipelines to ensure adequate supply and fair distribution of locally-trained health care workers. We also need inclusive and efficient strategies to welcome and support health care workers who have undertaken professional training in other countries and systems into the workforce.
5. Broad options for referral from ED - virtual care models have come into play during the pandemic. We need to make sure they are safe, effective and sustainable. Covered in point 14 in the new article.
6. Extended hours clinical services - Urgent care centres come in many varieties. Models which are embedded in ED governance can work well - for example a minor injuries unit, adjacent to the ED, which sees a mix of walk-in, booked, new and follow-up patients. This model can provide comprehensive care - with primary practitioners from a mix of medical, nursing and allied health, diagnosing and treating minor injuries in collaboration with relevant surgical teams. Feedback re the original article suggests that ED colleagues have had negative experiences of some urgent care centre models, including high volumes of referrals to ED for definitive treatment after urgent care assessment.
7. Clever use of information technology - we have seen some useful apps emerge for contact tracing and proof of vaccination during the pandemic. Let's make them even more useful for health care self-management with good patient information, self-monitoring tools, and links to appropriate services (but drop the surveillance when no longer required).
8. Health-promoting governance and financial structures - this is where it is at. When we design or redesign a model of care, we need to think about how and where the money flows. Time to stop the federal-state shifts. Time to stop being idealistic about clinical redesign and make sure that financing models align with, and don’t obstruct, desired health outcomes and service delivery. See point 12 in the new article.
9. Strengthen primary care - and broaden primary care. The Aboriginal Community Controlled Health Organisations model should be adapted for implementation in other contexts. See point 12 again - align financial drivers with desired health care outcomes better.
10. Rational and sustainable use of health resources - review this with an equity lens, see points 15 and 16 in the new article.
Thanks for reading. Here's another article to get you thinking about how the system could be better. https://insightplus.mja.com.au/2021/21/emergency-physicians-call-for-whole-of-system-reform/
Enormous thanks to everyone who has contributed to the pandemic response.
Thanks Dr Laksmi Govindasamy @LaksmiSg for your help with the article. And for the inspiration!
