Dave Caesar: Doing our best in tough conditions

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There has been much coverage recently of the Audit Scotland Report on Emergency Departments and their “waiting times target”. One helpful Evening News reader suggested (in response to the headline that the Royal Infirmary of Edinburgh’s performance continued to be one of the lowest in Scotland) that yours truly should stop writing this column and start concentrating on the long waits.

Unfortunately, if all it took was for me to spend two hours a month less of my free time explaining what happened in the Emergency Department to readers and added that to the 220 hours or so I spend in the ED a month, we would have fixed this ages ago.

Instead, I thought I would highlight some of the key findings of the report, and attempt to explain what it means to you as consumers of our service. The first thing to say is that the title of the report is slightly misleading. It refers to the “four-hour Accident & Emergency (sic) Waiting Times Target”.

It is more accurately referred to as the four-hour Emergency Access Standard. This is an important difference, as the reasons why many people wait beyond four hours in the EDs are not under the direct control or influence of those who work in the EDs.

When patients attend the ED, they do so for a variety of reasons, and by a variety of means. Most EDs have a mix of conditions that present to them, and the Audit Scotland Report makes note of this. Your local adult ED, at the ERI, sees the highest proportion of sick patients in Scotland. Not only do we see the largest number of patients, but we have a disproportionately high number of “majors” patients. This means that more patients may require laboratory investigations or X-rays, and the time spent assessing, treating and reviewing patients is longer. Despite this, we still manage to get many patients home. Of the number we do manage to discharge (more than 200 patients a day), 96-99 per cent get home within four hours of arrival.

Of our remaining patients who need to be admitted to hospital (around 80-100 a day), our ability to access a bed on the ERI campus can be challenging. This is where we can often struggle to admit patients within the four-hour window. Sometimes this is entirely appropriate – patients may have required specialist intervention whilst in the ED, or had an unexpected turn of events that required immediate treatment. Such is the volume of major illness in the ED at the ERI, that we are able to provide therapies for critical illnesses with a high level of expertise and consistency when required.

This ability, in partnership with our colleagues in the Scottish Ambulance Service, has led to major advances in the way that we treat patients who suffer cardiac arrests in Edinburgh. Our survival rates for this catastrophic disease are now comparable with the leading centres in the world, and we were recently voted the ED Team of the Year 2014 for this achievement.

However, for those patients, often frail and elderly, who are requiring a bed in hospital and are having to wait on a trolley, this will come as little solace. The ways in which patients are admitted to hospital beds are also very variable. Usually, the team in the ED make a decision about whether a patient can manage at home or will need to be admitted. The ED doctor may need to refer that patient to a receiving team. They may be available immediately, or it may take them an hour, sometimes longer, to complete what task they were doing elsewhere to review the patient. They may then decide that more tests or opinions are needed. Often, there is a hierarchy of opinion, that can take some time to progress up before a final decision is made for the patient. If an admission is decided, then the nurse co-ordinating the patient’s care in the ED will “book” a bed on the ward. We manage to book 60 per cent of our beds within two hours of arrival in the ERI. Despite this, we still only get 80 per cent of our admitted patients in to their bed within four hours.

The downstream wards then have to declare a bed available and accept the patient to that bed. That can often require a patient being discharged from that bed, which may require a discharge letter and pharmacy order being completed, plus the requisite cleaning and servicing of the bed space, prior to the bed being made available. Alternatively, it may require a patient being moved to another ward, which may require all those things to enable a discharge happening downstream, and then a patient moving between wards. It can sometimes be as simple as a patient waiting for a family member to collect them.

Once the bed has been declared available, we then just have to wait on the porter and the nurse to escort the patient to the ward. We know that for the ERI, we need to have 50 per cent of our daily discharges completed before noon to allow this sequence of events to match what will come into the ED. Currently, it stands at around 15 per cent. There is much work to do, but go easy on your ED.