Dr T in the ED
Sunday 15 September 2024
My "Alternative to Darzi" report:
Monday 19 August 2024
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.
Wednesday 3 July 2024
The Laryngoscope is Mightier than the Paperclip
Sunday 11 February 2024
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.
Sunday 4 February 2024
The Good, the Cheap and the Fast: the Iron Triangles of ED
Thursday 16 February 2023
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.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.
Sunday 10 January 2021
Rage, Certainty and a Ginger Cat
I’m pretty good at opening doors with my elbows or car keys now. I shower after hospital shifts rather than before, I carry sanitiser and hand cream around in my pocket, and I can do Microsoft Teams presentations while fending off a large attention-seeking ginger cat. All in addition to having developed near-perfect rituals of cleaning keyboards, donning and doffing PPE, and maintaining social distance in a subtly choreographed two-metre apart ballet with others.
Along with, and perhaps because of, the loss of certainty came the intolerant righteous rage of perceived selfishness and stupidity. Watching nonchalant young adults wander mask-less round supermarkets past elderly folk struggling to use a stick while fearfully adjusting their facemasks became the hypertensive equivalent of being tailgated on the motorway by a sales rep on a mobile phone. Listening to pandemic deniers recite Facebook anti-science with a partisan certainty and forcefulness normally confined only to evangelicals or football fans induced the temptation to share some inappropriately graphic stories from the frontline of destroyed lungs and lives cut brutally short.
When things eventually start returning to normal thanks to the clever vaccines, just enough people not being selfish assholes to make the public health actions work, and the determination of a National Health Service not to let people who love it down, I wonder if I will miss my newly acquired skills. I will however probably have to take the cat with me to meetings for a while when they restart in person again. He definitely considers himself a key worker now having attended all the meetings over the last twelve months.