Australasian Emergency Departments facing the challenges

[caption id="attachment_4973" align="alignright" width="200"] Senior House Officer Dr Giovanna Marchant doing an intubation[/caption]
A new initiative between the Australian Federal Government and the Australasian College for Emergency Medicine addresses some of the biggest challenges facing Australasian emergency departments, writes Sam Denny.
Australians are getting older, sicker and more numerous. This isn’t a cynical prediction but a statistical fact. The Australian Bureau of Statistics (ABS) projects the Australian population to exceed 30 million by 2050 and estimates approximately a quarter will be aged over 65.
The effect this will have on emergency departments can well be imagined. This age group has more complex health issues, with longer lengths of hospital stay and a greater likelihood of returning to the emergency department.
But an ageing, growing population is only one of the reasons why Australia’s emergency departments are under pressure. Other factors include inadequate resources available for training and a shortage of trained physicians, especially in regional and rural areas.
Beginning in 2011, a new joint initiative between the Australasian College for Emergency Medicine (ACEM) and the Federal Government has sought to address some of these problems in a systematic way. The National Program – Improving Australia’s Emergency Medicine Workforce, is a range of projects funded by the Commonwealth Department of Health and Ageing (DoHA) and overseen by ACEM, with the overall goal of improving emergency medical care in Australia. This article provides a brief background to some of the key challenges facing emergency medicine in Australia and the steps the National Program will take to address them.
ENOUGH TO GO AROUND
Like other specialties, emergency medicine was impacted by the Australian Government cuts to funding for medical education places made in the 1990s. As a young specialty, it also faced a ‘catch up’ phase in order to achieve adequate specialist coverage in the nation’s emergency departments. Today, the rising demand for emergency medicine care is exceeding the capacity of the number of specialists who are available to deliver it. In 2011 ACEM research showed that there were just over five specialist emergency physicians (FACEMs) for every 100,000 people in Australia. Nor is this ratio necessarily expected to improve. In 2012 Health Workforce Australia released its Health Workforce 2025 report, in which it noted that in the period to 2025 the inflows to the emergency medicine workforce brought chiefly by new ACEM Fellows and the immigration of international medical graduates (IMGs) would be outstripped by increased demand. The situation is particularly acute in rural, regional and remote areas (RRR), which represent the primary and/or secondary workplace for a quarter of Australian FACEMs.
FAST FORWARD
Another challenge lies in the speed with which emergency medicine has grown as a specialty. “There’s still a sense in some areas that anyone can run an emergency department, whereas for instance no-one would suggest the same thing about an ICU or surgical unit,” says Dr Sally McCarthy, a past President of ACEM and Chair of ACEM’s National Program Steering Committee. “This has meant that historically, emergency medicine hasn’t received the attention it should have at a jurisdictional level, which in turn has prevented emergency departments from receiving the resources they need.”
A particular area of constraint has been in the small number of senior staff available in emergency departments and thus their reduced capacity to adequately supervise the training of junior doctors. “In a typical emergency department on a clinical shift you might find one consultant, one or two junior registrars, four interns and then a couple of locums or middle grade doctors with variable training,” Dr McCarthy says. “The senior staff have to supervise the less experienced ones plus students and possibly other groups such as paramedics, all at the same time as looking after a continuous stream of patients –from the critically unstable to the less sick – and often many others who are awaiting a bed within the hospital. “You don’t find that level of disparity between senior and junior staff anywhere else in the acute care service.”
[caption id="attachment_4972" align="alignright" width="132"] Senior House Officer Dr Jess Payne doing bagging on a 'manikin'.[/caption]
GOING NATIONAL
Addressing these problems – and others – is a big part of why the National Program –Improving Australia’s Emergency Medicine Workforce was conceived. ACEM signed an initial contract with DoHA in 2011, which in 2012 was varied to extend the timeline and funding and include additional projects. ACEM has a National Program Steering Committee Chaired by Dr Sally McCarthy and a Program Director, Sam Denny. Each project is the responsibility of a College Committee and a project sponsor. A total of 17 projects are being undertaken covering a wide variety of areas including indigenous health and cultural competency, mentoring and leadership. Two of the most important projects are the Emergency Medicine Certificate and Emergency Medicine Diploma courses.
EMERGENCY MEDICINE CERTIFICATE / DIPLOMA
ACEM had developed and commenced early stage roll-out of the Emergency Medicine Certificate prior to its collaboration with DoHA, as a way to deliver up-to-date skills training to the significant number of medical practitioners (especially those working in regional and rural areas) not specifically trained in emergency care. The six-month competency-based Certificate combines workplace-based assessment, online learning, workshops and FACEM supervision. With the introduction of the National Program, resources for the Certificate have been supercharged.
“A typical candidate for the Certificate is a young doctor in their second post-graduate year who hasn’t decided on their specialty yet but is interested enough in emergency medicine to want to do the course,” says Dr McCarthy. “Equally it could be a very experienced doctor who has been working in the local ED for some time and now wants to update their skills and knowledge.”
A key aspect of the Certificate is that it requires candidates to undertake a work placement within an emergency department under the supervision of a FACEM. A parallel Clinical Teaching Course gives FACEMs the skills they need to become supervisors.
“The Certificate packs a lot of need-to-know emergency medicine training into a very concentrated package and it does it primarily within a clinical environment,” says Dr McCarthy. “This type of workplace-based training reflects current best practice and creates a really effective model for efficient teaching and learning.”
Demand for the Certificate has been strong. As of July 2013, 92 candidates have graduated from the course and there are 202 candidates progressing through it at time of writing. Over 200 FACEMs have completed the EMC Clinical Teaching Course.
As well as enhancing delivery of the Certificate, the National Program has also made possible the development of the 18-month Emergency Medicine Diploma (EMD), which provides greater depth and range of training than the Certificate. There are currently 27 students enrolled in the Diploma.
EMERGENCY MEDICINE EDUCATION AND TRAINING
With so many different projects involved, the National Program required from the outset a robust structure through which funded initiatives could be coordinated and delivered. The Emergency Medicine Education and Training (EMET) network provides that structure.
“There’s still a sense in some areas that anyone can run an emergency department, whereas for instance no-one would suggest the same thing about an ICU or anaesthesia unit.”
Dr Sally McCarthy
“In late 2011 ACEM sent a request to the Chief Executives of 356 public hospitals and to all FACEMs advising them of the opportunities for funding made available through the National Program,” says Dr McCarthy. “The College received 64 proposals of which 42 were funded. Some of these overlapped so following discussion with these hospitals there are now 33 EMET contracts in place.”
These 33 contracts form a network of hospitals and training locations throughout Australia through which EMC, EMD and other initiatives can be delivered. Due to a range of criteria – including the hospital’s requirements, its size, location and resources and the needs of the local community – a variety of EMET funding models have emerged, which can be divided roughly into four groups:

• EMET Hub: a hospital which has been funded for a Program Support Officer position, which supports both the Emergency Medicine Certificate and Diploma courses and which has a FACEM-led training program for smaller hospitals in the network.


• EMET (No PSO): a hospital with FACEMs supervising EMC/EMD candidates and/or providing a training program for regional, rural and remote emergency departments.


• Buy-in FACEM: a rural emergency department funded to buy-in FACEM supervision and training.


• Retrieval services: a remote location with minimal medical resources which a FACEM flies to in order to deliver a training session.

FINDING THE HUB
One example of how an EMET Hub operates can be found at Nambour General Hospital in Queensland’s Sunshine Coast. One of only 20 Hubs, Nambour has the funds for a Program Support Officer (PSO), a role which provides administrative support to EMC and EMD candidates, as well as other EMET activities. This frees up FACEMs like Dr Jo Deverill – a Consultant in the Nambour emergency department – to focus purely on training and supervision.
“We began delivering the EMC and then thought that we could make it more effective by adding simulation training,” says Dr Deverill. “With the EMET funding we were able to arrange for every EMC candidate to do a weekly session in the medical simulation centre here at Nambour where content from the EMC syllabus could be further explored using manikins, actors and task trainers.”
Beginning in July 2012, the Simulation Training in Emergency Medicine (STEM) sessions were an immediate success. A website was created (www.stem.org.au) to better prepare candidates for the sessions by pre-posting information about each week’s topic. This was followed by social media outreach, which attracted further attention. In the short space of a year the STEM sessions – originally intended for non-specialist EMC candidates – have become an integral part of the way emergency medicine training is done at Nambour.
“Simulation has been so effective that we started using it on ACEM trainees and now we’re going to orientate all our EM Doctors – including new interns – in it,” says Dr Deveril. “All that has stemmed out of the EMET.”
LET THE SUNSHINE IN
The way EMET has been implemented at Nambour also provides an example of how the program can be scaled to meet local requirements. Nambour is the lead hospital for the local Sunshine Coast health network which includes Caloundra, Gympie, Maleny and Noosa. Nine candidates have already been through the Certificate program on the Sunshine Coast and nine more are currently enrolled. Dr Deverill also got in touch with potential candidates in Gympie, 80km north.
“The people from Gympie weren’t able to make the journey to Nambour to complete the Certificate, but they did want to be involved,” says Dr Deverill. “We didn’t have the resources to deliver a full Certificate course in Gympie, but we were able to organize for a FACEM to visit once a week and provide teaching, an arrangement which has been in place now for over a year”.
The goal, Dr Deverill says, is to embed the changes brought about by EMET into the fabric of the local healthcare system, so that when the funding goes, the program will continue. To an extent this is already starting to happen. “The PSO role at Nambour has become a permanent position within the hospital,” says Dr Deverill. “So, the extra teaching and training time afforded by having that administrative support has now become just part of how we work. “The simulation program has already expanded to Caloundra Hospital and there are plans to create a pocket simulation centre there.”
The speedy uptake of EMET initiatives experienced by Dr Deverill and his team on the Sunshine Coast team is not unique. Feedback collated by ACEM over the past year from EMET participants suggests that receptivity to the different training offerings has been overwhelmingly high. This is also borne out statistically. An analysis of the EMET program to date indicates that up to 50 per cent of the 356 public hospitals identified across Australia and approximately 75 per cent of the regional and rural hospitals have become involved in the Program. This demonstrates a widespread need for this type of funding and acceptance of the National Program’s rationale. And EMET – which is made up predominantly of projects funded to last five years – still has a long way to go yet.
Sam Denny has held senior management positions in health, social services and medical education in New Zealand and Australia. On moving to Australia in 2008 Sam worked at Melbourne’s Royal Children’s Hospital and is now National Program Director for the Australasian College for Emergency Medicine.