COMMENTARY

Emergency Medicine Insight: 'Winter is Coming' 

Dr Dan O'Carroll

Disclosures

November 15, 2018

Game of Thrones burst onto the scene in 2011, few could have predicted that the rather bleak, foreboding Stark family motto, 'Winter is coming' would be adopted by Emergency Physicians across the country.

   

Dr Dan O'Carroll

Although we are not faced with an army of the undead, we, like the Night’s Watch are left facing what is predicted to be the toughest winter of them all. Emergency Department (ED) staff are left guarding the Wall, and like the Night’s Watch we are understaffed and under-resourced for the winter ahead.

 

Those of us that have worked in Emergency Medicine (EM) for many years are used to 'winter pressures'. It’s no surprise to anyone that winter tends to be associated with an increased incidence of illnesses. What has changed in recent years is the scale of the problem and perhaps even more worryingly is that the winter period seems to be almost all year around.

Worsening Situation

BMA analysis of NHS England data has confirmed a worsening situation and the below is taken from their press release:

The current crisis

  • In a snapshot of 3 summer months of 2018 (July to September), 125,215 patients were left waiting on a trolley for more than 4 hours after the decision to admit, with over 8% of emergency admissions resulting in a trolley wait, a figure that was greater than every winter (defined as January to March) between 2011 and 2015.

  • The figures were not far behind the last three winters, which registered record numbers of patients stranded on trolleys at 155,277 in 2016, 177,012 in 2017 and a record 226,176 in 2018.

  • Compliance with the waiting targets for patients to be seen in A&E, also set at 4 hours, were lower in the summer of 2018 than the winters of 2011 to 2015, with record lows recorded in the last three winters.

Comparing winter 2011 and winter 2018

  • Compliance with the 4-hour waiting time to be seen, admitted or discharged from A&E reduced from 96.6% to 85.0%.

  • Total trolley waits of longer than 4 hours increased from just 29,636 to 226,176, a seven-fold increase.

  • Total emergency admissions increased from 1,290,056 to 1,529,087 an increase of 19%.

Comparing summer 2011 and summer 2018

  • Average A&E 4 hour wait compliance reduced from 97.3% to 89.3%.

  • Total trolley waits of longer than 4 hours increased from 18,095 to 125,215, a six-fold increase.

  • Total emergency admissions increased from 1,247,113 to 1,558,691, an increase of 25%.

Although some of the headline figures are stark and depressing it is worth noting that the Royal College of Emergency Medicine states:

In 2017-18 there were 1,447,451 more attendances than in 2010-11 – equivalent to the annual workload of 14 large Emergency Departments.

We have not been provided with 14 more EDs or anything like the number of staff that would be required. Performance against the 4-hour target has deteriorated with over 200,000 extra patients waiting beyond the 4-hour target. Under the weight of the ever-increasing evidence of failure it is easy to forget what has been achieved. What can only be described as Herculean efforts, ED staff have seen over 1.2 million extra patients within the 4-hour target. A feat that deserves recognition and commendation.   

As the October half-term passed and performance against the 4-hour target rose to long forgotten levels of success, those of us longer of tooth were not reassured that we were any better prepared going into the colder weather. Our success against the target was not due to any change in our practice, just a reflection of lower attendances. Staff could enjoy the warmth of success and take time to enjoy the less frantic pace. It wasn’t long before the cold returned and once again we were reminded. 

'Winter is coming'

And boy, did it hit hard last week! 

Attendances 50% higher than the previous week for many of the days. Some departments reporting record numbers of attendances. Performance fell. Staff working at their absolute limits. It became a fight to maintain basic safety rather than being able to concentrate on delivering the high-quality care that we all aspire to. 

Perhaps surprisingly, patients and relatives cope with the long waits to be seen with good grace, they can see that the staff are working hard and there are very few complaints. Patients and relatives are seen in areas not necessarily designed for clinical assessment, as clinicians use their initiative to try to keep the flow going. Across the nation it is the frail elderly, who are spending far longer waiting for beds than any of us would hope for. Whether this is being parked under numbers on corridors (so that staff can keep track of where they are) or being asked to share two or three patients to a cubicle designed for one trolley. 

Attendances by ambulance hugely increased from the week before. Ambulance staff unable to handover their patients as there’s no staff free to receive the patient or at times no physical space or trolley to accept the patient into. Journalists were reporting that hospitals in the region had waits of several hours to handover patients and at points up to 23 patients (and their ambulance crews) stranded in corridors or being unable to be off-loaded from the ambulance itself.

This is one of the many big fears we deal with. The safety concerns are not necessarily about those patients waiting for the beds, they’re about the 999 calls with no ambulances free to attend, or they’re about the unselected patients in the ambulance queue waiting to be handed over/unloaded. At one point it was reported that there was only one free ambulance for the whole of the West Midlands. Departments were full, and consultants were left with the unenviable task of selecting the 'least sick' patient to move out of the high acuity areas to accommodate the yet to arrive "Alert".

At one point, newly bereaved relatives were moved to a relatives/viewing room only minutes after learning that their loved one had died, so that our next cardiac arrest could be accommodated, in an already over-capacity resus room. Our medium sized department had over 30 patients waiting to be transferred to the wards. This means that the nursing staff were in reality nursing an entire ward on top of the their 'new patient' responsibilities.

After a week of unrelenting pressure whilst on call, the weekend was a welcome arrival. Winter had come, having never really left and the spectre of my forthcoming next weekend on call weigh heavy on my mind.
 

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