Managing a busy emergency department

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This post was created by DFTB in collaboration with Health Education England, Respiratory Surge in Children programme (and thanks to Damian Roland for his input)

We were relatively lucky in paediatrics in the UK. During the COVID pandemic flow in our Emergency Departments (ED) was not a huge issue. With the upcoming predicted respiratory surge, it is likely that we will find our EDs full, potentially also with a full hospital and PICU. It’s therefore important to start planning for the consequences of this now.

Three key areas we should be focusing on in ED are: 

  • Departmental flow
  • Staff well-being and morale
  • Diagnostic and in-patient dilemmas (i.e. RSV v COVID)

And then we’ll discuss a bonus conundrum at the end. This post won’t give you the answers, but it aims to set out the key issues you should be thinking of now.

1. Flow – inflow, acuity, outflow, crowding

Example 1. You’re in charge of an ED. This weekend they are holding the World BMX Championships next door. There will be 1500 teenagers doing cool tricks and racing each other. Over the next 4-5 hours you’re going to see many, many long bone fractures. How are you going to get ready?

  • Triage. This will need to take place early in the patient journey.
  • Analgesia. We need to have good availability of appropriate analgesia (ibuprofen, paracetamol, and intra-nasal agents)
  • Imaging. We need to give Radiology a heads-up that we’re going to be sending a lot more children that usual
  • Plaster-casting. We need to make sure that we have enough space and equipment to be able to cast plenty of children
  • Orthopaedics. We should also give Ortho a heads-up that we will likely need more help from them than usual

Example 2. There’s an outbreak of Meningococcal C in your area. You are expecting to see lots of children with their parents worried about rashes. Hiding among those many well children, there may well be some who might deteriorate quite quickly. How are you going to plan for this contingency?

  • Risk assessment at the front door has to be thorough
  • Children may deteriorate in the Department and we need a plan to have ongoing assessment and management of the deterioration.

Having thought about these examples, let’s flip back to something more common – respiratory problems. As we are facing a respiratory surge or epidemic, it is unlikely that we are going to be facing a patient who suddenly deteriorates (as in example 2). We are going to face the more challenging problem of large volumes of worried parents of children with relatively minor respiratory illnesses. Our staff will have to make an early pragmatic decision about who can safely go home – even if they have some respiratory distress – and who needs to stay. The department is going to get overwhelmed and crowded if we don’t keep our eye on the ball. Let’s look at our four principles of managing flow…

Inflow

There are certain times of the day when we have an influx of patients, such as when parents come home from work. We need to manage our staffing appropriately for those times of peak demand. Our patients are going to be children less than 1 year old. Most departments try to prioritise those younger patients anyway. We are going to need to enhance our plan and priorities at the initial assessment stage. We should have a (senior) clinician at the front door, or just try to make sure we have as many patients assessed within 15 minutes as possible. Staffing constraints may make this challenging. We might need a different risk assessment pathway from simply that they are less than one year old (or less than six months old). How could we weed out those at higher risk?

  • Could it be work of breathing?
  • Could we pay more attention to those less than three months old?
  • Could it just be ex-prems or those with pre-existing respiratory conditions?

We need to think about a different way of managing that inflow risk.

Acuity

How are we going to define acuity in this patient group?

Respiratory status

Is it just going to be patients who have saturations of less than 90%? Are we going to consider those who appear to be working hard? Perhaps it should be those with apnoeas?

Timing

The acuity of patients is going to be really mixed. We will have lots of children who have very low acuity but are maybe day two of their illness and by day three so could be getting worse. Their acuity at the time of assessment might not be high but we need to think about what the trajectory of their illnesses might be.

Initially (sat at the beginning of a shift) overall acuity may not be that high, but as outflow becomes a problem acuity will rise. This is where the real issue lies. The hospital fills up with patients who do need ongoing intervention – patients who have oxygen requirements and patients who need NG or IV feeds. Our PICU will overfill with ventilated or unstable patients potentially reducing ward HDU capacity due to overspill. We will find that our patients in the ED have nowhere to go. Then we will start to see patients staying longer and longer in our department. That means that we will take away from the nursing and medical resources managing them, all the while more and more patients arrive.

How do we sort that outflow block?

Outflow

It’s not easy. We need to have some pre-agreed rules with our colleagues in the hospital -whether that’s our assessment unit colleagues or our general ward colleagues – surrounding the rules for mitigating risk. There are a few things we need to consider.

The ED cannot be the holding chamber for our whole hospital. Let’s say that a standard ward has a nursing ratio of one nurse to three patient beds. At some point, we are going to need an escalation process where those nurses are managing more patients. If the inflow in the emergency department is 20 patients an hour and we have no patients leaving, so our nurse to patient staffing ratio drops rapidly. We need to be able to decant some of those patients into the hospital. The hospital needs a plan for their discharges. Ideally, teams need to be discharging patients at a similar rate to the rate we are admitting them. There needs to be a whole-of-hospital approach to achieve this.

When things get into crisis point i.e. where we have no outflow at all, how are we going to reconfigure our Emergency Department to be more like a ward? Could we move cubicles and convert them into bays, creating a mini-ward that has a dedicated member of staff, so that those patients are distinct from the rest of the ED? Each Department will have its own configuration but this is worth thinking about now.

Let’s go back to that BMX example. Outflow is unlikely to be a problem. Most of those patients will go home. There will be a few that need to be admitted to go to theatre, but most problems can be managed in the ED. The emergency department will have to bear the brunt of the load because that’s our skill set. The problem lies with inflow, not outflow, and managing the security of a big media situation. In a bronchiolitis surge, the problem is more likely to be outflow, because we are going to admit more patients and the hospital is going to become full. So how do we mitigate that risk?

Crowding

When inflow rises, outflow falls and acuity climbs, we have crowding. We are left with an extremely busy Emergency Department with increasingly sick kids. Do you have an escalation plan so that the whole of the hospital is on the same page? We should have had these plans already as we have the same problems every winter, but because of COVID, processes might have changed and organisational memory lapsed. We need to refresh our 2019 escalation policies because we have probably forgotten all about them. When a department is crowded regular patient care can fall by the wayside. Here are a few things that we might consider to help resolve crowding.

Rapid near patient testing for RSV

At first glance, this sounds brilliant. Why wouldn’t we want to know whether or not someone has RSV? The problem is that bronchiolitis is a clinical condition and is really pretty easy to recognise. If a patient has a positive test result, because we’ve done a near-patient test in our department, then bed management may change their disposition destination. If our hospital has lots of cubicles then this might be a good plan and may work well for us. If our hospital has lots of cohort bays it might be a good idea to work out what virus our patients have, because that might improve flow. The converse could also be true. Our patients may sit in the department for the next 12 hours because we know they have RSV and there are only specific ward beds that they can go to in the hospital. These are discussions we need to be having now. RCPCH guidelines advise us to pick out the COVID patients then separate them with everyone else lumped together (whether or not they have RSV or a negative respiratory panel). This is because of the knock-on effects on flow. If we do near-patient testing then we may end up deciding to cohort or not cohort-based on these results rather than aiming to improve flow.

Ghost guidelines

Imagine that we have a ward in our hospital that only takes patients with certain characteristics (i.e. they have to be stretched two hours between inhalers before going to the ward). This isn’t actually in any Standard Operating Protocol or guideline. It is just someone said it once. It is a ‘ghost guideline’, It exists in practice, but there’s actually no evidence to support it. You may find that there are lots of different ghost guidelines for bronchiolitis. People may say that the patient has to have an NG or an IV to be admitted to the ward. These issues need to be aired and worked through before they become a problem. This might lead to some difficult discussions but it is better to deal with them now than when crowding becomes an issue.

2. The staff

Staff wellbeing

It’s been a long two years with COVID and now we’re going into another respiratory surge that’s likely to disproportionately impact paediatric staff. We need to recognise that staff are going to be at a low ebb and are going to need practical solutions to improve their morale. We have already been brought down by COVID, and things are about to get worse. We are going to have a really challenging winter. We need to recognise this. Calling it out is a good start. 

We need a suite of wellbeing resources – things that people have done already and have worked well. Just showing gratitude and giving thanks makes a difference. Greatix is a good example. It is amazing how much of a boost people get when they are recognised and are told that they’ve done something excellent. It makes us all feel part of the same big team. That sense of belonging is important

Time is running out already, but things will change when lockdown really eases.. Could you take your team away before the winter? Could you pay for them to go to a water park, or have a fun day out? You need something you can all do as a team together,  that makes people feel valued. 

Interpersonal relationships

Hospitals are big institutions, with lots of different personalities. Tensions exist between different teams and specialities. It is important that some of those tensions are called out now. People need to be honest about it. Sometimes, we have difficult relationships with the people that we’re referring to from ED and the reverse may also be true. There may be certain individuals within those teams who are known to be challenging. It needs to be addressed – we can’t just hide under the table. It needs either quiet corridor conversations or louder discussions with directors and managers. It’s going to be as important as ever this winter to be able to do that, however difficult it might be.


3. RSV versus COVID

Do we need to worry about RSV and COVID? 

COVID isn’t making children sick. What makes children sick is RSV. Ultimately when a child with a respiratory problem is seen in ED we decide if they need to come into hospital. If they do, that’s because of our respiratory assessment and history at the time of their presentation. When they come into the hospital, they need a swab, because we need to test them for COVID to stop us unintentionally spreading COVID. Technically, that’s where any discussion about COVID ends. The last 18 months have taught us that COVID rarely has a bearing on the outcome or course of illness of the child. RSV is completely different and the trajectory of illness is much easier to predict. 

Having said that, there is a question around whether we will start seeing PIMS-TS re-emerge within the paediatric cohort. We know this cohort has not been vaccinated and so COVID will likely be rife.

Will we see PIMS-TS in a younger cohort? We aren’t currently seeing lots of PIMS-TS cases in children under two years of age, so we may not see an increase in PIMS-TS in this age group. Ultimately, it is more likely that if a patient is really sick and they are young, it’s going to be RSV/flu /sepsis rather than COVID.

Bonus conundrum:  Oxygen +/- Beta Agonist in 1-2 year olds

We are seeing a number of respiratory patients in the younger (1-2-year-old) age group and often have discussions around whether they should be started on a viral-wheeze pathway, or as a patient with bronchiolitis down the high flow oxygen route. This is where BronchSTART, the new PERUKI study will come in.

Traditionally, bronchiolitis affects infants less than one year of age and viral wheeze commences after one year of age with asthma being formally diagnosed at primary school age. 2021/22 may well be different as we have a cohort of RSV-naive infants who could well present with primary bronchiolitis at 1-2 years of age. This will make management decisions tricky – do you just give oxygen or do you add in a beta-agonist?

Viral-induced wheeze and asthma are both caused by a restriction of the airways. Infants and children have difficulty breathing out rather than breathing in. You might not hear a wheeze in these patients, but there should be a prolonged expiratory phase. 

In bronchiolitis, on the other hand, the mechanism of respiratory compromise is different. The whole of the respiratory tree is plugged with mucus. The respiratory rate may be more erratic. As mucus plugs move, the child becomes well but then deteriorates rapidly with respiratory effort that may be significant. 

For one to two-year-olds, we will need to be much more focused on the child’s respiratory pattern and then make a decision to go down the appropriate route. This may not always be easy to determine hence the conundrum we face.

The emergency department has challenges ahead with the coming respiratory surge. By planning now and thinking about triage, risk assessment, admission routes, and discharge plans, whilst taking care of staff, we can be better prepared for what lies ahead.

Respiratory Surge in Children with bronchiolitis

Selected references

Boyle, A., Beniuk, K., Higginson, I. and Atkinson, P., 2012. Emergency department crowding: time for interventions and policy evaluations. Emergency medicine international2012.

Boyle AA, Henderson KCOVID-19: resetting ED care Emergency Medicine Journal 2020;37:458-459.

Care Quality Commission Insight 9: The impact of the pandemic on urgent and emergency services [Accessed 27/7/2021]

Higginson, I., 2012. Emergency department crowding. Emergency medicine journal29(6), pp.437-443.

Public Health England: COVID-19: Guidance for maintaining services within health and care settings, Infection prevention and control recommendations vol 1.2 [Accessed 27/7/21]

RCEM Best Practice Guideline: Emergency Department Infection Prevention and Control during the coronavirus pandemic, June 2020 [Accessed 27/7/21]

RCEM Resetting Emergency Care September 2020 [Accessed 27/7/21]

RCEM Cares Spotlight on: Crowding 2020 [Accessed 27/7/21]

RCEM Summer to Recover 2021 [Accessed 27/7/21]

RCEM Summer to Recover Guide for Clinical Leads 2021 [Accessed 27/7/21]

RCEM Tackling Emergency Department Crowding December 2015 [Accessed 27/7/21]

RCPCH: National guidance for the management of children with bronchiolitis  2021 [Accessed 27/7/21]

Riddick,L, Roland, D and Tagg, A. COVID and RSV, Don’t Forget the Bubbles, 2021. Available at: https://doi.org/10.31440/DFTB.33694

About the authors

  • Tessa Davis is a Consultant in Paediatric Emergency Medicine at the Royal London Hospital and a Senior Lecturer at Queen Mary University of London.

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