A&E Perspective: I Don't Like Mondays

Dr Dan O'Carroll


December 11, 2018

The list of people who famously don't like Mondays includes the Boomtown Rats, the comic-strip cat Garfield, and an awful lot of the working population. Those that work in emergency departments (ED), including myself, can definitely be included in this list.


Dr Dan O'Carroll

Most people assume that Friday and Saturday nights are our busiest periods and that was true until relatively recently. Monday has become the day that challenges us the most. There are multiple reasons for this, the most problematic from an ED perspective relates to (lack of) bed availability. Over the weekend, in hospitals across the country, the number of patients discharged falls, the result of fewer ward rounds taking place and reduced access to other services. The number of patients attending the ED on a Monday is, usually, greater than other days.

Why Is This?

Patients often delay their own presentation to the ED over their weekend as they hope that things will improve without medical intervention, they value their time off and don't want to be wasting their precious family time. The motivation for avoiding spending hours in the ED appears to be less strong when it's employer's or school time that's being sacrificed.

The combination of higher attendances and reduced 'flow' can result in the ED rapidly becoming crowded, which results in a poorer patient experience and increased staff pressure. One of my specialist trainees declared, only last week, that once he was a consultant, he would take every Monday off as annual leave. It's an idea that many of us have considered.

Planning Ahead

This brings us on to planning.

We know that it's going to be busier on a Monday.

We know that it's going to be busier in winter - we didn't know that last summer would be as bad as winter!

It doesn't appear that we are able to plan accordingly to account for the increased activity. There simply isn't enough slack in the system to accommodate these surges.

Last winter showed an average bed occupancy of 94.4%, and was more than 90% for all but 4 days over the winter period and 20 trusts had occupancy over 99% each day. Despite this hospital trusts across the country are running at worryingly high bed occupancy levels, with many reporting occupancy figures nearing 100%, this is far beyond the National Audit office level of 85%, above which quality of care is impacted.

Only last week the BMA published its analysis suggesting that an extra 10,000 beds were needed to meet the pressures the NHS is likely to face between January and March 2019. This is in excess of the 5000 extra capacity escalation beds that were utilised last year. These extra beds would be necessary 'just' to bring the bed occupancy down to NHS Improvement's safe limit of 92%, and it seems to be accepted that we cannot plan a system where the quality of care does not suffer, with the Royal College of Emergency Medicine welcoming the BMA's recognition of the importance of bed occupancy but also stating the Government winter pressure extra money is 'once again too little, too late to have a meaningful impact'

Trusts around the country are attempting to bring extra capacity into their systems but this is more than just cleaning and preparing the physical space and equipment for these 'mothballed' wards, it is finding the appropriate staffing. This often means reliance on expensive agency or locum staff - again we are reminded of the lack of reserves or of extra capacity in the current system.

'Inappropriate Attenders'

NHS Improvement wrote in September that amongst other measures, more patients with minor illnesses and injuries should be referred to services other than the ED and offered extra GP appointments, and community providers are to free up capacity across services and allow more patients to be cared for at home. These recommendations came with the welcome boost of £145m to the Department of Health and Social Care to support the implementation of the plan. I can only echo the RCEM comment that this appears inadequate. Many initiatives have looked at the problem of ED 'inappropriate attenders' - there do not  appear to have been many successful schemes for reducing this work load.

Ultimately the Emergency Departments across the country will remain the point of access of choice for many patients despite there being more appropriate services available to them. A recent report showed that there was poor uptake of offered 7-day GP services with as many as 25% of evening and weekend appointments being left empty. Despite the introduction of these extended hours and the costs associated with them, A&E attendances continued to increase.

As we're now firmly into the winter pressure period for emergency departments, the strain is starting to show on the staff. Tempers have been frayed, voices have been raised as frustrations boil over, there is pressure to avoid 4-hour breaches and maintaining safety becomes a struggle. Junior staff have looked worried as they hear several times a day 'this isn't busy, wait until you see it when it's really busy…'

'Happy Wheezers'

It's been observed by several members of staff that in this recent period we seem to have dealt with even more poorly children that we would normally expect, and it appears that this bronchiolitis season is resulting in a spike in attendances of the very young, with them ranging from the 'happy wheezers' that we are pleased to reassure and discharge, to those requiring intensive care management and specialist retrieval teams. This is one of the skills required of emergency medicine, being able to switch from dealing with our 'routine' frail elderly to being able to deal with the sickest of the young at the 'flick of a switch'.

Tears have been shed as staff members have struggled to deal with the workload and they try to reconcile the fact that no matter how hard they work, or how fast they see the patients, there will almost always be more to see. In this battle of attrition ED staff are hugely outnumbered - with no realistic prospect of any timely re-enforcements.

House of Commons Library. NHS Winter Pressures in England, 2017/18.
BMA: New BMA analysis shows NHS needs thousands of extra beds to meet pressures this winter.
Royal College of Emergency Medicine: RCEM welcomes BMA's call for extra 10,000 beds.
NHS Improvement: How we’re helping the NHS plan for winter.
Pulse: GP seven-day access programme did not reduce A&E attendance, study finds.5 December 2018


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