COMMENTARY

A&E Perspective: Corridor Medicine, Changing Targets, & Groundhog Day

Dr Dan O'Carroll

Disclosures

March 21, 2019

"OK, campers, rise and shine, and don't forget your booties 'cause it's cold out there. It's cold out there every day." This is the initially cheery greeting from weatherman  Phil Connor's radio alarm clock in the comedy Groundhog Day . In the movie, Phil is destined to live the same day over and over again until he gets it right

   

Dr Dan O'Carroll

Emergency medicine in the UK seems to be stuck in a similar loop. The same headlines greeting us when the latest performance figures are released.

I have reviewed emails, both received and sent, tweets and comments that show that all of the problems that we're currently facing in the emergency department (ED) are precisely the same as in previous years. Only worse!

Under Pressure

Full ambulance bays, and emergency departments looking after many more patients than they were designed for. Talking to colleagues and reviewing twitter feeds show that the pressure is being felt across the country, with many reporting that their departments have treated record high numbers of patients. It is perhaps understandable that the Government seeks to remove the adverse publicity the on-going failure to meet 4-hour target attracts by simply scrapping it!

In the last week, the Royal College of Emergency Medicine has announced the result of its Presidential Election and Dr Katherine Henderson is its first female president. In the opening press release she is quoted: "The recent news of plans to replace or amend the 4-hour target means that the work of the College has never been more important. 

"How we measure emergency care to ensure patient safety and drive flow is a key priority for me, but in addition to this I am determined to tackle the issue of corridor medicine, improve retention and enhance the value of College membership."

Corridor Medicine

Those not familiar with modern emergency medicine may not be familiar with corridor medicine. Emergency departments across the country are so crowded that patients are stacked in corridors waiting for cubicles, or trolleys to be handed over from the ambulance crews, or waiting for beds to become available on the wards for admission. Sometimes patients' clinical assessments or initial investigations may be carried out in these sub-optimal conditions. I have heard tales of temporary screens being used so that one poor patient could use a bed-pan in a public thoroughfare such as the labelled corridor space shown here.

 

 

How has this become acceptable? Why aren't our politicians being held to account by the patients who are suffering sub-standard care, often with privacy and dignity completely gone out of the window? Why are staff being asked to work in such over-stretched and pressurised environments?

It seems that what was once unthinkable has become normalised, our bar for acceptable standards has been lowered. Only last week a colleague was telling me that as long as the number of patients within the department was no more than about 100, it was OK. This is a staggering number of patients to be dealing with at the same time, and it's a number that only 5 years ago would have been unthinkable. The department in question has had over 150 patients at times this winter

Scrapping or Changing Targets?

It was perhaps telling that in the press release regarding the scrapping, sorry, changing of the 4-hour target the clinical oversight group included many eminent bodies including the Royal Colleges of Surgeons and Physicians. 

The Royal College of Emergency Medicine was notably absent and appears to not have been consulted. There have been suggestions in some places that the 4-hour target diverts precious resources away from critically unwell patients, as patients are seen with the avoidance of potential target breeches in mind rather than clinical need. Simon Stevens, the chief executive of the NHS in England, said on BBC Radio 4's Today programme: "The problem with [the target] is it doesn't distinguish between turning up at A&E with a sprained finger versus turning up with a heart attack. What senior doctors are telling us is that they think that the standards should focus particularly on those major conditions – like sepsis, heart attack and stroke. 

"The top doctors in the NHS are looking at what are the most appropriate clinical standards to improve outcomes in emergency care. They will make their recommendations and, on the back of that, we will meet them."

Many emergency physicians were somewhat taken aback by the insinuation that we don't prioritise those conditions already. Triage is hardly a new concept for us and has been in use in some form since approximately 1792.

Many of us see the performance of the emergency department as a barometer for how well the rest of the hospital and local healthcare economy is performing. The 4-hour target cannot be reached whilst the bed occupancy runs consistently higher than 90%, and when the social care system is failing causing the 'backdoor' of the hospital to be closed.  This target should not be considered in isolation. 

Part of the winter 'plan' last year was the cancelling of all elective non-cancer operations in the early part of 2018. This obviously then put undue strain on the surgical services to try to catch up over the succeeding months and meant that it was reported that over 4 million patients were on hospital waiting lists for routine treatment. It is therefore no surprise that 6 out of 8 of the existing targets for cancer diagnosis and treatment are being missed. This deteriorating position is unacceptable to patients and staff alike. 

The Government is rightly trying to address these with the Clinically-led Review of NHS Access Standards: Interim Report from the NHS National Medical Director but if the chronic underfunding and over-stretching of resources are not addressed the chances of making any meaningful improvement in this important endeavour are negligible.

Removing or changing the way the 4-hour target is measured and reported may mean that we are no longer stuck in our own Groundhog Day with the predictable reports and associated publicity announcing the new 'worst ever performance'. But the grave concerns remain that this will, at best, merely be hiding the problem or at worse have a catastrophic impact on patient safety within many emergency departments.
 
As it stands, we're like the residents of Punxsutawney, Pennsylvania, eagerly awaiting to see whether Punxsutawney Phil (the Groundhog) emerges to see his shadow and whether we're condemned to another 6 weeks of winter, or worse.

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