On increased risk in A&E minors:
🩼🤕
In my NHSE role I meet with operations teams regularly. A consistent comment relates to increased risk observed in the A&E minors area.
🩼😵
Why this observation?
To understand this, we need to first understand A&E scope and workflow.
The primary scope of Emergency Medicine (EM) requires the type of clinical work space found in A&E majors & resus (M&R) areas.
🩺😷
It is EM's equivalent of specialty clinic, theatre or cath lab, and without it EM is less effective.
(Minor injury/ illness is secondary scope)
When patients attend A&E, the process of triage assigns them priority.
This process also determines who is better suited to be cared for in M&R.
Triage takes place for ambulance and walk-in attendance.
🩼🚑
Patients who require M&R, is reliant on there being space in M&R. But presently EM competes with other specialties for M&R space.
🩼🚑 vs 🏥
This has the same effect as specialties competing for say specialty clinic, theatre or cath lab space:
🤚Some who require that specialised space will not be able to access it in a timely way.
👉 This increases risk.
Patients with high risk attendance (heart attack or stroke) attend mainly by ambulance, but also by the walk-in route. They always have, this is not new.
Low capacity in M&R space means risk is pooled in the area the patient attends to: ambulance or the waiting room.
🩼🚑
As an emergency physician, the balance between assigning risk to M&R from either the ambulance or waiting room queue is conflicting.
🩺🤔
There are tremendous pressure to offload ambulances. Too often some end up in the waiting room.
🚑...👉🩼
The result is more risk pooled in the part of A&E with the lowest staffing, beds & monitoring per patient.
😷 vs 🩼🩼🩼🩼🩼🚑😵
Understanding M&R capacity is crucial to A&E workflow. This requires knowledge of M&R occupancy & flow *by specialty*, to attribute accountability.
The simplest way to do this is measure EM & specialty caseload separately:
👉Use referral time/ CRtP as end point for EM, & starting point for specialties in realtime metrics.
👉Measure mean time to disposition.
👉(& if you can) Measure time to first specialty clinician.
📝
Summary:
🩼Increased risk in minors exists mainly due to non-EM M&R crowding.
🩼Individualise delay in M&R in realtime, by specialty, to improve transparency.
❗Sites with weak internal professional values are likely to struggle operationalising the latter❗
Royal College of Emergency Medicine
Getting It Right First Time (GIRFT)
Emergency Care Improvement Support Team
