Didn't go to Manchester. However, attended a Strategic Health Authority
meeting here with a number of presentations on see and treat (including an
excellent one on the work done in Kettering which is where a lot of the idea
comes from).
A few points:
1. See and treat isn't rocket science. At its simplest, if there's no
patients to be seen (and a lot of departments manage to empty at some time
in the day), then see patients as they come through the door rather than
having them go to triage, back into the waiting room, doctor goes to box,
pulls card, calls patient back into anther room. It is the reduction in the
number of steps involved that improves efficiency.
If it runs properly you don't need triage (patients are seen pretty fast
anyway).
2. The reason senior staff are used in Kettering is that it was felt that
SHOs lacked the experience in the first 3 months to see and treat
effectively (i.e. rapidly).
3. Interestingly, comparing the departments within our Strategic Health
Authority, the one that achieves the best figures on patients out of the
department within 4 hours is the only one not to have experimented with see
and treat (a different use of senior staff called 'Appropriate Care' is
applied- the consultant sees the sickest patients and sorts them. This was
intended to improve outcome from seriously ill patients- as pointed out
previously on this list, sorting out your sickest patients properly in A and
E has been shown to reduce mortality by around a third as well as reducing
hospital stay in survivors- but because a more senior doctor can focus on
the problem and sort out the patients faster it also frees up staff time to
deal with minors more quickly).
4. Training- not too much of an issue. If your SpRs are being asked about
the tricky patients by your ENPs they probably still get most of the
relevant experience but miss out applying Ottawa ankle rules etc. But they
only need a few months to get up to speed on these. If there are still
worries about lack of experience this can be dealt with by a day or two a
week on the minors side- or by follow up clinics.
5. I'm not sure how long a consultant would last devoting a heavy proportion
of their clinical time to see and treat- it looks as though it could get
tiring after a while.
6. Adrian's point about A and E being used in preference to GP may be borne
out in practice- Kettering reports increased attendances since introducing
see and treat.
7. Of course if you are doing it, a physician's assistant is useful.
Personally when dealing with minors I spend about as much time on paperwork
as I do actually dealing with the patient. Use of a scribe/ runner as well
as a dressings nurse would make the process a lot more efficient.
8. Another way to speed things up is to have enough cubicles that the
patient can already be appropriately undressed by the time you see them.
9. Overall it is an interesting idea that will probably work well in some
departments (particularly those with relatively low numbers of critically
ill patients). However, A and E departments vary; as has been shown there
are other ways of speeding up care of the less seriously ill patient; and
see and treat is not universally applicable. Pushing senior staff too much
into see and treat makes it harder to try other strategies.
Matt Dunn
Warwick
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