> > For example, in my experience, departments that don't allow
> inpatient
> > specialities to clerk patients in their departments seem to
> have much
> > shorter waiting times than departments that do. No
> published evidence, but
> > its an interesting thought.
>
> That's fascinating, but are these patients then directly admitted by
> emergency physicians, or just seen briefly by admitting teams? Can you
> expand further?

Patients are admitted directly by emergency physicians after calling the bed
manager or admitting physician. Any patient likely to deteriorate needs
stabilisation by A and E and informing the admitting physician. Once
inpatient teams are allowed to see patients in A and E they start sending
down the JHO or SHO to assess and see if the reg needs to come down; the
JHO/ SHO then does a full clerking and sends off bloods etc before calling
their reg; patients finish up waiting in A and E (and don't count as waits
because no decision to admit has been taken) and tie up nursing staff and
cubicles thus slowing down A and E process (I've seen departments that think
their shortage is of doctors not nurses, but when you look at what their
doctors do, they spend half their time doing things like calling in patients
and form filling that could be done by nurses or trying to find a nurse)

> > empowered triage
> Tell me more...?


Someone else mentioned this. But basically the idea is that the triage
clinician sends some of the patients away to a more appropriate level of
care. Most triage systems at present triage everyone and they all get seen
anyway. My understanding from the ECLs meeting is that if you add a bit of
basic treatment to this it counts as a sort of see and treat.

> > increasing the distance patients have to travel to A and E
> departments
> I love this one; I think I'll move my department to the Cairngorms!

I think this came from East Anglia somewhere. Basically looked at postcodes.
Disproportionate number of patients (particularly with very minor problems)
came from within a mile and to a lesser extent two miles of the department.
This probably partly explains why urban departments see a greater number of
patients per head of population.

>
> > offering booked appointments to lower triage category patients
> Not sure about this Matt, the patients will definitely
> "punish us" this way,
> and the GPs will have nothing left to do...unless the booked
> appointments
> are with the primary care physicians who already work in our
> departments.
>

There are some things that are A and E rather than GP (mainly in the minor
injuries side) that can wait. Most cost effective way of getting these
patients seen by a consultant. If you've already got primary care bods
working in your department, then booked appointments with them sounds like a
good idea. The idea of allowing patients to phone in to be seen at a certain
time might generate demand as you suggest, but I'm just chucking up ideas
here, not saying which ones will work in which department.

> > bypassing A and E with certain categories of patients
> You mean GP-accepted patients going straight to the ward?
> (full circle, was
> routine in the "bad" old days)

Didn't say it was a good idea, just that it was a way of cutting waits.
Might work in some departments. Here, GP accepteds go straight to the ward
anyway (not much point in being seen by GP, A and E and inpatient team.
Particularly from the nursing view, generates vast amounts of paperwork).
Actually, what I was thinking of was things like 999 calls- if an elderly
patient comes in with a collapse, unilateral weakness and decent
haemodynamics, any reason for them to go to A and E? Other patients could be
sent straight by the triage nurse (if you've got one).

>
> > item of service payments to GPs for minor injury treatment, charging
> patients.
> Too political, especially the latter.

Probably. These ideas are used in other countries, though.

> My comment about optimism was to Brendan's suggestion that we
> could persuade medical teams to take clinical responsibility or
> patients that we had seen and put in distant wards without
> seeing them first. They will start by throwing clinical
> governance at us,
> follow it up with a swift risk analysis to the midriff and
> finish with a left root cause analysis to the head.

Not so. It has been tried and works in a number of places. It depends on A
and E assessing and resuscitating the patients first. For sick patients,
discussion and handover is needed, but for the great majority of admissions
there is sufficient information on the A and E card. Direct referral to the
ward means the admitting team are not tied up anwering their bleeps (and so
see the patients earlier than they would with a handover) and A and E work
more efficiently first because they don't have to repeat what they've
already written down, second because they don't do unneccessary
investigations because the RMO thinks they might be needed and its quicker
to ask A and E to sort them out than to think about them and thirdly because
time isn't wasted arguing with and admitting junior who thinks giving the
referring doctor a tough time might make them discharge the patient.
In the years we've been doing this I've not come across a patient referred
direct to the ward who ran into problems that would have been avoided by
calling the admitting team.
Examples of conditions where this is appropriate are: Low risk chest pain,
rule out MI; suspect PE without major haemdynamic changes; overdose of
relatively safe drugs (or paracetamol once the parvolex is up); fracture NOF
with analgesia on board; suspected appendicitis but not toxic; alert head
injury for observation.

I would note that David Lammy (Parliamentary Under Secretary of State for
Health with responsibility for emergencies) has spoken out against having
admitting teams assessing patients in A and E as to whether they should be
admitted- the idea being that the first person to assess them should be
competent to make the decision and if this can't be done, they should go to
a clinical decision unit (which he feels should be in a proper ward).

Matt Dunn
Warwick


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