Totally Inappropriate

There were ten mourners at James’ funeral; two paramedics, two staff from Gregg’s bakery, and six staff from the A&E department. 

The paramedics brought James to A&E every morning after a 999 call for “man with SOB”. The A&E staff gave James his morning COPD nebuliser with a cup of tea, and the Greggs staff across the road gave him a breakfast pie after he was discharged. He spent the rest of the day walking around with his tartan shopping trolley before returning to his bed in a hotel doorway.  He always refused admission or social work, and never saw a GP. James was an inappropriate A&E attender. He should not have been there contributing to overcrowding. 

Inappropriate attenders roll in across the shift.  An older woman with new abdominal pain and vomiting whose worried spouse very reluctantly called an ambulance for her. A middle-aged builder, who for the first time ever, self presents with the worst headache of his life.  A diabetic man books in with new chest discomfort after a heavy meal last night. Two CT scans, a couple of ECGs, a bunch of blood tests and all are discharged home. Total waste of resources - A&E over-investigate everyone.  Gastroenteritis, migraine and reflux are never investigated like that in primary care. If only they could be redirected we would save a fortune and A&E would have enough space for proper emergencies.

  

Across in minors other inappropriate attenders wait and wait. Swollen optic discs from the optician, blocked catheter from the district nurse, intractable back pain from the physio, suspected drug ingestion from the police cells, suicidal thoughts from the social worker, post –op wound infection from the private surgical clinic, off legs from the nursing home, needle stick injury from the medical ward.  If only all these patients realised just how busy the ED is tonight, they would have thought twice about following the instruction to book themselves in - especially as there are no cubicles because of properly sick patients waiting hours and hours for a bed in a very full hospital.

The minister at James’ short crematorium service said he was glad that James had people who looked out for him:  “It is such a comfort that the A&E department always keeps a light on for any and all of us whenever we are sick and have no-one else to turn to”.  

Bizarrely, the four-hour target didn’t improve after James died.

NHS Tattoo

I think I need to bite the bullet and just get the NHS logo tattoo on my arm I’ve been thinking about for the last 20 years. I’ve nearly had a tattoo only twice before. The first was on the Incirlik Air Base, Turkey in 1991 en route home after the Kurdish Refugee Crisis. The American Army tattooist was however decidedly opposed to adorning the arm of a tipsy British civilian medic with an enormous campaign eagle. The second was after completing the Rangitoto Swim in Auckland. I’d promised myself a volcano tattoo if I managed the 4.6k open water crossing in a wetsuit, but was put off after being overtaken by bunch of teenagers effortlessly completing the swim in just their shorts.

 

The reason why I want the NHS tattoo now more than ever, is that over the last four weeks, I’ve realised it is my existential axis. To me, it is simply the best idea in the world: the ultimate demonstration of a civilised country, a pinnacle of social evolution. I’ve worked in it since I graduated, with the exception of an eight-year stint in its New Zealand equivalent. I’ve belligerently defended its many failings and faults, citing the sheer universality and measureable efficiency of it as a system. It is the Sydney Harbour Bridge, the Hoover Dam, the International Space Station – a massive visible-from-space triumph of collaboration, equality, courage, vision and public expenditure. I have taken great pride over the years in delivering exactly the same health care to the homeless drug addicts and asylum seekers as to Members of Parliament and celebrity sportsmen. Even in the many interminable management meetings, in which any kind of binding decision comes as a pleasant surprise, the break point is always what provides best care for patients.

So after the last four weeks in New Zealand Covid-19 quarantine and then lockdown, having spectacularly mistimed a visit over to see my two adult sons, I find the gravitational pull back to my Glasgow NHS team overwhelming. Getting back to answer this visceral call is not easy. Multiple flights have been booked, then cancelled by the airline and not refunded. I’ve started to feel like a spawning salmon instinctively drawn to its home; leaving the calm, safe, sunny waters of Auckland, and the comfort of being within a 500 mile radius of all my children (even if I still can only Skype them), to leap upstream into the uncertainty of working in a Scottish Emergency Department during a novel pandemic.

Emergency Medicine doctors always have a sense of FOMO when big thing are happening and they are not on duty. They have an intense desire to be part of the action, do a great job and receive the dopamine squeeze, inner validation and external acclaim that follows. This time it is different as there is real uncertainty, and risk, both physical and mental – but the sense in the NHS of resolve, camaraderie and destiny is not only palpable, it is reflected in the reactions of the public as they applaud in the streets. This respect for the NHS as both an entity and an idea resonates within me like a harmonic frequency. Every pub argument with a private healthcare supporter, every tough A&E night shift wrestling with drunks, every email written to document gaps in care suddenly have context and purpose.

Perhaps my NHS tattoo won’t actually happen. I expect like the eagle and the volcano, there will be others who already deserve one much more by the time I’m back moaning about yet another backshift in Minors.

Little Sums

My local supermarket is pretty good at managing crowding. They seem to staff the various areas according to predicted demand, while holding some extra staff in reserve tasks to cover surges in essential activity. They also know exit block at the tills is usually the major bottleneck, and understand the need for escalation actions (like opening more tills) when impeded flow is causing crowding in the aisles. Crowding quickly impairs the core business of the supermarket, and shoppers become frustrated and leave, so the duty manager must respond effectively. The formula that the retail industry uses to understand crowding in their stores is Little’s Law: Average number customers in store = average rate arrival X average length of stay.

In the much more complex environment of A&E, control of length of stay is even more essential, as the consequences are not lost business revenue or someone running out of milk, but unnecessary deaths. In an Emergency Department setting, Little’s Law can be adapted to: average number patients = rate of arrival X length of stay. Some patients may be suitable for a waiting room, redirection elsewhere or “see and treat” (the equivalent of the supermarket 12 items or less queue), and can be excluded from the space calculations. However, the “majors” need not only a clinical space for assessment and treatment to occur with any dignity, they also require timely and potentially life-saving care. The rate of arrival of such patients is surprisingly predictable for most departments, with a steady peak between 11am and 11pm. Therefore:

Number staffed A&E trolley cubicles needed = average peak majors arrival rate x average length of stay.

(Example: If there are 31 suitable staffed spaces and average peak arrival rate of 12 patients per hour. The average length of stay must be 2.58 hours or queues for spaces will develop and persist until the rate of arrival subsides. If there are 61 staffed spaces and the same average peak arrival rate then the average length of stay can be 5.08 hours.)

What dictates the balance between number of cubicles and length of stay? Most discharged A&E “major” patients need a minimum time of 2 hours (for triage, assessment, investigation, review, discharge). 4 hours is thought to be a reasonable time frame for the majority of the admitted patients to be worked up by A&E, referral to in-patient units made and patient transferred out. Clearly there are important clinical exceptions, but the concept of a maximum 4-hour target length of stay sets an overall reasonable mean length of stay for majors of around 3 hours. If A&E departments are properly configured in terms of trolley space by Little’s Law and staffed for their expected workload to meet these timeframes, then the transfer out of A&E to in-patient beds remains the only significant variable affecting length of stay (equivalent to queues at the supermarket tills). This figure is closely related to hospital occupancy as it relies on the ready availability of the in-patient beds.

In a full hospital, patients awaiting admission cannot be moved out of the ED. Once average length of ED stay then exceeds the calculated required average for the number of staffed majors cubicles, there are no longer safe and appropriate spaces for new patients and A&E becomes overcrowded.  In an overcrowded,A&E there are multiple well known adverse consequences. Violence to staff, increased complaints and critical incidents, missed diagnoses, missed treatments, complications of long trolley stays (bedsores, infections, DVT, falls), all resulting in 30% increased mortality in admitted patients and 70% in discharged patients.

Despite all the evidence of overall positive effect of time targets from around the world, there are now voices in the UK health sector calling for the abandonment of the A&E 4-hour time target. The emphasis it places on rapid treatment of acutely ill and injured patients requiring admission is no longer being portrayed as an essential safety requirement, but as an encouragement to over utilise the allegedly overpriced and inefficient free acute care supermarket.  The future, we are told, is in developing health delivery alternatives analogous to small local stores and home delivery services. However it is very unlikely that emergency departments will be short of business as a result of any changes in that direction, and without ED crowd control time targets, every day in them will feel like Black Friday.

The Morning After in A&E

The atmosphere in A&E the Friday morning of Brexit was more subdued than normal. Medical, nursing and portering staff busied themselves with administrative tasks at the staff base rather than indulge in the usual noisy banter that acts as a team fist bump for the start of a shift.  Sometimes you get this sort of disconcerting quiet in an A&E when the normal routine exchange of gossip, inappropriate innuendo, informal medical education and war stories of previous shifts is temporarily suspended by a collective unspoken distress.

Usually this arises as a result of a particularly harrowing case: the death of a young patient or a staff member. But this time it was a political event: a democratic decision to leave a seemingly distant political institution. Why did this feel so upsetting and so personal to a bunch of people used to seeing tragedy and some of the worst of human nature? Young people with cancer, abandoned frail elderly, savage beatings, domestic violence, drug punishment stabbings and the ravages of drugs and alcohol are all part of the daily routine here, managed by resilient staff with empathetic yet technical efficient objectivity.

As the morning wore on and disbelief morphed into anger and alarm, the reasons started to crystallise as staff began to discuss the events of the previous evening in small huddles while beginning to attend to the first ambulance arrivals of the day. The common theme was one of a damaged sense of collective purpose and identity. The mirror of the referendum had been held up and we did not like how we were being reflected as a nation. Narrow minded, parochial, fearful, selfish, and most significant of all for A&E workers – not team players.

Some very limited consolation was taken from the Scotland result and the possibility of another Scottish Independence Referendum, but even here in Glasgow, 1 in 3 voted to leave, if they bothered to vote at all. One or two of the team even sheepishly confessed one or other of these sins to the silent incredulity of the others. Others searched for demographic groups to blame for the shame of lurching the country towards its isolationist, xenophobic and right wing future, oblivious to that irony.

But more and more patients rolled in, and as the shift busied up, conversations were replaced by frenetic activity. There were major road accidents resulting in life changing injuries, newly diagnosed lung cancers, a ruptured aorta, and many frail elderly patients with complex needs to care for. A committed team, guided by objective evidence, worked collectively to protect all comers from the misfortune that had befallen them, including those that had made poor life choices with very serious unforeseen long-term consequences.

By the end of the shift, the general mood had shifted somewhat back to normal. As the team changed out of their scrubs and headed for home, there was perhaps the reassurance that, within the walls of the A&E department at least, cooperation remained the best way of doing business.

57 Minutes to Save Your Life

57 minutes: The required average length of stay for “major case” patients during peak periods in the new South Glasgow Emergency Department when it is fully operational as one of Europe's largest hospitals by the end of May. More than this and patients will begin to queue for trolley spaces based on current projected numbers. Fifty-seven minutes to make an accurate diagnosis and clinically intervene to maximise the chances of a successful outcome. Fifty-seven minutes to establish a bond with a distressed patient and provide sympathy, understanding and compassion.

Fifteen years ago, when we argued that we needed to close and merge many of Glasgow’s crumbling hospitals to create centralised centres of excellence in state of the art buildings, we made some pretty big promises. There was to be a trade off between losing local access to familiar hospitals and gaining faster more effective, efficient care with sustainable staffing in modern surroundings. Now that the time has come, we need to deliver on those promises.

If we are to make our fifty-seven minutes work, the entire hospital will need to operate like a Formula 1 pit team all the time. Those patients with evidently serious problems such as stroke, major fracture, heart attack, appendicitis, or septicaemia will need to be rapidly sent to appropriate specialist care wards after receiving essential emergency treatment. There will be no time for the traditional multiple repeat assessments in A&E by a hierarchy of junior doctors from the in-patient teams. Patients with more minor problems such as cuts, sprains, skin infections will need to be dealt with in a separate fast-track stream by nurse practitioners or by re-direction to GP services.

For patients with indeterminate symptoms such as collapse, abdominal pain or chest pain, who may or may not have significant illness, blood tests, x-rays or scans will need to be very rapidly available 24/7. By abandoning the old idea of just “admitting for tests” in this large group, we can provide not only more rapid reassurance for many patients but also protect hospital beds for those clearly requiring them. Finally, patients with violent, demanding and disruptive behaviour will need to be rapidly removed by the police if there is no reasonable suspicion of significant illness or injury to prevent interference with the care available to other patients.

Many of these changes are partially underway already, but are often patchy and inconsistent. The 57-minute window will sharply focus the attention of all of us starting work in the new hospital. Some of the changes will involve both a culture shift and spending money. Specialist medical staff from every department, traditionally tribal in loyalty, will need to co-operate with each other as never before for the common good. Managers will need to realise that change of this magnitude cannot be used as a short-term opportunity to look for savings. It will be impossible to achieve the lengths of stay required throughout the hospital without realistic nursing ratios, adequate medical staffing and appropriately matched support services such as physiotherapy, radiography, labs, portering and domestic services. Delayed discharges in the wards awaiting social work placement will need to become nothing more than a regrettable historical blip.

Above all, the entire staff will need to feel proud of their roles in order to maintain a positive attitude through the inevitable challenges. Valid concerns about new working patterns, transport, overcrowding and staff ratios need to be carefully listened to. Recurring problems in these areas will then need to be rapidly addressed by a leadership team who are prepared to make the changes necessary if initially processes do not work and targets are missed. Ultimately, if fifty-seven minutes cannot be made to work we need a Plan B to avoid returning to the misery of overcrowded emergency departments experienced by patients and staff over the last two years.

 The new hospital is an iconic cathedral to 21^st century healthcare and the NHS. The high profile features such as the helipad, single rooms, colour schemes, artwork and use of natural light are great improvements on the tired and decrepit Victorian facilities currently in use. However the new hospital needs to be even more about people working together to make Glasgow a beacon for the world-class quality of care the NHS can provide. Patients should be able to clearly agree that those difficult decisions taken 15 years ago were correct.

When Saturday Comes: Politics, Health and Football

The NHS is political football, whatever David Cameron says. Healthcare policy is realised through relentless, tribal warfare of deep-seated ideologies and the fierce factional loyalties of rival die-hard supporters. Like Rangers v Celtic, Real Madrid v Barcelona, in the Healthcare Championship, there is an historic struggle of ideas and identity going on, but with vested financial and political interests manipulating the conflict in the background. The players on the pitch, the NHS staff, want to put in a shift, score goals and defend well, but the refereeing is inconsistent and frankly a little suspect.

Over recent weeks, many grudge matches have been played out over the UK A&E overcrowding crisis. Every lobby group jumps in to the tackles with their own theory as to the cause. According to them, it is variously the fault of the public for attending with trivial hang-nails, the GPs for not liking being out in the dark or working weekends, the A&E staff for being risk averse and admitting everybody, the closure of local hospitals by cynical politicians, the global financial crisis, the Barnet formula in Scotland, the elderly population, collapse of social care, insufficient district nursing and so on. Every side sets out to secure maximum points and their win bonuses, but no one gets shown a yellow card if the play was unsporting or goals should have been clearly disallowed. Maybe the game could be massively improved if referees looked to reliable data and reproducible evidence rather than the shrill appeals for penalties from the partisan stands or players on the pitch.

In Scotland (using Auditor General data), the numbers of emergency attendances have been going up, but only gradually and slowly (15% in 10 years). On the other hand, the number of elective (planned) admissions has risen rapidly (36%) to meet crowd-pleasing treatment guarantees. The length of stay has dropped in keeping with a degree of modernisation, but this has been way offset by a substantial reduction in bed numbers (7%). The net effect of these changes is increased occupancy, and progressively fewer beds to put emergency patients in. Once a crucial hospital occupancy tipping point is reached, the system collapses because patients are admitted here, there and everywhere, get poorer care and stay longer thus compounding the bed problem exponentially. The Emergency Department then becomes a holding warehouse for new admissions, the staff get burnt out and irritable, and the occasional patient who wanders in with a minor complaint (even though international evidence clearly shows that this group do not ever cause overcrowding) gets the blame for the whole debacle. Losing every week like this has been enough to cause some staff to quit their NHS club and look for an overseas team.

The use of impartial evidence focusing on capacity and occupancy could therefore be the match-winning strategy to resolve the issue of A&E overcrowding. Globally though, the biggest healthcare game is between the self-reliance, competition and market forces of the private sector versus the equity, co-operation and cost-effectiveness of publicly provided services. Here too, use of scores from fairly conducted matches rather than the opinion of pundits may improve the sport for everyone. In a recent properly refereed international play-off, for example, the Commonwealth Fund reported the UK NHS to have been the most cost-effective and equitable healthcare system in the world. Some heavily sponsored teams setting out to take on the NHS may indeed find a level playing field difficult to manage. In fact one such team, Circle United in Cambridge, recently suffered such a humiliating defeat that they voluntarily dropped out of the entire league and are now restricting themselves to playing Rounders.

When Saturday comes, the NHS staff will boot-up and trot onto the pitch. Their long-term performance in the league will crucially depend on their manager, the board of the club but also critically, the backing of the fans.

Never Mind the Bollocks: 10 Things Emergency Medicine Consultants Can Do Now to Help the NHS Stay the Best Healthcare system in the World

Scotland has a serious politics hangover, and now the party conferences have started up in earnest. The NHS is front and centre as usual, wheeled out like a beat up old Jag that mostly still goes like a dream, but has had some very unfortunate internal modifications over the years, and is currently towing a caravan full of improvement specialists. It needs some expensive work done, but the garage report says its well worth saving and is definitely much better value than using rental cars.

We know that politicians mostly talk bollocks about the NHS, influenced by which lobby group or vested interest has their ear at the time. We in Emergency Medicine on the other hand can have some real influence on whether we stay at the top of the healthcare global charts in spite of them. Here's my 10 point check for us EM consultants to do our bit, divided into DCC and SPA activities.

On the Floor: Speed, Safety, Cost-effectiveness

1.     Make clear disposition decisions based on risk, and only admit patients who really need it. Think: “If not me, then who better to be gatekeeper?”

2.     Use robust evidence-based guidelines combined with experience to assess risks and standardise treatments in the right context. Science and art of medicine.

3.     Ensure important time-critical things happen quickly. Early resuscitation, sepsis care, pain-relief, revascularisation and haemorrhage control improve quality, outcomes, patient experience and length of stay.

4.     Consider early DNR and end-of-life care when treatment futile and simply prolonging inevitable death. What would we want for ourselves?

5.     Avoid confusion and duplication by clear communications with in-patient team, GP and patient/family. What needs to happen next and by whom?

In the Meeting Rooms: Focus, Clarity, Candour

1.    Say at the start of every meeting; “This meeting will have been a success if we achieve what outcome?” If no clear answer given, leave and go do something useful for patient care instead.

2.    Do not tolerate the cruelty, danger and inefficiency of ED overcrowding. Make everyone’s life hell until they fix it - the more senior the better.

3.    Talk up the importance of EM senior cover at every opportunity, and plan how to stretch cover across as much of the day as possible. We are the answer, now what was the question?

4.    Take every opportunity to analyse, critique and evaluate EM service performance. Seek to improve every small pixel that makes up the picture. No one looks good with their head up their own ass.

5.     Teach, support and inspire trainees, med students, ambulance staff and nursing colleagues to understand the key role of EM in turning chaos into order. We are the NHS.