Thursday, November 01, 2007

RATty, Mole and Badger


I'm going to try and pen something sensible, instead of the usual drivel. I'm not sure it'll work.

Big Hospital is trying to achieve Foundation Status. I'm sure this is very important, but can't shake the image of committee rooms full of people stood, arms aloft, fists clenched, chanting 'Foundation! Foundation! Foundation!', in a vaguely 1930s Germany sort of way.

All that stands between them/us and it, is the ED. We need to achieve 98% in the four hour target. To the uninitiated, this means 98% of our patients need to be in and out within four hours. I think it's a facile target. It does not mater what happens to these patients, as long as it takes less than four hours. So, me, a triage room and a large syringe of potassium (or air, for that matter) would actually improve our performance ratings.

Anyway, we're falling short by 0.62%, overall. Most of the damage is done at nights and weekends, when staffing levels fall, and patient numbers do not.

So, the three line whip is out. See more people, faster. But don't let clinical care suffer. After a point, these two things become mutually exclusive. To avoid that, the solution will inevitably be to refer more people for admission. If you're not sure whether you can discharge someone, simply admit them. Why waste time trying to sort out (i.e treat) patients in the ED, when it's far quicker to refer the job to someone else. (Buck, anyone? Anyone? Anyone? Bueller?)

To aid this process, the Senior Docs are engaging in a Rapid Assessment process. (Rapid Assessment and Treatment? or Triage?... I'm not sure. I've missed it being up on PICU, but re-enter the ED today.) Patients are seen and rapidly assessed on arrival, before being palmed on to an SHO, with a provisional diagnosis and plan - i.e. do these bloods, this X-ray and refer them to these guys.

We are becoming triage monkeys.

This will undoubtedly speed flow through the ED. But is it right? I don't think so. We are being asked to work more anti-social hours to achieve this target. To agree to this is surely a mistake. Other specialities do not have two Registrars on overnight. Other speciality consultants do not routinely work on the floor until midnight. (ITU excepted)

By increasing numbers of referrals we will clog the hospital with patients awaiting a 'specialist' opinion. Why not make these bastards change their working practices? Ask the surgeons to have a team dedicated to operating, an another to seeing ED referrals. That would speed up decision making, and flow. Ask the other consultants to work until midnight, seeing patients and making decisions - and, incidentally, for less money.

I can't imagine they'd stand for it.

Why should we?


Tedwood said...

I'm a mere medical student but its a shame to reduce medicine to care pathways and protocol.

The target has become king rather than patient care.

Will there be a role for doctors in EM if this trend continues?

Really enjoy the blog. Keep it going.

ERnursey said...

That is just like here, the ER is given a mandate to improve throughput but none of the things that affects flow is addressed ie. the wait for consultants to come see patients, the wait for the rads to get around to read scans, the wait for a patient to be discharged and a room to be cleaned, the wait for a nurse to actually accept the admitted patient and so on and so on.