Emergency departments have thousands of ‘stops’ a year because of the crowds

It starts with doctors noticing that the emergency room is filling up. More and more ambulances are arriving, while people in the department are sicker than expected. For the people who feel better, there is no place on the regular nursing wards. There are people in the waiting room of whom the doctor thinks: oops. With a broken arm, a person can wait a few hours. But someone who is getting more and more stuffy should really be seen now. Nurses start running, the rooms fill up and paramedics are in the hallway with new people. Then the doctors decide: we’re going to stop, because the quality of care is getting too bad, the dike is flooding. Hospitals around it will suffer from it, but it is no different.

This is how David Baden, emergency physician in the Utrecht Diakonessenhuis and chairman of the professional association of emergency physicians, describes the situation just before an emergency stop.

From research of NRC shows that emergency departments make stops many thousands of times every year due to crowding. In the provinces of Noord-Holland and Flevoland alone, this happened almost 9,000 times in the first nine months of this year. In total, such departments had a stop for 18,707 hours in that period.

Excessive busyness

Stops are a well-known phenomenon in acute (urgent) care. With a stop, the doors do not literally close, but an emergency department signals to other hospitals, general practitioners and ambulances that they are too full. The cause: excessive pressure.

Stops are most common in urban areas, where ambulances can drive to another hospital – although several hospitals in a city regularly have a stop at the same time. But they also occur in Limburg and Brabant, where hospitals have actually agreed that they will not make stops – in Brabant even more often.

The regional partnership (in jargon: ROAZ) of North Holland and Flevoland was prepared to give NRC the most extensive insight into all stops that are registered. It therefore concerns the number of stops in two provinces. Most of them are in the emergency room (a kind of emergency room for heart problems). These departments had almost 3,000 shutdowns in the first nine months of this year. The heart monitoring emergency departments (a kind of intensive care unit for heart problems) closed more than 2,500 times in these months. The emergency departments more than 2,000 times. The trauma rooms (for accident patients) and CT/thrombolysis departments (for cerebral hemorrhages and infarctions) have both closed more than 500 times.

The number of stops in these provinces is rising rapidly, but an important reason is that the region has also started to register stops differently. Stops officially last a maximum of two hours, and since this year departments have to report a new stop after two hours. The total number of ‘stop hours’ shows that emergency departments have managed to reduce the stops, but that the number of hours that acute cardiac departments are closed has risen sharply.

Stops are by no means a problem for these two provinces alone. In the Central Netherlands region (province of Utrecht), only the emergency departments had more than 600 stops last year, which are called ‘bypasses’ in this region. In total, such departments were closed for more than fourteen hundred hours.

The number of stops is also very high in the region around Rotterdam, doctors say, but this regional partnership wants to do not provide insight into the number of stops. Rotterdam hospitals sometimes close their emergency departments up to three times a day, and three (out of five) are closed with some regularity.

Stops are difficult, says a spokesman for the ROAZ in North Holland and Flevoland, but also a tool. It is a way to prevent dangerous situations (overcrowded departments) and to spread crowds well between emergency departments.

Each region has agreements about stops, for example about when a stop may be announced. In North Holland, Flevoland and Utrecht, patients whose ambulance had already reported that they are coming are still welcome. Just like people with a certain condition that can only be treated in a specialized hospital. Even if the danger to life is so great that the ambulance cannot continue, patients are welcome. But the rest of the ambulance drivers know through stops: we skip this emergency department. That means ambulances have to drive further than to the nearest hospital.

Difficult outflow

Stops are due to excessive crowds, and there are all kinds of reasons for this, such as a shortage of personnel and an aging population. But the main reason is at the ‘back’. The outflow of emergency departments is difficult because the rest of the care system is stalled. Emergency departments often cannot get rid of people. The shortage of beds in hospital wards is a major problem, says Prabath Nanayakkara, professor of acute internal medicine at Amsterdam UMC. Often there is nothing else to do than call other hospitals. “Sometimes we have to call thirty before there is room.”

And the shortage of beds in the hospital is also related to the pressure on home care and in nursing homes. Research by Nanayakkara shows that one in five patients who were in hospital (during the study) actually no longer needed to be in hospital. Pol Stuart, emergency room doctor at the Franciscus Gasthuis & Vlietland in Rotterdam, describes how he sees stops coming in the morning. Then he is told how many free beds there are in the nursing wards of his hospital. “Sometimes I hear: zero free beds. Then it’s: oh dear, what will this day bring?”

In the course of the morning, some beds often become available, because doctors discharge patients to go home. But not enough to accommodate all the people coming in from the emergency room. “Sometimes it is not possible to find a bed, and someone stays overnight in the emergency room. Ten years ago it was completely unthinkable for anyone to spend the night on such a bed. Now it happens with some regularity.”

A patient in the emergency department of the Amphia Hospital in Breda. John van Hamond’s photo

respiratory distress

For years, fewer and fewer beds have been available in Dutch hospitals. Doctors have been able to cope with this by working more efficiently (and sending patients home more quickly, for example). But that can’t go on indefinitely, and now, according to many doctors, a critical limit has been reached. For emergency care, it is necessary that this trend is reversed, and that hospitals keep more extra beds.

But beyond that, there are all sorts of other things that could ease the pressure on emergency departments, doctors say. Professor Nanayakkara points out the importance of a national electronic patient record. Currently, a lot of time is lost in retrieving patient data. Because it is so important that someone is known in a hospital, some regions have agreed that stops do not apply to patients who are already being treated at a certain hospital.

Baden, president of the association of emergency physicians, says it would also help if GPs know their patients and give them more time for their consultations. “Patients who have been seen by a regular GP end up in the emergency room 20 percent less often. A GP knows well: is this really different from the normal complaints, or is the patient just very worried?

Conversely, if the GP does not know the patient well, strange situations arise. “For example, I witnessed someone coming to the emergency room with chest pain. The patient had called the doctor and asked for new puffers for her asthma. Because if she doesn’t get it, she’ll get chest pains. The GP immediately sent her to the emergency department, even though she just wanted new puffers. ‘You are the first to ask me what I actually want,’ is what I hear.”

Another factor is the increased medical caution. Those who used to be drunk on the street were brought home by the police or ambulance. Now the protocol says: this person is going to the emergency room. There is always a small chance that someone will vomit and become short of breath. But that chance is very small. “Sometimes we get people who have regained consciousness during the ambulance ride and start acting funny,” says Baden.

Rapid blood test

The figures show that emergency departments that focus on the heart have the most stops. Joan Meeder, president of the Dutch Association of Cardiology (NVVC), explains that there are two main causes. The group of patients with cardiovascular disease is growing rapidly due to the aging population, and at the same time there is a shortage of personnel in the emergency room and cardiac monitoring. “In the case of major heart attacks, we have properly arranged care in the Netherlands,” says Meeder. “Then, if necessary, the patient is referred to another hospital for emergency treatment in case of admission stops.” But people with heart failure, smaller infarctions that are less urgent and people with arrhythmias – that care is under pressure. Cases have been reported to us where people had to wait longer for admission or treatment than doctors would like. To our knowledge, this has not resulted in death. But we sail very close to the wind. There is a clear chance that we will end up with our head to the wind and things will go wrong.”

There is also more medical caution in the field of heart care than before. “In the past, the doctor first went to someone’s home to see. But at the heart it is now: immediately call an ambulance, better safe than sorry. So often it is not necessary, but if we do not do it, things sometimes go wrong.” More and more regions are participating in an experiment in which the ambulance or general practitioner can ask a few fixed questions at people’s homes and do a quick blood test to see whether or not there is a major danger. A bit back to the past, but safer. “In the ambulance with flashing lights to the hospital: that is a traumatic experience. We should not underestimate that.”

Leave a Comment