> BUT, the next initiative from management and upper nursing
> echelons has
> been causing me some more concern: care pathways for the majority of
> majors patients coming through, to be funnelled off to gynae,
> orthopaedics, cardiology etc, after assessment by a senior nurse in
> order to beat the four hour targets.
>
> There are advantages of a senior nurse assessment around the
> clock, as
> they can spot a problem early and involve medical input earlier.

Depends on how it's handled. There seem to be a lot of patients who are
admitted, but do not require the resources of a consultant emergency
physician (moderate asthma; lowish risk chest pains; vaginal bleeding in
early pregnancy etc.). To a certain extent the conditions will be determined
by local protocols. If it is felt that these patients require E consultant
input then it still makes sense to start arranging a bed for them before the
consultant has time to see them (even have the admissions ward under the
care of E). Might also make sense to have the necessary investigations back
by the time the patient is reviewed.

> However, it seems that in our eagerness to comply with 4 hour waiting
> times we are doing ourselves out of a job.

I don't think we're doing ourselves out of a job all that much. We're
talking about transferring much of the simpler work currently done by junior
trainees onto nurses. The way to raise the profile of the speciality is to
expand the role of our consultants, not to have our consultants take on SHO
work. Certainly, it will reduce the extent to the consultant expansion
needed. However, this does carry its own benefits (fewer consultants means
each maintains higher levels of experience)

> I can see 10 Emergency
> Medicine SHOs in the near future twiddling their thumbs while the
> majority of patients funnel straight past them

In the longer term I don't see E SHOs having a major service input into
departments. If we are to move towards a consultant delivered service,
initiatives like this seem a sensible way of freeing up consultants to
devote their skills to those who need them most.

> OR lie in
> the corridor
> waiting for the specialty doctors to arrive and see them.
>

Best case scenario of course is that these patients are no longer seen as
part of the E department, thus meaning that other specialities do not
automatically prioritise them lower than their other patients for beds.

I have mixed feeling on this, but on the whole it has some advantages. The 4
hour wait is not such a bad thing- critically ill patients can generally be
sorted out in 4 hours with adequate resources; less ill patients for
admission generally have the 4 hours wait because of lack of beds and this
puts pressure on the hospital to provide these beds; patients who are
awaiting results of investigations with a view to admission or discharge
should really be in a more comfortable and private area than the E
department while waiting.

Matt Dunn
Warwick


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