COMMENTARY

Why Can't All Hospitals End A&E Corridor-Medicine? 

Dr Dan O'Carroll

Disclosures

October 15, 2019

The Royal College of Emergency Medicine (RCEM) Annual Scientific Conference was held in Gateshead earlier this month. This gave the warriors that choose Emergency Medicine as a career the opportunity to meet up, swap horror stories of how bad it has become, and to feel, strangely, slightly reassured that this is a national problem rather than a local or even departmental issue.

The Conference, as seems the norm, was sold out, with a broad mixture of delegates and great representation from a multidisciplinary workforce. It's almost impossible to leave such a meeting without feeling enthused and more positive about the future of the specialty.

'Corridor-Medicine'

The new RCEM president, Dr Katherine Henderson used her inaugural conference speech to address 'corridor-medicine' and said that it is unacceptable for patients and staff, and needs to be stopped. She gave examples of trusts that have bought into this, and the question remains that if they can do it, why can't we all?

There are long-held concerns about the sustainability of careers in EM, and the challenges facing departments regarding recruitment and retention are well-recognised and at times seemingly unconquerable. Dr Rob Galloway of Brighton and Sussex University Hospitals NHS Foundation Trust gave a presentation about how his department had adopted annualised self-rostering, and had successfully increased their consultant numbers and filled all their rotas with clinicians at all tiers, which subsequently nearly eliminated their reliance on expensive locums.

This approach seems to be particularly worthwhile and attractive for those who wish to work less than full time in the ED, whether that be for family reasons or to develop portfolio careers.

EM-POWERing

It was no co-incidence that RCEM published its new strategy EM-POWER, which gave details on the benefits of a more flexible and innovative approach to rostering. Looking around the conference and seeing that Emergency Medicine is still attracting positive and enthusiastic individuals makes these types of initiatives even more important, and we need to get on top of these problems before the ever-increasing demands of the service reduces this goodwill and passion to jaded cynicism.

Interesting conversations were had around the dinner tables and whilst socialising, mainly with the focus of what we should be doing to fix this increasingly broken system?

One suggestion was sitting ED's behind a primary care service, to filter out the non-emergency workload so that we could concentrate on the 'genuine' emergencies. How would we get GPs to do this, because on the face of it, this would seem an unappealing job?

Four Hour Target Questioned

Another suggestion was to scrap the 4-hour target for 'minors', ie, patients who are being discharged, but keep it for those requiring admission, to maintain pressure on the system and to ensure that these patients' on-going medical care is delivered in a timely fashion on an appropriate bed. Interestingly, since the conference, there appears to have been a softening of the College's stance on scrapping of the 4-hour target, provided that the benefits it has delivered are maintained.

Perhaps the target does need re-examining. Medicine, and the circumstances in which we find ourselves, has changed hugely since it was first introduced in 2004. There are more and more decision-making pathways that we can access to try to avoid unnecessary in-patient admissions, for example to rule out low risk DVT (deep vein thrombosis), PE (pulmonary embolism), and acute coronary syndrome, but even with the best will in the world, the timing margins are tight to be able consistently to carry out these within the 4 hour window.

Charging for attendances was also proposed, to make patients think about whether their use of an ED is warranted. This obviously falls down, in my view, as there will be some patients who will sit at home whilst having a myocardial infarction rather than incur the cost.

And probably the most unlikely solution of all was to have a properly-funded health and social care service with access to an appropriate number of in-patient beds and a sufficient number of appropriately trained clinicians.  A controversial suggestion, but probably the only one that had any agreement.

Winter is Coming

Many of us came away from the conference with ideas on how to improve our own departments both for the patients and for the staff, and this warm glow of enthusiasm is going to be needed to try to sustain us through the oncoming winter.

EDs across the country are already buckling under pressure, the BMA warned only last week that the NHS is on a collision course for the worst winter ever, as it follows its worst ever summer in terms of performance, and this very much tallies with the experience of those on the frontline.

The total number of attendances in September 2019 was around 2 million, with over half a million emergency admissions, increases of 6.9% and 3.8% respectively compared with the same month last year. Yet still the ED is managing to admit, transfer or discharge more patients within 4 hours than the preceding year, with the target being met for 1.6m attendances, an increase of 2.6% on last year. Unfortunately, this has not kept up with the increased demand and 'only' 85.4% of patients met the 4-hour standard

This does raise interesting questions on how heavily staffed should we be planning the departments to be? How many additional staff should we try to recruit? In my department, we are planning a long overdue and welcome re-build and will also uplift our medical work force, but already, even though these staffing plans are yet to be approved, demand in recent weeks would have already outstripped supply of our future planned workforce on the busiest Mondays. We fully accept that it would be financially wasteful to be paying for excess staff to deal with these unusually busy days, but how much slack/tolerance, or robustness if you prefer, can we build into these future plans, when demand shows no sign of abating?

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