Hello Sue
We use a system called RAM (not as bad as it sounds) - a rapid assessment in majors nurse (usually a band 6/7 nurse distinct from the shift leader) will triage all ambulance borne patients and will order certain initial appropriate tests and investigations - if necessary with the support of an Advanced Clinical Practitioner (who may be a nurse, physiotherapist, Physician Assistant or Paramedic Practitioner) or an ED registrar/consultant - the need for the involvement of others is however minimal and the RAM nurse most often allocates a cubicle for the patient and requests HCA's to undertake initial assessments such as 12 lead ECG, phlebotomy, basic observations, assessment of social history and will themselves be x-ray requesters where this is appropriate. We are also considering nurse led requesting of CT scanning- this is already possible under an algorithm for head trauma but CT scanning for other conditions (i.e. abdomen for renal colic) is also being considered. Nurse requested ultrasound requests are already well established to exlcude DVT for instance in high Wells score patients. This is all well supported by a Hospital avoidance team (HAT - a mnenomic for everything) who may receive a direct referral from RAM
Obviously in reducing the need for senior medical intervention it works more effectively in this respect but still falls down when:
1 - there are not enough cubicles to allocate patients to for initial assessment
2- bed occuapncy is so high that patients already assessed just end up laying on corridors awaiting an inpatient bed
3- when such a high influx of ambulance borne patients arrive at any one time that even with these resources the 15 minute target becomes unachievable
regards
Jim Bethel
________________________________________
From: Accident and Emergency Academic List [[log in to unmask]] on behalf of ACAD-AE-MED automatic digest system [[log in to unmask]]
Sent: 13 April 2013 00:10
To: [log in to unmask]
Subject: ACAD-AE-MED Digest - 4 Apr 2013 to 12 Apr 2013 (#2013-28)
There are 3 messages totaling 597 lines in this issue.
Topics of the day:
1. 15minute turnaround times (3)
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Date: Fri, 12 Apr 2013 17:15:37 +0100
From: Suzanne M Mason <[log in to unmask]>
Subject: 15minute turnaround times
Dear Acad
I am writing to see whether any of you have come up with any innovative
ideas for handling the new push to achieve the ambulance service turnaround
time target?We are really struggling with this in Sheffield and anecdotally
I know others are. We are keen, however, to learn from how others might be
doing this. We run a pitstop system in Sheffield with consultants taking
paramedic handover and assessing patients at the front dorr, ordering tests
at the same time. However the changes this week have meant that this is
nigh on impossible. I know the whole system is bonkers and that this target
really does nothing for improving patient care or safe cross-boundary
working, but am keen to see whether any of you have cracked a way of doing
this safely and sustainably??
BW
Sue Mason
--
Suzanne Mason
Professor of Emergency Medicine
Director of Health Services Research
School of Health and Related Research
University of Sheffield
Tel: 0114 2220751 (PA: Jo Turner)
0114 2714972 (NHS Secretary: Jill Bishop)
------------------------------
Date: Fri, 12 Apr 2013 17:43:28 +0100
From: Babak <[log in to unmask]>
Subject: Re: 15minute turnaround times
Sue
It is heart warming to see even university hospitals with more resources than us; lowly DGH EDs, are struggling with the new changes. The concept never the less is sound and we are having a senior nurse led hand over with capacity to take on 4 ambulances at the time but anything more and the process start to fall apart, the same happens when department loaded above capacity, with boarding and overcrowding of ward patients awaiting admission. The solution as anything else in ED is not only on the front but on the whole process of care. By the way I am like u wondering if it has any real impact on quality of care we deliver to our patients. Considering ever shrinking resources available to deliver ever expanding set of quality initiative. It reminds me of a scene of the "Titanic", the movie, that the ship was inevitably sinking and everybody was trying to survive and the music band keep playing like there is nothing more important in the world than listening to what they play...
Babak Allie
Consultant Emergency Physician
Tameside Hospital
On 12 Apr 2013, at 17:15, Suzanne M Mason <[log in to unmask]> wrote:
> Dear Acad
> I am writing to see whether any of you have come up with any innovative ideas for handling the new push to achieve the ambulance service turnaround time target?We are really struggling with this in Sheffield and anecdotally I know others are. We are keen, however, to learn from how others might be doing this. We run a pitstop system in Sheffield with consultants taking paramedic handover and assessing patients at the front dorr, ordering tests at the same time. However the changes this week have meant that this is nigh on impossible. I know the whole system is bonkers and that this target really does nothing for improving patient care or safe cross-boundary working, but am keen to see whether any of you have cracked a way of doing this safely and sustainably??
> BW
> Sue Mason
>
> --
> Suzanne Mason
> Professor of Emergency Medicine
> Director of Health Services Research
> School of Health and Related Research
> University of Sheffield
>
> Tel: 0114 2220751 (PA: Jo Turner)
> 0114 2714972 (NHS Secretary: Jill Bishop)
>
------------------------------
Date: Fri, 12 Apr 2013 21:37:37 +0100
From: Rowley Cottingham <[log in to unmask]>
Subject: Re: 15minute turnaround times
Suzanne, I think you have hit the nail firmly on the head with your last
sentence. The system clearly is bonkers, and I think that we must start to
ask what we are doing playing along with it. There are incredible
difficulties with exit block - that is to say that we cannot get patients
out of our EDs when they are ready to leave as the wards are not getting
patients out when they should as patients cannot get community services.
The seeds of this slowly worsening situation were laid by Alan Milburn, then
Secretary of State for Health, in his deeply flawed decision to not to
amalgamate health and social services in his NHS Act of 2006. This meant
that funding for Social Services remained with local authorities and this
set up an inevitable boundary tension when central funding for local,
borough and unitary authorities was reduced and the authorities were then
told to cap rises in spending in the financial crisis. Paradoxically, the
simultaneous preservation of government funding for the NHS probably
worsened the situation. As inflation has risen little it has meant that the
NHS can be and probably has been viewed as comparatively protected, and when
cuts needed to be made by local authorities provision of social services
could be viewed as reasonable reassignment. This meant that access to social
care became more difficult and was slowed down. The authorities would like
this as it had a relative lack of harmful impact on their own services and
did not attract negative publicity for them, but the inevitable knock-on
effects for the NHS have meant a gradual silting-up of hospitals and
eventually access to medical care at the front door has become strained.
Whenever a system becomes strained it is very difficult to prevent the
hamster-wheel effect; medical delivery systems are difficult to scale and so
people tend to try to work harder rather than cleverer. A perception that a
person arriving at hospital needs immediate attention from a senior doctor
now has arisen despite well-designed and easy to implement prioritisation
systems such as the Manchester Triage Score and much better training for
pre-hospital personnel to spot and start treatment for the seriously ill and
injured.
However, the systems within the EDs are being steadily crushed by the
juggernaut of patients arriving before those already receiving attention can
be admitted. Even worse, thanks to laudable systems trying to keep patients
at home as much as possible those arriving are now commonly much more sick
than heretofore as they are attending because community treatment has
failed, and usually come with a fresh deterioration of one of several
disorders. One memorable recent patient presented with severe unilateral
chest pain that came on abruptly on rising from the toilet. In the past he
had received conservative treatment for a thoracic aneurysm dissection, had
suffered PEs and had disseminated prostatic malignancy for which he had
received radiotherapy to painful bony secondaries. Do you do the CTPA, CT
aortogram or bone scan first? Who'll be brave enough to anticoagulate him?
The only ones who can call a halt to this acid-trip craziness are
clinicians, and senior ones at that. We have to say clearly that this is not
manageable in the short term or sustainable in the medium and long term. A
great deal can be achieved if agreements can be put in place with local
authorities. All sorts of gaming is going on for local gain within, and at
boundaries between, systems as they simply are not properly joined up. Most
importantly, there has to be an adult discussion with the electorate. It is
pointless health straining every sinew to get frail, chronically sick people
ready to go back to the community when the community cannot afford to
continue their care so that they just deteriorate and return to the front
door a bit more damaged than last time.
BW
R
_____
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Suzanne M Mason
Sent: 12 April 2013 17:16
To: [log in to unmask]
Subject: 15minute turnaround times
Dear Acad
I am writing to see whether any of you have come up with any innovative
ideas for handling the new push to achieve the ambulance service turnaround
time target?We are really struggling with this in Sheffield and anecdotally
I know others are. We are keen, however, to learn from how others might be
doing this. We run a pitstop system in Sheffield with consultants taking
paramedic handover and assessing patients at the front dorr, ordering tests
at the same time. However the changes this week have meant that this is nigh
on impossible. I know the whole system is bonkers and that this target
really does nothing for improving patient care or safe cross-boundary
working, but am keen to see whether any of you have cracked a way of doing
this safely and sustainably??
BW
Sue Mason
--
Suzanne Mason
Professor of Emergency Medicine
Director of Health Services Research
School of Health and Related Research
University of Sheffield
Tel: 0114 2220751 (PA: Jo Turner)
0114 2714972 (NHS Secretary: Jill Bishop)
------------------------------
End of ACAD-AE-MED Digest - 4 Apr 2013 to 12 Apr 2013 (#2013-28)
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