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We read with interest the article and accompanying editorial by Lecky et al in the Emergency Medicine Journal.1 Of note, between 1989 and 1994 there was an increase in the proportion of trauma patients (ISS>15) in whom a consultant was involved in their care: at the same time, trauma related mortality fell. Since then, both the level of documented consultant involvement and the mortality have plateaued. Documented middle grade involvement is unchanged from 1989.
This lack of improvement in the involvement of consultants and middle grades is of concern, and there is great pressure from many sides to increase senior cover on the shop floor. This includes BAEM’s 1995 recommendations for increasing the levels of senior staff in A&E departments.2 Many of these recommendations were repeated in the Workforce Planning Document from BAEM and FAEM3: one of the main recommendations of this paper is that shop floor consultant cover should be available 12 hours a day, 7 days a week. This is to achieve the objective of allowing all patients to have an experienced clinician (specialist registrar, non-consultant career grade, consultant) either care for them directly, or supervise their care closely. In addition, the recently published NHS Plan made plain the government’s intention to have more consultants involved in patient care.4
To investigate the current level of availability and involvement of senior and middle grade doctors in patient care in A&E departments, we undertook a survey of the 12 A&E departments in the South West deanery. These departments see between 24 500 and 85 000 new patients each year, and are staffed by between one and five consultants. We looked at the level of medical staff actually available to see new patients throughout two days in April 2001, and obtained information on all patients presenting on those two days, including triage category and level of seniority of doctor involved in their care.
Nine departments responded. No department provided 12 hour consultant cover. Most had at least 12 hour cover from a middle grade doctor, and three departments provided 24 hour middle grade cover. Consultant cover was poor: at the maximum, only five departments had a consultant on the shop floor at 1200 on Wednesday—other times had lower levels of cover. The level of middle grade and senior cover in these departments was worse at night and at the weekend.
The proportions of patients in each triage category seen by more experienced doctors or with more experienced doctors involved in their care is shown in table 1.
As expected, there is a trend towards senior and middle grade involvement in the more seriously ill patients (although our sample is too small too prove a statistical relation). Sixty five per cent of triage category 1 patients had senior or middle grade involvement, compared with 32% of category 4 and 5. Serious problems occasionally occur in patients triaged to category 4 or 5: in our sample, one patient died and one was admitted to a high dependency unit despite being triaged priority 4.
After comments from some hospitals that not all the senior involvement might have been documented, we undertook a one day audit of our own department, looking at whether the involvement of more senior medical staff is actually recorded in patient’s notes. On the day studied, 218 patients were seen, of which 61 (28%) were seen initially by a senior or middle grade doctor. Of the 157 seen initially by a SHO, 39 had a senior or middle grade involved in their care at some stage (either seeing the patient, or giving advice on their care). Thus 100 patients (46%) had senior or middle grade involvement. Unfortunately, of the 39 patients for whom SHOs asked advice, this involvement of the more experienced doctor was only recorded in seven (18%).
While we acknowledge that our study was too small to draw statistical conclusions from, there is recorded experienced staff involved in the care of 36% of patients. In many ways this is better than the impression given in many documents that A&E is still a service provided primarily by SHOs,5,6 but it is concerning that the proportion of patients seen solely by a SHO (54%) seems to be little improved despite increasing numbers of consultants and middle grade staff, since the Platt report in 1967, which found that 66% of patients were seen by a SHO only.7
We have approached BAEM to raise the possibility of this study being expanded across the country. In the meantime, even if senior and middle grade doctors involved in the care of patients, this involvement may not be getting recorded
I read the response from Wallis and Guly with interest. From the study they describe it is clearly possible that the level of senior doctor involvement is underestimated on the TARN database because of a failure of notekeeping. However, there is no reason to suspect that failing to record senior doctor involvement would be more prevalent in 2000 than in 1989 therefore there should be no systematic bias in our trends analysis.
More importantly, the failure to record senior doctor involvement may be one reason why there is no significant outcome difference in the patients “seen” by different grades of doctor (according to their notes)—figure 5 of our article.1
It is probably advisable for all senior doctors to record any involvement they have had with patients—even just the giving of advice—in the notes. As well as satisfying clinical goverenance requirements this will improve our ability to examine future trends in trauma care.
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