Distraction: "Closer to Home" Sings the Innovation Choir

Jimmy Carr used to have a game show where contestants performed challenges while unpleasant things were happening to them. This appears to have set the model for healthcare innovation. An NHS illustrative video shows how this will work to save the unscheduled care system.

In it, an elderly patient experiences red flag symptoms of a brain haemorrhage while baking a cake. Her concerned husband calls 999, an ambulance attends, and she is taken to A&E. Instead of being “admitted for tests and monitoring,” she is sent home to a virtual ward. Once home, she then answers a quiz on the phone and gets to test her IT skills by setting up a web-based monitoring system sent by courier, presumably while still dealing with the thunderclap headache and related symptoms. She then must make her way back to the hospital for the necessary scans at some point later. Unless that is, she collapses at home from brain haemorrhage complications, when her husband would presumably be guided to call the 0800 INTUBATE line for immediate help.

This novel approach replaces the outdated idea of using the first attendance at the Emergency Department to relieve the distressing symptoms and rapidly carry out a CT scan to exclude a potentially fatal but treatable condition.  An ED scan carried out within 6 hours means a lumbar puncture at 12 hours is not required so the patient can be rapidly discharged, and further complications avoided. 

Meanwhile on the bigger scale, hospital managers and planners get to play their own game of Distraction where the big question is on how to fix the overcrowding crisis at their front door. In this game however, the discomfort is borne by other people. Patients spend nights on ED trolleys without ready access to food and toilets, in bright lights, exposed and surrounded by noisy violent drunks. Staff burn out from witnessing their distress and the moral injury of being unable to provide the care they know is warranted. 

The answer, they reply with the confidence of evangelist preachers, is to discourage, redirect and procrastinate emergency patient care at every possible opportunity to reduce demand. “Closer to home” sings the Innovation Choir behind them. The voice of expert opinion, trying to supply the correct answer of focusing on shortening bed stays and maximising physical capacity, struggles to be heard in the background. Jimmy Carr laughs and raises an eyebrow. 

https://www.healthcareimprovementscotland.scot/publications/independent-report-finds-that-nhs-greater-glasgow-clyde-must-repair-relationships-to-improve-care/

My "Alternative to Darzi" report:

1. Act early in time critical conditions to prevent expensive disability and costs of long term care. Ensure equitable & rapid emergency access to STEMI PCI, stroke thrombolysis, prehospital critical care in trauma & cardiac arrest to stop secondary harm after primary damage. 

2. Investigate possible new cancer in days, not months to reassure most and intervene at stage 1 for those that need treatment before social and NHS costs mount up managing metastatic disease.

3. Protect ED capacity to rapidly rule out or treat NSTEMI, surgical abdomens, sub arachnoid bleeds, head injury, limb/mobility threatening fractures, complex wounds, poisoning, delirium, DKA, sepsis. Acute timely care with scanners & specialists, not fob off, redirect, and hope expensive procrastination does not lead to an adverse event and costly legal settlement.

3. Rehab the shit out of all admissions from day 1 to save money. Intensive and relentless focus on speech, mobility, ADLs, psych, diet. Maximise potential to get the patient home, looking after themselves, or even back paying taxes and caring for their dependents.

4. Prevent delays to social care. Empty out people lying about in wards losing muscle, confidence, & social networks. Pay carers properly, encourage overseas workers to come and stay, nationalise care homes. Way cheaper than blocking hospital beds, hobbling ED, & cancelling electives.

5. Support primary care as a medical home for long term care of chronic conditions with clinical continuity and regular medication review. Mental health, COPD, diabetes, frailty, arthritis, renal failure. Nip deterioration in the bud, keep them out of hospital. Clear, pre-agreed, treatment escalation plans for those approaching end of life.

6. Insist private hospitals doing the quick and easy electives compete on same field as NHS by charging for clearing up their messes and half-arsed referrals to ED. And subject them to same critical governance and scrutiny. And charge a levy for using NHS trained staff. And legislate no exclusion clauses from health insurance policies.

7. Ban all NHS meetings that last more than 1 hour, or involve more than 7 people, or recommend setting up a SLWG to report back, or use the phrase "moving forward". Remind senior NHS managers that fixing problems is better than looking for who is to blame.

Summary: Early definitive & intensive interventions in acute problems. Continuity, stability and vigilance in chronic problems. Staffing, flow and urgency in hospitals. Make costs of private care realistic to prevent parasitism on public, universal healthcare. Cut out all the bullshit meetings, directives, zombie ideas given birth on post-it notes, hobby horse re-organisations and DO THE REAL WORK.

💙 NHS. 

You're welcome.

https://www.gov.uk/government/publications/independent-investigation-of-the-nhs-in-england/summary-letter-from-lord-darzi-to-the-secretary-of-state-for-health-and-social-care

The Fantasy Maths of Redirection

Here’s why the potentially risky and unpopular redirection of patients away from A&E is a distracting side show from the real cause of service failure. A long thread with sums. Take a medium sized average A&E seeing 200 patients per day.

50% patients are very unwell or have high risk presentations and need a full history, examination, ECG, X-ray, scans, blood tests, and treatment. This takes approx 120 mins in total of clinical time in a cubicle. Total time = 120 x 100 = 12,000 mins per day.

50% patients need a more focused quicker assessment for less complex, lower risk problems. This takes 20 mins for those that need a test, treatment or X-ray and 10 mins for those that don’t. Assuming 50:50 split: Total time = 50 x 20 + 50 x 10 = 1,500 mins per day.

30% of the all patients (60) need admitted to hospital and wait in A&E for a ward bed occupying a cubicle space. This wait is 60 X B where B is the bed wait in minutes. This is normally 60 mins when beds are available: Total time = 3,600 mins per day.

So in our average department, we need 12,000 + 1,500 + 3,600 mins = 17,100 mins of cubicle space per day with a 1 hour bed wait and no redirection. This works out at 17,100/1440 = 12 staffed cubicles.

If all the patients (25% = 50) who need neither a full assessment nor tests are redirected at the door, we save 10 mins per patient = 500 mins (assuming redirection takes negligible time). This reduces the staffed cubicles needed to 16,600/1440 = 11.5 staffed cubicles.

If instead the average wait for a bed increases due to a doubling of admission delays to 120 mins, the bed wait becomes 60x120= 7,200 mins. We now need 20,700/1440 = 14 cubicles to avoid corridor waits or queues for assessment.

And if those bed delays further increase to average out at 4 hours, we need 60x240 extra cubicle mins which means a requirement for the ED to have 27,900/1440 = 19 staffed cubicles.

So increasing bed delays (which btw add no clinical value and put patients at real risk of harm) from 1 hr to 4 hrs means the necessary ED footprint to avoid crowding and queues increases by 7 cubicles.

Whereas, redirection of every patient not likely to require the services of an ED reduces the necessary ED footprint by less than half a cubicle. 

Currently, bed waits can exceed 10 hours. But hey, let’s look over there at a few unfortunate patients who have for a multitude of reasons ended up seeking help from an overcrowded A&E rendered too small by the maths of poor hospital flow. 

The Laryngoscope is Mightier than the Paperclip

It’s that NHS no money time again. Every new paper clip to be signed off by the chief finance officer. Hiring freeze, travel ban, recycle the teabags. These savings are a matter of familiar ritual - as much as the spending frenzy of late March. Badged as efficiency, managers flex and pump their iron fiscal will on the profligate and wasteful clinical teams who get on with business as usual. 

In addition to the “efficiency” savings, the rationing chat volume gets turned up from normal distracting background hum to persistent shrill whistling. Can’t do everything for everybody, patients need to take more responsibility for their own health, care needs to be provided closer to home. Patients however continue to thwart and dodge the various hurdles set for them by having complicated illness that doesn’t algorithm too well and gets worse when ignored, deferred or redirected.

Meanwhile lurking in the shadows ready to burn through massive piles of fivers are the lost opportunities to prevent the eye-watering cost of disability and long term care needs. Patients no longer able to feed themselves because they didn’t have their airway secured quickly after their head injury. Families giving up jobs to care for a relative with severe neurological complications due to prolonged hypotension and hypoxia post cardiac arrest. Beds blocked for months by patients with complex infected compound fractures that lead to life-changing amputations for want of  early reduction and antibiotics. 

The dividend from good emergency care preventing secondary insults and early intensive rehabilitation adds up to an awful lot of paper clips and teabags. We can’t afford not to invest in preventing harm when money is short. As the man said: "Nothing is more expensive than a lost opportunity".

The Broken Bus: a Public Service Allegory

Once upon a time a bus station in a big city had only one broken bus on an essential route into town where all the services were. It spouted toxic fumes into the cabin and had three loose wheels and a broken back door. Now and again, passengers would die in it because it would crash, they were overcome in the toxic atmosphere, or the back door jammed and they couldn’t get out and asphyxiated. The bus drivers had been saying for 10 years the vehicle would wear out if it continued to be thrashed every day. 

They repeatedly contacted their managers about the safety of continuing to drive in it with passengers at high speed. Their managers said they were just poor drivers who just needed to do fewer journeys (like they did in a town far away who liked to speak to the government). Staff often went off sick rather than drive it, and some left for jobs with Uber.

The drivers were fed up and decided to take the bus to an allegedly independent garage who said they would review it. Unfortunately, the garage didn't look at the vehicle - they just asked the managers who said it was fine. The drivers then asked the garage owner to look again properly, and he apologised and said he would do a proper mechanical inspection. Meanwhile, the managers bugged the drivers rest room and threatened disciplinary review of anyone suggesting the vehicle wasn't roadworthy. 

The managers finally offered to visit the drivers to understand their issues, despite them being very busy and important people. They explained that they have superior knowledge of driving buses and were very passenger-focused, but that they would make time to visit the bus station to show staff how much they care. The garage report on the vehicle could wait, they said: "We are all one big team that needs to respect each other, and actually fixing a bus is difficult". 

The drivers told the managers they would prefer not to meet until they had the garage report. “We believe it needs a new exhaust, a working back door and three new wheels. There is no point in meeting until it is safe to drive again. Then we can meet with you and discuss how we maintain the vehicle and expand the fleet to prevent this problem in the future.”

So the meeting was cancelled, the vehicle was fixed, and passengers arrived safely. The managers were given MBEs for services to transportation and lived happily ever after. The End.

The Good, the Cheap and the Fast: the Iron Triangles of ED

The Iron Triangle is a model that describes the relationship between good, fast, or cheap in any given enterprise. Two sides of the Iron Triangle dictate the nature of the third.

 

Increasing speed may compromise quality unless further resource is deployed. Increasing the quality (or range of services provided) may require additional resource to be spent unless more time is allowed. Decreasing the cost requires a compromise in either speed or quality. Emergency Medicine is subject to the same trigonometry, but only one format prevents the shape from corroding and fracturing.

For an Emergency Department, each attribute might be defined and measured as follows:

1. Quality: How “Good’ is the ED? 

Look at the key performance indicators for clinically important conditions such as hip fracture, major trauma, cardiac arrest, sepsis. Next review the ability of the department to fulfil its role in the provision of emergency health care by looking at its breadth of service. A “Good” department will protect primary care and the in-patient specialties from work best addressed in an Emergency Department by Emergency Physicians, such as the rule out of serious conditions, reduction of fractures/dislocations, wound management, and front door critical care interventions such as emergency anaesthesia. It will reliably deliver “well-packaged” patients to the in-patient units and avoid hidden cost and delays downstream. Finally, a “Good” department will have low rates of bad outcomes as measured by x-rays misses, left without being seen, reattendance rates, death after discharge, drug errors, procedural complications, and other serious or adverse events.

2. Speed: How “Fast” is the ED? 

This is more straightforward. The most significant overarching metric is the 4-hr target. This can be broken into component parts such as time to triage, ambulance offload, first assessment, decision to admit and discharge from the department. 

Fast is not only popular with patients, but also reputationally good for the hospital (and managers and government) and prevents the harm resulting from crowding and delays to admission. Speed will be determined by the input demand, staff processing capacity and the speed of discharge to the community or an in-patient bed. These factors are then inextricably linked to “Cost” in terms of staffing and bed availability.

3. Price: How “Cheap” is the ED? 

The most easily measured cost is the direct staffing cost in the Emergency Department, together with the related cost of supporting services such as radiology access, lab tests, and administration. Higher staffing levels are likely to be associated with better quality and higher speed if effectively deployed.

The direct ED costs are however only part of the story. Flow out of the department is critically dependent on bed availability in the in-patient wards, and this is directly related to hospital occupancy. Keeping occupancy at the ideal level for ED flow of around 85% requires a commitment to covering the cost of some flexible bed capacity. Running at higher occupancy is superficially more cost-effective but leads to severe impacts on ED speed (and subsequently quality).

Departments that offer limited scope may divert work to other places concealing the true cost. Extensive pre-hospital screening such as phone advice lines designed to reduce ED demand may be expensive, and savings are only possible if this additional tier diverts very significant numbers with minimal or no costly errors. Redirection to primary care may displace cost to the community sector which may not be recouped as these patients are likely to be the “cheapest” (especially if primary care is less well equipped to process the nature of the conditions diverted e.g. injuries requiring x-ray). Similarly, handing off specific conditions or tasks to in-patient specialties such as chest pain assessment or resuscitation may mean costly duplication of “front doors”, when these tasks were previously all efficiently covered by the Emergency Department.

So, what departments can we have (assuming any two of three Iron Triangle conditions can be met):

Department A: Cheap, Fast. Not Good. Low staffing, limited scope – work is displaced to community or in-patient specialties and may be of low quality. ED staff either hate it or love it depending on their philosophy. Costs hidden elsewhere due to work displacement. Popular with managers (good 4 hr target) and patients who are not displaced or damaged (quick turnaround). Unpopular with specialties and GPs unless resourced (see hidden costs). FAIL

Department B: Good, Cheap. Slow. Low ED staffing, high hospital bed occupancy leading to processing and discharge delays. Scope often attempted to be maintained, but quality eventually suffers due to harm from crowding and delays. Unpopular with managers (poor performance on target), staff, and patients due to delays and adverse events. Ends up costing more anyway due to complications and issues with staff retention. FAIL

Department C: Fast, Good. Expensive. Well-staffed, low bed occupancy so excellent flow. Costs high and visible upfront. Comprehensive scope, good outcomes, low adverse events. Popular with staff, patients, and managers. Perceived as not cost-effective by accountants. Significant downstream savings in absence of hidden diversion costs, staff retention and avoidance of adverse outcomes for patients. PASS.

Most EDs are currently a failing Model B with long waits due to high bed occupancy and understaffing. Quality and safety inevitably suffer, and staff leave. There is often a short-sighted executive / political push to move to Model A which better hides its failings, though ultimately it becomes just a shell triage service incapable of providing Universal Healthcare to those in urgent need and incurring heavy downstream and upstream costs. Model C is the only corrosion resistant Emergency Department Iron Triangle that maintains its shape.

RIP EM

Who will miss us when we are gone?

Emergency Medicine has had a red form completed. Talked about in hushed tones, its prognosis is recorded as “guarded” with a likely poor quality of life. Those watching it desperately struggling want it to be allowed to go now and for the suffering to be over. Even the specialty itself has agreed with its carers that it can’t go on like this. 

Overcrowded, miserable, making mistakes, Emergency Medicine is no longer coping, letting people down and making them cross. Its vital sign, the Four Hour Target, has been permanently in the red zone of its observation chart. Tales of its failing and flailing in the press make everyone uncomfortable, especially politicians. The patients in corridors, ambulances stacked outside, and the red 999 calls unanswered in the community serve as grotesque external symptoms of an underlying necrotic process.

So, arrangements are made for its demise. Resuscitation is to be handed to tertiary specialists for them to argue amongst themselves over who will look after the kaleidoscope of the undifferentiated unwell. Paramedics will need to call phone lines before transporting and be advised where to take their 999 calls when ED is no more. Some patients will be left with their problem at home, some will be signposted to community services that may or may not have capacity or even exist, and some will be shoehorned into clinical decision pathways that allow rapid one-disease-only processing in a same-day unit. Walk-in patients will be redirected to ABH (Anywhere But Here) unless they need resuscitation or can be made to fit one of the specific pathways. Once the last rite arrangements for Emergency Medicine are complete, the oxygen of staffing will be turned off, the monitor of four-hour target will be silenced, and the inotrope of senior experience will be discontinued.

Who will mourn its passing? For sixty odd years the Emergency Department has been a beacon of the welfare state. A place that in physical form, boldly stated that all people are important, equal, and worth saving. A light always on for lords and laggards. It became expert in ruling out and in tricky serious illness like subarachnoid haemorrhage, acute coronary syndrome, abdominal sepsis, meningococcal disease, tricyclic overdose, ectopic pregnancy, head injury and aortic aneurysm – especially in those high risk populations that felt unwell enough to call an ambulance. It skilled up to provide time critical treatments to ensure that vast teams of specialists did not need to be on hand all the times to intubate, start pressors, insert lines and tubes, treat severe sepsis, cardiovert, reduce fractures and dislocations, and sedate agitated delirium. It advocated for patients needing admission or specialty care even in the face of reluctance, resistance, and sometimes frank hostility from those guarding lofty silos. It took out rust rings, fishhooks, bits of Lego and misplaced vibrators.

Is it too late to ask for a review of the terminal diagnosis - without the boot of exit block on its throat? Especially given the number of its dependents.