As ACEM surveys members about emergency department time-based targets, FACEM Dr Peter Roberts shares his thoughts and provides a human perspective to the discussion.
I got an email the other day from one of my hospital’s managers after a busy shift.
“With this week’s 4 hour performance this month is in danger of being worse than last year’s. Can I ask you all please to focus for the rest of the week?”
My hospital is ugly, small, middle class and bypassed. It is a suburban museum piece. Hunchbacked men in overcoats with kerosene lanterns show visitors around. Yet still, that day, I felt I played it like a Stradivarius.
The three year old with high fever, two vomits, and corrected tetralogy and nothing to go on did well. The cheerful COPD that the intern wanted to discharge, with FVC less than a litre, got by. Calm was restored as a 13 year old head injury eventually stopped asking the same question. And the 94 year old who “wasn’t quite herself” had gone into AF.
I had prepared for the shift, twelve years at school, five at university, 10 more till the Fellowship, then years of experience, city and remote work, cool Continuing Professional Development, and reflection bordering on rumination.
But what can prepare you for the tragedy of ED arithmetic?
Some times are busier than others, so mostly the department is not at its busiest. But busy times are caused by lots of patients presenting, so most patients see the department when it is busy. Staff visit at routine and random times, so mostly they don’t see it at its busiest.
All the ED director can do is try to match staffing with predictable peaks in presentations. But complex cases, bus crashes and bad weather still happen.
The ED doctors work faster and faster. They instinctively know that more patients are coming; that if they are to do a decent job, they can’t have too many patients in front of them. Time spent on one patient rationed by the next.
Alas, the ward teams know that each patient needs as much time as required. Don’t take another until you are ready. Less than a couple of hours on a patient is negligent.
Those in the waiting room know that secretly, this is a general practice. Fifteen minutes each. So if only two are waiting, how could it be longer than 30 minutes? Less if there is more than one doctor.
But at our place we take about one hour of doctor time per patient. In USA, with scribes and IV techs, they can reduce it to nearly 20 minutes.
In our place, there’s 100 hours of doctor time per day. And 100 patients. One hour of doctor time per patient.
Our doctors each have an average of four patients at any time. This gets worse, not better, if they stay longer. Longer stays lead to more divided attention on each patient, not more focus. That’s a little counter intuitive.
Is it good medicine or bad, for each patient to spend more time? Longer patient stays lead to more patients in front of each doctor, crowding, worse outcomes. Worse time to antibiotics, thrombolysis, definitive treatment. Longer patient stays lead through crowding to worse mortality.
But that doesn’t gel with convention. The good doctor has as much time as it takes. The case review looks at the case, not the ones that were also in the room.
The intensivist wonders why you don’t devote more time to the sickest patients; there are only a few each day. The paediatrician and the geriatrician are concerned that you neglect the vulnerable. And the psychiatrist has a lot to say.
So the boss is right to worry about 4 hour performance. Just a pity he didn’t email someone who could do something about it…the medical registrar who took two hours to come, radiology where a CXR took two hours, pathology where the machine broke down, or the bed cleaners or wardsmen who held us up.
Hmmm. It is so counter-intuitive. The less time you keep each patient, the better the outcomes.
Author: Dr Roberts the Director of Emergency Medicine at Ryde Hospital in Sydney.
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ACEM survey
ACEM is seeking members’ views on time-based targets for Australian and New Zealand emergency departments in order to inform policy and strategy around improving emergency department performance.