This problem focuses on the Emergency Department (ED) of a public sector tertiary care hospital in a low-middle income country in South Asia. Comparative analysis indicates that this ED is the busiest nationally in relation to the average flow of patients per day (figure 1& 2). As compared to other EDs in the public sector hospitals that have an average case load of 200-250 patients/day, the ED of this hospital receives around 1600 – 1800 patients per day. A one month data analysis indicates that 80% of the visits are non-urgent patients. The magnitude of these statistics is compounded by an average of 4 to 6 relatives accompanying each patient as there is no policy of 1:1 ratios (patient: attendant). The high caseload of patients encompasses a myriad of patients suffering from minor acute problems to vital emergency conditions. Consequently, the presence of a large number of non-urgent cases and patient attendants not only affects the timely care of patients requiring emergency care but it also complicates the Utilization Management (UM) process; notably, the resources are either over-utilized or mis-utilized (misused).
This critical situation, data analysis along with interviews with key stakeholders reveals copious reasons for this patient overload. Firstly, the topographical location of the hospital; it is located at the entrance to the capital city, and its closeness to the main road makes it the first point of care for the severely ill and wounded patient coming from far-flung districts. Secondly, historically it enjoys a great acceptance among the inhabitants who have the notion that the hospital provides quality services with distinct specialties. Thirdly, due to a fragmented referral system in the primary and secondary level healthcare facilities hence patient do self-referral as far as a 200 kilometers distance. Furthermore, there is a cultural certainty among the population visiting the ED after the official working hours when the out-patient services are closed with the “belief” that they have the right to access these free services. These include “cold cases” that can be delayed without jeopardizing patients’ health and life. On the other hand, structural factors also contribute gravely to crowd the development; the ED and the outpatient departments (OPD) are located very close to each other. As a result, quite often ambulatory patients requiring outpatient services find their way to the ED. Finally, the healthcare workers habitually bring their relatives to access free of cost and faster health services in the ED. The current system allows the patients to be managed on ‘first come-first served’ basis and this puts severely ill patients at a great disadvantage.
Figure 1- February, 2018 patient caseload
Figure 2- March, 2018 patient caseload
The administration of the ED and the hospital are in dire of a strategy to control “ED crowding” and to develop a triage system to deliver timely, quality services to the patients who deserve it most. The target is to ensure that the ED is used only for emergency patients and that patients are provided the level and quality of care according to their clinical needs and to improve the UM process.