Creeping and chronic disasters.
We all know about canaries and coal mines. In the days before ventilation was invented and coal was king, the canaries were the pawns. If they stopped singing, or dropped over dead, the miners knew the methane was thick and they needed to get their bigger human lungs to fresh air. I wonder if it was as black and white as that. Maybe if the canary got asphyxiated very slowly, she might keep singing, maybe a sadder tune, but for a lot longer. The danger might go unrecognized. Or if one canary took one for the team, and the miners didn’t get around to replacing him for the next day’s work, they might have gotten used to not hearing the background birdsong. The new normal would have been only the industrial tunes of picks and hammers, or singing Sixteen Tons, or learning to appreciate the grunts and curses of your shaft mates. Do we not recognize disasters when they creep up on us, or drag on becoming chronic? Has the canary been forgotten?
There are dozens of definitions of disaster. I was excited and enthusiastic when I started a Master’s degree program in Disaster Management. Six weeks into the program, finishing up the first course (Foundations of Disaster and Emergency Management), I was a bit annoyed that we still hadn’t quite defined the term that was the name of my program. Debating many slightly different perspectives, even making up our own, there were dozens of definitions of the word disaster to choose from. And that’s not even including the ones I used to call disasters - like punch spilled on the carpet, or burnt cookies. Often, the definition includes a time frame. Sudden being the keyword (Merriam Webster; dictionary.com). The rest is pretty standard:
“Disasters are typically characterized by widespread disruption that inflicts significant environmental, material, economic, or human losses, while exceeding existing societal resources” (Ciottone).
That definition is complete in and of itself. And it doesn’t say anything about sudden. If we require that temporal aspect then we don’t see disasters in chronic, creeping, or drawn-out events, though they may cause widespread disruption, inflict huge losses, and exceed existing resources. Emergency department overcrowding is an example.
Emergency department overcrowding has been around for decades. Events at local and global levels cause surges that are recognized as disasters, and we manage. Sometimes well, sometimes not. And then the surge recedes we go back to normal. Normal being over-capacity (widespread disruption, huge losses, exceeding existing resources). But that’s not a disaster. That’s normal.
“The chronicity of gradually evolving disasters makes them insidious. As a disaster lingers, prolonged exposure to its negative effects can result in the normalization of limited responses. When communities and societal systems begin to “return to normal,” they can inadvertently incorporate these suboptimal approaches into the flow of everyday operations. This damages care in normal times and can even compound future disasters” (McNeilly).
“...because of the constant state of crowding, we have lost sight of what defines true hospital capacity.” (McNeilly).
Should we think about this problem more in terms of disaster management? “We know how to prevent this loss of life; the concepts are part of straightforward disaster medicine” (Boyle). In disaster science, we think in terms of preparedness, prevention, mitigation, response, and recovery. Do we think about ED overcrowding with these principles in mind? Maybe we hope to prevent it, we definitely do what we can to respond. Do we prepare for it, do we look at mitigation, do we try to recover (and not just back to the normal disaster)? If we looked at ED crowding from a disaster management perspective, we might see some more solutions. We might see routine vulnerability assessments. We might see ‘reverse triage’ where the priority is on discharging patients rather than on admitting them (see Boyle). We might see more emphasis on staffing and retention. We might also recognize understaffing as a real threat, even a disaster?!
We also miss out on an opportunity to bring focus (and maybe funding??) to the issue when we ignore the disaster classification. Disasters are way more engaging than chronic dwindles. Can we really call a crowded waiting room a disaster? Existing resources lacking? Duh, of course. The ‘resources’ are home sick, or burnt out, or took a job outside the hospital because it pays the same (but you get your breaks, and don’t get sworn at, or asked to take on more patients than you can safely handle). Widespread disruption? On any given day at work, it is not at all unusual for me to be told (sorry, I don’t usually hear it, I’ve kind of tuned it out) that a section of the ER is closed due to nursing shortages. Can’t put patients there, the whole machine slows down, effects upstream (longer waits) and downstream (admissions delayed). Huge losses? …“for every exposure to a shift that fell 8 hours or more below the targeted staffing level, a patient’s risk of mortality increased by 2%.” (McNeilly).
“Although the importance of addressing ED crowding is more salient in the acute setting, it inflicts even greater mortality in the chronic setting” (McNeilly)
But we don’t need more solutions at the emergency department level. Tweaking our care models, rearranging spaces, monitoring door-to-whatever (door-to-doc, door-to-disposition, door-to-discharge) time can only take us so far. Solutions need to be at all levels. “… the single biggest contributor to delayed admission is lack of hospital capacity and subsequent access block it creates.” Anecdotally, but regularly (ie every single shift) I see emergency department visits that stem solely from a lack of primary care. I'm sure my experience is not uncommon. Solutions to emergency department problems will come from improvements in primary care, long-term care, and coordinated hospital management. Not sexy. Not easy.
Focusing on the ED is of limited benefit. It's like blaming the canary for the methane.
“This is as effective as shouting at a moribund canary.” (Boyle)
ED overcrowding is a problem. A big problem. A disaster, even. And we can manage disasters. We might manage this one better by recognizing it as it is. How many more canaries do we have to sacrifice?
McNeilly BP, Lawner BJ, Chizmar TP. The Chronicity of Emergency Department Crowding and Rethinking the Temporal Boundaries of Disaster Medicine. Annals of Emergency Medicine. 2022 Sep 15. [link]
Boyle, A. A. & Beniuk, K. (2010). Overcrowding: emergency departments are the canary in the coal mine and overcrowding is the poisonous gas. European Journal of Emergency Medicine, 17 (6), 354. [link]
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