Tuesday, March 11, 2008

If Ever I Enlist For The Army Again...

A post mostly about time; Unfinished.

For starters, Mousie, over at Mouse Thinks has some things worth reading about the current obsession with time that dominates Emergency Medicine in the UK. History would seem to have taught us that when you set a man an unrealistic target, he usually learns how to appear to meet the target, rather than actually meet it. (c.f Communist China, or USSR)Clearly, none of this occurs at Big Teaching Hospital, which is above reproach. I also have a few things to say regarding evidence based practice; none of these apply to my workplace either.

What I most wanted to commit to print, while the mood has me is this:

Purely hypothetically, you understand.

Consider the following:

When a service is judged as much, if not more, by a temporal rating as much as a clinical care rating, might time become pre-eminent? Might time come to dominate the clinical picture? Might this become more so when pressure is applied from above? When this temporal rating comes to have repercussions beyond care? When it might affect the hospital as a whole, and managerial jobs, specifically, might we lose perspective, and come to see time as the pre-eminent factor in patient care?


So, if this temporal rating is measured by timing patients in, and out of the Department, might there be a temptation to 'amend' the reading? If one loses points when patients tarry in your Department beyond a certain time (for example, four hours), might you consider changing figures so that more patients meet that target? Where's the harm? If my patient is in the Dept for 4 hrs and 10 ins, who gets hurt if I back-time him, just a little. Just enough that he appears to have been our guest for 3 hrs 59?

What if this is extrapolated, so you find a patient, still waiting to see a doctor, but ALREADY booked out of the Department? Half an hour ago. Officially, he's not here anymore.

Well... if it's a simple case, done and dusted in a few minutes... where's the harm? Right?

But what if it's not simple? What if you have to see a patient, already documented as having left the ED, with a diagnosis of "nothing wrong", legally recorded by one of your colleagues? What if they subsequently need treatment, need admission? What happens then, when the times don't match? When you have to explain why your entry in the notes begins almost an hour after that patient was discharged? When your entry is not of "nothing wrong"?

How far can you bend the rules? And if you don't, what of your colleague, who already 'saw' this patient...

This is, of course, hypothetical, and over the next few days, I will explore the hypothetical fallout from such an incident. Hypothetically, you understand.

Coherent edit to follow...

And on a lighter note, I've developed a crush on the Surgical SHO in Holby City...


Kate said...

I suppose that you don't have to deal with this sort of thing, but this past year there was a big uprising when the largest US payer (Medicare) decided not to reimburse for any pneumonia patients not receiving antibiotics within a 4-hour window. Ridiculous stuff, particularly when patients often sit in the waiting room for 4 hours before being seen by a physician. I think all of this timing and tracking business is getting out of control. I'm trying to take care of people, not operate a fast food window!

Faith Walker said...

Haha- I remember you saying. I've forgotton her name (the curly haired one right?)

I'm quite taken with the scottish one that insists on doing inappropriate surgeries in the AAU theatre.


the little medic said...

In the last few days i've seen this happen! I was rather surprised that the figures could be 'edited' quite so easily. Makes the whole thing look rather like a joke if you ask me!