Andrew Gosbell

Quantifying the proportion of general practice and low-acuity patients in the emergency department

Objective: To accurately estimate the proportion of patients presenting to the emergency department (ED) who may have been suitable to be seen in general practice.

Survey of alcohol-related presentations to Australasian emergency departments

Objective: To determine the proportion of alcohol‐related presentations to emergency departments (EDs) in Australia and New Zealand, at a single time point on a weekend night shift.

Telephone triage is not the answer to ED overcrowding

Yusuf Nagree, Peter Cameron, Andrew Gosbell and David Mountain Emergency Department, Fremantle Hospital, Fremantle, School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Department of Emergency Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Emergency Medicine, Monash University, Melbourne, Victoria, and Policy and Research, Australasian College for Emergency Medicine, Melbourne, Victoria, Australia

Determining the true burden of general practice patients in the emergency department: Getting closer

Yusuf Nagree, Andrew Gosbell, Sally McCarthy, Katie Moore and David Mountain Emergency, Fremantle Hospital, Fremantle, Western Australia, Australia, School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Nedlands, Western Australia, Australia, Australasian College for Emergency Medicine, West Melbourne, Victoria, Australia, Agency for Clinical Innovation, Emergency Care Institute NSW, Sydney, New South Wales, Australia, and Emergency Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia

Perceptions of Australasian emergency department staff of the impact of alcohol-related presentations

Objectives: To survey emergency department (ED) clinical staff about their perceptions of alcohol‐related presentations.

Australasian specialist emergency medicine workforce: Here and now … and beyond

The Australasian emergency medicine (EM) workforce has greatly expanded over the past decade. Demand for emergency medical care has also escalated, at a rate substantially higher than population growth. Ideally, there should be sufficient numbers of qualified experienced emergency physicians appropriately distributed to ensure all people in Australia and New Zealand can access high-quality EM care regardless of location or economic status. Balancing supply of specialists with demand for care is challenging in our highly dynamic complex healthcare systems. From a supply perspective, EM, as a relatively new discipline, has required rapid expansion of consultant numbers to meet immediate needs and anticipated growth in demand, along with longer-term consideration of replacement stock. To achieve this, building the trainee cohort has been critical, but with the inherent time required to complete vocational training (Table 1), medical immigration with processes for recognition of overseastrained specialists (OTS) has contributed to meeting EM workforce needs. Most recent analyses, based on 2009 datasets using scenario-based modelling, estimate 1780 to 2041 Fellows of the Australasian College for Emergency Medicine (FACEMs) will be needed in Australia by 2025; with a moderate likelihood, the projected supply will not meet demand. Forecasting for New Zealand suggests fewer additional trainees will be required to meet future need. The Australasian College for Emergency Medicine (ACEM) is mindful of the interaction between current trainee and consultant workforce and future service requirements while maintaining and enhancing high-quality patient care. ACEM is therefore building an evidence base to inform discussions on the future development of the EM workforce in Australia and New Zealand. This includes updating the membership database, for robust analysis of workplace information, collecting ED workforce and workload metrics through annual surveying of Directors of Emergency Medicine and biannual surveying of new FACEMs regarding their experiences entering the consultant workforce. This perspective article presents some of this data, exploring possible ways the EM labour market may evolve, and factors potentially influencing the workforce in the coming years.

THE MEDICAL BOOMERANG—WILL IT COME BACK?

Objectives To explore the increasing numbers of emergency medicine (EM) registrars that obtained their primary medical degree from UK or Irish universities, who work in emergency departments (ED) throughout Australia and New Zealand. Methods The Victorian Emergency Registrar Study was published at the Australasian College for Emergency Medicine (ACEM) annual scientific meeting in Adelaide in November 2013. As a follow on, ACEM provided the authors with data regarding country of primary degree for international medical graduates (IMG) working as registrars in Australasian EDs. Results UK and Irish EM registrars make up the largest proportion of IMGs working in Australian and New Zealand EDs. These figures have increased from 34% in 2008 to 45% in 2013. In 2013, there was the highest yearly intake of UK and Irish ED IMG registrars, representing 41% of registrars joining the Australasian EM training programme. Current data show that >25% of all ED registrars working in Australasian EDs studied for their primary medical degree in a university either in Ireland or the UK. Conclusions While there have been anecdotal reports of increased outflow of junior EM doctors from the UK and Ireland, we provide quantitative data on the extent of the recent (5-year trend data) emigration of UK/Irish EM trainees to Australia and New Zealand and discuss the impact of this on both the UK/Irish and Australasian health systems.

The need to maintain quality and build capacity for emergency medicine training

The growing demand for ED training experiences, because of increases in medical student, intern and registrar numbers, highlights key issues for the future of medical training in Australasia. ED experiences provide junior doctors with an important and unique experience of generalist medicine, with exposure to a broad range of undifferentiated acute illness and injury not often encountered in other clinical environments. However, practical constraints to supervisory capacity and availability of placements in existing teaching hospitals threaten to dilute the value of these experiences. The question is: how best to provide this highly valued emergency medicine experience to the greatest number of recipients without diluting quality of the learning or further increasing pressures on busy ED clinicians? The most immediate concern is the number of places available for interns. However, there is a looming potential bottleneck in the training pipeline as, in the near future, more early-career doctors than ever will compete for junior medical officer and vocational training positions. Selectively optimising intern experiences in EDs and/or limiting trainee placements in accredited EDs is a potential approach to manage growing demand. Limiting placements suggest exclusivity somewhat at odds with the egalitarian values of Australasian emergency medicine. Furthermore, forecasting indicates that Australia will not achieve self-sufficiency by 2025, but continue to rely on overseas-trained doctors to supplement the emergency physician workforce. So, capping trainee numbers would seem somewhat ill-considered and avoids addressing the fundamental issue, namely, supporting and expanding supervisory capacity within EDs. Training in clinical settings is essential to medical workforce development. This requires high-quality supervision to facilitate competency development and progression of junior doctors towards independent practice. In Australasian EDs, Fellows of the Australasian College for Emergency Medicine (FACEMs) provide a major supervisory role for junior doctors; yet there is no doubt whatsoever that capacity for supervision is increasingly constrained. Training and workforce data support this: in 2008, FACEM to trainee ratio was 1:0.8 and FACEM to intern ratio was 1:2.0; by 2012, the ratios of FACEMs to trainees was 1:1.5 and to interns was 1:2.2. Clearly, the situation is rapidly evolving whereby there are twice as many trainees, as well as more than twice as many interns, as Fellows. The reasons for this are varied and complex, but most critically these statistics demonstrate that supervisory demands on existing FACEMs are becoming increasingly unmanageable. This is further exacerbated as actual supervision of students, interns and registrars in the ED is often delegated to those emergency physicians with an interest and commitment to medical education. This smaller group of FACEMs shoulders much of the burden of supervision, assessments and educational oversight of doctorsand specialists-in-training. Consequently, a tipping point is approaching where required capacity to effectively train the growing cohort of junior doctors exceeds available supervision time of these experienced physicians. The contemporary operational paradigm for EDs is challenging for medical education. The increasing demand for ED services exceeds population growth and government health reform initiatives are driving clinical service delivery models geared to optimise patient flow and benchmarked to time-based targets. These factors impact on the educational experiences in the ED, including the ability to expand supervisory capacity to meet the needs of the junior doctor cohort who require emergency medicine training. However, increased quality and access to supervision not only improve education-related outcomes but, importantly, result in better patient outcomes. This crucial factor must be considered in terms of the multiple demands on the public health system, where service demands

The emergency medicine events register: an analysis of the first 150 incidents entered into a novel, online incident reporting registry

Incident reporting systems are critical to understanding adverse events, in order to create preventative and corrective strategies. There are very few systems dedicated to Emergency Medicine with published results. All EDs in Australia and New Zealand were contacted to encourage the use of an Emergency Medicine – specific online reporting system called the Emergency Medicine Events Register (EMER).

What lies beyond: Findings from the Early Careers Survey of new Fellows of the Australasian College for Emergency Medicine 2013-2014.

Department of Policy and Research, Australasian College for Emergency Medicine, Melbourne, Victoria, Australia, Department of Emergency Medicine, Royal Brisbane andWomen’s Hospital, Brisbane, Queensland, Australia, MedSTAR Emergency Medical Retrieval Service, South Australian Ambulance Service, Adelaide, South Australia, Australia, and Department of Emergency Medicine, Austin Health, Melbourne, Victoria, Australia