Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Departments of Available Medicine
- Paul A Cunningham (18 October 2002)
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Silly anecdotal letter
- John A. Chambers (21 October 2002)
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Emergency Room is an open door
- Ricardo F Savaris, 90035-003 (25 October 2002)
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Open Door in the US for Emergency care
- John Robshaw (26 October 2002)
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The A&E pyramid is inverting already.
- dr Matthew W Cooke, Karen Castille. (27 October 2002)
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A+E would be very different if the knowledge pyramid was inverted.
- Chris Chung (5 January 2003)
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Paul A Cunningham, Director Emergency Department Ryde Hospital, Sydney NSW.
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Were the young couple who used your A&E as a campsite asked to leave? Unfortunately our work in A&E requires telling a lot of people things they do not want to hear. They may be patients, they may be colleagues and they may be prospective campers. By the way, the notion that A&E overcrowding is due to inappropriate usage does not seem to be the case in Australia. Most of my colleagues agree that it is the lack of hospital beds that is the problem. Not inappropriate presentations for ambulatory care. |
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John A. Chambers, Director Emergency Department Dunedin Hospital, Dunedin, New Zealand
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I am utterly amazed that the BMJ published this anecdote about two people camping out in an Emergency Department waiting room. I fail to see what it added to any reasonable debate on the provision of emergency care. Such tales only confirm the bias of otherwise intelligent people that the problem in the busy Emergency Department - particularily in the developed world - is the patients (and other hangers on.)If only they would go away. I have lost count of the number of times professional colleagues who attend an ED as a patient or a relative comment that the "other people" in the waiting room and/or treatment area did not look very "sick" or were clearly there due to some "self inflicted" mishap. Even more surprising that your comentatators have links with psychiatry - an empathetic profession. Give us a break... anecdotal tails about Emergency Departments can have a very negative impact. The article on NHS Direct referred to in your link presents the truth in a more scientific way. Despite the best evidence based efforts attempts to reduce attendances at the ED have limited impact . Surprise surprise by far the majority of our patients make the correct decision for themselves when they decided to go to the "Emergency Room". |
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Ricardo F Savaris, Professor ObGyn ED at HCPA - Brazil, 90035-003
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I was not impressed with the case writen by Dr. Trevor Turner. In a world where priorities are set according to personal needs, rather than for the colletive, this type of attitude developed by this couple is expected. I used to work at a tertiary hospital with a very busy Emergency Department (40,000 consultations/month). I sadly realized that this war is lost. The more beds, observational rooms and high tech lab we provide, the faster it will be overloaded with patients and unnecessary exams. In countries where medicine is granted free by the government, like in Brazil, it is common the misuse of emergency departments for getting a faster exam, a quick look on my condition - things that could be easily done in a primary care. But a patient may wait 6 months to get an appointment or an exam collected. Nevertheless, since we are open 7/24 for the people, now we try to close the doors for them, in order to prevent costs or misuse of the service. Screening patients seems to be quite hard too in an era of law- suit. Without mentioning the fact that most of the patients learn how to lie to overcome the screening. Put a definition of emergency on the door does not prevent the presence of an angry patient before the doctor, after all, s/he thinks that what her/his condition is an emergency. "And doctor" they might say, "I am here already, why don´t you ask a pregnancy test for me now?" We could argue for few minutes with the patient, and loose precious time to see another patient in need, or ask the unnecessary exame to get rid of the patient and see the emergency. This is a catch 22. Therefore, by opening Emergency Departments we are creating an open door for a patient to get in, and we have to learn how to deal with it. The solution for such situation is to be answered. |
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John Robshaw, ED Director, St. James Mercy Hospital, Hornell, NY, 14843 USA
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I imagine not too many non-US based physicians are aware of the federal 'COBRA' (Combined Omnibus Budget Reconciliation Act) law in the USA with which all Emergency Rooms must comply. Any patient who comes to the ER has to be seen and offerd a medical screening exam (the MSE) by a physician. A very small proportion of hospitals use specially trained nurses. This applies to all, regardless of the presenting complaint, acuity, frequency of visits to the ER or availability of primary care clinics. Failure to provide the MSE is a serious breach of said COBRA law and usually results in civil penalties if prosecuted. These routinely are 5-figure sums. Technically the person has to ask for care but the prudent department would show extreme caution before ejecting anyone from the property. Patients who are intoxicated are especialy risky as they are considered incompetent and might expect to be given an MSE even if they refuse it. COBRA also applies to all people outside who are within 250 yards of the main building who ask for help.In the USA then the 'campers' would most likely have to be offered a medical screening exam to comply with the law. Also the placement of the 'legend' as referred to in the letter may induce people to leave the department without being seen and would therefore not be permissible under COBRA statute. |
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dr Matthew W Cooke, Senior Lecturer inEmergency Medicine Univ Warwick, Karen Castille.
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EDITOR, We are pleased to see Turner and Collinson’s suggestion [1] that it is time to invert the knowledge pyramid. Consultant triage was shown to be effective many years ago with 30% of patients needing no further care in the A&E department [2]. Since then it has been shown that creating a one-stop system for patients with minor injuries is also effective in reducing waits [3]. Further redesign of having senior staff as the first clinical contact rather than a triage and wait approach is now being used in several A&E departments and is successfully reducing waits [4,5]. For this reason, The NHS Modernisation Agency’s Emergency Services Collaborative is hosting a series of national workshops focusing on this new principle of “see and treat” and, with the support of BAEM and the RCN, will be issuing guidance on establishing such systems. Every A&E department in England has been invited to these workshops which will be taking place during November 2002. The principles of “see and treat” draw on the learning of the primary care collaborative that pioneered the concept of advanced access in England. In primary care, advanced access is concerned with seeing today’s patients today. In emergency care, this can be translated to mean seeing this minutes patients this minute. Interestingly, in primary care, no increase in activity was noted despite concerns that this might have occurred. Turner and Collinson also suggest ways of dissuading people with “non -emergency” problems from attending A&E. This resurrects the faded idea of inappropriate attendance that in the emergency care world has long since been replaced by the concept of an inappropriate NHS response; thus taking the blame away from patients and instead thinking through how can we best meet their needs. It is perhaps unfair to expect users to know and understand the intricacies of the NHS’s complex emergency care system when the average person visits A&E only once every five years, and calls an ambulance every 17 years (and for a different condition each time). A more positive approach would be to modernise and improve integration of emergency services to meet patients needs. Many A&E department staff are working hard to develop local partnership arrangements with primary care, ambulance services, dental services, walk-in centres, minor injury units, local pharmacies, NHS Direct and others to demystify service provision and improve access for the benefit of patients. The further development of local emergency care networks is also aimed at supporting these changes [6]. Matthew Cooke National Clinical Lead, Emergency Care Performance Improvement, NHS Modernisation Agency; Senior Lecturer in Emergency Medicine, University of Warwick Karen Castille, Director of Emergency Care, NHS Modernisation Agency 1. Turner S, Collinson T. When is an emergency department not an emergency department? BMJ 2002;325:901 2. Redmond AD, Buxton N.Consultant triage of minor cases in an accident and emergency department. Arch Emerg Med. 1993 Dec;10(4):328-30. 3. M W Cooke, S Wilson, and S Pearson The effect of a separate stream for minor injuries on accident and emergency department waiting times Emerg Med J 2002 19: 28-30. 4. Improvement in Emergency care: Case Studies. NHS Modernisation Agency . 2002 ( also available at http://www.modern.nhs.uk/esc/8237/Case%20Studies%20%20Low%20Res%20.pdf ) 5. Dancocks A. Improving Waiting Times EMJ online http://emj.bmjjournals.com/cgi/eletters/19/1/28#37 accessed 20th October 2002 6. Reforming Emergency care. Department of Health. London 2001. ( also available at www.doh.gov.uk/capacityplanning/reform.htm ) |
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Chris Chung, SHO ROYAL HOSPITAL FOR SICK CHILDREN, GLASGOW
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If an A+E Consultant and experienced nurse were to triage and only let genuine emergency cases into an Emergency department through, then the number of other staff i.e. nurses, SHOs needed would be less. Such a department would be indeed efficient in terms of seeing only those patients it was designed for and more focussed in it's emergency training. Most of my work in A+E involves seeing patients who can be managed well by their GP. If a consultant were to triage then SHOs would have less to do. However on the other hand, those SHOs seeking a GP orientated training would have to find their general training in the GP arena. If it were possible to increase the numbers of GP (this would be a huge undertaking in itself) in turn to manage those who are turned away from an A+E department on ground of inappropriate attendance, then the A+E part of the NHS would be far better utilised. Competing interests: None declared |
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