"It's time for your enema Number Six!"
I'm a Medical Student Get Me Out of Here has an excellent post on the total fuckwittery that is NHS Government targets:
Patients are no longer known by their names or by their conditions, they're not even known by a number, at best it might be a location; bed 5 but often patients are referred to by their time. By this I mean how long they've been in the department. On the whiteboard (big list of all the patients currently in A&E or waiting to be seen) as soon as a patient ticks past 3 hours their name lights up like a Christmas tree in bright red, if their stay approaches 3 hours 30, then the managers start to appear from their hidden lair where I imagine they must watch intently the time spent in A&E by each individual patient. Of course they don't actually care in the slightest about Mr Jones who is having a heart attack right there in the department, he's got to go, wherever it may be, as long as its not A&E, its not their problem. If you even mutter the word 'breach', the description of those who miss the 4 hour target, in the vicinity of the A&E department you'll either be shot, or smothered in managers eager to find out what you know and what they can do to stop it.
In my few days in A&E I've already seen patient care put at risk due to this target. To me this is ridiculous, in fact, its beyond ridiculous, its dangerous. I imagine this target was thought up by someone in an office somewhere who'd not been near an A&E department since getting a little too drunk one night during their politics degree at Oxford.
More here.
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11 comments:
'I imagine this target was thought up by someone in an office somewhere who'd not been near an A&E department since getting a little too drunk one night during their politics degree at Oxford'.
An interesting hypothesis 'medical student' but the target was actually introduced (in part) to reduce the growing list of well known horror stories associated with very long waits - such as 26yr old Russell Williams who died after waiting 8hrs in A&E without ever seeing a doctor
http://news.bbc.co.uk/1/low/wales/3104694.stm
Or 74 yr old Thomas Rogers who bled to death after waiting 9hrs to see a doctor
http://news.bbc.co.uk/1/low/health/1574652.stm
Or Marion Rees who died on trolley after waiting in A&E for hours - she also bled to death, perhaps because lessons were not learnt from the death of Thomas Rogers ?
http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2001/08/26/nnhs26.xml
Or the target may have been introduced simply to prevent NHS patients, like Tony Collins from ending up in the Guiness Book of Records after spending over 3 days on a hospital trolley ?
http://student.bmj.com/issues/03/03/news/48a.php
Once the clocks are finally switched off whose responsibilty will it be to manage the gridlock that will inevitably arise when 19 million patients pitch up at the 200 or so A&E departments every year ?
Thanks for the link Dr Rant.
the a&e charge nurse - On no account do I disagree that patients should be seen, assessed and treated quickly but I do have objections to this target being the main focus which it seems to be on many occasions rather than the patients themselves.
There have been warnings in the past about the 4 hour target and its negative impact on patient care. I'm sure it has prevented many a patient being left on a bed for hours but at what cost I wonder?
I'm not saying things would be better without this target but targets seem to be taking over from what should be every healthcare professional's primary concern: the patient and their indiviual case.
It's not just about patients being left on a trolley medical student, although that's bad enough if you are 80yrs old and it takes 2 or 3 days to find a ward for you (as used to be the case).
No it's about ordinary people bleeding to death right in the middle of an A&E department because of the sort of conditions that arise once staff lose the locus of control.
The official report into the death of Thomas Rogers makes for grim reading - we cannot comfort ourselves by suggesting that this type of incident was peculiar to Whipps Cross: one of the key findings in the inquiry was this type of incident could, and in fact did arise in other A&E departments.
http://www.guardian.co.uk/society/2001/oct/03/hospitals.nhs
In short this was not an isolated case - to get an idea of what A&E used to be like (pre-target) type 'casualty watch trolley waits' into google.
Feedback from user groups was not very flattering back then.
Surely, there is something profoundly amiss when a patient can slowly exsanguinate (due to waits) despite being surrounded by doctors who are trained to recognise and treat life threatening emergency ?
If a patient exsanguinates whilst waiting in a casualty department then I wouldn't have thought it was just the fault of the Doctors. Surely the A/E charge nurse bears some responsibility for poor triage and hospital management has some culpability?
I remember those days, when I regularly worked in an English Casualty dept. We had "hello" nurse to say "hello" to the patients so we could tick the box that patient was seen within 5 minutes of arrival, even though they were often not seen again for hours. This met the "patients charter" requirement of the Major years.
I agree that the 4 hour wait is now causing significant problems. Perhaps the A/E charge nurse should visit some of the patients being bounced out of the A/E department without having their problems sorted, or admitted to a MAU or SAU then discharged the next day as a "finished consultant episode". If your only view is of the A/E department rather than "the complete patient journey" then it can appear that all is rosy.
The reason Hospital Consultants like me and GPs like Dr Rant loathe the artificiality of the 4 hour wait is that we see the rest of the journey, though not as clearly as the patient pushed from pillar to post do.
I also worked in a Casualty department in another Country in the early 1990s. The average wait to be seen was 15 minutes to 90 minutes at peak times. It amazing how easy it was to arrange this by having adequate funding for staffing!
Well said Dr Rant........the trouble is most NHS managers are not leaders.....leaders don't need targets and don't look for a scapegoat they take the blame and get it sorted......as for the 4 hr waiting time - If Comrade Blair had not told the public then they would have been non the wiser.
What about the patients that are kept outside in ambulances parked at the doors of some A&E departments like at Addenbrookes?
their "clock" doesn't start until they cross the threashold......... outrageous
http://www.theregister.co.uk/2008/03/13/hewitt_joins_bt/
hewitt_joins_bt/
That's a very interesting link, and one I will visit in more detail later!
Here's a
It might suprise you fox in the sox but the patient was correctly triaged, at least according to the inquiry chair, Dr Ruth Brown, consultant in emergency medicine - ideally the patient should have been seen within an hour after this assessment.
http://news.bbc.co.uk/1/hi/health/1574652.stm
Are you suggesting that a nurse (or the C/N)should have made the diagnosis of AAA clinically, without the aid of x/ray, ultrasound, or C/T ?
I daresay there are one or two experienced A&E nurses who might have suspected this condition, but surely we are straying into very dangerous territory if thousands of patients have to rely on a nurse because they must expect to wait for many hours before being properly examined by a doctor.
It is also unfair to suggest that I cannot see things from an in-patient perspective - you can't just walk into an A&E nursing post without having done your stint on the wards first.
I am not a fan of managers.
I am not a fan of clocks.
But in my humble opinion clinical standards in A&E (overall) are probably better than say 10yrs ago, notwithstanding a certian % of gaming and hurried care.
Can I make a suggestion ?
EVERY time care is compromised in A&E (because of the target) ask your juniors to religiously complete clinical incident forms - I'll bet that within a few weeks steps wil be taken to try to improve things.
Dear A and E charge nurse,
I am sure that you have excellent inpatient experience, but is that experience from before the 4 hour target time or have you seen the effects on MAU/SAU? Things have changed and not for the better.
If a Nurse sees a patient, "correctly" triages them then they have to wait a few hours before the Dr can see them then surely the nurse has a responsibility to check back on them from time to time?
Of course now the Nurse would now have the ability to discharge "correctly" triaged patients from the dept to meet a target, so instead of waiting a few hours they do not see the Dr at all. But that is a seperate issue...
The other noticeable effect of the 4 Hour wait is to slow down the productivity of both nursing and medical staff, by getting them to spend loads of time completing EDIS rather than actually see patients.
Its this sort of Bollocks that caused my wife (former Staff Nurse in Casualty) to quit NHS nursing.
this, fox, is the link, I'm going to quote from it to illustrate a & e cn's points
http://news.bbc.co.uk/1/hi/health/1574652.stm
"Mr Rogers, 74, died after he was left for nearly nine hours on a trolley at the Accident and Emergency Department of Whipps Cross University Hospital, in Leytonstone, east London."
and
"His condition was assessed by a triage nurse who decided he should be seen by a doctor within one hour.
However, a doctor had still not seen him at the time of his death."
and
"The official report of the inquiry team says that Mr Rogers' long wait was not unusual for patients at Whipps Cross."
and
"The report says that it was probably not obvious that Mr Rogers had suffered a ruptured aneurysm."
and
"However, it says that if he had been seen earlier by a doctor, and the diagnosis made, it is possible that he might have survived.
The nurse who initially assessed Mr Rogers prioritised him correctly, the report says, but heavy demand from other patients made it impossible for him to be seen within one hour.
Given this, Mr Rogers should have been re-assessed, but this secondary assessment appeared not to take place. "
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