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
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%20Issues%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 (
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
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