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Thanks for the discussion Currently approximately 50% of the emergency admissions to this hospital are admitted directly to inpatient assessment areas, and do not come to the ED. We admit the other 50% who are brought by ambulance following 999 calls. We have well-established bypass to Coronary Care and the heart attack centre Occasionally speciality-accepted patients are diverted into the department (but these are relatively few as you can see from my figures) - and I accept that these are a nursing burden and a space-occupying problem as we are small and easily over-run Our flow perhaps reflects our geographical situation - we are the biggest inland county in England and also serve a lot of Powys - so we have a large footprint and a population of 350,000 or more from which we see only 38,000 patients a year (a select bunch!) - reflecting both very good General Practice, and the filtration effect of distance for patients to travel. Our ability to have speciality-accepted patients managed in their assessment area is not a reflection of lots of empty beds here - we currently run a bed-occupancy of about 98% - including some speciality wards. With our bed occupancy we do have to look after patients that we have referred for admission - and these patients are the ones who are the main cause of our 4hr breaches and are a burden on our nurses who thought they had escaped from ward-work when they came here.. I would like to see a single-door system but accept that it can only be successful if we had the right environment for it (we do not) and the commitment to it by inpatient teams. We are about to be joined by a single acute physician which may help us develop this further. You mentioned the significant amounts of money invested for the 4 hr target - I wish!! It is true that investment has been in staff rather than buildings. Only recently have we had anything - when we seem to be failing the target and endangering out FT application investment came here - as temporary junior locums and doubling the consultant numbers - so we will have 4 when we fill the post remaining. Clearly other Trust managers valued their targets enough to invest in them earlier!! Mark ________________________________ From: Accident and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of Rowley Cottingham Sent: 11 March 2010 13:22 To: [log in to unmask] Subject: Re: GP referrals to specialities I think you may be confusing several different issues. You refer to the well-known elastic wall syndrome. We have all seen that, but as time has gone on it has become clear to me that this has several causes. When the 4 hour target (now standard) was first introduced, significant amounts of money were put into emergency department resources - but mostly in human resources, what you and I call colleagues. Few departments were expanded. When allied to improved flow through these departments there was a significant fall in the number of patients in ad hoc care spaces - Corridor Ward and such. However, the 4 hour standard has fallen victim to the same fallacy that Nye Bevan convinced himself of when he set up the NHS. He thought that once all illness was cured the need for medical care would diminish dramatically. In the same way, it was felt that a single change to working methods that the 4 hour standard prompted would allow hospital bed numbers to be cut and stay cut. Unfortunately, attendances have risen by 8 to 10% per annum in our department since and I suspect we are not alone. This means that unless a vast and increasing number of people get sent home the number requiring admission at any time also rises. There has been a gradual resilting of the admission wards in our Trust and we are back to square one. How many of Mark's patients make it past his department straight into a bed? He mightn't have to deploy resources to look after speciality patients in his department but his nurse manager sure does and that will slow care for his patients. So already his team are doing someone else's work. There are some occasions on which bypass of an ED does work; for example, all our acute cardiac work now goes straight to the cath lab. This is clearly better for patient care and I support it. I am yet to be convinced that this is the case for other patient groups. Mark's problems may well be alleviated by getting together with his acute physician colleagues, pooling resources and sharing the load. It's not a cop-out - it's doing patient care better. Any PCT managers reading this - you do need to think how you are going to deal with this as the patient numbers are continuing to increase, and the patient population attending EDs, particularly by ambulance, is increasingly unwell. BW R ________________________________ From: Accident and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of Prescott Mark (RLZ) Sent: 11 March 2010 11:32 To: [log in to unmask] Subject: Re: GP referrals to specialities So once again the ED is expected to have rubber walls and unlimited resource to manage everyone's problems!! - nice cop-out for everyone else! As you can tell - I am dead against us duplicating someone else's work - it pisses off me, the patient, the GP and the managers - is there anyone who is not upset by this? I am not a megalomaniac who wants to take over the whole of medicine! If a GP has seen and assessed a patient and refers, for a specialist admission, to a speciality team - then neither they nor their patient have any business in my department unless the patient is unstable and needs resuscitation - which we will do better than any other speciality Yours grumpy! Mark P ________________________________ From: Accident and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of Rowley Cottingham Sent: 11 March 2010 09:52 To: [log in to unmask] Subject: Re: GP referrals to specialities Not dyspeptic at all, Vic. In fact you have supported my argument most cogently. GPs have a vital role to play in admission avoidance and as you say seniority helps immensely. GPs can't contact specialties for all sorts of reasons. Sadly, while it may be better that a patient goes directly from bed to bed I'm afraid that is the exception rather than the rule. It is ridiculous to set up parallel access systems as well as expensive in terms of staff and resources. Published data shows that patients get investigated more quickly and treated earlier if they come to EDs. There is no evidence that in house teams are any better at determining whether a patient goes home or comes into hospital, and maybe that is because of seniority issues. The urgent care centres are proving, where they work well, to support this system very successfully. I'm pleased to say that our own joint venture was described as a potential future model in the long awaited Primary Care Foundation report (page 37) http://www.collemergencymed.ac.uk/CEM/About%20the%20College/Current%20Is sues%20and%20Statements/Primary%20Care%20and%20Emergency%20Departments . Power to your elbow in this work, but don't bother referring to specialties. BW R ________________________________ From: Accident and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of Victor Calland Sent: 11 March 2010 08:40 To: [log in to unmask] Subject: Re: GP referrals to specialities I think Specialists are archaic ;-) Come on Rowley, I hope you took some Rennies and got over your dyspepsia! Working at the Urgent Care Centre in Ambulance Control at the moment I am coming across situations where the GP is either not referring to a specialty because they can't get to talk to the admitting doctor because they are in a phone queue or the bleep is unanswered, or they ask the family or nursing home to call the ambulance - so it goes to A&E. It is clearly better if a frail patient is transferred from bed to bed and does not have four hours on a trolley. It takes the pressure of the Emergency team. Unfortunately the whole system is running at capacity and so everybody is looking at ways of dumping the burden of unscheduled care simply because it hasn't been scheduled. Part of what we do is to deflect 999 calls to the GP, part of it is to upgrade where necessary - often admissions direct from a GP's surgery which have been automatically downgraded because there is a defibrillator on site. Initially I was profoundly sceptical of the project, but even at this early stage I am becoming convinced of the need for someone with experience and authority to direct where people go. Its amazing how professional staff are more prepared to accept their responsibilities when they know the call is recorded! Vic Calland On 10 March 2010 22:16, Rowley Cottingham <[log in to unmask]> wrote: I think GP referrals to specialties are archaic and should be banned. BW R -----Original Message----- From: Accident and Emergency Academic List [mailto:[log in to unmask]] On Behalf Of Redman Paul (Frimley Park Hospital NHS Foundation Trust) Sent: 10 March 2010 22:07 To: [log in to unmask] Subject: GP referrals to specialities I seem to be seeing a spate of referrals from GPs to the speciality teams that are being batted sideways with a request from the specialities that the GP send the patient to the ED and the speciality SHO can be called by the ED staff if we are concerned. I eventually lost my rag with the ortho sho today over this - it wouldn't have arisen if the letter from the GP hadn't incriminated the sho in question. Is it our hospital or is it becoming more common? How have others dealt with it? Are you ignoring it? It seems all specialities are involved but obviously some personalities are more apparant than others. Paul Redman ************************************************************************ **** **************************************** This message may contain confidential information. If you are not the intended recipient please inform the sender that you have received the message in error before deleting it. Please do not disclose, copy or distribute information in this e-mail or take any action in reliance on its contents: to do so is strictly prohibited and may be unlawful. Thank you for your co-operation. 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