Improving care in accident and emergency departments
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7303.39 (Published 07 July 2001) Cite this as: BMJ 2001;323:39
- Lee A Wallis, specialist registrar,
- Henry R Guly, consultant
- Correspondence to: L A Wallis
- Accepted 23 April 2001
Many articles have highlighted deficiencies in the care delivered by accident and emergency departments in the United Kingdom. We examined the provision of services in these UK departments, on the basis of a systematic review of the literature and an analysis of papers critical of the services.
Summary points
Many articles have criticised the standard of care delivered by accident and emergency departments
Most care in accident and emergency departments is delivered by senior house officers
To improve the standard of care, more middle and senior grade doctors are needed
Senior house officers should be allowed to spend an introductory period shadowing more experienced doctors
Methods
We hand searched the Journal of Accident and Emergency Medicine (now the Emergency Medicine Journal) for research or audit articles critical of accident and emergency care published from January 1996 to December 2000. For the same period we also conducted a literature search using Medline and Embase (with the WebSpirs interface) and the Cochrane Controlled Trials Register (under the search term “accident and emergency”). Articles were included if they primarily criticised management of accident and emergency departments or if they highlighted some deficiency in care or suggested that a specific area might be improved on.
Emergency medicine in other countries is organised differently from that in the United Kingdom, so we excluded papers describing emergency care outside the United Kingdom. We also excluded case reports and nursing journals (as we tried to focus on problems with medical care). From here on, we use the term “emergency” to denote “accident and emergency.”
Results
We found 56 relevant articles (see references w1-w56 on the BMJ's website). Some problems were identified by more than one paper; problems were found in 35 different areas (table). Some of the identified problems were specific (for example, giving advice to women on oral contraception when prescribing oral antibioticsw1) and some were general (for example, interpretation of radiographsw38 w39).
The authors of these articles were predominantly emergency doctors, but 14 of the articles were written by doctors from other specialties without input from emergency doctors.
Doctors bore the criticism in about half of the studies (see table A on the website). Other criticisms were directed at various aspects of service provision, such as telephone advice.w52
Over half of the studies were reviews of clinical practice (prospective design 16, retrospective design 14). Nineteen were questionnaires or “quizzes” (for example, about interpreting x ray films). There was a good mix of other study types. Only six of the 56 studies introduced a recommended change and then reassessed.
Nineteen studies criticised the level of knowledge of medical staff; 17 criticised various aspects of staff skills or abilities; 2 criticised communication within emergency departments; and 18 criticised various other aspects of care. Almost all the studies made some recommendations for improvement. The most common recommendation was for more education of junior medical staff (25 studies). Six studies suggested new guidelines and seven suggested using printed forms. Other suggestions included the use of protocols in the management of some common emergencies.w7 w9 w14 w24 w31 w45 w46 Some studies made more than one recommendation.
In six articles the performance of emergency doctors was compared with other doctors. In only one article was the performance worse,w29 and in one the emergency doctors fared better than doctors from other specialties.w11
Criticisms of accident and emergency departments found in 56 articles
Discussion
Attendances of new patients in accident and emergency departments continue to increase by about 2% a year, with the biggest increases seen in the numbers of medical and surgical emergency admissions.1 This has placed an increasing demand on both doctors and nurses, especially as more of the investigations and emergency care occur within the department.
Our study shows that many patients attending emergency departments could be managed better. Concern was also expressed about doctors in other disciplines, including their abilities in cardiopulmonary resuscitation,2-6 communication with patients,7-9 and diagnosis of subarachnoid haemorrhage.10-12
Quality of studies
Nineteen studies were based on a quiz or questionnaire (face to face, postal, or telephone), but answers in these contexts do not always reflect how people work in practice. A recent paper highlighted problems with questionnaire studies, such as poor methodology and lack of reproducibility.13 The studies in the form of video tests or simulation tests—for example, quizzing a doctor about an x ray film without the patient being present—are also artificial. In real life, a patient's symptoms and signs will help in making a correct diagnosis, and there is usually the option of asking advice. In real life there are also prompts (nurses, handbooks, etc) to ensure that doctors do not forget some aspect of management. In only one study were suggested guidelines introduced and audited.w13
Staffing
Emergency departments provide a service across all specialties and for all ages. They also see patients with primary care problems.w41-w44 Despite growing numbers of consultants and middle grade doctors, most patients are still seen by senior house officers, often in their first post-registration job. It is therefore unsurprising to find that the care in emergency departments needs improving. Staff should be educated to improve their abilities, but little evidence exists that specialists perform any better. Most of the studies compared management of patients in emergency departments with an “ideal” proposed by specialists, but there is no evidence that the specialists practise to that level. Among the six studies comparing emergency doctors with specialists, the specialists performed better in only one. Furthermore, no evidence exists that the specialists would manage these conditions better than an emergency doctor if they were working in an emergency department.
How to improve care in emergency departments
Most of the papers made recommendations on improving care, but many were inadequately thought out, and they could not all be implemented without changing the way in which emergency departments work. To fulfil all of the recommendations in the articles, the following would be needed: extra teaching sessions for emergency doctors (some at senior house officer level only); new guidelines or protocols for the management of certain clinical conditions; and new forms. Other recommendations would also affect the way the service is provided—for example, daily review of radiographs by a senior radiologist; use of general practitioners in the department to see patients with primary care problems; and increased clinical supervision of senior house officers.
Improvements for patients with one disease should not be made at the expense of another group of patients, who may be given less priority. It is not wrong to investigate management of individual diseases or injuries, but emergency departments should also be judged for their overall management of all patients. Seven forms and other types of documentation were recommended in the papers studied. Further forms could be used to improve the management of other conditions for which treatment has not yet been audited. To have too many forms, however, causes difficulties: computerised protocols may help.
The cost of many of the recommendations has not been considered. Nobody would disagree that doctors should communicate better, write better notes, and spend more time with specific groups of patients. A medium sized emergency department, however, with 66 000 patients a year, sees about 180 patients a day. One additional minute per patient will require an additional three hours of doctors' time a day. If, on a busy day, that department with four doctors on duty sees 150 patients (with the department never being empty), one additional minute will add 37.5 minutes to the waiting time by the end of that day.
Education
We identified 25 areas where better education of emergency doctors has been recommended. If each topic required an average of one hour's education this would require 25 hours of educational time in addition to existing teaching. In most emergency departments a senior house officer will have 75 to 100 hours of formal teaching over a six month appointment, with many teaching sessions occurring on days off or during the daytime after a night shift. Even if all the teaching recommended could be crammed into a six month period, teaching that occurs later in the six months might not improve care during that doctor's appointment.
Studies critical of emergency care most commonly recommended more education for junior medical staff
Audit and senior staffing
Audit is not an especially useful tool for changing the behaviour of senior house officers in emergency departments as it is rarely possible to audit a topic, introduce changes, and then reaudit the same topic within a six month period. A recent paper from the United States described improvements over four years in the interpretation of x ray films by emergency doctors.14 The staffing of the department is not stated, but we assume that it was by trained board certified emergency physicians. We doubt if such an improvement would have been possible in a department in which most patients were seen by, and had their x ray films interpreted by, senior house officers.
The UK government believes that there must be a “guarantee of excellence for all patients.”15 Most doctors would agree with this aim, but the cost must be acknowledged. An excellent service is not achievable when an emergency department is staffed mainly by senior house officers.
It has long been accepted that senior house officers need supervision from more senior staff. The National Audit Office recommended rotas for consultants to minimise the times that inexperienced doctors are without access to advice from an experienced emergency doctor in the department.16 The Audit Commission recommended that there should be a senior or middle grade doctor in all departments for at least 15 hours a day, 7 days a week, and a middle grade doctor in the hospital for the remaining time.1 We did a telephone survey of 25 major emergency departments in the South and West health region to ascertain the current level of cover by senior and middle grade doctors. Nine departments provided middle grade cover in the hospital 24 hours a day; 12 departments provided senior or middle grade cover from 0830 to 12 midnight or 0100; and four departments provided less cover than this. Most departments were planning to increase the level of cover in the near future.
Twenty four hour cover by senior or middle grade doctors is essential but unlikely to be sufficient to improve standards adequately. Middle grade and senior doctors tend to concentrate on treating the most severely ill and injured people and try to be available to give advice to the senior house officer. Most errors probably relate to minor problems, which may be dealt with by senior house officers, who may not know when advice is needed. The staffing structure of emergency departments needs more radical changes.
Emergency departments are recognised as an ideal setting for training senior house officers for work in many specialties, but the middle grade and senior staffing should be substantially increased to allow more experienced doctors to participate in the care of most or all patients. Senior emergency doctors, for example, are considerably better at interpreting x ray films than senior house officers,w38 and patients with major trauma have a better outcome if treated by a consultant.17 Other advantages of 24 hour senior cover are described by Cooke et al,18 although there are also substantial disadvantages, both professionally and socially.
Furthermore, substantially increasing the numbers of middle grade and senior doctors would allow senior house officers to have a dedicated teaching period (say, three or six weeks), plus time shadowing a more experienced doctor, before starting clinical work; such a scheme currently works well in anaesthetics. For their own development, all senior house officers should be allowed to make clinical decisions, but they should have to pass a formal test before taking clinical responsibility. The emergency service would be provided largely by doctors in middle grade or career grade posts supported by nurse practitioners, general practitioners, and senior house officers working under much closer supervision than at present.
Acknowledgments
Contributors: HRG had the original idea and provided many of the references. LAW hand searched the journals, did the literature review and the telephone survey, and wrote the original draft. Both authors contributed to the writing of the final version of the paper. LAW is the guarantor for the paper.
Footnotes
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Funding None.
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Competing interests None declared.
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The 56 articles studied are listed on the BMJ's website, together with an extra table