In Stitches
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Well-intentioned cock-ups like this have happened throughout the NHS. Within A&E, we have the 4-hour target – we have 4 hours from when a patient arrives to either discharge them or admit them; 98 percent of patients need to meet this target. Don’t get me wrong; on the whole, the 4-hour target has banged heads together and brought about some good changes to the way we work and treat patients. Patients no longer wait 12 hours to see a doctor for a broken toe and being admitted to hospital has been streamlined. However, unintended consequences do exist and they can be harmful for patients. Let me explain with a couple of examples.
Last week, we were having a very, very busy day. There were massive delays in X-ray and an old lady who had fallen had had to wait 3 hours and 40 minutes to confirm the diagnosis of a fractured hip. She had been given some morphine while waiting for her X-ray, but was still in pain. The clock was ticking – it was 3 hours and 55 minutes since she had come in and the porters were about to be called to take her to the ward. In 5 minutes I could have given her some more morphine. However, it has side-effects such as slowing down the respiration rate (she also had a chest infection, which had caused her to fall in the first place) and nausea. What is just as effective but without the complications of a second morphine injection, is an injection of local anaesthetic into the area around the nerve going to the hip. It numbs the area within 10 minutes, and around 12 hours of pain relief is provided. However, it takes around 15 minutes to do. I told the nurse in charge that I wanted the patient to have the injection and not go to the ward just yet. I was told that she would fail her 4-hour target. This is known as a ‘breach’. In these days of targets it is so hard to argue back. If a patient breaches, then the consultants have to ‘examine’ why. If too many patients ‘breach’, then the NHS managers come down on the hospital like a ton of bricks and there are potential financial penalties.
But aren’t we in the job to provide the best possible care for the patient and not there to worry about targets? No wonder so many nurses and doctors are leaving A&E. They are doing so because they are not allowed to do their job properly – caring and managing patients.
After a 10-minute delay, we all agreed that it was in the patient’s interests to give her this injection and the figures were fiddled. (I deliberately do not get involved in this fiddling, because I think we should be producing honest figures so that something gets done rather than just massaging the ego of the Secretary of State for Health.) The department pretended she had left A&E 20 minutes earlier than she had. The figures said that she stayed 3 hours and 59 minutes. It is ridiculous that so much time and energy is spent trying desperately to meet targets, but when we fall short, someone has the job of adjusting the time. I don’t blame the A&E department for adjusting the figures. There is such pressure on us to comply with the target that adjustment is seen as acceptable. It means the hospital won’t get penalised financially or by a reduction of its ‘star performance score’ status. By fiddling the figures, it also means that we can concentrate on looking after our patients.
If there hadn’t been this target culture, then there wouldn’t have been this unnecessary stress and pressure on everyone. Perhaps if targets were used to identify where more resources were needed, rather than to punish failure, patient care might be improved. This time the potential breach was caused by a delay in X-ray (which often occurs). The solution might be to hire an extra radiographer. If this was done – if cash was invested to sort out this problem – then this delay might not occur again. But no, we fiddled the figures so we didn’t lose money and hence no one could highlight the problem. And the government could say everything is lovely-jubbly.
Another example was a 16-year-old girl who came in last Thursday. She had been drinking in the joyous surrounding of the local park. (Oh, the joys of the Anglo-Saxon drinking culture.) The ambulance was called because she was unconscious in the street. She needed fluids and a period of observation. At 3 hours and 30 minutes, my colleague reviewed her and determined that although she was now conscious, she was not well enough to go home yet. She needed another few hours to ensure that she didn’t still choke on her own vomit, etc. Before the days of targets, she would have stayed in A&E until she was well enough to go home. However, now we could only keep her for 4 hours, although she needed more time. My colleague was then told to refer her to the paediatricians to go and sober up on the kids’ ward. This was not appropriate. The paediatricians were busy enough and didn’t need to see a patient that my friend knew didn’t need their specialist skills, but then there is this bloody 4-hour target. Except in a very few clinical exceptions, we are not allowed to care for someone for longer than this time period. My colleague refused to succumb to the pressure of the nurse managers and did not refer her to the paediatricians and ended up getting a lot of grief for it.
She reviewed the girl 2 hours later. She was fit enough to go home with parental supervision. However, she was discharged about 45 minutes earlier than would have been ideal. The next day the doctor was expecting an interrogation into why she had let someone ‘breach’ but the figure had been fiddled and the patient was apparently discharged at 3 hours and 59 minutes. Again, I can understand why the figure was fiddled, but if we hadn’t fiddled the figures we might have seen the problem and a solution – a properly staffed paediatric A&E observation bed, where patients can be admitted while staying under the A&E team.
Figure fiddling happens everywhere. A recent survey by the British Medical Association and the British Association of Accident and Emergency Medicine showed that 31 percent of A&E doctors admitted to working in a department where ‘data manipulation was used as an additional measure to meet emergency access targets’. In other words, they admitted to working in an A&E where the figures were fiddled (for those of you who want to read more on this please go to http://www.bma.org.uk/ap.nsf/Content/Emergencymedsurvey07).
This is further backed by research from the City University business school that looked at the records of 170 000 A&E attendees and applied ‘queuing theory’. The conclusions were reported by lead researcher Professor Les Mayhew, who said:
‘The current A&E target is simply not achievable without the employment of dubious management tactics. The government needs to revisit its targets and stop forcing hospitals into a position where they look for ways to creatively report back, rather than actually reducing waiting times for real people.’ (further information is available from http://news.bbc.co.uk/go/em/fr/-/1/hi/health/6332949.stm).
When the Department of Health spokesman responds by saying back to the BBC, ‘It’s absolute nonsense to suggest that the A&E waiting time standard is not being met,’ who do you believe?
It is not just the raw data that is manipulated. There are other ways in which 5 hours to you and me means 4 hours to the Department of Health. Examples I have heard from various colleagues throughout the country include:
1. Corridors are re-designated admission wards by the simple application of a curtain rail. As soon as you are admitted to the ‘admission ward’ the clock stops.
2. Patients are discharged on the computer before they have left the A&E (i.e. before they have got their discharge drugs or similar).
3. As soon as a bed on a ward is allocated to the patient, the patient is transferred to that bed on the computer, regardless of whether they have to wait an hour for the porters to take them to it.
4. Patients can be admitted by computer to an A&E ward (and not breach) but physically not move because there are a lot more beds on the computer than there are in real life.
5. The time it takes from the ambulance bringing a patient in to being logged onto the computer can take up to 30 minutes longer if there are no nurses to meet the ambulance. The clock starts ticking when we are ready and when the receptionist has had her cup of tea, NOT when you arrive.
6. If a patient has been referred by a GP, they don’t come to A&E anymore, but to an admission ward. As they are technically admitted, there is no target for how quickly they get seen and so they can often languish for hours before seeing a doctor.
7. Patients for whom A&E doctors have asked for a review by a specialist can get admitted to a ward regardless of whether the specialist has seen them or not and regardless of whether they actually need to come in or not. Once admitted to a ward they can stay there for ages without being seen by the specialist as they are no longer in A&E and so cannot breach.
8. Originally, there were specific days when the 4-hour rules were being assessed. On that day, the hospitals would cancel elective operations so that there were spare beds and employed loads of extra locum doctors and nurses to make it look as if the hospital was more efficient than it really was.
So, as you can see, hospitals feel compelled to massage their figures. The target was brought in for the right reason and initially did a very good job. But we need clinicians to make the priorities, not politicians. If the government is going to insist on targets, then let’s make some sensible ones such as all urgently triaged patients to be seen within 5 minutes of arrival. Or how about patients being able to expect a bed 30 minutes after they have been fully treated in A&E, etc? These targets may not be as glamorous to tell voters about, but they might actually improve care without distorting priorities.
The reason I moan so much about this is that what was once a tool to improve A&E is now damaging patient care and doctors’ and nurses’ sanities. I just hope a politician or two reads these words and does something about it other than claim that what we are saying is just ‘nonsense’.
At work on New Year’s Eve
I am writing this on New Years Day. Last night I was at work and it was absolute hell. The A&E looked like a war zone – police restraining aggressive drunks, teenagers vomiting and crying and overworked staff acting as bouncers. I can only assume that the managers thought that someone might fiddle figures for the night and so didn’t bother to employ any extra staff despite knowing how busy it was going to be. I was knackered by the end of the shift and was pissed off with some of the patients’ attitudes, but in all honesty, I quite enjoyed myself.
But I can hardly blame the new drinking laws. I started my shift at 9 p.m. and the drunks were already there. The first was quite a nice lad of about 17. He had fallen asleep in the street and someone had called an ambulance because he had wet himself and was vomiting.
‘So what happened?’ I asked.
‘You tell me,’ he retorted.
‘No. I asked first. What happened?’ I countered.
‘Don’t know mate. Been larging it,’ he said in his irritatingly pretend street speak accent – posh but with a touch of Estuary English.
‘It says on the notes from the nurse that you have been drinking. That can’t be true as you are under 18 and so surely can’t have been drinking. What actually happened?’ I mocked.
‘Nah mate, I gone massive. I am quality,’ he retorted in Mockney.
Luckily, I listen to Radio One, so I sort of understood what he had said.
‘So how have you gone massive mate?’ I enquired.
‘Vodka mate. Bottle of vodka – down in 1 hour. Larging it. So what I am doing here?’
I explained that an ambulance had been called for him as he was so drunk.
‘That is quality. Coming to hospital ’cos so drunk. Quality.’
I asked some questions to check that he was OK and had suffered no ill-effects from his night’s drinking. I asked him if he thought a bottle of vodka was really that sensible for a 17-year-old’s liver.
‘I can do it because I am so f**king hard. I am hard as nails me.’
‘Right … so hard you end up vomiting all night and pissing yourself so that your mummy had to collect you at 10 p.m.? Yep, hard, aren’t you? Well done mate.’
I called in his mother, and as soon as he was able to walk without falling over, he went home. Except that that wasn’t all he had to say for himself. While waiting for his mum, every couple of minutes he would call out to one of the nurses.
’Oi! Beautiful! I am quality – do you want to come home with me?’
He was harmless but irritating after a while.
The next case was a 14-year-old girl. The ambulance called ahead to say they were blue lighting her in as she was completely unconscious. The nurse and junior doctor tried to wake her up and couldn’t. I got a call on the intercom.
I walked in and initially failed as well. If she was truly unconscious then we might have to intubate her (i.e. put her to sleep and take over her breathing) so that she wouldn’t choke to death on her own vomit, which I was currently sucking out of her mouth (with a suction tube). Then I tried a ‘registrar’s trapezius squeeze’. (Basically, you squeeze as hard as possible on the bit of muscle between the neck and shoulder, then carry on squeezing until they wake up.) She did wake up – very quickly. I checked that she hadn’t hit her head or taken any drugs, asked the senior nurse to put in an intravenous cannula, watch for more vomiting, and give her some fluids.
Giving fluids to someone who is drunk is a little controversial. We spend tax-payers’ money helping them to sober up and not get as bad a hangover which may positively reinforce their A&E-seeking behaviour after drinking. This can’t be good, but I am still a believer in giving them lots of fluids when people are drunk because it helps to get rid of them more quickly. It helps them sober up, and also they soon wake up needing to go to the toilet. Sometimes it backfires and they end up losing full control of their now full bladder – but the risk is worth taking as it is so effective in aiding appropriate discharges.
I explained to the girl’s mum what was happening and why we were giving her daughter fluids. We put the girl on her side and left her where we could watch her closely. We also gave her little sister, who had to enjoy her New Year’s Eve watching her big sister vomit, a chair and a blanket to cuddle into.
After 3 hours and 59 minutes the girl was sober enough to go home with her mum, who was furious with her daughter. As I came to see her, her mum was in the middle of telling her off.
‘This is the second time you have done this now. You have ruined your New Year and everyone’s else’s, you selfish girl,’ I heard her say. I introduced myself to the young girl and checked she was OK. I then said she was free to go but before that I wanted give her some useful patient education.
‘You could have died you know – you are only 14. Don’t be so dangerous in future.’
She looked at the floor.
‘Do you want me to tell her off?’ I asked her mum.
‘Please do,’ she said.
‘I have seen loads of people ruin their lives by binge drinking. You have been so stupid. We had to suck out the vomit from your mouth. Do you realise that? Do you? You could have had the vomit go into your lungs and then you wouldn’t have been able to breathe properly. You could have died, and in that state anybody could have done anything to you and you wouldn’t have known. Don’t be so stupid again and drink with some self respect.’
Her mother seemed suitably pleased with me. But I hadn’t yet finished.
‘You have also stopped me seeing really sick people who needed my help. The elderly lady in cubicle 5 had to wait an extra 30 minutes for me to give her pain killers for her broken leg because of your selfish stupidity.’
Her mum seemed very pleased with my chastising abilities, but then said, through gritted teeth, ‘You wait till you get home and then you’ll get a proper telling off.’ I felt sorry for the girl: I obviously had not been stern enough!
There are probably some trust guidelines saying that my attitude to this patient was probably not appropriate – I didn’t treat her in a holistic way and I didn’t communicate in a way appropriate to understanding her cultural needs (i.e. she was an Anglo-Saxon who culturally needed to binge drink). A lot of doctors, who are worried about having to be politically correct, may not have acted in that way for fear of being complained about. But I think that we should be complained about if we don’t try and educate patients on harm prevention. We need them to know the danger of their behaviour and it has been shown that short blasts from A&E doctors can make a difference. It is also quite enjoyable for us, but that is not the point. If I really wanted to go into a job so I could tell off teenagers, I would have gone into teaching. But then all my teacher friends say that if they really wanted to go into a job where they could tell off teenagers, then they would have been A&E doctors. Anyway my fears that I had gone a bit over the top subsided when in the morning, her mum brought round a thank you letter and a box of chocolates. I have never been thanked so kindly for being so forthright to someone’s offspring before.
The effects of drinking continued. Luckily, as it got later in the evening, the patients generally got a little older. Unfortunately, they also got a little more abusive as their waits to see me increased. There was a lot of drinking going on – mostly on empty stomachs but largely on empty heads as well – a particularly dangerous combination. The only difference from New Year’s Eve in the days before liberal drinking laws is that now cases of alcohol intoxication continue from 8 p.m. to 6 a.m.
The thing to remember is that these patients do need proper medical care – in fact they often need even better attention than sober patients as it is easy to miss injuries when someone is drunk. More seriously, it is easy to misdiagnose an unconscious patient as someone being drunk, when in fact they have had a serious head injury. I left work absolutely exhausted, but with a thought. If only we could videotape these patients and then show them what fools they made of themselves …
Why bother coming?
It’s a Sunday. The weather is beautiful. There are hills to walk up, football matches to watch, women/men to chat up, beer to drink and the seaside is only an hour’s drive away. You are young and healthy, with money in your back pocket – the world is your oyster. Lastminute.com is offering you 12 hours in New York for £3, the cinema has a new movie on; you have a new horny girlfriend who has lost her rabbit. You could do anything. So why on earth do you sit in A&E for 5 hours (sorry, Mrs Hewitt, 3 hours and 59 minutes on the computer), for me to see you and say there is nothing wrong with you? Look, go to your GP if you are worried about non-urgent things and next time you come, read the sign outside – ACCIDENT AND EMERGENCY DEPARTMENT.
Some examples from the last few days:
1. 8-year-old kid at school. Fell over and grazed his knee. Played football for 30 minutes after injury before the bleeding became too noticeable. His school was not happy to take the responsibility to wash the graze and give him a paracetamol. So the poor kid waited 4 hours and 30 minutes (whoops … 3 hours and 59 minutes to you, Mrs Secretary of State for Health) to see a nurse to have it cleaned and bandaged. If the kid had just had a teacher who was legally allowed to show common sense, he could have been at school having fun and perhaps learning something, as opposed to sitting in the waiting room all day.
2. 50-year-old man: ‘Doctor, I went to bed and woke up and felt scared and so called an ambulance.’ He was having a nightmare. Now, I am not annoyed with him, just the lack of mental health support in the community, which can look after patients with his type of condition.
3. Man with chronic hip pain – no worse – had it for two years. The GP he likes is on holiday, so came to us instead. Needs a new hip, but doesn’t need to come to A&E. Poor bloke, not annoyed with him, but more at the system for allowing waiting lists of eight months for hip operations. (N.B. Clever statistics would show that he has only been waiting four months for the hip, but he waited four months to see the orthopaedic surgeon to tell him that he needs an operation. In the real world that is an eight-month wait. In NHS world, it is four months. However, that is still much better than in the days of the Tories ruining the NHS. Now at least the waiting lists are coming down quickly – even if they have done it in a very expensive and divisive way.)
4. 28-year-old man – pain in his foot for three days after playing football. No obvious injury and has been able to run on it but as it was still sore this morning, he called an ambulance. Not taken any analgesia. Well, if he had, it might not hurt so much. He demanded an X-ray; I asked why he had called an ambulance. He said he paid his ‘f**king taxes to get X-rays when he wanted one’, but didn’t answer my ambulance question. I reminded him that he paid his taxes so that I could decide if I would X-ray him. He went on about patient choice to call an ambulance and choice of getting an X-ray. I had to listen to his twaddle and be polite. It was hard. I wish there was a campaign for doctor choice as well as patient choice. I would have chosen to tell him where to go. Instead, I was polite and moaned about him when I got home from work.
There are loads more. People will not take responsibility for themselves or others. Some are just selfish, others just have mental health issues and the community services are not in place. Some just don’t go to their GP for one reason or another. In the end, there is no inappropriate A&E attendee, just someone who doesn’t know what the alternatives are (and when they should be used), or who lives in an area where the alternatives are not properly resourced.
I am so glad I am tired
Last night I went to bed at 10 p.m. My wife was not well at all, high temperature, coughing and sneezing and lethargy – Man ’flu, I diagnosed, and so I agreed to look after our non-sleeping child all night. I was nervous and the anticipation of being awakened stopped me falling asleep. I resorted to desperate measures – I started reading the British Medical Journal: 30 seconds later, I was out like a light.
Two hours later the crying started. Back to sleep, and then up again at 2 a.m., then 4 a.m. and then 5.30 a.m. I wish I could invent a cure for colic and teething – something more ethical than ear plugs. But alas no … So, off to work at 7.30 a.m. and I was exhausted. I believe that the bastard who invented the term ‘sleeps like a baby’ never met anyone under five.
I arrived as the red phone went off. Information from the ambulance crew – paediatric arrest. Patient, six months, mottled and blue on arrival. The senior nurse called the paediatric resuscitation team down, but we all knew the probable outcome: this was a cot death and we were going to be going through the motions just in case and also to help the long-term grieving process.
The child came in with mother screaming. The thing I noticed was that he had the cutest little blue socks on which were the same colour as his skin. Our initial expectations were correct. We had all agreed our jobs, with the paediatric registrar being in charge of us all. My job was to get an interosseous line in (this is where a needle is quickly inserted into baby’s leg bone as a very quick way to give fluid and drugs – you do this when they are so ill they have no visible blood vessels). I got on with my job, but felt sick. I wasn’t in charge and could just concentrate on my job. Somehow I felt very detached from the whole situation. All the voices seemed distant. The mum’s cry was audible, as was the counting of the cardiac compressions, but it all felt surreal. I can’t explain why I felt like this but I did. I pushed the needle a little harder and felt the pop of the needle going through the baby’s bone. It was a huge sense of relief that I had done the part I was supposed to do. I attached the needle to fluids and gave drugs that others had drawn up.
The drugs were not helping – nothing was. We were keeping his blood pumping with the compressions and the anaesthetist was breathing for him – but he was dead and had been for a long time. We all knew it but nobody wanted to give up. Nobody wanted to stay ‘Stop’ in front of mum.