Full Capacity Protocols

March 23, 2013 by · Leave a Comment

[image via NetDance on Flickr. CC License]

Hospitals are busy places. We have no space, no beds, no staff and inevitably less money to make this all happen. This is the situation we have.

We’re fairly pragmatic folks so we find ways to manage the work more efficiently and try and do more as an out patient or involve things like ADPs (accelerated diagnostic protocols)

But when we get slammed and have more admitted patients than you have trolleys to put them on then the system grinds to a halt and you can’t assess treat and admit/discharge anyone new.

In Stony Brook in New York, the hospital (and that’s the important bit, not just the ED) decided that when the ED was choked that they could put some of the stable patients as extras in the hallways of the wards. You can imagine what the ward staff thought of that.

This is a brief paper reviewing their experience.

Viccellio, Asa, Carolyn Santora, Adam J Singer, Henry C Thode, and Mark C Henry. “The Association Between Transfer of Emergency Department Boarders to Inpatient Hallways and Mortality: a 4-Year Experience..” Annals of Emergency Medicine 54, no. 4 (October 2009): 487–491. doi:10.1016/j.annemergmed.2009.03.005. PMID 19345442

This is a review of patient flow effectively and not a trial in any prospective sense. All they wanted to show was that this was happening and what the effects were.

It is not the highest quality science and does not claim to be.

RESULTS

  • 25% of those assigned to a hallway bed actually got a proper bed immediately
  • another 25% got a proper bed within an hour
  • the rest got a proper bed within 8 hrs.

THOUGHTS

Your hospital probably has more beds than they say they do. Spreading the crowding from one place to the whole hospital spreads the moral and professional responsibility to a hospital wide problem. It’s remarkable how that motivates resources.

Importantly it must be realised that this is no panacea for a poorly run hospital. In fact every time a hospital implements something like this it’s a sign that something is deeply wrong. However it can alleviate a crisis.

The Irish Association has a nice statement on FCPs. And indeed a nice EMJ paper on the same too.

Filed Under: critical appraisal, health care systems · Tagged: , ,

Patients per hour, turn-over and efficient use of staff

September 22, 2012 by · 7 Comments

There’s some interesting stuff on how best to use physician time. When I see a patient who’s been waiting 6 hrs I always apologise for the delay and if I order an x-ray I tell them that it shouldn’t be too much longer as the major delay is usually to see me.

The other parts of the system, like triage and x-ray seem to work a lot more “efficiently” than the Dr part. We inevitably get called away to various important situations and the patient has to wait.

What I struggle with is that my time – in many ways the most important rate-limiting factor in patient flow is often used in desperately inefficient ways. Most of this comes from having inadequate nursing or ancillary staff.

Most hospitals (at least in US, Aus and Ireland) have patients admitted pts in ED corridors or cubicles. ED nurses time is then spent looking after admitted patients. Sometimes this is actually 2/3 of the patients in the department. As a result ED nurses are not available to do what ED nurses would like to do – look after ED patients and employ their full range of skills of assessment, interventions and procedures like IV lines and the like.

Instead, given that the nurses are so overwhelmed it falls to the Dr to do a lot of these tasks – everything from bringing patients to the toilet to get urine samples, testing urine, placing cannulas. moving patients to x-ray or even into a room where we can actually examine them.

I could easily double the number of patients seen an hour if:

  • I could tick a box to request investigations as opposed to fill forms or take the blood myself.
  • I could have a scribe or even dictate notes instead of hand writing.
  • patients were in a gown, in a cubicle, ready to be seen when I come to see them.

Unsurprisingly, in an efficiency driven, for profit system like the US – they have already adopted most of these features that enable maximum throughput. They also have many, many more senior EM clinicians as opposed to essentially independently working trainees of varying experience.

This is very much NOT a slight on nursing staff. This is a criticism of short sighted planning that while the long wait in ED might be to see a doctor that’s actually because we have nowhere near enough nursing staff and we make poor use of their skills and training.

We get paid the big bucks to see patients, make decisions and spend time with patients. Anything that detracts from that is poor use of our time on on the floor.

Thoughts?

Filed Under: Featured, health care systems · Tagged: , ,

Too many hospitals?

December 6, 2011 by · Leave a Comment

For the non-Irish, remember that Northern Ireland has a total population of 1.5 million, and the 7 hospitals concerned are covering less than half of these (depending on how you read the numbers of course).

You can drive across the whole province of northern ireland in 2.5 hrs.

Incidentally I went to school with the guy in the video. That’s how small the country is!

Filed Under: health care systems ·

Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada BMJ 2011;342:d2983

July 21, 2011 by · Leave a Comment

There’s a lot of developing stuff out there that waiting times are bad, not just for patient experiences but also for clinical outcomes.

METHODS

These guys took a big Canadian database and looked at it to see what happened.

The key here is happened. It’s retrospective data from computer records, so beware; it’s good data but know its limiations.

  • ED attendances who were either discharged or left without being seen
  • stratified attendances by length of stay (the reasonable assumption here is that length of stay correlates with how busy the place is)
  • defined adverse events as death or hospital admission with 7 days

 RESULTS

  • 14 million attendances (or so…)

Fig 1 from paper

I don’t really understand ORs, or at least I don’t know how to apply them so here’s some easier to understand numbers.

Comparing visits of <1 hr with >6 hrs:

  • death changed from 0.1% to 0.15% in the high acuity groups and:
  • 0.02% to 0.04% in the low acuity groups.

There were of course differences in terms of admissions too but they’re a wee bit more open to bias so I’ll not go into them.

INTERPRETATION 

There are of course multiple ways to critique these kind of papers as to whether we can say anything “true” about such things but I don’t think they’re overwhelming problems.

So the dfference in terms of death isn’t huge by any means but it does seem to be there

Of course, this is fairly intuitive and obvious but it’s interesting to see the data behind it.

One of the reasons why it might be so difficult to show is that we do a damn good job – considering. The “considering” is the important part. When the place is crazy, we manage to do a decent job and it needs to be really bonkers for it to show in studies.

Though just because we cope under pressure doesn’t mean we should be happy with it.

Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ. 2011 Jun 1;342:d2983 PMCID 21632665

Filed Under: critical appraisal, health care systems ·

How does the centralisation of specialties affect the ED?

June 26, 2011 by · 2 Comments

This blog helps me vent a bit. That probably comes across I know.

I have at times talked fairly critically about the state of EM in the UK/Ireland and I definitely think we have some serious issues that will take a long time getting sorted.

But this is largely because this is my context. If I worked in the US then I’d be bitching about the evils of privatised health care, if I worked in NZ/Aus then I’d be…well… disappointed in the quality of the locally brewed Guinness…

This doesn’t mean that we spend all our time doing a bad job here. Or at least that we do any more of a bad job than anyone else. Patients don’t really care who is intubating them or fixing their nose bleed and so a lot of this is an internal discussion to the profession.

Having said all that I still want to have another bit of a moan.

Northern Ireland has a historically bad setup when it comes to hospital care.

Our two largest hospitals are within 10 minutes walk of each other and both on the south side of Belfast.

The hospital where I work is in the wrong place to cover the population we have. It should be in Dungannon or Armagh or somewhere a bit further west.

West of the Bann seems particularly poorly served. The problems anticipated in the run-down of services in the Mid-Ulster highlight this. @lizzyferret has written some on this

And while we have a “rural” population in UK terms it’s really nonsense when we compare it to places like rural australia (check out the awesome Broome Docs blog to see what a true generalist really looks like)

An ideal solution might be rub it all out and start again. I suggest making a new island in the middle of lough neagh and connect it to each of the adjacent counties by motorway spreading out like spokes in a wheel

I can’t see this happening any time soon.

So there has been a move in recent years to centralise services. As twitchy as it makes me feel not to have things like vascular on site, it seems necessary to centralise this type of thing as much as possible.

For the ED firstly – the knock on effect of this will be reduced support from the specialties

The second thing is EWTD – the slightly bizarre idea that it is illegal to work more than 48 hrs in a week. There are lots of reasons why doctors working 60 hrs a week may be bad, (thought that’s not as problematic as 100 hrs a week or 60 hrs a week of constant intense activity) but a blanket ban seems like a very poorly thought out idea. The chronolgical gymnastics needed to have a rota that fits has not done much for working conditions for most, never mind for patient care.

Either way it has further diminished speciality support for us in the ED, things like ENT are more likely to be on-call off site than just upstairs.

The reduced speciality support is not what I’m here to rant about. I think that that’s actually a good idea on the whole.

This may sound odd but I only started cauterising my own noses (I should have thought of a better way to phrase that…) in the past couple of years. They used to all get shipped up to ENT to clear the cubicles for yet more new patients with the dubious reason that the ENT trainees needed the practice.

You see centralising services and having less immediate support on-site is entirely appropriate to the scope of the ED and the docs working there.

The deficiencies in both our training and the system (remember it’s not just as simple as not knowing how, it’s also that we don’t have the time or resources or space to do it) are exposed as the specialties retreat off site and to the big city. This doesn’t have to be a problem, instead we can see it as an opportunity to get our shit together.

I found this video via @cliffreid which shows Dr Kas outlining the appropriate scope of our practice. (I love the way he shuts the door before he starts!)

Filed Under: health care systems, thinking about medicine ·
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