Editor: This is a guest post by Simon Horne. It is likely one of the last posts from Virchester before the festive season properly commences. Take care and stay safe. Happy holidays everyone!
Three jobs, same problem
I consider myself blessed that I have three distinct, but complimentary jobs. Half of the week, I’m a consultant in a regional Major Trauma Centre (MTC); then I spend a day or so as the Consultant Advisor to the Army for Emergency Medicine (preparing myself and colleagues for deployment in one of our small field units and considering ways emergency care can be delivered to meet the Army’s various requirements); and finally I run the Centre for Defence Healthcare Engagement (CDHE), which contributes to military health service development through partnerships overseas.
Whilst the emergency medicine in each job is completely different, all three areas share the same fundamental problem: inadequate resource to meet demand.
Balancing system demands
Under normal circumstances our MTC has enough capacity that we can expect to practice Emergency Medicine almost unconstrained. But with years of rising attendances, changing presentation patterns and now COVID on top of that, we are running beyond maximum occupancy all the time.
An Army medical unit deploys to environments where just keeping oneself functional can be a challenge, but despite this provides a full suite of trauma resuscitation (including REBOA), wherever we go. Our most typical configuration though has only two beds and an operating table – in other words very high capability, but extremely low capacity. While our limited capacity has not been an issue on recent deployments, our râison d’etre includes fighting a war where cases per day might be in the thousands. In those scenarios, capacity will be our biggest challenge.
At CDHE, supporting implementation of, for example, Emergency Medicine training for the military in Pakistan, or pre-hospital trauma management in Mexico, I see systems that have developed through completely different routes, under different pressures, and within different cultural, historical, economic and political constructs. These systems often have far greater capacity – the main hospital in Peshawar sees several thousand patients per day in its 200-bed emergency department for example – but often systems trade this off against a slightly lower capability.
Each system I’ve seen is finding its own way of balancing the tension between the standard of care that you have the technical capability to provide, and the resources and capacity needed to consistently deliver to that standard.
Mismatching demand, resource and quality
This tension is exemplified in the progression from normal business, to major incident, and then to mass casualty situations. In normal business, resources are matched to demand, such that (within certain realistic bounds of variability) we always have the capacity to operate at our full capability. The civilian expectation, quite reasonably, is that we provide gold standard care to every patient. The four-hour standard, MTC tariffs, stroke targets and dozens of others metrics, are only viable demands on the basis of this assumption.
In major incidents we have to mobilise extraordinary resources to manage demand. There is still an expectation that we will deliver the necessary care to all patients, but only by bringing in more staff, opening more theatres or wards, or shipping in additional equipment and consumables (I would contest that this is unrealistic – a degree of mismatch between demand and resource is inevitable and so at some point patients will not get what they need according to defined NHS standards, even if in its mildest form it only manifests as delayed care).
If we were able to, we would never become overcrowded, but in these contexts we always do. At the same time, studies into crowding in EDs show indisputably that crowded departments have worse outcomes – in other words they cannot reliably deliver these gold standards. There is a tacit acceptance of lower capability, and worse outcomes – as the widening gap between demand and resource makes a drop in standards inevitable. This is demonstrated in the figure below, where increasing demand is plotted against resources and the quality of care.
Taking this example to its extreme, analogous to high intensity war-fighting, the Beirut explosion was a true mass casualty situation. Local services were utterly overwhelmed. All their clinical systems collapsed under the pressure. How do you prescribe drugs if you can’t register a patient? If patients have no identifiers, how do you give them blood products safely? Where can you possibly find the space to treat 7,500 casualties in a timely fashion?
At the same time your available resource plummets, as staff themselves may be involved in the incident, or supplies start to dwindle. At some point the overwhelming demand becomes so painfully obvious that we are forced to tolerate lower standards of care, recognising that quite frankly there is nothing else we can do.
But is there really no other option but for the system to gradually buckle, and then suddenly succumb as demand inexorably ramps up?
And given current trends, what would that mean for emergency care in our NHS?
Closer to home
The NHS is already in Major Incident phase most days. Some might even argue that we are in a situation more analogous to a mass casualty: we constantly scrabble to fill shifts, relying on locums and bank nurses; waiting times are climbing; and performance standards are a distant memory.
We may have badged the 4-hour standard’s demise as a search for a better measure, but that glosses over the fact that it is likely to be unachievable right now. Rising patient demand and increasing global competition for resources have squeezed a health system that was run near maximum occupancy for years before being hit by COVID. The result is that it is sometimes impossible, at least in the short term, to deliver the care we want to give, to everyone who needs it.
Military emergency care is having to be brutally honest in approaching this gap when considering mass casualty scenarios. When pushed to the edge, you have two choices; resist to the end and then fall, or accept what’s coming and plan for how you will land. Accepting that when overwhelmed we cannot achieve gold standard care, ethical analyses are clear that providing good enough to as many as possible is far better than trying to deliver perfection for a few and then failing to deliver even adequate care to the rest.
So first, we need to understand what good enough looks like. In any effort to deliver quality, there is a law of diminishing returns. Inevitably, parts of the care pathway add a little value, but at disproportionate cost.
What does that mean for a crowded ED? In circumstances where care is significantly compromised by inadequate resource, steps that add little or no value, must go. We should find the 80% of care that impacts most meaningfully on mortality and morbidity and deliver that for everyone, every time.
When pushed to the edge, you have two choices; resist to the end and then fall, or accept what’s coming and plan for how you will land.
The Pareto principle
The Pareto principle tells us that this 80% – the portion that really, really matters – will consume substantially less than 80% of the resources in use. In other words, falling back on a well-planned, high-quality silver (or best-feasible) standard of care is far safer than holding to our gold standards, in the face of what is plainly obvious, failing, and then having to fashion a plan on the fly. Not least because this self-delusion prevents us from honestly appraising the facts and improving the way we manage the situation.
So, identify the steps that add tangible value and focus on delivering them consistently.
Hand in glove comes the need to strip away activity that does not help. A junior recently asked me whether to add on an additional test in case it was useful down the line. On the face of it: an efficient use of whole system resources, and there is no question that if the test was needed, it should be done. But more often, this is discretionary activity based on what-ifs, rather than any real clinical justification.
Let’s assume we take an additional 10 minutes per patient doing such low value activities. Think how easily that is done: that last ECG (just in case); ordering that CRP (that won’t change our management); that patient going to a ward on a bed, requiring two staff for transfer (when it could be done with a wheel chair and one staff) – and in so doing delaying the administration of care to the next patient by 10 minutes.
But it is just ten more minutes per majors patient. It is hardly anything, isn’t it?
It is also 1500 extra patient-minutes per day in majors in my department. Or 25 hours. That equates to closing a majors cubicle, all day, every day, forever. For no benefit to patients in the department. Given ambulances ramping outside to offload: is that test really the right thing to do? Or putting it another way, does it fall within the high impact 80% of the care pathway?
Lessons from the frontline
Historical lessons from conflicts, where hospitals were overwhelmed, are simple and relevant. First, care should be delivered by the lowest capable provider – where possible on an ambulatory or distributed basis to prevent acute facilities overflowing. The NHS emulated this principle with ambulatory care for DVTs: when under bed pressures we devised an alternative to the historical approach of admission until warfarinisation reached therapeutic levels.
This was initially thought of as an enforced silver standard (although not explicitly described as such), but patients prefer it, and outcomes turned out to be better. When resources are tight, well-delivered silver standard care can be worth more than the wait for gold.
Next, we ask how we can boost the workforce capable of delivering the necessary care through a process called task-shifting. This could simply be a matter of training nurses and HCAs to take on a new role or task. Or it could involve tech innovations that can make delivery of care easier.
The development of TXA autoinjectors in Defence will allow for a life-saving drug to be safely delivered by minimally trained personnel. The pool of capable providers will increased by a magnitude, allowing it to be delivered at the point of wounding, rather than waiting for a higher level of care to arrive. But you can’t just give these providers the tools. You must also empower them make decisions about when they are needed, so training becomes a key step too.
And finally, we look at where this care can be delivered. The advent of smart dressings and wearable biomonitors make platform-agnostic remote monitoring feasible. COVID has seen hospitals around the country initiating virtual wards to facilitate early discharge or reduce borderline admissions. Imagine if their phone or smart watch were monitoring them too, flagging them up as soon as their physiology changed.
Be honest and be bold
None of these concepts are new to the NHS, as they are not new to the military. But bolder implementation requires an honest admission that we fail to deliver gold standard care for many patients in our EDs. That will then allow us to design context appropriate levels of care, so all of our patients always get the best care that available resources allow.
As a speciality, we must acknowledge the limitations that capacity places on us. We must still advocate, constantly, for the resources we need to provide optimal care at all times, but in the absence of those resources, we must also always deliver the best care possible.
Lieutenant Colonel Simon Horne is a British Army Consultant in Emergency Medicine, based in Plymouth. He is currently head of the Centre for Defence Healthcare Engagement and Army Consultant Advisor for Emergency Medicine. Simon was awarded an OBE for work during COVID19. He is currently working on a PhD on medical civil-military relationships through King’s College London.
Further reading on ED management and hospital flow
- Cardiac output as a metaphor for flow through an urgent care setting
- Improving patient flow
- Changing Clinical Standards for Emergency Care
- Similar challenges, different approaches – Mass Casualty Incident training lessons from Pakistan
- Only a game? Infinite game theory in Emergency Medicine
- Tough Times in the Emergency Department
- Securing the Future of the ED workforce