A recent death in a government hospital has once again reignited familiar questions about delays in emergency care. Predictably, public attention has centred on identifying individuals who might be responsible.
Was the patient made to wait too long? Did the security staff fail to respond appropriately? Was there a delay on the part of the nurse or the casualty medical officer? These are legitimate questions, and every such incident deserves an objective inquiry. Yet, they also divert attention from a far more fundamental question that receives remarkably little public discussion: Why are our emergency departments so crowded that genuine emergencies must compete for attention in the first place?
Having worked for several years in Kerala’s public health care system, much of that time in casualty services, I have watched emergency departments gradually evolve into something they were never designed to be. Once the outpatient departments close for the day, the casualty increasingly functions as a general walk-in clinic.
Patients with genuine emergencies arrive alongside those with common colds, sore throats, prescription refill requests, symptoms that have persisted for several days, and complaints that could comfortably wait until the following morning. Many find the evening a more convenient time to seek medical attention. This phenomenon is no longer occasional. It has become routine.
This is not criticism of the public or any government mechanism. Most people use the health care system exactly as they have learned to. The real problem lies in the absence of clearly defined boundaries between emergency care and routine outpatient care.
Universal health care remains one of Kerala’s greatest achievements, protecting millions from catastrophic medical expenditure and ensuring access to treatment regardless of financial status. That achievement deserves preservation.
However, universal health care should never be mistaken for unrestricted utilisation of every service at every hour. A health care system should not be judged merely by how much access it provides. It should also be judged by whether it preserves its ability to deliver timely, effective care to those whose lives genuinely depend upon it.
Whenever discussions arise after an adverse event in a casualty department, one recommendation inevitably surfaces: improve triage. Although well-intentioned, I believe this recommendation no longer addresses the root of the problem. The difficulty is not that triage is inadequate. The difficulty is that triage begins too late.
Under the present model, virtually everyone is permitted to enter the casualty department before any meaningful filtering occurs. Only after entering are patients classified into Red, Yellow, or Green categories based on urgency. While this system may have functioned adequately when patient volumes were lower, present-day realities have exposed its limitations.
Over time, people have become increasingly familiar with the symptoms that attract priority. A mild headache may be described as the “worst headache ever.” Gastritis becomes “acute chest pain.” Nasal congestion becomes “breathlessness.” Whether such descriptions arise from anxiety, misunderstanding, or deliberate exaggeration is often impossible to determine immediately. The practical consequence, however, remains the same. Individuals without genuine emergencies frequently enter emergency pathways, while patients with truly time-critical illnesses compete within an increasingly congested clinical environment.
Every unnecessary consultation consumes resources that cannot be multiplied on demand. It occupies the attention of doctors and nurses, utilises diagnostic equipment, occupies physical space, interrupts workflow and, above all, consumes time. Emergency medicine depends upon uninterrupted concentration and rapid decision-making. Crowding steadily erodes both. The consequence is not merely an inconvenience for healthcare workers. It represents a genuine threat to patient safety.
What can be done?
The solution, therefore, should move beyond improving conventional triage. Kerala should instead consider establishing patient control centres in every taluk hospital, district hospital, general hospital and medical college hospital.
Positioned immediately outside the casualty department, these centres would become the true first point of clinical assessment. Their purpose would not be to deny health care. Rather, they would ensure that every individual is directed to the most appropriate level of care.
Patients presenting with genuine emergencies would proceed directly to the casualty department for assessment and treatment. Patients whose conditions can safely wait until the next outpatient session would receive appropriate advice, be redirected to scheduled outpatient services, and would not be allowed to access emergency services under any circumstances, thereby restricting crowding in the emergency unit. This represents an important philosophical shift. Instead of asking, “Which patient should be seen first?”, the health care system would first ask, “Does this patient require emergency care at all?” These are fundamentally different questions.
Conventional triage assumes that everyone entering the casualty department belongs there and merely determines who should receive priority. A patient control centre performs a more fundamental function by determining whether access to the emergency unit is required before the patient enters the emergency environment. Only after that decision has been made should conventional emergency triage begin. Such a model would substantially reduce unnecessary crowding, preserve emergency resources for genuinely critical cases, reduce cognitive overload among health care professionals, and improve the efficiency, safety, and responsiveness of emergency care.
Complementary measures should accompany this structural reform. State-wide guidelines should clearly define what constitutes a medical emergency. Public awareness campaigns should educate citizens on the appropriate use of emergency departments. Outpatient services should also be restructured to reflect present-day lifestyles.
A significant proportion of evening casualty attendees are working individuals who are unable to seek care during conventional office hours. Splitting general outpatient services – both specialist and general OPs into two sessions—for example, from 8 AM to 1 PM and again from 4 PM to 9 PM —not with the existing manpower, but with the addition of extra manpower, would better accommodate this population while substantially reducing unnecessary migration into casualty departments after routine OP closure.
Health care systems function best when compassion is balanced by organisation. Roads require traffic rules. Airports require access control. Courts function through jurisdiction. Emergency departments should be no different. Unlimited access should never be mistaken for effective healthcare delivery. The objective is not to make healthcare less accessible. It is to ensure that emergency care remains immediately available for those whose conditions truly cannot wait.
If Kerala wishes to preserve the remarkable achievements of its public healthcare system for future generations, it must begin thinking beyond affordability alone. The next frontier of health care reform is not merely universal access, but universal access to the right service, at the right place and at the right time.
Protecting emergency care demands more than refining triage protocols. It requires preventing unnecessary congestion before it reaches the emergency department itself. Patient control centres offer a practical way to achieve exactly that. By filtering non-emergency cases to appropriate outpatient services, they can preserve the casualty department for its intended purpose. Only when unnecessary crowding is effectively contained can genuine emergencies be managed with the speed, precision and undivided attention they deserve.
(The author is a public health care practitioner, writer and published translator of three books)
The opinions expressed in this article are those of the author and do not purport to reflect the opinions or views of THE WEEK.
