(Ed – there are two parts to this post. The slightly tongue in cheek beginning and a more serious endpiece that addresses the very real and very dangerous issues of ED overcrowding. If you’re interested in the useful stuff then skip to the end)
Why have we created the FCM?
Emergency physicians are renowned for embracing new ideas, new concepts and new techniques to benefit our patients and departments. In recent years we have seen the development of resuscitationists, paediatric emergency medicine, ambulatory emergency medicine, geriatric emergency medicine and prehospital care. Many of these subspecialities have generated sub speciality accreditation and fellowships to recognise the additional skills, knowledge and training gained by thos studying in those areas.
In a similar vein The University of Virchester has teamed up with the College of Virtual Emergency Medicine to develop an approved training program in Corridor Emergency Medicine.
This new course and exam is based on the need to care for patients in non-traditional ED settings when all cubicles are full, the resus room is at 150% capacity and where in the past it was considered that there was ‘nowhere to see the patients’. This lack of ED capacity led to a number of clinical incidents and deaths where patients waiting for admission to the ED, or awaiting transfer out of the hospital were left unattended in Corridor space.
Like many subspecialities in EM the drive to develop Corridor medicine has been led by innovators and enthusiasts who have chosen (Ed – forced you mean) into taking medical care to the patient in whatever thoroughfare they may reside.
A detailed curriculum is available from the College. The main areas of study include
- Study guides
- Although the faculty relies heavily on experiential, unguided and quite frankly dangerous policy of learning through personal error the study guides available at Life in the Fast Lane are highly recommended.
- This short video on the development of Utopian Medicine from Life in the Fast Lane explains the historical development of the sub speciality.
- You can check the local requirements for corridor medicine through the publication of local statistics in the UK on the BBC website. If your hospital is failing the 95% target then there is a strong case for the development of a specialist in corridor medicine at your facility.
- Listen to the CEM #FOAMed podcast on overcrowding with Ian Higginson and Tim Nutbeam. http://www.cemfoamed.co.uk/portfolio/4559/
- Definitions of ED overcrowding.
- Review of the data on increased mortality, infection rates, length of stay and morbidity as a result of ED overcrowding.
- Estimating excess deaths as a result of ED overcrowding
- Review of the data on increased mortality, infection rates, length of stay and morbidity as a result of ED overcrowding.
- Review CEM documents on effects of crowding in EDs. CEM6296-Crowding-1
- The International perspective including US ACEP reports on overcrowding
- Practical skills
- Negotiating the deflection of patients prior to arrival by ambulance
- Triage of patients to high dependency areas when workload exceeds capacity.
- Rapid reconfiguration of non standard space to see and assess patients (to include sluice, offices, triage rooms, waiting rooms. corridors, storerooms, toilets)
- Effective triaging patients in standing, lying, sitting positions in the ED without access to physiological observations.
- Writing high level incident reports & assessing performance when harm takes place.
- Whistleblowing policy
- Interpersonal skills
- Negotiation skills with colleagues
- How to manage the burn out of colleagues unable to manage corridor care.
- Apologetic skills to patients who have substandard care
- How to address and interact with HM Coroner (Procurator Fiscal in Scotland).
- Supporting colleagues who have made clinical errors as a result of workload pressure and ED overcrowding
- Careers advice for those unable to continue in speciality, or in UK practice.
- Fantasy/Future planning section
- Whole hospital response protocols – the Full Capacity Protocol
- Shared risk protocols
- Well funded and responsive community service integration for early safe discharge of patients.
- Any policy that states that we can manage ED overcrowding by reducing attendance.
- Log book
- Candidates will present a log book of reflective reviews based on their experiences of ED overcrowding and corridor medicine. A minimum of 20 episodes including at least 20 serious harms to patients should be included.
- Short answer questions on legal, clinical and management topics.
- Choosing which of the 8 patients who require resus care in the 4 available beds are most likely to survive.
- Assessing patients for serious illness injury whilst fully clothed, sat in a wheelchair and without recent observations.
Successful candidates will be awarded the Fellowship of Corridor Medicine. The awards ceremony will be held by the bins at the back of the Albert Hall in London on Saturday 14th. Sadly Cirque de Soleil are using the Albert Hall that day, so we have moved the ceremony to an alternative location. As FCMs the location does not matter. It will surely be just as good.
Established clinicians with past experience, credibility and evidence of performance in corridor medicine can apply for fellowship through the presentation of a CV and a log book detailing their strategies and reflections on the practice of the speciality.
Prof. S. Cared-Tofail
University of Virchester
The serious bit.
Top 10 tips for managing the overcrowded department.
Many of not all UK EDs are facing periods of severe overcrowding this winter. This places a huge strain on resources, and by resources we mean people. Some of the most challenging times I have had in the ED are not when deciding to do the thoracotomy or the USS procedure, it’s when the capacity for safe treatment of patients has been overwhelmed and as a senior clinician I have to make invidious decisions about who goes where, when and how quickly they get seen. Let’s consider a situation that a UK ED consultant may face when arriving for an evening shift.
Your department has 4 resus beds, 18 cubicles in majors, 10 cubicles in minors.
You arrive to find 6 patients in the 4-bedded resus. Two are ventilated. 4 are in beds, 2 others are in the middle of the room attached to portable monitoring (one in fast AF, another with chest pain and an ischaemic ECG). None is fit to be transferred out of resus. All cubicles in majors and minors are occupied by patients waiting to be assessed or who are waiting for in-patient admission. There are 6 ambulance crews waiting on the corridor to off load patients. As you walk past a crew asks you to see their patient who they think is drunk. His GCS is only 11 and they are starting to get a bit worried.
There are currently 90 patients in the department and a 3 hour wait for patients to be seen at both ends of the department. A glance at the computer screen suggests that (roughly) there are 30 patients waiting to be seen in minors, there are 10 patients waiting to be seen in Majors (plus the 6 on the Corridor). There are 15 patients waiting to be triaged. There are 25 patients waiting for in patient admission. You have one consultant, 10 junior doctors and 2 ENPs. Every cubicle is full with a patient on a trolley.
You are the only consultant on duty in the ED, the day shift consultant hands over and leaves looking exhausted and in no fit state to do a few extra hours. What are you going to do?
What can you do?
1. Be Strategic
- It is easy to get sucked into the care of individual patients when the department gets busy. So many people need help at these times and you can quickly fall into the trap of losing oversight of the unit. When it gets busy, take a step back and assess the entire department, not jus the patient you are looking after.
- Make an assessment of the current situation. How risky is it? Is this a temporary situation or is the overcrowding likely to persist.
- On some of my busiest days I see few patients. Busy days require strong departmental leadership.
2. Talk: Communicate up, down and sideways.
- Talk to your senior management directly and tell them what you want them to do. Don’t just moan. Give them actions. Duty managers are often unfamiliar with the ED. Help them by giving suggestions as to what you want them to do.
- Talk down to your team (the multiprofessional team) empathise, understand and explain what the situation is and how they can help.
- Talk to your colleagues in the ambulance service to understand their current and predicted demand. Can they deflect patients to other hospitals? What’s the workload like in other centres (they will know).
- Talk to your in patient colleagues. Again tell them how they can help. Be as specific as you can.
- Get your shop floor management team together regularly (hourly) to discuss what can and cannot be done.
- Walk the shop floor. Talk to all the staff. Gather information.
3. Be positive
- Your attitude, your behaviour and your words will be heard by all. If you adopt a passive, pathetic or hopeless position then so will your staff. Great shop floor leadership sometimes means putting on a persona that can support and motivate others, no matter what you feel inside.
- Challenge (gently) other senior figures who publicly catastrophise the situation. Ask them what they can do to support their juniors, and how you can help them.
4. Allocate a corridor doc.
- If ambulances are waiting to offload then allocate a competent doc to speak to all patients and waiting crews. Task them to make an assessment of who gets the next bed. Tell them to alert you if they have concerns.
- Task them to make a rapid assessment of priority and then to report back to you and the triage nurse.
5. Get inpatient teams to review their patients in the ED.
- Some patients wait for admission in the ED for up to 16 hours in the UK. A decision of need to admit at 1 hour may have changed by the 15th hour. Some specialities are reluctant to review patients in the ED. Encourage them to be less reluctant.
6. Report the overcrowding
- Unless the overcrowding issues are shared across an organisation nothing will happen. We risk spending too much time firefighting the acute event without making plans for the future in a sustainable fashion. Whilst it can often seem pointless to fill in incident reports about overcrowding (it happens so often) it is a mechanism for making senior figures in the trust take note.
- Report individual patient harms
- Report overcrowding in general (let’s face it, overcrowding kills).
- Tomorrow – look at the trust risk register. Does overcrowding feature on it. If not, why not.
7. Use non traditional space
- If you are told that there is nowhere to see patients be pragmatic, think about what urgent clinical assessments can be made in different areas and prioritise. Try and ensure your patient’s dignity and confidentiality.
- In a crisis any space can and may be used. See patients wherever they can be safely reviewed.
8. Be honest with patients.
- Apologise for the delays.
- Apologise for the circumstances they find themselves in (no-one wants to be on a corridor for 4 hours)
- Tell them about delays when they first arrive and (where appropriate) suggest alternative health care providers.
9. Look after your staff
- No-one goes to work wanting to do a bad job. All our staff want to deliver great care, but that cannot be done in an overcrowded ED. Overcrowded EDs deliver poor clinical care and an awful patient experience. Inability to deliver care to the level that we would wish is probably the biggest stressor for our teams. Recognise this. Thank them, be nice, look after them. If you recognise your colleagues becoming unwell as a result of pressures in the ED help and guide them to whatever support they need.
10. Look after yourself
- As a senior clinician you’re expected to be able to suck up all the pain, the risk, the danger and yet still lead with a positive attitude that supports everyone else. This is tough and I know of many casualties. If you think you need help ask for it before it’s too late.
When the team reviewed this article we did wonder whether it sounds negative as we still love emergency medicine and we love our jobs. However, when the times are tough we recognise that the ED can be a challenging place with the potential to harm both staff and patients. The Faculty of Corridor Medicine is clearly a spoof and is used here as a vehicle to help us engage with the problem, but to also to think beyond helplessness in the face of difficulty such that we can do the best that we can.
Despite the pressures there is much we can do to help our patients, friends, colleagues and staff. Do the best that you can. Good luck and as the RAMC motto In Arduis Fidelis states, be Faithful in Adversity.
Please share your top tips for managing the ED overcrowding problem? Share them in the comments below.
Good luck and best wishes.
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