One evening in June, Hobart mother Alice Moore noticed blood was "absolutely pouring" from her son Teddy's mouth and nose.
Just the day before, the three-year-old had surgery to remove his tonsils and adenoids, so the bleeding was a potential medical emergency.
Ms Moore drove Teddy straight to the Emergency Department (ED) at the Royal Hobart Hospital.
After he was triaged, Ms Moore sat with her son in the crowded ED waiting room.
"We sat in the waiting room for about four hours, they pretty much only saw us because I kicked up a fuss," Ms Moore said.
While they were waiting, Teddy "passed out" and couldn't be woken, continuing to bleed from his nose and mouth.
"There was a little girl sitting next to us who had severe burns to her hands, and the parents had to keep going into the bathroom to fill up water to keep her hands cool," Ms Moore said.
"At this stage, I'd gone past angry and was just feeling helpless, and I was sitting there crying, and the mother of the little girl with burns was trying to comfort me and no one else helped us."
Her son was checked by a nurse and eventually placed on a bed in a corner of the ED.
"They just closed the curtains and left us, we had no blankets, no pillows," she said.
"I gave them about 40 minutes and I pressed the call bell. Another 40 minutes went by, nobody had popped in to see what the call bell was about."
"At this stage, no one had even done any obs (observations) on him, so I packed his bags and found the head nurse in the area and said 'we're leaving, do you need me to sign anything?'"
Ms Moore said a young doctor examined Teddy and said the bleeding was unlikely to be a sign of a serious problem, but that an ear, nose and throat specialist wouldn't be available until the next day.
"It's really ruined our trust in the hospital system," Ms Moore said.
"I had surgery [recently] and broke my stitches open and I haven't bothered to have it fixed because I know I'd sit in the hospital waiting room for half a day and I don't have time to do that when I've got kids to look after."
More Australians going to EDs, waiting longer
Australian EDs are seeing more patients than ever.
A decade ago, in the 2011-12 financial year, there were about 6.4 million presentations to EDs, according to the Australian Institute of Health and Welfare.
Last year, there were about 8.8 million presentations, an increase of 27 per cent.
Doctors and nurses in EDs are also seeing patients with more complicated needs.
When Dr Clare Skinner started working in EDs more than 20 years ago, most patients had a single illness or injury.
Now, patients are more likely to be older, suffer from chronic diseases and be facing a variety of social challenges that mean they need more care and for longer.
"These days quite often it's elderly people with a little bit of shortness of breath, a little bit of dizziness, not coping well at home, possibly an infection that has made things worse, problems with their medication, problems with accessing the degree of social support they need to live independently in the community," she said.
Dr Skinner is the national president of the Australasian College for Emergency Medicine, and said there is a common myth that patients with minor medical problems are taking up time in EDs.
"A far bigger issue is the people who have complex chronic disease which require really well coordinated and integrated care in the community to be managed well.
"And that just is really hard to coordinate, it's often not affordable, it's not accessible in the time frames it's needed and so those people tend to fall through the cracks."
'Overloaded' hospitals spill over to EDs
Emergency department beds are filling up faster and staying full for longer, preventing new patients from being admitted, and forcing ambulances to "ramp" outside EDs, while paramedics look after patients in corridors.
"When I'm working in the emergency department, it's heartbreaking to have to have to look after someone in the waiting room, or in a corridor, or in the back of an ambulance when I know they need a bed," Dr Skinner said.
This hospital gridlock is called access block, or bed block.
It happens when all of the in-patient beds in a hospital are full, so new patients from the ED cannot be admitted.
Those patients stay in ED beds, meaning there's not enough free beds in the ED for new patients.
"It's a sign that the hospital system is totally overloaded, it's really common in all states of Australia at the moment, it's something I'm hearing about from members constantly," said Dr Skinner.
Public hospitals and their EDs are paid for and run by the states and territories.
Access block is often a symptom of problems in other parts of the health system that the Federal Government is responsible for, including aged care, disability care, mental health care and general practice.
The Federal Government recently revealed at the end of June this year more than 1,400 Australians with disabilities were stuck in hospital beds, unable to be discharged because suitable accommodation hadn't been arranged.
The Australian Medical Association's national president, Professor Steve Robson, said Australia's dwindling number of general practitioners was also keeping many patients in hospital unnecessarily.
"By having pressures on general practice it makes it more difficult to confidently discharge patients from hospital knowing that they'll get quality care when they leave hospital," he said.
"It's critical to get things right in every part of the health system. You need a healthy and well functioning health system to solve these problems."
"It's difficult, you can't just throw resources at emergency departments if the rest of the hospital isn't resourced properly and functioning efficiently."
COVID-19 exacerbates existing ED problems
Dr Skinner describes the COVID-19 pandemic as "the straw that broke the camel's back".
"COVID is having an acute impact on the health system at the moment, but the problems we're seeing are exacerbated by COVID, not caused by COVID," she said.
One of the biggest impacts of COVID has been on the already strained workforce of doctors and nurses who work in emergency departments.
The CEO of the Australian College of Nursing, Adjunct Professor Kylie Ward often hears from nurses who are struggling.
"There's a nurse that spoke to me only last week that works in a major tertiary emergency department at a hospital in New South Wales, and they have had 15 nurses out of their workforce leave, they can turn up and be working at a third of the number of nurses that they should on a shift," she said.
"So it's incredibly stressful to try and cover the shift, provide the care, knowing that they're working down and can only do so many double shifts before they burn out themselves."
More than two years into the COVID pandemic, nurses are also noticing an up tick in abuse.
"That is something that nurses have shared with me, they're used to getting abused, maybe physically, but definitely verbally, once a shift, or twice a shift, but now it's increased by eight-fold, ten-fold, of what they're experiencing."
"They're just going home absolutely shattered in their ability to continue to cope with that and provide the care that they need to in the stressful environment that they are."
Whole system needs emergency care, not just EDs
There's agreement among doctors and nurses that comprehensive hospital reform is needed to make a meaningful improvement to EDs.
Professor Robson said Australia's health system was designed for a different era, with vastly different medical and social circumstances.
"Thirty or 40 years after Medicare was set up the landscape is very different, with burden of complex disease, and a wave of mental health issues," he said.
"The demand for care is high, and a system set up that was designed to fund quick through-put for patients really is not fit for purpose any more."
Professor Robson said the primary care sector that general practitioners operate in needs to be properly funded so GPs can coordinate care for patients with complex and chronic medical conditions.
"If you get that model of care right, you have a patient-centred model of care run by general practice that assembles the resources around the patient and ensures continuity you have enormous savings to the system and that frees up funding to other parts of the system."
Dr Clare Skinner agrees the health system needs to be better coordinated, and orientated around helping people manage chronic disease.
"It's tempting to think if we just build bigger emergency departments that will solve the problem, but it doesn't, it just creates a new bottleneck," she said.
"What we need is to make sure the system as a whole, the acute hospital system, community-based care, and the transition between them are all functioning as effectively as possible so Australians can get the care that they need."
