ED Crowding Conundrum

Gracie has done well.  She was born in 1927, was a young adult when the NHS was born, and has weathered that time with a positive and humble spirit.  But her body is starting to creak, and 40 years of smoking before anyone really knew the long-term effects has left her arteries stiff and clogged with debris.  Over the weekend, she had developed pain in her foot, and by Monday morning, her toes were black, there was some skin break-down, and some angry redness spreading up her foot.  The blood supply to her foot had been blocked, and her toes were dying in front of her eyes.

She presented to the Emergency Department just after 12 noon, the start of our plateau of peak activity, having called NHS24 and being advised to attend by ambulance.  The Department will be receiving between 20 and 30 patients an hour till around 10pm, all with various severities of illness, and about a third of these patients will need to be admitted to hospital. 

She is seen by one of our nurses at triage, has some pain relief administered and some blood tests sent, and then is assessed by one of our medical team.  The diagnosis is straightforward, and she is referred to our colleagues in Vascular surgery to assess her and arrange an admission for on-going treatment, possibly an operation.  The Vascular surgeon is able to attend promptly, and agrees with the assessment so far, and suggests the exact treatment schedule whilst liasing with our bed management team to organise a bed for Gracie.

This has all been done by 2.30pm, and the bed has been booked.

Unfortunately, a common scenario now unfolds.  There is no bed available for Gracie on the vascular ward, or even remotely close.  Now, she has to wait on a trolley until either a bed becomes vacant, or a different patient is moved to an alternative bed, or a bed in a remote location is found and staffed.

However, there is no reduction in the numbers of patients coming into the Emergency Department, so Gracie not only has to wait on a trolley, but we have to move her out of her cubicle space into the corridor, so we can assess the patients in cubicles that have more recently arrived. 

And so this goes on through the afternoon, with more and more patients arriving, a proportion are able to be discharged home, some come back to clinic settings, but the patients who need to be treated as inpatients in hospital stack up in the corridors of the Department as the supply of available beds is way below what the rate required.

As the Department becomes more and more crowded, the nursing and medical staff have increasing demands on their attention and time, as the nursing and treatment requirements for patients waiting for beds do not stop once their bed is booked.  Pain relief, toileting, pressure care, communicating plans and apologising for waits, checking fluid balance, giving antibiotics, finding meals: it all has to continue whilst dealing with the patients who are just arriving.  Just keeping track of who is who can be challenging, and the chance of near-misses and mistakes undoubtedly increases in this situation.

So why does it happen?

This issue, which is referred to as "access (to bed) block" is one of the key determinants of ED overcrowding.  The injustice for us is that the causes of access block usually sit out with the ED, whilst the effects on patients and staff occur within the ED.  It occurs at times when the "flow" of patients into, through and out of the hospital system has been impaired. 

 Imagine a river with a series of locks that a patient has to navigate through on their way downstream to the sea (the community).  Upstream is a pool with a flow of water into it (the ED, with patients arriving).  Every step along a patient's inpatient stay, whether it be an X-ray being ordered, a Consultant making a decision about treatment, an Occupational Therapist assessment, a discharge letter being written, a relative picking the patient up, a social care package being confirmed, medications being prepared for discharge, or a nursing home placement organised, are akin to the locks in the river.  All of these steps are subject to potential delays, and these cause a back-pressure upstream.  The result is that the pool breaks its banks, flooding the staff and other patients in that area, and the management of that area becomes far harder to control.

The real tragedy is that this effect impacts the most vulnerable and frail of our patients.  The average age of our admitted patients is around 76yrs old, so these are not the archetypal “A+E timewasters”.  These patients that wait many hours are those that absolutely need to be in hospital, when all other alternatives have been exhausted.  Creating the incentives for all the locks in the river to work as effectively as possible (and maybe take some locks out altogether) to achieve a smooth and timely flow of patients from the community setting to the Emergency Department, the hospital, and then back to the community is one of our biggest challenges.