Thursday, September 18, 2014

4 hour A&E targets are good for the impatient, but not necessarily for the patient
What you are about to read is probably wrong. See the foot of the page.

Sonia Powell, 73, died in an ambulance while waiting for 35-minutes to be admitted to the A&E at Morriston Hospital, Swansea. She was seen by a doctor soon after her ambulance arrived, but the A&E was very busy.

There is to be an investigation.

The question I would put to the investigation is this:

Was Sonia's ambulance asked to wait before passing her into the care of A&E in order to meet the A&E's 4-hour target?

A&E departments are required to ensure that  95% of their cases be in their department for no more than 4 hours before they are discharged or admitted to a ward.

It is often pretty demanding to meet this target. In busy times, staff have to do one of these things:

  1. work quicker, which brings with it the risk of mistakes, which lead to complaints, which lead to staff being off sick or working while in a depressed and anxious state, which leads to more complaints
  2. get wards to accept patients quicker, before a firm diagnosis has been made, which may mean the patient is put on the wrong ward, which may lead to complaints, which lead to staff being off sick or working while in a depressed and anxious state, which leads to more complaints
  3. reduce the rate at which people come in through the doors of A&E. The way to do this is to leave patients coming in by ambulance in the care of the ambulance crews. These patients are technically not in A&E and so do not figure in the target statistics. 

I have been in this situation, on a trolley outside the door of A&E, chatting to my ambulance crew.  I was not acutely ill, and would personally rather not have been there, but a nurse from a MIU had insisted I go in order to avoid risk of a complaint, even though I had told her I was not a complainer.

My ambulance and crew were out of action during my 20-30 minute wait, leaving their colleagues on the road more busy, which brings with it the risk of mistakes, which lead to &c.

Sonia Powell was not that old. She may or may not have had multiple problems that doomed her to die. She might have died in A&E or on the ward - or she might not.

The investigation may decide that one factor in her death was the 4 hour waiting target. Or it may not.

In the end, to avoid mistakes, A&E departments do not need targets set by politicians and applied by managers. They need adequate levels of medical, nursing and diagnostic staff.

Having posted this, I tweeted this to the excellent Malcolm McKenzie, A&E consultant, who informed me most politely that what you have just been reading is wrong. However, it may be a bit right imo.


Richard Lawson said...

This comment is composed of tweets of the good Dr McKenzie, knitted together by yours truly.

Thanks! In my experience waits outside A+E are not directly because of the four hour standard. Such waits are because the ED is full with patients who are waiting to go to a ward (because the hospital is full, or awaiting discharges). I've encountered waits outside ED in many departments, it has never been to try to manipulate the 4h standard. By the time that patients are waiting out of the door, those inside awaiting beds will likely have long breached. Dept will have other focus at this time rather than the four hours. This story is tragic but I'd be amazed if it's down to 4h-gaming. Also, hospitals get fined, I understand, far more for ambulance waits and prolonged handover than for 4h breaches.

Richard Lawson said...

Hi Malcolm
Thanks for putting me right.
However, the fact remains that I did have that wait outside in the care of a crew who should have been outside scouring the roads for human roadkill.

Clearly it is inefficient to have ambulance crews waiting outside of A&E. Therefore A&E depts need more resources, more capacity, and managers need to be made to understand the bell shaped curve. Sometimes uncommon things happen.