We have a big problem in EM that lies outside the walls of our departments: Our health care systems are failing. This is having profound effects on the daily operations of EDs around the world. Packed waiting rooms, treatment delays, poor patient outcomes, frustrated families of patients, EM provider burnout and ED closures. In order fix EM, each of us needs to understand systems issues and systems thinking, and advocate for a better system based on sound systems principles and specific solutions. In this main episode EM Cases podcast Anton is joined by Dr. Alecs Chochinov and Dr. Davie Petrie, two systems thinkers and leaders in EM. They discuss solutions for how to fix EM in 5 spheres: having a coordinated mission, optimizing access points, accountability, disaster preparedness and adaptation/evolution. They answer questions such as: What can we glean from how EM has evolved in the last few decades to help shape the future? How can we utilize virtual care to make it work for us and our patients well? How can we improve our EMS systems? How can we change the system to prevent emergency provider burnout? How can we integrate systems thinking into the daily operations of EDs to improve patient flow and outcomes? and many more…

Podcast production, sound design & editing by Anton Helman

Written Summary and blog post by Anton Helman February, 2024

Cite this podcast as: Helman, A. Chochinov, A. Petrie, D. The Future of EM – Systems Thinking. Emergency Medicine Cases. February, 2024. https://emergencymedicinecases.com/future-of-em-systems-thinking. Accessed February 20, 2024

“Waves of medical refugees are landing on our shores. With the decline and fall of their primary care home, they present to EDs with more co-morbidities and in ever greater numbers. Those requiring admission often face siloed services, quotas, ‘closed borders’; so, they wait, and those behind them wait, with predictable results.”

Dr. Alecs Chochinov

The topics of discussion in this episode were gleaned from EM Power: The Task Force on the Future of Emergency Medicine Care report at the Canadian Association of the EM. The EM POWER task force is a team of Canadian EM leaders who developed a systems-based approach to the future of emergency care, where integrated networks with multiple access points–not just emergency departments–are responsive to patient needs and adaptive to changing conditions.

How did we get here? Historical background to help understand the present situation in EM

Recent history and the evolution of the specialty of Emergency Medicine within health care systems reveals 4 key pathologies:

  1. Population–capacity misalignment – with increasing and aging populations we have outstripped the capacity to take care of them
  2. Accountability failure – each service/program has failed to be accountable for their patients with patients ending up in the ED because they have nowhere else to go in a timely manner
  3. Lack of readiness – with most of our attention paid to efficiency rather than readiness/resilience, it is increasingly difficult for our system to handle surges in patients, pandemics and other disasters; we need to build in capacity, safe redundancies and optionality in our health care systems
  4. Complexity creep – our patients are getting sicker and more complex; patients that are categorized as low acuity are often high complexity

How best to define the scope Emergency Medicine

A core moral dilemma in EM is how to define the scope of Emergency Medicine. EDs should prioritize emergent and urgent care based on the definitions of all the EM governing bodies (essentially, the diagnosis and treatment of unforeseen and time dependent illness and injury).

If we are going to redesign an emergency care system, we have to understand what is the purpose of that system and what is the role of the system. We cannot be seen as the universal contingency for every other part of the system. We should review our ED usage, identify non-emergent populations that have the greatest impact on our bottlenecks to flow, and then negotiate the most appropriate alternative care options and care pathways for these patients. While we arguably should have a role as a “safety net” for some patients, we should not be the “safety net” for other specialties or sectors that are unable to fulfill their own mandates, be it through poor design, misunderstanding, or lack of accountability.

“Counterbalancing the paradigm of sovereignty over closed borders with a common good approach, in which resources are equitably allocated to those most in need–including those we have variously called boarders, orphans or refugees– will be a major step forward. If the ED is the wrong place to meet a given need, then the right place must be clearly defined, appropriately resourced, and accountable for managing all patents with that need – including those waiting for care”.

The 5 Spheres of the future of EM as part of the health care system: The Quintuple Aim 

5 spheres future of EM

Source: EM Power – The Future of Emergency Medicine Care in Canada draft report https://caep.ca/empower-2/

Sphere 1: Coordinated mission

5 point purpose for a coordinated mission in our health care systems:

  1. Improved patient satisfaction
  2. Improved population health outcomes
  3. Cost considerations – getting value for money invested
  4. Robust and resilient workforce
  5. Health equity

Patient satisfaction has to be balanced with health outcomes for the entire population, at a reasonable cost and in an equitable way. Sometimes the doctor patient relationship may need to suffer for the greater good of the community. While our Hippocratic Oath states “first, do no harm” to the patient, we need to consider “first, do no harm” to the system which indirectly impacts patient outcomes.

Integration of care and improving access to primary care

A coordinated mission requires integration of care and improved access to primary care. We need:

  • A culture of respect between specialties and programs (A Culture of Respect Part 1, Part 2)
  • To understand population needs and match them with specific services
  • An independent public entity at arm’s length from government for health planning and design to reduce the impact of election cycles on health systems decisions
  • To learn from other international health systems – which ones work well?
  • Unified digital health integration and direct-to-patent digital access
  • Leaders in EM need to be engaged in systems issues so that simplistic responses to complex problems are not relied upon and to encourage system innovation
  • Coordinated relationships between the availability of same day/next day primary care, urgent care, and emergency care in system redesign
  • The availability of on-call specialists in an integrated network of emergency care – both for peer-to-peer virtual care and through patient transport systems
  • Vertical integration of programs: from the home, public space, roadside, or clinic to the ED, and then on through to surgery and/or admission and ongoing in-hospital care if necessary
  • For patients with complex chronic care who contribute greatly to ED bottlenecks in flow, and may not be best served in the ED, we need regionally rostered multidisciplinary primary care access with advanced access scheduling

Sphere 2: Optimizing access points

First, determine the size of the workforce and match the workforce to need by size of population and location

A single system with many access points generally operates more efficiently and with better results than multiple independent systems. In order to design an effective single system one needs to first assess the size of the population, the distances between patients and their access to care, and the connections between access points. Only then can the size of the required workforce be accurately determined.

Second, evaluate current triaging systems

There is a need to evaluate current triaging systems in terms of patient outcomes, improving access, diversion from EDs and cost. Eliminating poor systems and developing ones with proven benefit would go a long way to improving access points for patients in a cost effective way.

EMS and pre-hospital triaging strategies

  • Multi-option EMS is an approach to ambulance trip destination alternatives for some low acuity patients. Virtual triaging, where patients get triaged directly to an on call non-EM specialist, a primary care physician or the ED with next day appointments may help to lessen the volume of non-emergency patients presenting to the ED. This can be thought of as “Choosing Wisely EMS”
  • Mobile Integrated Healthcare (MIH) is patient-centered, mobile resources in the out-of-hospital environment. MIH components may include traditional EMS response, community paramedics, advanced practice provider (PA-C, NP) responders, 911 nurse triage lines, and alternate destination/ER diversion. The approach aims to deliver higher quality and more cost-effective medical care by coordinating resources and helping patients get the right care at the right location, including assisting them in taking better care of themselves in their own homes. Benefits include reducing unnecessary ED visits, reducing hospital readmission rates and saving time and money.
  • Reassessment on arrival at the destination. With more time and information, is the ED still the best destination? Would an urgent treatment centre or same day/next day appointment at the patient’s primary care home be a better alternative?
  • Expanding the role of EMS to include in home palliative care and in-home simple procedures such as suturing lacerations, thus preventing transport to the ED

Sphere 3: Accountability

Access block is ubiquitous throughout the health care system. Accountability is the evolutionary stressor that allows programs to respond to demand and not be able to close their doors. Every specialty, hospital floor, medical program and medical service needs to be accountable for the system to work well. If there exists demand-driven accountability to a zone in which, for example, all renal patients from prevention to dialysis and beyond are looked after by that program, there would likely and predictably be less stress on EDs and improved patient outcomes.

Healthcare leaders should create accountability measurement and reporting systemsmonitor for care gaps and define performance measures – this will inform how these are best addressed – through new capacity, enhanced efficiency or reallocation of existing resources.

Solutions to improve accountability include:

  • Demand-driven overcapacity protocols:
    • Use of formal or informal overflow areas for either ED patients awaiting admission or inpatients awaiting discharge
    • Processes, protocols, and meetings (whether triggered by overcapacity conditions or maintained under all conditions) that govern assignment of patients to different areas
  • Invest in alternate level of care – programs that keep older people at home
  • Publicly report ED performance

More on accountability with Dr. Grant Innes in Episode 129 ED Overcrowding & Access Block – Causes & Solutions

Sphere 4: Disaster preparedness

A disaster occurs when demand outweigh resources. We are currently in the midst of a chronic ongoing disaster. Thus, disaster preparedness can be thought of as a proxy for general system preparedness. The principles of Disaster Medicine should be applied even when there is not an acute disaster such as pandemic, natural disaster or war.

  • There exists an increase in preventable deaths partially attributed to long ED patient waits
  • Hospitals needs to be ready for disasters with surge plans
  • Practice and testing of mock disasters and surge plans in real disasters is essential for readiness and effectiveness during a disaster
  • Redundancy built into our systems is essential during a disaster
  • Integration at a national level will likely improve disaster preparedness

More on Disaster Preparedness on Episode 100 Disaster Medicine

Sphere 5: Adaptation and evolution

Our world is constantly changing, and we need to be prepared for these changes as they are likely to impact our workforce and the way we treat patients.

  • A research network in which researchers across the country and disciplines work in the same integrated network instead of in silos, including integrated data sharing.
  • EM providers embracing leadership roles in digital health – digital health tools to help patients be more autonomous and look after their own care, make their own appointments and follow up, have their own results
  • Incorporating health policy and advocacy in medical school and EM training curriculums – the 3 pillars of education include research, basic/clinical sciences and health system science; all 3 are required to practice high quality care in a modern health care system
  • Trends in JEDI – Justice, Equity, Diversity and Inclusion are likely to impact the workforce and the way we treat our patients.
  • Climate change – applying the principles of disaster preparedness to somewhat predictable events such as floods, forest fires and hurricanes

EM provider burnout prevention

  • “If we have resilient systems, we will have resilient EM providers”
  • We need to appreciate each other by personally and publicly praising each other
  • Positive reinforcement
  • This helps to strengthen teams and develop a culture of shared purpose

Quote of the month

“We don’t rise to the level of our goals; we fall to the level of our systems”

-James Clear, author of the popular book Atomic Habits

References

  1. Chochinov, A., Petrie, D.A., Kollek, D. et al. EM:POWER: if not us, who? If not now, when?. Can J Emerg Med 25, 11–13 (2023).
  2. https://caep.ca/empower-2/
  3. Kreindler S, Aboud Z, Hastings S, Winters S, Johnson K, Mallinson S, Brierley M. How Do Health Systems Address Patient Flow When Services Are Misaligned With Population Needs? A Qualitative Study. Int J Health Policy Manag. 2022 Aug 1;11(8):1362-1372.
  4. Rivas J. Advanced Access Scheduling in Primary Care: A Synthesis of Evidence. J Healthc Manag. 2020 May-Jun;65(3):171-184.
  5. Louras N, Reading Turchioe M, Shafran Topaz L, Ellison M, Abudu-Solo J, Blutinger E, Munjal KG, Daniels B, Masterson Creber RM. Mobile Integrated Health Interventions for Older Adults: A Systematic Review. Innov Aging. 2023 Mar 1;7(3):igad017. doi: 10.1093/geroni/igad017. Erratum in: Innov Aging. 2023 Jun 22;7(5):igad053.
  6. Kreindler SA, Star N, Hastings S, Winters S, Johnson K, Mallinson S, Brierley M, Goertzen LN, Anwar MR, Aboud Z. “Working Against Gravity”: The Uphill Task of Overcapacity Management. Health Serv Insights. 2020 Jun 12;13:1178632920929986.
  7. Krishnamurthy S, Soltany KA, Montez K. Incorporating Health Policy and Advocacy Curricula Into Undergraduate Medical Education in the United States. J Med Educ Curric Dev. 2023 Jul 31;10:23821205231191601.

Drs. Helman, Chochinov and Petrie have no conflicts of interest to declare