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 Abstract
Four
Hour Accident and Emergency Wait: Can it
be achieved in the UK?
Introduction
The NHS plan sets out an ambitious programme
that by 2004 no one is to wait more than 4
hours in an Accident and Emergency
(A&E) department. At present at
least 25% of patients still wait more than
4 hours within the department. The Way
Forward document by the British
Association of A&E Medicine suggested
that a Senior House Officer (SHO) should
see about 5000 patients per year.
Objective
To assess a real world working model of an
A&E department and correlate the
number of patients assessed with the
number of doctors working in the year
2002/2003.
Method
This study was carried out at City Hospital,
Birmingham where 87,000 new patients were
seen during the year 2002-2003. The
A&E department was manned by 3
Consultants, 4 Specialist Registrars, 2
Staff Grades and 12 SHO's. The
number of patients assessed by each
individual doctor was recorded on a
monthly basis and this data was analysed.
Results
On average 240 patients were seen per day in the
department with no more than 6 SHO's
working in 24 hours. On average a
SHO assessed no more than 1.46 patients
per hour ranging from 0.7 patients/hour to
2.4 patients/hour. The total numbers
of patients seen by the SHO's in a day
were on average 87 patients. The
remaining 153 patients were seen by the 3
middle grades and the consultants.
No more than 85% of patients were seen
within 4 hours in any given period.
TABLE
1
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This table outlines the number of
patients seen in A&E at City
Hospital between the months of
August 2002 and January 2003.
The number of patients seen by each
SHO is shown and an average number
of patients seen by SHO's is shown
at the bottom.
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Conclusions
This study shows that SHO's, who make up maximal
doctor numbers, are expected to see the
majority of patients attending an A&E
department. However in reality they
each take care of no more than 2500
patients per year. The data clearly
shows that the majority of patients are
dealt with by the middle grade
doctors. This study shows that the 4
hour waiting time laid out by the NHS is
an achievable target but will require most
A&E departments to increase the number
of middle grade doctors and increasingly
efficient junior doctors.
Four
Hour Accident and Emergency Wait- Can it
be achieved in the UK?
Introduction
The National Health Service (NHS) is second to
none in responding to major
emergencies. The response to recent
rail crashes was something in which the
NHS can take pride in.(1) At present
80% of all Accident and Emergency
(A&E) attendees spend four hours or
less in A&E waiting rooms.
Trolley waits over 12 hours have been
reduced by 80% since 1999. 87% of
patients needing a bed from A&E get it
within 4 hours but some patients still
wait for too long.
The development of new walk-in centres along
with NHS Direct, Minor Injuries Units and
Primary Care Emergency Centres may improve
the situation. Although these
services are liable to cause confusion and
duplication of services.(2) It has
been recognised that with many similar
services it is going to be difficult to
get the right person to the right source
at the right time.(3)
The Audit Commissions Accident and Emergency
Report (October 2001) identified that the
number of patients attending A&E
continues to grow at a modest rate of 1%
per annum since the mid-1990's.(4)
The NHS plan sets out an ambitious programme of
investment and improvement of emergency
care in the UK. It is envisaged that by
March 2004 all patients to see a GP will
do so within 48 hours and no-one will wait
in A&E for more than 4 hours. The
Department of Health has spent £150m in
upgrading A&E Departments nationwide.
The concept of a 4 hour wait in A&E is based
on the 'Way Ahead Document' by the British
Association of A&E Medicine which
suggests that a Senior House Officer is
capable of seeing 5000 patients/year.(5 )
Objective
This paper is an attempt to recognise problems
in achieving various targets set out by
the NHS plan and suggest various
methodologies which aim to achieve the
targets set out above. This paper
takes into account that present investment
in A&E will continue in the future.
Methods
A detailed study of available literature was
carried out. After visiting many
large and small A&E Departments in the
UK, USA, Australia and Saudi Arabia, it
was noticed that some departments in the
world operated extremely efficiently,
keeping waiting times for patients
minimal. A study was also conducted
at City Hospital, Birmingham to see the
working practice of Senior House Officers
at City Hospital.
The number of patients assessed by each
individual doctor was recorded on a
monthly basis and this data was analysed.
The data was accumulated using IT systems
already in place at City Hospital,
Birmingham.
87000 new patients were seen during the year
2002-2003 at City Hospital. During
this period the A&E department was
manned by 3 Consultants, 4 Specialist
Registrars (SPRs), 2 Staff Grades and 12
SHOs.
On average 240 patients were seen per day in the
A&E Department with no more than 6
SHOs working in 24 hours. On average
a SHO assessed no more than 1.46 patients
per hour.
The average number of patients assessed by each
SHO ranged between 0.7 - 2.4 patients per
hour depending upon the seniority of the
SHO. It was also noticed that the
number of patients seen by SHOs increased
as they gained more experience in the
A&E Department.
At City Hospital, on average, only 87 patients
per day were seen by SHO's and 153 were
seen by SPR's, Staff Grades and
Consultants. No more than 86% were seen
within 4 hours. None of the SHO's saw more
than 2500 patients per year.
Discussion
Considering the literature available and looking
at various A&E departments, the
authors recognized many factors
responsible for lengthy A&E
waits. Two main factors were
identified in the study which are key to
the efficiency of patient flow, assuming
the availability of beds for transfer of
patients out of A&E:
I/
Streaming of Patients
Most A&E Departments in the UK at the moment
are structured around a single stream of
patients.
Data from the University of Warwick has shown
that introducing streaming for major
injuries can reduce the time of waiting
for more than one hour by 30%.(6) This
study recommends the following streaming
of patients (figure 1):
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This
figure dramatically depicts the
optimal working of an A&E
department in the UK
Figure 1
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1- Chest Pain Unit
A separate unit manned by a cardiac nurse
practitioner and one junior doctor
supported by a SPR in A&E. Each
patient with chest pain will be referred
to this unit where an ECG will be done
within 5 minutes of arrival. If
diagnosis of ST elevation Myocardial
Infarction is made, then thrombolysis will
be given within 20 minutes otherwise
patients will be investigated for other
causes of chest pain.
2-Children's Unit
Every A&E should have a separate child unit
manned by an A&E Consultant and a SHO.
It has been shown repeatedly that children
require different treatment to adults and
they cannot be expected to wait in an
adult waiting area.
3- Main A&E Department
This will have two separate triage rooms. One
will be manned by an A&E Consultant or
SPR. All GP referrals will be
triaged here, with some being treated and
discharged immediately.
The second triage room will be manned by a nurse practitioner who will be
able to treat some category 5 patients.
The remaining patients will be streamlined
according to their triage category and
will be sent to various areas of the
department depending on their triage
category:
-
Triage Category 1 (red)
These patients will be taken directly
to the resuscitation area where an
A&E Consultant, SPR and a SHO will
initiate immediate assessment and
resuscitation. These patients
will be stabilised and moved from the
resuscitation area to the care of
definitive Consultants as soon as
possible.
All G.P. referrals will go directly to
Paediatrics area, Medical Assessment Unit,
or Surgical Assessment and will be
assessed and managed by the specialities.
II/ Medical Staffing
The results from City Hospital showed that the
majority of patients are seen by middle
grade and senior doctors in the A&E
department. An improvement in
medical staffing is needed to decrease
waiting times in A&E. Based on the
findings, an A&E department seeing
80,000 to 100,000 patients per year will
require at least 9-10 Consultants, 10-12
SPRs and staff grades and 6-8 SHO's.
Preference for SHO's in the department
should be that of training rather than
service commitments.
Conclusions
This study shows that SHO's, who make up maximal doctor numbers, are
expected to see the majority of patients
attending an A&E department.
However in reality they each take care of
no more than 2500 patients per year. The
data clearly shows that the majority of
patients are dealt with by the middle
grade doctors. This study shows that
the 4 hour waiting time laid out by the
NHS is an achievable target but will
require most A&E departments to
increase the number of middle grade
doctors and increasingly efficient junior
doctors. Nurse practitioners will
also play a key role in reducing waiting
times in A&E.(7)
We, the authors of this paper, believe that the investment in A&E by
the NHS has provided us with an
opportunity for change. This
opportunity can be used to decrease
waiting time for patients in A&E and
providing patients with a more efficient
and focused consultation.
A recent article published in a local newspaper in Birmingham entitled
"Consultant Argues More A&E
Specialists Needed," highlights the
need in the UK for increased numbers of
doctors to decrease waiting times.(8)
References
Other
Topics:
Original Study #
2 - Patterns
of Adult Chest Injuries and Suggestions For
Prevention at
King Hussein Medical Center in
Jordan
Original Study # 3
- Management of Non-Penetrating
Traumatic Hyphema in Ophthalmology
Department of HMC Review of 83 cases
Original Study # 4
- Visual Impairment and Motor Vehicle
Accidents
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