Flow

I have just come off a night shift, clerking in new patients on the acute medical unit, or AMU. The AMU is effectively a transient short-stay ward where new patients with medical (rather than surgical) problems go for initial assessment and treatment. Those who are well enough, or can be treated quickly enough, are turned around after a day or two on AMU and discharged. Those needing more specialised input or who are anticipated to have a long hospital stay are transferred to ‘downstream’ wards. The empty beds are then filled by new (medical) patients referred by GP or being admitted from A&E. This concept of moving patients is known as flow.Ever played this?I’m sure you’ll have played with one of these at least once in your life. It’s also a reasonable analogy of what happens when there aren’t enough downstream beds – if there are no empty beds on the wards to transfer people to, then AMU (which is usually at least 95% full) saturates. The flow of patients from upstream cannot be stopped, and because of the dramatic cuts in bed numbers as part of the austerity drive in recent years there is much less slack in the system. This means if even a few patients don’t get better fast enough, or a few more people out in the community get sick, the hospital as a whole gets into trouble fast. Bed managers and co-ordinators do their best – discharge lounges, overflow wards, enhanced supported discharges, outlying patients to surgical wards. These are not simple solutions – discharge lounges can’t operate at night because it’s generally not ok to discharge people in the early hours and people do need to be fit enough to actually go home. Overflow wards need safe staffing levels at short notice, enhanced supported discharge is only appropriate in specific patients and needs significant community resources, surgical patients need beds too.

Last night, the hospital had no more beds.* AMU was saturated within hours and, without any downstream movement, the backlog began to flow upstream. The last of the days GP referrals sat on a trolley with paramedics for 4 hours before a bed became available, but even that was a minor issue compared to what happened to A&E.

By midnight A&E was operating at 200% of bed capacity. Patients who had been seen, investigations done, diagnoses made and who were ready for the ward couldn’t leave. Trolleys were lining the corridors, around the nurses station, majors patients in minors, staff completely overrun. They wore brave faces, were focused, disciplined; they fought tooth and nail to deliver the best care they could. A fully-staffed tertiary hospital ED department is a highly trained, specialist team of experienced doctors, nurses and healthcares who together form an incredibly potent group of people, but how could it ever be enough in the face of such overwhelming odds? By 3am the waiting time to be seen was 6 hours. Remember the target is to be seen, investigated, treatment started and either discharged or admitted within 4 hours.

It makes me so angry (bold cannot express how angry and upset this makes me). These people care, and I care, that we can’t look after patients the way they should be looked after. You can not and should not run a hospital without some empty beds, for days like today, for nights like last night. Every time you (I’m talkinmg to you, government) close an A&E department, cut beds, reduce budgets, you make things worse. Ultimately, you funnel more patients into units and hospitals without the capacity or staff to deal with them. I mean seriously: what the bloody hell did you think would happen? A child could tell you that if you have some A&Es, and you close a bunch of them, the ones that are left will get busier!

What makes me angriest of all is that the blame is laid not at the door of cost cutting measures, not at the door of bed numbers reductions enacted by multiple political parties, but at the door of patients attending the one place that should be able to help them, 24 hours a day, 7 days a week, 365-and-a-quarter days a year. Yes, not every patient who attends A&E needs to be there – but the majority do, and crucially the vast majority at least believe they do, and that is good enough for me.

At half 5 in the morning I am in an A&E going critical. Everywhere, there are crowds – patients, medics, nurses, security, police. Staff are staying (very) late. An elderly man, unwell, is shuffled out of resus to make space for a baby under a year old, ribs heaving with the effort to breathe, attendant mother in anxious tears, and a resus nurse and doctor change tack from one patient to the next as seamlessly as they have for the last eight hours. The tannoy announces another cardiac arrest, inbound, ETA ten minutes. The sister turns to the board, begins to plan another move of the puzzle pieces on a board with no spaces, and the clock ticks another minute away.

Sometimes you can’t go with the flow, and you have to battle for every tiny victory, spend your shift fighting fires, and hope that when the morning breaks the downstream teams can clear enough beds to recover A&E before the next wave hits. driving headlong

*a combination of winter pressures, norovirus and a slightly-busier-than-usual week.

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