McCreadie DWJ (a) Singhal P (b) and Baksi Arun (c)
(a) Emergency Medicine (retired), West Midlands. (b) Dept of Medicine, Weston-super-Mare, Somerset, (c) Former consultant physician, St Mary’s Hospital, Isle of Wight
Introduction
Throughout the UK, small Emergency Departments (ED), defined as those with up to 60,000 attendances per year (1), are at risk of being downgraded to a minor injuries unit, partial closure, night hours closure or full closure due to financial or clinical issues. By deploying the use of medical multi-disciplinary teamworking it is our opinion that such EDs will be able to manage the rising patient workload of today.
The current COVID 19 pandemic would seem to be an ideal opportunity to pilot such a scheme in an effort to test this hypothesis especially when conventional approaches over the last decade have manifestly failed to improve the ineffectiveness of ED, failure to meet targets and its consequent negative effects on the other functions of the Trust.
Problems in Small EDs
These problems may be real or perceived but they have severe repercussions on the hospital and community.
Small ED’s are invariably in geographically isolated areas, serving small communities who value and require the services of a local ED.
ED medical staff, both senior and junior are difficult to recruit and consequently there is much reliance on locum doctors, who are itinerant and costly. In addition, the locum staff often do not always have the desired competence nor experience. This leads to inappropriate referral decisions to on-call teams, resulting in unnecessary admissions and ineffective use of staff.
Triage units are more often than not staffed by inexperienced doctors and nurses resulting in inappropriate decisions.
External overseeing agencies (CQC, GMC, Deaneries, Medical Colleges, and HEE) apply the same level of scrutiny and expectations and standards as they do to the more central and better funded EDs. This practice by such bodies appear to be unrealistic, unattainable and not appropriate for a service unit for a local hospital, and certainly not to be insisted upon during the current crisis.
Proposal
We acknowledge that small EDs are unlikely to see major trauma; the majority of the workload involves medical, surgical or paediatric in nature, whilst the minors and walking wounded are managed by Enhanced Nurse and Advanced Care Practitioners.
We propose that middle and junior grade medical, surgical and orthopaedic staff are based in the ED when on-call and work alongside the ED staff as an Integrated Team (2). The level of staffing and expertise from the specialty middle grades within the ED would significantly improve the quality of care.
It is important to ensure that the Triage team consists of experienced staff able to identify those patients suitable for care in the Surgical or Medical Ambulatory Emergency Care or Same Day Emergency Care centres (3) This will enable appropriate patients to be managed by the onsite on call teams. The ED staff could then concentrate on treating patients who require their immediate attention. The presence of the on-call teams will assist appropriate decisions and investigations.
The walk-in minor illness will be transferred to AEC further freeing up ED time.
The current practice of clerking patients is duplicated by specialty teams, resulting in unnecessary waste of time and frustration for patients. It is therefore proposed that a single clerking form is used and this should follow the patient throughout the period of care.
Benefits of this proposal
This will lead to increased staffing within ED. The presence of the on-call teams will also enable junior medical staff to gain greater insight and experience, leading to greater job satisfaction. An important gain will be reduction in the cost of employing locums.
Greater efficiency in Triage will lead to reduced delays in patients being seen quickly and managed effectively. Patients needing resuscitation will be managed by ED staff with nearby specialty help if required. These changes will lead to earlier admissions and discharge, appropriate investigations and educational experience of doctors in training.
It will allow the middle grade doctors to function as “reviewers” rather than additional clerking of patients.
Avoiding duplication of work by multiple medical staff members will help reduce the spread of infection to both staff and vulnerable patients.
Discussion
Small EDs and Trust are there to provide a wanted service to their local community and the various quality control health organisations should do all they can to enable such a provision as mentioned above. Organisations such as the GMC, CQC, HEE, Medical Colleges and Deaneries should support these smaller Trusts by allowing junior doctors, especially the Foundation doctors, to practice across specialties when on-call rather than insist they only work in their appointed post.
They can gain experience in their specialty when not on-call. Out of hours ward work should be minimal if there is cooperation between on-call and on-duty colleagues but any work should be addressed to the appropriate specialty doctor based in the ED. Junior doctors in such Trusts should be made aware of such working arrangements and indeed it may be an attraction to such juniors as they are likely to gain a greater range of medical experience with deeper understanding of ill and worried well patients.
Although different NHS trusts follow various accepted models, it is common for a patient to meet several health care staff during their initial few hours in hospital. In truth one sufficiently trained team member would suffice. For example, a patient will often meet an ED junior, followed by their Consultant or middle grade, only to have the process repeated by their medical or surgical counterparts. This leads to duplication of work with staff and resources that could be used for caring for patients elsewhere tied up unnecessarily. Clinical opinion can often vary between teams resulting in confusion and stress for the patient.
During times of limited financial resources and public health crisis, it is important that systems are efficient by avoiding duplication and by reducing unnecessary investigations and locums, the front door model can be made affordable.
This proposal under normal circumstances is not thought to be suitable for the larger Trusts because their ED staffing is better, both in quality and quantity but given the cancellation of Elective work this model could still be considered even in the larger Trusts to be prepared to deal with the challenge of Corona Virus.
Summary
This proposal is designed to ensure the continued presence of small EDs by a novel way of deploying medical staff and improved processes. This will ensure continued availability of EDs for local communities with significant reduction in cost of locums, a more logical use of medical staff providing quality care in addition to improving the learning experience and job satisfaction.
This model of integrating the ED with Speciality teams, in our opinion would help in dealing with rise in demand during the current crisis.
This proposal may well prove to be a model to be adopted for general structure of EDs beyond the period of crisis.
Reference
1 – RCEM Workforce Recommendations 2018; Consultant Staffing in EDs in the UK, Sept 2018.
2 – Roy Col of Physicians: Patient Safety – Improving Teams in Healthcare, Nov 2017.
3 – NHS Long Term Plan (HWE) Jan 2019