Will COVID force us to think about how quickly we need to see patients?
Just recalling the start of my A&E shift this morning – equivalent to a reef on which the tsunami of COVID is breaking. The volumes of patients are now tremendous. Unwell patients one after the other with little time for thought or reflection. Pulse rates over 120 per minute, and that’s just the doctors and nurses.
In awe of some of my colleagues – juggling multiple patients with gallows humour making a thankful return after years of sanitised political correctness. This is what we all trained to do. Usually patients have so little wrong with them that one of my colleagues describes going a whole day without seeing either an accident or an emergency. That's not the case now.
We are starting to see extraordinary positives coming to medicine as a result of this pandemic. Wars and plagues have been fertile grounds for the development of medicine and surgery since time immemorial. One specific area that is re-emerging is the art of triage – designed in the Napoleonic wars as a way of seeing patients in the order of medical necessity rather than as a simple bus queue or by ability to wait.
For many in A&E this is an odd feeling - so long have we imagined the death stares from the waiting room for seeing people ‘out of time order’ or in other words patients who have not queued as long and hence not ‘earned’ the right to be treated yet. No longer do I note the hushed grumbles as the waiting room speculates why an apparently fit and well person has been chosen to receive treatment first.
We had all been preparing for the end of the four hour A&E target being implemented but had no real idea of how this would play out in practice. We are no longer seeing hordes of patients coming to A&E to avoid the queue at the GPs. For once we are turning patients away because they were not appropriately showing up at A&E.
Many of us remember the A&E system in the UK before Tony Blair’s government introduced the four hour target – those who remember the difficulties in getting diagnostic imaging and lab tests will testify to the significant positive benefits of actually being able to access timely CT scans. However, the four hour target was always a blunt instrument, and accelerated the shift towards patients being consumers – as if complex medical interventions could be bought off the shelf with little or no knowledge.
Busy A&E departments mean that it is common for patients to be first seen by a doctor after nearly three hours. Due to the four hour target this leaves less than an hour for the doctor to see a completely unknown patient, organise tests and get results before the sisters and consultants are asking for an admission decision. Too often it is impossible to safely discharge patients with the inevitable result that patients are referred to medicine for admission hence worsening the shortage of available beds. In effect the bottleneck has been simply moved somewhere else in the system
Hence, the hope is that we can see a more finely grained triage system of which a range of targeted response times from immediate in the case of a person with life threatening injuries to the maximum two week wait for suspected new cancers through to longer targets for more elective procedures.
It remains to be seen just how long these changes last when COVID is gone. Hopefully the various powers from the Royal Colleges to the Government will start to see the potential benefits of a more transparent and ultimately most clinically relevant set of targets.
Photo: Flickr/Lydia