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Improving the care not just the figures
We are all too well aware of the problems of waits in emergency health care. They are consistently the issues that the public and media comment about when asked about emergency medicine. Delays in the emergency care system are invariably attributable to a complex mixture of problems before, during, and after the hospital episode.1 Measures of performance in emergency care have focused on a few specific areas, for example, ambulance response to arriving at an incident and waiting times in the emergency department.2 The blame for poor performance has often been cast on the area where the indicator has been measured rather than at the root cause. This has also allowed other areas to shy away from their responsibilities. These are all symptoms of an emergency care system that is fragmented,3 with each component struggling to solve its own problems.
Some issues can be partially solved by one organisation working alone but this is rare.
An ambulance service could achieve an eight minute response for all category A calls by its own action. But this would be an inefficient method of achieving such change—how much better to look at joint initiatives. Rather than blaming hospitals, working with them to reduce turnaround times and free up ambulance resources. Looking at how they can take some patients to more appropriate destinations, resulting in a better service for the patient, and a more even spread of the workload. Within the hospital, the most important factor in preventing waits in A&E is the hospital bed occupancy.4 But many colleagues will recognise that bed management is all too often a fire fighting function by comparatively junior staff not a predictive planning function with responsibility lying with an executive director. But the factors affecting bed occupancy are also outside the hospital. The ability of the community to accept patients back from the acute hospital is a key determinant of hospital length of stay, including availability of social care but also of primary medical care. It is however easy to use the whole system concept to blame others. None of us work in perfect systems and we can all make changes in our own areas to contribute to improved care. Ours may not be the biggest cause of delays in the system but, we have more influence to change our own area. This edition of EMJ highlights many projects across the whole system of emergency care and confirms the enthusiasm for change.
Emergency care networks are now being established in the UK, bringing together all organisations involved in emergency care in one locality. Their aim should be to look at issues across the whole system. In the past, such groups looked at contingencies for when the system was overloaded. This needs to change to looking at how the system can be changed to improve care at all times. By undertaking patient tracking, networks can rapidly discover where the system faults lie. Personal observation has shown how often the faults lie in organisations working independently without appropriate mutual respect and trust. I believe there should be a lay person on each network group, perhaps chairing it, so that vested interests and perverse incentives are overruled in favour of quality of care.
But performance indicators can also deceive. A patient may get their ambulance in eight minutes and be through A&E in less than four hours and still have a poor experience of emergency care. Often too much effort is focused on improving the figures not the care. At worst, this is demonstrated by the time invested in defining, interpreting, and manipulating the figures rather than investing it in patient care improvement. Examples that I have witnessed include hospitals not allowing ambulances to unload as they believe A&E time starts when the patient is unloaded from the ambulance trolley, or declaring certain areas of A&E as a ward so the patient is considered to have been admitted. Fortunately clinical staff still act as the champions of quality care and highlight these problems, but we need to ensure their voices are heard and acted upon. More commonly the effort to improve a performance indicator has focused on establishing new systems simply to improve the performance indicators results, for example moving patients direct to coronary care unit when A&E is delivering better door to needle times than the coronary care unit. The goal is not improved performance indicators, it is improved care. The best judge of care is the patient. Why do we not have patient representatives on our emergency care management groups? Why do we not use patients to monitor the performance indicators and the patient experience?
Emergency care is a complex component of health care. If I could change one thing to help emergency care, it would be to include a user and a junior member of nursing and medical staff on every committee that talks about emergency care. In my experience of visiting many emergency care communities, they know the problems and, very often, the solutions.
Improving the care not just the figures
Competing interests: the author is also A&E Advisor to the Department of Health.