"In summary, the NHS is faced with options that are either unaffordable (increasing A&E capacity), unsuccessful (diverting people away from A&E) or unpalatable (giving up on the four-hour target)." (Blunt 2014).
As a Consultant in Emergency Medicine with special interest in the care of children and older people, I think the recent QualityWatch report is a coherent attempt to describe the process implications in our "stretched" A&E departments.
The report provides food for thought on the relative impact of patient co-morbidities, satisfaction with GPs, inpatient discharges, departmental occupancy and alteration in number and type of attendances, on the four-hour target over the last few years.
The impact of older patients
I work in a department with a catchment of over one million people, a fifth of whom are over 65 years of age.
My personal experience has been more rich and biased, however. I work in a large department adjacent to an urgent care centre, 10 miles from a big minor injuries unit and with a catchment of over one million people, a fifth of whom are over 65 years of age. As a result of these we see fewer walk-in patients and more ambulance transferred older people. These walk-in "diverts" into alternative centres has probably only worsened our four-hour performance.
Concurrently, we have failed to implement many ambulatory emergency pathways, including those for older people. We carried out a "frailty mapping project" few years ago, which found that this "frail" group comprised 3% of our attendees, 11% of waiting time "breaches" and 43% of admissions to acute medical ward. Of these patients, 92% experienced confusion.
Dementia, with and without delirium, is a big contributor to our process and safety inefficiencies (this is not restricted to the A&E department). Yet a nationally commended Emergency Frailty Unit was left impotent by process driven "turnaround" teams who did not heed advice from frontline staff, or from Dr Deming for that matter.
Capacity pushed to the limit
Our department experiences overcrowding a lot of the time. We typically get sandwiched in the hours 12.00-14.00, 18.00-21.00 and 00.00-01.00. The contributing factors include high ambulance inflow and poor outflow, with a lack of timely availability of inpatient beds. The delays contribute to long waits, as admitted patients vie with non-admitted patients for scarce cubicle space. We are hoping to have a much needed new A&E with integrated urgent care and medical assessment units in two years’ time.
Although the main problems include poor flow and lack of capacity, one only needs to throw in a few shortages in staffing, poor locum cover and stressed staff members of varying efficiency into the boiling mix to cause more delays. During the evenings we tend to receive a barrage of children with common coughs and colds, with summer contributing a fair share of paediatric broken bones.
The cauldron explodes with the addition of some resuscitation calls or a few agitated octogenarians, including several every week who have ‘do-not-attempt-to-resuscitate’ forms, but no end-of-life pathway.
Surfing the edge of chaos
Most emergency care providers are not trained in older people’s issues. This contributes to poor quality care.
Most providers in emergency care are not trained in older people’s issues and this contributes to poor quality care. Quality indicators for frail older people (see the Silver Book") and indeed those for important groups, including patients with sepsis, mental health concerns and pain management issues are not captured by the four-hour target.
The fact is, an A&E department is an example of a complex system. The complexities in the A&E department stem from the patient, the environment, the clinical care process and the providers. As a complex system, A&E departments operate at the edge of chaos and are meant to be highly resilient. Resilience in systems and in people fail predictably when resources are affected, including human motivation.
A need for robust leadership
Leadership remains paramount – the type that resources the infrastructure across the emergency care system and with reference to the population served. This leadership needs to be shared between the patients and their families and carers, the providers, the regulators and the politicians. This report highlights the importance of a much needed dialogue between these groups.
About Dr Jay Banerjee
Jay Banerjee, FRCS, FCEM, MSc, is a Consultant in Emergency Medicine, with a special interest in paediatrics and geriatrics, and the Associate Medical Director for Clinical Quality & Improvement at the University Hospitals of Leicester NHS Trust. He is a Health Foundation Quality Improvement Fellow.