The Archers of the Emergency Department. St.Emlyn’s

Archery in the ED-1It is a little known fact that to be successful as an emergency physician in the UK it is vital to take a three month rotation in Archery. Archery is a key skill for us all dating back to Medieval times when we introduced the longbow into warfare. This devastating tool could cause panic in opposing forces, scattering them into many wide and ineffective directions. In short they were an effective tool to cause and disruption inthe opposition ranks whilst the noble English armies of old strode forward with their visions of the future. Soldiers trained using targets to hone their skills and to focus on the aim – meeting the target.

Of course these days we do not have real bows and arrows in the emergency department, but archery remains alive and well. In the modern NHS we still train our troops in archery, or at least in the principle aim of archery – to meet the target.

With our long history of target setting and target hitting it is therefore no suprise that we are world leaders in standards/targets/indicators….., whichever term you prefer in fact and it has to be said that a target culture in the NHS has been criticised widely, even being blamed for the exodus of trainees to Southern climes, but there is arguably more to it than that.

In last weeks episode we touched on new targets around trauma care in the UK and that raised many questions and opened a debate on twitter. This week we want to take those thoughts further and ask what we, as the archiest of arch archers across the entire NHS can do with these externally set targets.

What we forgot to say in the podcast is the absolute need to work alongside a short stay admissions unit under the ED umbrella. Without that you would really struggle to deliver safe and efficient care. We both work in units with short stay admission units that allow us to deliver safe diagnostic and therapeutic interventions to our patients.

The bottom line is that we didn’t choose the target, we didn’t agree with the targets, but we as they are there we need to ask what we can do with it to ensure that our patients, our staff and our systems get a better deal.

So, with some trepidation Iain and I ask whether all targets are a bad thing.

vb

S

 

UPDATE: Since recording this podcast the College has published an update on emergency care. This is relevant and worth a read to all involved in setting, battling and achieving targets.

CEM update on Emergency Care July 2014

References

Mid Staffs enquiry http://www.midstaffspublicinquiry.com/

Posted by Simon Carley

Professor Simon Carley MB ChB, PGDip, DipIMC (RCS Ed), FRCS (Ed)(1998), FHEA, FAcadMed, FRCEM, MPhil, MD, PhD is Creator, Webmaster, owner and Editor in Chief of the St Emlyn’s blog and podcast. He is Professor of Emergency Medicine at Manchester Metropolitan University and a Consultant in adult and paediatric Emergency Medicine at Manchester Foundation Trust. He is co-founder of BestBets, St.Emlyns and the MSc in emergency medicine at Manchester Metropolitan University. He is an Education Associate with the General Medical Council and is an Associate Editor for the Emergency Medicine Journal. His research interests include diagnostics, MedEd, Major incidents & Evidence based Emergency Medicine. He is verified on twitter as @EMManchester

  1. Simon Rothwell July 23, 2014 at 3:00 pm

    Thanks for the podcast. Having worked in Emergency Departments for a number of years, I too remember the days before the 4 hour targets. Although they have been a very blunt tool, they have improved the experience of patients accessing emergency care. They have also created greater career opportunities for medical and nursing staff, as an increased number of skilled and experienced staff have been required to meet the increased demands created by the targets, which I think is a good thing for both staff and patients.

    As you missed the “one more thing” question at the end of the podcast, I have a question. You stated that the targets aren’t necessarily the targets you would have chosen, what target would you choose, and what impact would you want it to have on patient care?

    Reply

    1. Good question Simon.

      If I were to choose an ED target then it would be this….

      90% of patients should be seen within their predicted triage time using the Manchester Triage System

      Red patients – immediately
      Orange patients – within 10 mins
      Yellow patients – within 1 hour
      Green patients – within 4 hours
      Blue patients – redirect

      http://www.alsg.org/uk/MTS

      I think this would build clinical/patient need into a time based target. We could then justifiably argue for appropriate resource for our sickest patients and not just for the many less unwell patients who make up the majority of target chasing.

      vb

      S

      Reply

      1. Where is this Manchester you talk of?

        But seriously, is a bit easy to game that one? How would you deal with higher triage for severe pain-analgesia and re triage- do they then have two targets or does the analgesia mean the box is ticked?

      2. You can game all targets (as we both know) if you want to. If I was brave enough I’d do a podcast on the 10 ways to cheat the 4-hour target (but I won’t).

        I’m very happy for pain to be a high priority issue as it’s a really patient focused outcome.

        S

  2. Disclaimer – Self confessed Semmelweis reflex sufferer.

    Thanks Simon and Iain for a cracking podcast rammed full of insight and wisdom. I particularly appreciated the outing of Mrs Miggins as a major trauma patient although was slightly disappointed when her MOI appeared bereft of both pies and claymores.

    A few responses have been handed to me from the Devil’s Advocate…apparently just in the hope of stimulating further exploration of this very important topic:

    1 – Simon Rothwell posed the question of alternative targets and you plumped (some might say parochially..) for adherence to a triage criteria from the northwest of England………I would like to ask when did we lose sight of mortality reduction as the single greatest target for emergency physicians? Or even as the benchmark by which we judge whether the introduction of secondary clinical endpoints such as when a physician first greets you and when they say farewell should continue in usage at all? We see the lion’s share of sick folk through the front door and the sickest ones at that, we believe our early intervention is worthwhile…why are we not assessing that intervention package on its global effect on mortality first and foremost? My favourite target in UK EDs is apparently the least favourite of my colleagues. It involves a stranger with a clipboard assessing how many of us wash our hands, how many times in a shift and how well. Occasionally there are audible moans at the demeaning and patronising process of someone other than your grandma telling you to clean up your mess and yet I think this target at least is based on the fact that some Austro-hungarian fella reduced the mortality of his patients from 18% to somewhere near zero. That kind of target feels more like a doctor looking out for their patients real interests…continued living. The first 10 years of the 4 hour rule was a massive deafening silence when it came to evaluating its effect on mortality in the country where it was introduced.

    2 – You also identified the moral complexity encountered when one arbitrary secondary non-clinical endpoint (time in ED) conflicts with another such metric (time to elective theatre) with an almost unquantifiable patient cost resulting somewhere, to someone, probably. Why not focus on universal, patient-centric metrics like mortality first and foremost and work your way back from there? It’s not actually hard to identify how to kill less people. Medicine was working hard at exactly that quandary for around about 3000 years before these targets appeared and set clinicians to developing pathways and packages to satisfy needs that were at best parallel to mortality reduction but potentially at times (as you highlighted) actively obstructing safe decision-making.

    3 – You both made the disclaimer that you were speaking for your departments only…and hope that other departments were similarly able to use the targets and not be abused by them. You also mentioned the revelations of clinical disaster amidst target success in Mid Staffs. Having worked in a few EDs in the UK over the last decade, my personal feeling is one of complete heterodoxy. In some departments like your own the targets have been embraced, to the better deployment of resources for where our patients need it most. In other departments the targets have been embraced as a way of shifting work away from the ED and attention away from the need to actually treat the sick where and when they are first found to be sick. As such…are the targets then just a monumental stall in progress with no true global effect, given they have allowed good departments to remain good and struggling departments to struggle further?

    4 – You made some trumpeting noises about this approach to emergency medicine being exported elsewhere. To what extent do you think the state of emergency care in say Australia in 2014, matches the UK ED of 2004 that you describe (somewhere between a Dickens poorhouse and Lebanon c.1982)? Disclaimer – I don’t disagree with your description of work intensity pre 4 hour rule but I was in a department which went from safe to the opposite post implementation of the rule. Sending all your patients away doesn’t necessarily make them safe, it just puts them somewhere else where you can’t se them. The crowded corridors of 2003 in England and 2005 in Scotland are replicated elsewhere in the hospital in 2014.

    5 – You highlighted the development and proliferation of short stay wards next to the ED as a positive step and even as an ‘innovation’. Having worked in the UK before and after the introduction of acute medical receiving wards etc I would put these in the same boat as having been also triggered by the four hour rule. To what extent do you think these two places in the hospital have been simply a rebranding of beds that could otherwise just have been resourced in more homogenous fashion to the ED? Are they perhaps a target-beating code-changing measure that places a patient 20ft further from the ED nurses station with a wall and sign saying ‘short stay ward’ between them?

    6 – To entirely flip sides here….your frustration at the trauma target of 30mins to CT, 5mins to consultant assessment etc being fine for the MBA but inappropriately difficult with good old Mrs Miggins seems blatantly at odds with the whole ideology of the target. You are not good enough at seeing geriatric polytrauma says your target-maker, the target is there to help you be a better clinician, you need to make your system better for the Mrs Miggins’s of this world whether you like it or not and it sounds like the big ugly stick of the target is going to succeed in making you do that. (Disclaimer – wife may be a geriatrician)

    Thanks again for a cracking discussion and the bravery of both of you in chatting it over in public sphere!

    Luke

    Reply

    1. Hi Luke,

      I think your comment is almost as long as the blog so I’m not sure whether that’s fantastic for getting you excited about the subject, or whether we should have said more at the time. Thanks for the comments in either case.

      Your question about using mortality as a target is great and difficult to argue with. However, mortality benefit is very difficult to measure and impossible to measure in real time. The question I was answering from Simon Rothwell was about an alternative time based target to the 4-hour rule. Of course we could ask that the time based target is abandoned altogether (and many would say so) though we are realistic to know that that’s not going to happen here. I was chatting to Simon R about this in the department this week and I was answering his question from that time ‘If you had a time based target what would it be?’, it was more focused than what targets (if any) should we have.

      We only speak from our own experiences but we are aware that targets can be damaging to departments, staff and patients (Mid Staffs as an example). The point we were making and the one we stated was that as a UK doctor we live in a world of targets. They are part of our practice landscape and we can’t get away from them so we can either complain a lot (and we both have), but ultimately we have to see what we can do with them. As we say, we would not have selected targets in the way they have been imposed – but what can we do with them to help achieve your laudable aims.

      I think Australian EM in 2014 is very different to the UK of 2004 (you already know this 😉 ) so you will have a different set of problems, challenges and outcomes. I’ve not worked in Australia so can’t be specific about the how but I do know that if you get a 4-hour target it’s going to be a significant challenge to how you work and to how you interact with other parts of your organisation and funding streams.

      The short stay wards we refer to are different to acute medical receiving wards (AMUs) . The AMUs are run by inpatient physicians. The CDU/CLDU/CCDU/OMU short stay model is part of the ED, run by the emergency physicians and can be used very successfully.The innovation is not so much about the physical space (beds have been around for a long time) but rather the innovations around decision support guidelines to safely and effectively investigate or treat patients. We have about 100 of these now.

      Lastly, I have real issues with putting the geri trauma in with the same target for high energy/penetrating polytrauma (in fact I have probs with the 30 min target full stop). I think this is clear in the podcast & I fear that it will lead to bad medicine. However, if it persists (and I’m hoping it does not) then the question will remain – what can it do for us? Thus far it has allowed us to do several things that have potential benefit. For example it was probably the principle driver for getting interdepartmental agreement for a head injury specific trauma team response that allows us to get all patients with isolated heads through rapid imaging. I’ve got at least one anecdotal example of this delivering a patient to neurosurgery more rapidly than perhaps we might have done in the past. Geri trauma is a major issue for us and will increasingly be so. It’s a real area of interest and one where I think we can make a difference.

      As for chatting in public – Iain is rather persuasive!

      Hope you’re enjoying your EM.

      vb

      S

      Reply

    2. As for MTS – it’s the one that we use so I have some familiarity. I’m sure you could use other systems in exactly the same way.

      S

      Reply

  3. Thanks Simon!

    I feel you’ve responded to my large quantity comment with a high quality one…although as the number of words used is much easier to measure than their overall clarity and impact, perhaps it keeps a target counter somewhere happy:)

    Happily agree that AMAUs v CDUs have different staff complements and profiles to each other. I’ve yet to be convinced either location are any more innovative a place for the treatment of the acutely unwell patient. What they add more uniformly is an extra change of bed and delay of first senior assessment and first significant intervention to a patient who previously received those things routinely in their first port of call, the ED. I’ve yet to see pathways or interventions in a CDU or AMAU that are anything beyond the redesign of a circular device for transport purposes.

    Agree its difficult to measure mortality in real time. But as you highlight, with admin burden and all, it’s actually difficult to measure ANYTHING and not waste time better spent on pt care….so surely we should focus on measures we KNOW are meaningful rather than ones we still, ten years on, have yet to establish true patient benefit from?

    Geris, trauma, hospital networks. As much as these three things are generating migraine pains in Virchester, they are very plainly the priorities of medicine in the coming decade so we might as well try and be ahead of the game on this no?

    Is mortality worth measuring?
    Is geriatric trauma worth examining?
    If you make vast system based admin changes to your practice can you, should you, must you examine the mortality effects just as if you’d introduced a new drug or procedure?
    Is the UK unique in having a non commercial national health service that can measure these things?

    A recent study whose findings nicely touch on quite a few of these strands (without in any way entering a debate on the nature of targets) looked at OVERALL mortality benefit of the introduction of a major trauma network system to an area associated with more than its fair share of grey hair, motorbikes and gunshot victims…Ang et al’s JTACS article on Florida MTN introduction effect on mortality on the older folks who fall…and then fill our still heaving corridors:)

    http://t.co/wkArdZuahx

    Reply

    1. Pretty much agree with all of that. I’m all for measuring everything you say, though it’s important to clarify that we do so not as an OR, but as an AND. Let’s measure those outcomes, and see if we can work with the externally applied process measures as well (to influence outcome wherever possible).

      The ageing population is both our biggest threat and our greatest opportunity in Emergency Medicine. One thing that’s for sure is that we will all see more of them, and with Mrs R being a geriatrician I suspect you will be in a most envious situation to guide us.

      tvb

      S

      Reply

Thanks so much for following. Viva la #FOAMed

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