So far this year UK national news has been dominated by A&E units in crisis; stories abound of long waits in A&E for beds or even longer waits in ambulances at A&E doors before entering an overcrowded environment where staff struggle to cope.
Many English hospitals declared major incidents in the hope of enabling an extraordinary response. Last week figures stating over the festivities only 88.8% of patients attending Scottish hospitals met the four hour target for care.
While Ministers took comfort from Scotland faring better than England,( just 82.8% avoided a wait greater than four hours), this will be of little comfort to the general public.
These descriptions of departments in crisis are not universal. In Tayside we experienced a typical festive period no quieter or busier than usual yet despite pressures within the hospital; delayed discharges and closed wards due to winter vomiting bug, we coped with 98.1% of patients managed within 4 hours. Central belt cynics suggest we are not busy, it's easy to meet targets when you are faced with only small numbers of patients like Stornoway and other remote locations. Our major A&E is in Dundee, Scotland 's 4th city and one not without health challenges . How do we manage the seemingly impossible?
Well it's not rocket science, but takes joined up services and commitment from everyone . The 4 hour targets are for all parts of Emergency care and all services need to be engaged. A&E departments are finite resources, able to quickly respond to rapidly evolving situations, the arrival of the patient in cardiac arrest or the patient critically ill or injured.
If the department is full to capacity and patient flow to the wards is restricted then your Emergency Department will simply not have the space and resource to do what it does best, manage the time critical seriously ill and injured. In Dundee we are busy but never filled to capacity. Why should every GP referred admissions have to come into hospital via A&E as still occurs in many units within the UK? We have excellent GP's who correctly determine if patients need admission and refer them directly to the ward,removing need for A&E involvement. Acute Medicine, work closely with us and offer this direct access.
Patients who self present, often via 999 ambulances, on initial nurse assessment, if they appear to need admission, will be referred to the ward before medical assessment and management in A&E has taken place. This gives the ward a heads up to find a bed for the patient which is invariably ready when the A&E work is complete.
We give the ward 2 hours to find the bed, if not available by then the stable patient is move up to the ward area, where we know a patients wait for a bed will be shorter. Sometimes, Seniors will decide the patient can go home; the bed is cancelled. This system streamlines the admission process and prevents long waits for patients within A&E A&E is for Accidents and Emergencies, not anything and everything. Undoubtedly with the changes to access to primary care and a societal need for immediacy some presentations to our service are not emergencies . In order to focus on the true emergency we operate a re-direction policy. Such cases are interviewed by a senior doctor to determine what service best serves their need and then redirects them to it.
Last week the Health Secretary said "it is clear we must improve performance"... This I suggest is not the personal performances of the Nurses and Doctors who in every A&E department are working tirelessly to deliver quality emergency care. What we need and need now are whole system improvements, as this Tayside model outlines. Such will go a long way to relieving A&E overcrowding and improving the delivery of care to emergency patients . If we can consistently meet our emergency targets in Dundee surely these changes are worthwhile, not least for the Emergency patient waiting on an emergency trolley in a department near you.
Dr Barry Klaassen Full time Consultant in Emergency Medicine, Ninewells Hospital and Medical School, Dundee Tayside
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