Workforce and Wellbeing

Regardless of current community case numbers, emergency clinicians have been, and will continue to need sustained vigilance in the application of new processes to assess and manage possible or known COVID-19 patients attending Emergency Departments (EDs). In areas of outbreaks, additional escalated strategies will be essential

We recommend that: 

1. Organisations establish lines of communication to emergency clinicians ensuring daily and urgent updates on the emergency response planning, patient management, logistical and workforce wellbeing issues. Short team pre-briefs and debriefs should be used for every clinical shift to reinforce infection control measures, update processes and discuss staff and patient safety issues.
2. Organisations ensure a sufficient supply of PPE is available to emergency clinicians at all times. Access to appropriate PPE, and relevant training, is a prerequisite for the delivery of patient care (see Personal and Protective Equipment section) and should be incorporated into organisational policies for ED to ambulance interface (see ED–Ambulance Interface section), triage and reception (see Triage and Reception section), patient treatment (see Treatement section), management of cardiac arrest (see Adult Cardiac Arrest Management section), patient transport (see Transport of Patients section)  and management of specific patient presentations such as trauma (see Trauma section) and occupational violence and security policies.
3. Organisations rapidly prioritise the training of emergency clinicians (including ongoing, temporary and rotating staff) in policies and procedures related to COVID-19 healthcare delivery.
4. Non-clinical team members, for example administration, transporters and security staff should be included in support and training initiatives.
5. Organisations identify emergency clinicians vulnerable to COVID-19 infection (pregnant women, older clinicians and those with comorbidities) and offer alternative work away from frontline patient care.
6. Emergency clinicians meeting COVID-19 case definitions have prioritised access to testing and expedited results in order to minimise staff furlough.
7. In the setting of significant rates of community transmission, it is reasonable to escalate PPE requirements such that droplet precautions are utilised for the whole ED. This will minimise the risk of staff members becoming ‘close contacts’ resulting in furlough and reduce complexity in processes.
8. Should a COVID-19 vaccination become available, administration should be prioritised for emergency clinicians and their immediate household members.
9. Organisations develop a visitor policy that is consistent with contemporary government guidelines and recommended infection prevention and control measures. Policies should aim to facilitate patient-centred care while minimising the risk of nosocomial transmission.
10. Organisations employing emergency clinicians provide sufficient security staff to manage occupational risks through crowding, violence and other behaviours of concern. Memoranda of Understanding with local law enforcement, and/or other agencies, may be required to facilitate increased organisational security.
11. Organisations employing emergency clinicians endeavour to provide clean scrubs and access to change areas for use on every clinical shift.
12. Consistent with section 22.4 below, organisations employing emergency clinicians provide food, water and a ‘clean’ (low-risk for COVID-19 transmission) break area, compliant with physical distancing guidelines.

We align with:

1. Royal Australian and New Zealand College of Obstetricians and Gynaecologists, COVID-19 and pregnant health care workers statement. [Link]
2. Australian Health Protection Principal Committee recommendations for managing vulnerable workers. [Link]
3. Coronavirus disease (COVID-19) physical distancing guidance. Australian Government Department of Health. Version 3, 26 March 2020. [Link]

EDs must maintain adequate staffing to ensure clinician and patient safety at all times. There must be sufficient redundancy to account for significant and unpredictable rates of staff absenteeism through forced quarantine, sick leave and staff wellbeing considerations. Given the ongoing unresolved issues of ED overcrowding, new and rapidly changing models of patient care, infection control requirements and new complexities in patient care delivery, it is unsustainable for emergency clinicians to work in an under-resourced environment. Allowing this to continue is harmful for patients and clinicians and will lead to increasing infection and burnout among staff

We recommend:

1. Emergency clinicians are retained for their core roles and responsibilities (i.e. the delivery of emergency care). When considering using ED workforce outside of their usual scope of practice (for instance, in community public health emergency response), this should be balanced against the IPC implications of moving staff between a hospital and community setting and workforce issues.
2. Organisations review their staffing requirements to determine the need for additional human resources. Consistent with ACEM guidelines on constructing and retaining a senior emergency medicine workforce, departments should determine the minimums safe number of staff, including “senior decision makers” within the facility at all times.
3. Organisations establish a clear and transparent mechanism for clinicians to raise workforce concerns to the appropriate level, with transparent organisational and system level triggers to respond with workforce support for both ‘business as usual’ and surge response.
4. Where additional staff are required to supplement the emergency clinician workforce, the credentialing process for external staff and volunteers (both medical and non-medical) should balance patient safety and timeliness.
5. Emergency clinicians unable to work due to COVID-19 illness or public health isolation measures (for themselves or dependents) have access to paid leave for the duration of the illness/enforced leave. 

We advocate for jurisdictions to establish:

1. A formalised process for ongoing COVID-19 system response reflection and quality improvement.
2. ​A transparent data solution to ensure real-time monitoring of suspected and confirmed COVID-19 caseload, staff availability and PPE supply across health care services. This will facilitate resource sharing and redistribution at times of increased stress across the emergency care system. Established state, national or binational emergency management platforms, such as Critical Health Resource Information System (CHRIS), should include EDs.
3. Central oversight of emergency care capacity and response across the system. This should include a centralised ‘Emergency Operations Centre’ that can facilitate real-time escalation and coordinated muti-disciplinary operational responses to system-wide issues.
4. Clear processes to facilitate efficient and effective communication between facilities and across the entire emergency care system. This is an essential strategy to ensure operational responsiveness in times of increased stress.
5. Measures to address pre-existing maldistribution of the emergency clinician workforce between metropolitan and rural/regional healthcare services.
6. Resource sharing among local facilities and networks. Effort should be made to assist regional, rural and remote EDs, as well as metropolitan EDs facing surge events, to maintain capacity for the delivery of safe and effective patient care at all times. This may require consideration of redistribution of the available workforce (in consultation with the affected clinicians), however where outbreaks have resulted in lockdowns, clear jurisdictional guidance will be required on where staff can travel from and to, acceptable behaviours whilst travelling from outbreak areas and alternative workforce options for organisations heavily reliant on workforce travelling from outbreak areas.
7. Transparent triggers for times of surge or staff incapacitation that escalate jurisdictional and inter-jurisdictional resource support which may include;
   • creation of a jurisdiction wide “emergency relief” workforce to be used in times of need. This may address issues such as sustainability through workforce relief and recovery, staff furlough, sick leave and surge support.
   • Triggers for inter-jurisdictional resources including additional emergency care workforce and infrastructure, as provided for example by Australian and New Zealand Medical Assistance Teams (AUSMAT) and the Australian and New Zealand Defence Force.
   • Triggers for temporary closure of EDs for either IPC or workforce crisis. 
8. Centralised contracting and credentialing processes for the healthcare workforce. This will allow greater flexibility and responsiveness in the workforce.
9. ​Appropriate support and transport arrangements for fly-in-fly-out (FIFO) emergency clinicians. Where clinicians are supporting organisations distant to their place of residence, arrangements should balance personal wellbeing with public health control measures. Sensible arrangements are required to ensure workforce supply and limit maldistribution.

We align with:

1. ACEM G23 guidelines on constructing and retaining a senior emergency medicine workforce [Link].

It is well established that rostering practices impact on clinician physical and psychological wellbeing. Evidence has also shown that risk of COVID-19 infection is increased with longer shifts.

To minimise the risk of fatigue and burnout among emergency clinicians, we recommend:

• Rostering for all staff members is consistent with fatigue management principles and best practice in ‘safe working hours’. Clinicians should not be rostered to excessive duty hours and must retain regular access to days off (free from work). This includes casual or supplementary staff members.
• Emergency clinicians are rotated through shifts in areas of high stress (eg, a high-risk zone) to areas of low stress. They should also be provided with regular breaks, ideally every 4 hours.
• Organisations develop staffing models that partner inexperienced or rotating staff with more experienced colleagues.
• Emergency clinicians are provided with appropriate remuneration for any additional working hours, consistent with relevant industrial agreements and frameworks.
• Emergency clinicians are provided with safe places to sleep at work (if required), and taxi vouchers if unsafe to drive home after a shift.
• Any proposal for the rostering of emergency physicians to night shifts should be consistent with the principles outlined in ACEM S456 (Statement on Night Shift Rostering of Emergency Physicians).

 We align with the human resources sections of:

1. World Health Organization (WHO), Hospital Readiness Checklist for COVID-19. [Link]
2. AMA National Code of Practice - hours of work, shiftwork and rostering for hospital doctors [Link]
3. ACEM G23 guidelines on constructing and retaining a senior emergency medicine workforce [Link]
4. ACEM S456 Statement on night shift rostering emergency physicians [Link]

It is essential that EDs maintain sufficient facilities for clinicians to change, rest, eat and refresh before, during and after shifts. The available infrastructure must enable clinicians to take meal breaks, as well as other necessary activities, without compromising physical distancing and IPC measures.

We recommend:

1. Hospitals audit the capacity of existing non-clinical areas (such as tea and changing rooms) to safely accommodate staff. These facilities must be large enough to enable staff members to access them while maintaining physical distancing.
2. Hospitals consider the need for temporary structures or the repurposing of existing infrastructure, to expand waiting rooms, offices, ambulance ramping areas and non-clinical areas to comply with physical distancing and other IPC requirements.
3. Consideration of automated systems of sign in for communal break areas, such as QR code linked data bases and time stamps to enable contact tracing.

We recommend:

1. Staff wellness (both physical and psychological) measures are incorporated into organisational emergency response and post response planning. 
2. Emergency clinicians have access to free psychological support and debriefing (including one-to-one) when required. This may include, peer support programs, drop in centres or telehealth support.
3. Emergency Clinicians have access to a period of recovery, including debriefing, psychological support or leave in an appropriate timeframe during and after the COVID-19 response, specifically where identified outbreaks have required a surge response.

Exemplar documents

1. A wellbeing plan from WRaPEM (Wellbeing, Resilience, Performance in Emergency Medicine) for Wellness Week 2020 [Link]
2. A webpage addressing staff wellbeing within domains, tied to organisational values [Link]

The following resources were used in the preparation of this section:

• American College of Emergency Physicians, National Strategic Plan for Emergency Department Management of Outbreaks for COVID-19. [Link]
• Ran L, Chen X, Wang Y, Wu W, Zhang L, Tan X. Risk factors of healthcare workers with corona virus disease 2019: A retrospective cohort study in a designated hospital of Wuhan in China. Clinical Infectious Diseases. 2020 Mar 17 [Link]

Resources that are relevant to this section can be accessed through the Clinical Guidelines web-based material [Link]. COVID-19 related ACEM Resources [Link], COVID-19 related external resources [Link], and the latest Government advice on COVID-19 [Link] are also available.

This section is targeted at clinicians only. Patients, parents or other community members using it should do so in conjunction with a health professional and should not rely on the information in the guideline as professional medical advice.

The section has been developed by an expert team of practising emergency physicians, by consensus and based on the best evidence available. The recommendations contained do not indicate an exclusive course of action or standard of care. They do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type.

The section is a general document, to be considered having regard to the general circumstances to which it applies at the time of its endorsement.

It is the responsibility of the user to have express regard to the particular circumstances of each case, and the application of the section in each case.

The authors have made considerable efforts to ensure the information upon which it is based is accurate and up to date. However, the situation is rapidly evolving, and a certain amount of pragmatism needs to be employed in maintaining such a ‘living document’. Users of this section are strongly recommended where possible to confirm that the information contained within the document is correct by way of independent sources. The authors accept no responsibility for any inaccuracies, information perceived as misleading, or the success or failure of any treatment regimen detailed. The inclusion of links to external websites does not constitute an endorsement of those websites nor the information or services offered.

The section has been prepared having regard to the information available at the time of preparation and the user should therefore have regard to any information, research or other material which may have been published or become available subsequently.

Whilst we have endeavoured to ensure that professional documents are as current as possible at the time of their creation, we take no responsibility for matters arising from changed circumstances or information or material which may have become available subsequently.