Accident and emergency medicine the next by jolinmilioncherie


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48                                                                                              4     JAccid Emerg Med 1999; 16:48-54


                            Accident and emergency medicine the next
                            25 years
                           James Binchy

                           The founders of the Casualty Surgeons Associ-        numbers will continue to increase until 2020
                           ation could scarcely have envisaged, back in         by which time the number of people over 75
                           1967, that their successors 30 years later would     will have stabilised. There will be a similar rise
                           be giving streptokinase to patients who pre-         in the number of patients with Colles' frac-
                           sented to their departments with acute myo-          tures. As these are manipulated in many
                           cardial infarction. Therefore I shall not try to     departments this will consume more resources.
                           predict what will be going on in accident and           (4) Increasing incidence of deliberate self
                           emergency (A&E) departments in 25 years              harm. In Plymouth the number of patients
                           time. What I would like to do is look at some of     presenting with deliberate self harm or over-
                           the issues that face us, suggest how these might     dose increased by 21% between 1994 and
                           develop in the future, and how we might              1997 (from 2406 to 2912).
                           address them.                                           (5) Increased fear of litigation leads to an
                                                                                increased referral rate, increased investigations,
                           Increasing work load                                 and decreased discharge rate.
                           The number of new attendances to A&E                    (6) Changes in the provision of out of hours
                           departments has risen by an average of 2% per        primary care
                           year since 1981.' The rapid increase in the             These pressures are likely to increase in the
                           workload experienced by many A&E depart-             future as new treatments become available for
                           ments in recent years has exceeded this and is       the acute management of such diseases as
                           largely due to a rapid rise in the number of         stroke. Any new treatment for strokes will be
                           admissions. Most of these are due to the             extremely time dependent and will most likely
                           increased numbers of medical admissions. In          involve immediate computed tomography in
                           my department between 1994 and 1997 the              such patients. This will result in increasing
                           number of new attendances increased by 1.4%.         numbers of strokes attending A&E depart-
                           (This has been distorted by the opening of a         ments for assessment and initial management.
                           minor injuries unit two years ago.) However             We should be embracing these changes and
                           over the same period the number of medical
                           admissions via A&E has increased by 30%              ensuring that patients get the most appropriate
                           from 3100 to 4100. Some of this can be               treatment at the earliest opportunity in our
                           explained by an increase in the elderly popula-      departments.
                           tion with greater health needs. However much            General medicine in the UK appears to be
                           may be due to changes in medical practice.           following the same trend as in the United
                           Other factors that are greatly increasing our        States, with increasing subspecialisation and
                           workload and will continue to do so are:             concentration on outpatient care, with the
                              (1) Changes in medical treatment: for exam-       demise of the acute general physician. This
                           ple streptokinase in myocardial infarction, use      puts greater pressure on A&E departments to
                           of N-acetylcysteine in paracetamol overdoses,        make a definitive diagnosis, institute early
                           continuous positive airway pressure and the          treatment, and refer to the appropriate subspe-
                           use of intravenous nitrates in acute left            cialty. It may be that A&E medicine replaces
                           ventricular failure.                                 acute general medicine and will fully work up
                              (2) Greater expectation of investigation and      patients resulting in discharge or admission
                           intervention by the general population. One          and referral to the appropriate subspecialty. In
                           study in Nottingham showed a twofold in-             order to fulfil this role A&E medicine will have
Accident and               crease in chest pain assessments for myocardial      to have ready access to laboratory and
Emergency                  infarction in the A&E department over 10             radiological investigations on a 24 hour basis
Department, Derriford      years.2                                              seven days a week. Many departments abroad
Hospital, Plymouth,           (3) Increasing numbers of patients with frac-     operate such a system with regard to patients
Devon PLI 8DH
                           tured neck of femur. Where I work the number         with chest pain and non-diagnostic electrocar-
Correspondence   to:       of fractured femurs coming through the               diography. These patients are admitted under
Mr Binchy, Consultant in   department has increased from 2.8/1000 new           their care for observation until myocardial inf-
Accident and Emergency
                           attendances in 1990 to 4.2/1000 in 1997.             arction can be confirmed or refuted with the
                           These patients, while not using a lot of medical     help of biochemical markers. In such a system
Accepted 7 August 1998     resources, consume a lot of nursing hours. The       the A&E department would have to have more
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Accident and emergency medicine-the next 25 years                                                                                 49

                             high dependency beds with the appropriate             destroying, and may lead to consultant burn-
                             staffing levels to match.                             out. Most doctors didn't go into A&E medi-
                                The last 25 years has seen the transforma-         cine to spent most of their clinical time seeing
                             tion of the casualty surgeon to the A&E physi-        sprained ankles and other minor conditions. It
                             cian. Will the demise of the general physician        is important that we try to define exactly what
                             complete the transformation of the casualty           a consultant's clinical role should be, ensuring
                             surgeon to the emergency physician?                   that they are involved with a more balanced
                                                                                   case mix. It may be that we should define a
                             Consultant work patterns                              comprehensive list of patient categories that
                             It is neither realistic nor economically viable to    should have consultant involvement. Perhaps
                             have a consultant based service in which most         every patient referred to an inpatient team by a
                             patients are seen and treated by consultants.         SHO should be discussed with a consultant
                             The number of consultants required would be           before referral. Ensuring that departments are
                             excessive. Most doctors in their 50s and 60s do       adequately staffed with experienced doctors
                             not want to work night shifts. There is little        will go a long way to enabling consultants to
                             evidence that the presence of a consultant on         have a more diverse clinical involvement.
                             site 24 hours a day improves outcome. Unless             The move to multiconsultant departments
                             such work patterns were the norm for consult-         will no doubt lead to subspecialisation within
                             ants in all specialties there would be difficulties   the specialty. Obvious areas include paediat-
                             in recruiting high quality candidates to training     rics, sports injuries, pre-hospital care, acute
                             posts.                                                general medicine, and possibly toxicology. This
                                A&E services should continue to be pro-            can only be of benefit to patients and
                             vided as a consultant led service but with con-       departments.
                             sultants leading the charge. Consultants
                             should spend a significant proportion of their        Middle grade cover
                             working week on the shop floor, actively super-       There is no doubt that, if we are to improve
                             vising senior house officers (SHOs) and seeing        and maintain standards of care to patients,
                             patients as necessary. It goes without saying         increasing numbers of patients must be seen by
                             that they should be actively involved with or         trained and experienced doctors. It is not feasi-
                             supervising the resuscitation of all seriously ill    ble for all of this to be taken on by consultants
                             or traumatised patients within the department.        and so there needs to be an expansion in the
                                The continuing rise in medical patients            numbers of middle grade doctors.
                             requiring active intervention within A&E                 If most departments have three or more con-
                             departments means that junior doctors require         sultants the total needed will be 700 to 800.3
                             more teaching and supervision. The reduction          Estimating the average consultant life span as
                             in junior doctor hours, protected teaching            30 years' service, we would then need about 30
                             time, and the more structured approach to             new consultant appointments each year. As-
                             training have already and will continue to make       suming a five year training programme that
                             great demands on consultant workload. We              gives a total of 150 trainees nationally. These
                             need to embrace these changes and use them            trainees will spend one year on secondments
                             as a tool to increase the numbers of consultant       outside the department leaving 120 trainees to
                             and middle grade doctors. I think that the            provide a middle grade service nationally. Even
                             arguments in favour of having a minimum of            if we expand to 1000 consultants we are
                             three consultants in any department providing         unlikely to need more than 200 trainees to
                             a comprehensive 24 hour service are over-             replenish them. These will almost certainly be
                             whelming.                                             concentrated in teaching hospitals and the
                                In departments with more than two consult-         larger centres with some rotation out to small
                             ants (which I think should become the norm)           district general hospitals. Obviously it is
                             there will be pressure to provide extended con-       impossible to provide an adequate 24 hour or
                             sultant presence within departments perhaps           even 16 hour middle grade cover with these
                             until 10 pm or midnight. I think that this has        numbers and therefore most departments will
                             been accepted by the majority in the specialty.       come to rely on other grades, such as staff
                             However it is important that this is undertaken       grade doctors, to fill this role.
                             within some national terms and conditions for
                             such antisocial hours. Time off in lieu is often      Staff grade doctors
                             not practical as most meetings occur during           In 1990 there were 40 staff grade doctors in
                             office hours and therefore doctors end up             A&E. There are now between 250 and 300. If
                             coming in during their time off. It may be that       the specialty is to recruit and retain suitably
                             the specialty should refuse to provide such a         trained candidates for these posts it will have to
                             service until the increased workload is recog-        redefine and increase the profile of the staff
                             nised and financed appropriately. One answer          grade doctor. It is important that they are not
                             to this may be the option of early retirement on      solely used as work horses to fill gaps in the
                             full pension at 55, as was the case for medical       service but are given appropriate teaching,
                             officers of health.                                   management, and audit roles as well. They
                                The present clinical role for consultants          must also have protected study time and be
                             seems to    be limited to leading resuscitations,     encouraged to continue to develop profession-
                             running review clinics, and queue busting.            ally. With the present system and the inability
                             Queue shifting is a pragmatic solution to the         to advance both professionally and financially
                             problem of prolonged waiting times. However           there is a risk that we could end up with a
                             it is not necessarily good medicine, can be soul      disillusioned workforce. The new staff grade
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50                                                                                                       Binchy

      contract with its optional points system may go       result in cost savings as it may lead to an
      some way to addressing this.                          increase in supply led demand. The marginal
        These positions are often perceived as being        cost of treating minor injuries in larger A&E
      second rate and filled by doctors who didn't          departments is low. If most of these patients are
      quite make the grade in hospital medicine. We         diverted to minor injury units the marginal
      need to be proactive in dispelling this miscon-       costs of treating other patients will rise.
      ception as many are highly trained doctors who           However minor injury units can provide a
      have for personal reasons chosen not to pursue        local service which is responsive to the needs of
      a consultant career path. It may be that we           patients. Reports suggest that patients use
      need to reinvent the post with a more positive        these appropriately and that their satisfaction
      image and a new title such as staff physician.        with them is high.5 These units should not
        Part time working and job sharing have              receive ambulance calls and it must be well
      become accepted career options and their              publicised that they do not treat medical emer-
      popularity will probably increase. A&E work is        gencies.
      especially suitable for sessional work and we            It is important that the specialty continues to
      should be actively encouraging appropriately          maintain standards in A&E care and therefore
      trained and motivated doctors who wish to fol-        it should ensure that these units continue to be
      low this career option to take up such posts.         under the control of consultants in A&E medi-
                                                            cine based at the central A&E department.
      Senior house officers                                 This will provide the opportunity for training
      A&E departments will continue to require              and supervision of both medical and nursing
      SHOs to see a large proportion of the patients.       staff and allow members of staff to rotate
      However as the staffing levels in A&E expand          between the departments. It will also facilitate
      with more middle grade doctors I expect SHO           the transfer of care of patients between the two
      numbers to remain static and so become a              departments. There needs to be good commu-
      smaller proportion of total staffing require-         nication, probably with video links, between
      ments. These will remain as training posts for        more remote units.
      general professional training.
                                                            Nurse practitioners
      Centralising trauma services and the                  There is an increasing trend to employ nurse
      amalgamation of smaller department                    practitioners to see and treat patients with
      In its report By Accident or Design? the Audit        minor injuries and illnesses and so decrease the
      Commission suggested closing some A&E                 number of patients who have to be seen by a
      departments that were seeing fewer than               junior doctor, thus freeing up their time. I am
      50 000 patients a year and were less than 10          not sure that the rush to develop the role of
      miles from an alternative centre.' However the        nurse practitioners in A&E departments is a
      case for centralising trauma services has been        good idea in the long term. Much of this
      weakened by the recent findings from the              appears to be based on the push to reduce jun-
      North Staffordshire experience.' Major trauma         ior doctor hours by off loading some of their
      only accounts for about 0. 1% of all A&E              more mundane tasks onto the nursing staff. I
      attendances and the mortality from road traffic       know of no A&E department that has a surplus
      accidents and industrial accidents has contin-        of nursing staff to its requirements and simply
      ued to fall over the last 20 years. I think that      giving nursing staff further duties, in the glori-
      while the management of multiple trauma will          fied guise of nurse practitioning, is adding to
      remain a priority and continue to consume a           their already overstretched position.
      large amount of resources it will be a small part        If nurses can be trained on day release
      of our workload and will probably decrease.           courses to assess wounds and prescribe, why
         However life threatening medical emergen-          do doctors need five years in medical school
      cies, which are 10 times more common than             learning about anatomy and pharmacology?
      major trauma and now account for 1 % of                  While there have been some studies looking
      attendances, are likely to increase with an           at nurse practitioners ordering and interpret-
      increasingly elderly population at risk. Inter-       ing x rays I am not aware of any studies
      vention in medical emergencies is more likely         comparing the clinical effectiveness or the cost
      to be time critical and therefore the argument        effectiveness of nurse practitioners as com-
      for centralising key services to larger units, with   pared with junior doctors in A&E
      the closure of more peripheral smaller units, is      departments.6 In large A&E departments there
      not necessarily valid. There is no acceptable         are disadvantages to training nurses to practice
      evidence as to what good access is: 10 miles in       as nurse practitioners in that it decreases the
      a rural area may be fine but in a built-up met-       number of nurses available to undertake nurs-
      ropolitan area it is another matter!                  ing roles for the iller patients. In the short term
                                                            and especially around the changeover periods
      Minor injury units                                    of February and August it may be very advan-
      The Audit Commission suggested that some              tageous to have members of the nursing staff
      smaller departments be replaced with minor            who can see, treat, and discharge patients.
      injury units. There is also a move to open               Moreover I think that recruiting nurse prac-
      minor injury units in large urban areas to meet       titioners in place of SHOs may be short sighted
      the local needs while major injuries and medi-        in that it decreases the flexibility available
      cal emergencies are admitted to a larger central      within departments. SHOs are an extremely
      unit, thus relieving the pressure on the central      versatile group generally and can be trained
      A&E department. However this is unlikely to           very quickly and adapt to rapidly changing
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Accident and emergency medicine the next 25 years                                                                                 51

                             circumstances. If you replace large numbers of       for a service which is already provided on an
                             SHOs with nurse practitioners who can see            informal basis in many areas. A&E depart-
                             and treat possibly up to 20% of the A&E              ments are in a unique position to provide this
                             attendances you may find that you do not have        service. They are staffed 24 hours a day by
                             the medical staff available when large numbers       experienced nurses who have been trained in
                             of medical or more seriously injured patients        triage. There is always a doctor on site and in
                             attend. The advantage of having SHOs seeing          many cases there is a senior doctor available.
                             the minor conditions is that when all hell           The specialty has already drawn up guidelines
                             breaks loose the SHOs can be redeployed to           on how these should be run. There are reports
                             working on the major side. If SHOs are not           documenting their usefulness and there is
                             exposed to these conditions they may have no         some evidence that it may reduce the workload
                             other opportunity to gain experience in them.        at A&E departments.8
                             Having to employ extra nurses at F grade or             If we are to take this forward we must act
                             above decreases the financial argument for           quickly as more work needs to be done to
                             such a move.                                         standardise the service and to ensure that the
                                The major role for nurse practitioners is in      advice given is safe and consistent. This should
                             minor injury units where they can see and treat      be undertaken in conjunction with local GP
                             a wide variety of minor illnesses and injuries       groups, ambulance services, and health infor-
                             according to strict protocols.                       mation services.
                                If we want to free up doctors' time we need
                             to train people as physician assistants who will     Hospital admissions unit
                             have no medical or nursing role but who will         There should be a single unit through which all
                             undertake manual tasks such as cannulation,          emergency admissions to the hospital come to
                             phlebotomy, arterial gas sampling, electrocar-       be assessed by a senior doctor in the appropri-
                             diographic recording, plastering, etc, and cleri-    ate specialty.
                             cal duties such as contacting inpatient teams,          Many hospitals have already established
                             etc. Such a system already operates in the           medical admissions units as a method of deal-
                             United States and in the military here. These        ing with increasing numbers of general prac-
                             posts must be new posts extra to present staff-      titioner (GP) referrals and admissions. There
                             ing levels.                                          are many reports of these working well. There
                             Government white paper                               is no doubt that they greatly improve the proc-
                             Having read the white paper I am very                ess of patient care and will no doubt become
                             disappointed by the absence of any concrete          more widespread. However it is important that
                             proposals as to how they plan to manage the          they are adequately resourced and are staffed
                             ever increasing demand for A&E services.7            by senior doctors, who have no other fixed
                             There is usual talk of "hard choices and third       commitments for that session, and not viewed
                             ways" but the only real references to emer-          merely as a means of avoiding admissions.
                             gency services were:                                 These units could be expanded to include
                                (1) Individual patients, who too often have       acute surgical and gynaecological patients. It is
                             been passed from pillar to post between              common sense to have these units located close
                                                                                  to A&E departments and radiology facilities.
                             competing agencies, will have access to an              These units will provide an invaluable
                             integrated system of care that is quick and reli-    opportunity for training in acute general medi-
                             able.                                                cine and a period working in such units should
                                (2) Front line patient services will be backed    be an essential requirement for training in A&E
                             by more resources and better technology.             medicine. Some of these units may well come
                                (3) If you are ill or injured there will be a     under the control of A&E physicians. One of
                             NHS there to help: and access to it will be          the ways that we could greatly improve the
                             based on need and need alone.                        relationship between medical assessment units
                                There is of course the commitment to estab-       and A&E departments is by the appointment
                             lish a 24 hour nurse based help line. The gov-       of consultants with shared responsibilities
                             ernment appears to be under the delusion that        across the two units. It may be the appointment
                             increased access to health information will          of a consultant physician with a special interest
                             decrease demand. While increased access to           in trauma or a consultant in A&E medicine
                             information may help the public choose the           with a special interest in general medicine.
                             most appropriate service there is no evidence        Such posts already exist between intensive care
                             that it will decrease demand and anecdotal evi-      and A&E and apparently work well.
                             dence suggests that it will increase.
                             Telephone advice lines                               Information technology
                             A&E departments have historically provided           Most of the recent advances in computer tech-
                             medical advice via the telephone to the local        nology other than advances in radiology have
                             population. In its recent white paper the            failed to deliver any real benefits to the practice
                             government states that it intends to set up tele-    of A&E medicine. Most departments are com-
                             phone advice lines nationally. It has apparently     puterised, some better so than others, but most
                             allocated pl/person in England and Wales to          of these are mainly concerned with collecting
                             set up such a service. This amounts to               information for management purposes and
                             C250 000 for the average district general            meeting patient's charter standards.
                             hospital population. This is an opportunity for         On the whole computer systems will not
                             A&E medicine to gain recognition and funding         improve the quality of care in terms of outcome
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52                                                                                                    Binchy

     to the patient but they may greatly improve the       College of accident and emergency
     process of care. Examples that come to mind           medicine
     are:                                                  We now have our own intercollegiate faculty
     * Real time tracking of patients through the          with a fellowship examination. However I do
        department, entering of discharge diagnosis        not think that we will be accepted as equals
        and management, with creation of the               with other specialties until we have our own
        discharge letter before discharge. This could      college. It is important to have the prestige of
        either be typed and picked up by the patient       college status if we are to have a major
        or e-mailed to the GP.                             influence on the future development of emer-
     * Online ordering of radiography and labora-          gency services.
        tory investigations.                                  The specialty is already being discriminated
     * Rapid access to previous records and results.       against in that it is not represented on the Spe-
     * Online prescribing where the pharmacy               cialist Training Authority or the Academy of
        receives the order before the patient has even     Royal Colleges.
        left the A&E department.                              Service alone will not gain college recogni-
     * The move to digital radiology will allow            tion. We must increase our academic profile if
        rapid access to x rays and joint viewing with      we are to get proper recognition from our
        a radiologist at another site.                     peers. If A&E medicine is to advance there
     In the long term there is the possibility of direct   must be high quality research within the field.
     access to GP records and the possibility of           This requires the establishment of full time
     patients carrying SMART cards with their              academic posts within the specialty. Most A&E
     medical histories into which we could put             doctors are not particularly interested in
     updates.                                              research and we will need to attract academi-
                                                           cally minded doctors into the specialty. The
                                                           best way to do this is to have some academic
                                                           centres with a track record for quality research
     Audit and quality assurance                           and attracting grants.
     At the present time the only way of comparing
     a department's performance with others na-            Defining a core service
     tionally is via the patient's charter standards       Many of the roles thrust upon A&E medicine
     such as triage times and times to see a doctor.       over the last 25 years have been reactive and as
     While these do have some reflection on the            a result of failings of other parts of the health
     process of care, they take no account of the dif-     service to provide comprehensive cover. A&E
     ferent case mixes.                                    medicine has established itself as a unique spe-
       The specialty needs to be proactive in defin-       cialty with its own training programme, exami-
     ing standards or goals which will be useful in        nations, and intercollegiate faculty. It is impor-
     assessing the performance of departments.             tant that we take a more proactive role in
     Many departments are already involved with            defining what is a core A&E service and how it
     one of these, namely the Major Trauma                 should be provided. Obviously there will be the
     Outcome Study. Other parameters that could            need for some flexibility to take account of the
     be measured that reflect both on the quality of       variations in the needs of the local population.
     care and the clinical outcome are:                    However while A&E departments will continue
     (1) Outcome from cardiac arrests that occur           to function as a safety net for the health
         within an A&E department.                         services we must strive to ensure that A&E
     (2) Door to needle time for patients present-         departments are not used to plug the deficien-
          ing with acute myocardial infarction.            cies in other aspects of the health service. As
     (3) Percentage of patients with fractured necks       clinicians at the interface between primary and
          of femur who spend more than two hours           secondary care we should be the driving force
          in the department.                               behind future developments in the provision of
     (4) Number of unplanned return visits.                emergency care.
     (5) Number of patients who did not wait to be            The British Association for Accident and
          seen.                                            Emergency Medicine (BAEM) has, in its
     Individual departments should develop quality         document The Way Ahead, already defined
     standards for the management of common                what should constitute a core service.3 This
     conditions presenting to A&E. These may               can be essentially summarised under four
     include national standards but would need to          headings:
     be much more comprehensive. Some examples             (1) Assessment, resuscitation, and treatment,
     could be:                                                  by appropriately trained staff, of all acute
     * All patients who fulfil the criteria receive             emergencies be they medical, surgical, or
        streptokinase within 15 minutes of arrival.             traumatic in all age groups.
     * All deformed fractures receive analgesia            (2) Management of acute injury-less than 48
       within 10 minutes of arrival.                            hours.
     * All patients discharged with asthma receive         (3) Management of acute pain.
        steroids.                                          (4) Management of patients with acute
     * All patients who are discharged with frac-               changes in respiratory, cardiovascular, or
       tures receive analgesia.                                 mental status.
     Staff would be expected to treat patients to          In defining a core service it is often important
     these standards and regular audit would               to define what is not appropriate use of A&E
     highlight cases that failed to reach the accepted     departments. Again this has been addressed by
     standard.                                             BAEM. The problem, however, is that "Joe
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Accident and emergency medicine the next 25 years                                                                             53

                                                                                are probably appropriate. Studies have shown
     MIU                                                                        that a significant number of these patients end
                                                                                up being admitted to hospital.9 Many are
                                                                                prepared to wait three to four hours or longer
                                                                   GP pracic    to be seen.
                                                                                   The size of this group of patients has been
                                                                                estimated at between 7-70% depending on the
                                                                                source. More realistic figures are between
                                                                                25-30%, though there is wide geographical
                                                                                variation. However the term "inappropriate
                            P         Admim ons                                 attender" is probably inappropriate and it is
                                  -       unit                                  best to think of these patients as having
                                                                                primary care problems-that is, they are in an
                                                                                inappropriate place. Many of these patients
                                                                                attend because of the difficulty in getting
                                                                                access to primary care, especially out of hours.
                                                                                   Whether we like it or not the "inappropriate
                                 Main hospital                                  attender" is here to stay. I do not think the way
                                                                                to tackle this problem is by trying to decrease
Figure 1 The "one stop shop' "; MIU = minor injuries unit.                      the demand side. There have been studies in
                              Public" hasn't read and is unlikely ever to read the United States that have showed that
                               The Way Ahead. A simple measure may be for redirecting primary care patients back to the
                              the specialty to announce nationally that it community does not have any significant
                              does not provide a family planning service and impact on the A&E workload. The way to
                              that departments would not stock the morning tackle this is to identify this group of patients
                              after pill. This would not involve a great change and to accept that they have a need. It has
                              in practice and would only affect a small group already been demonstrated that this need may
                              of patients. However it may help to get the be more efficiently met when the patients are
                              message across that the role of A&E is not to seen by more experienced doctors.'0 In using
                              provide a primary care service.                   this we should be pushing either for the
                                 Perhaps we should take this a stage further as employment of more consultants or staff grade
                              there appears to be an ever increasing demand doctors in the A&E department.
                              on A&E services. The specialty could an-             In departments that have an excessive
                              nounce that it was no longer prepared to see      number of these patients, such as inner city
                              and treat patients with conditions more than departments, there may be an argument for
                              five days old, unless they were accompanied by employing GPs to see these patients. However
                              a letter from a GP. The cut off period could I think it would be best to take this one step
                              then be reduced by one day each year until we further and open adjacent primary care units.
                              reached the 48 hour threshold. Of course we
                              would not refuse to see such patients but they Single point of access to emergency
                              would be informed at triage that they would services: the "one stop shop"
                              have to wait until the more acute patients had The answer to the problem of inappropriate
                              been seen. Again this may not greatly decrease attenders and out of hours primary care cover
                              our workload but it may to get the message may be to embrace the "one stop shop" model
                              across as to what is the role of an A&E depart- (see fig 1). A&E departments, primary care
                              ment. This would have to correspond with clinics, and admission/assessment units located
                              improved access to primary care services.         together on one site. These would be separate
                                                                                departments, probably with a common en-
                                                                                trance and triage area but with close links
                              Primary carelinappropriate attenders              allowing for the easy transfer of patients and
                              The first question is from whose point of view staff between them. There would need to be 24
                               are these inappropriate. Most of the patients hour access to high tech investigations such as
                              that we classify as "inappropriate attenders" do computed tomography, venography, biochem-
                              not think their attendance is inappropriate. istry, etc. Patients would be worked up and a
                              They may have a minor medical condition but definitive diagnosis made before admission or
                              they do not perceive it as such and until they discharge. Under such a system patients
                               are reassured to the contrary their attendances presenting with chest pain would be admitted
                                                                                when a myocardial infarction was confirmed by
                                                             Ambulance          electrocardiography or by biochemical mark-
                                                           n   control          ers. Patients with non-diagnostic electrocardio-
                                                                                grams or biochemistry would have an exercise
                                                                                stress test before discharge or within 24 hours.
                                                                                Similarly patients with an acute wrist
                                                                                (?scaphoid) injury would have bone scan or
                                                                                computed tomography.
                                                                                   If such units were to function properly they
                                                                                must have their own support services such as
                                                                                social workers, physiotherapists, and occupa-
                                                                                tional therapists working on an extended hours
Figure 2 Out of hours telephone advice.                                         basis.
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54                                                                                                                  Binchy

        Similarly the nurse telephone advice service     future provision of emergency care. I hope to
     and primary care out of hours service would be      have raised some points for further discussion.
     based at the same centre (see fig 2). Patients
     would ring to seek medical advice. If it was          1 Audit Commission. By accident or design? Improving A&E
                                                              services in England and Wales. London: HMSO, 1996.
     thought that the patient needed to see a doctor       2 Williams B, Nicholl J, Brazier J. Health care needs assessment:
     at that time they would be instructed to attend          accident and emergency departments. Sheffield: Department
                                                              of Public Health Medicine and Sheffield Centre for Health
     either the primary care centre or the A&E                and Related Research, University of Sheffield, 1996.
     department. If it was felt that a doctor should       3 British Association for Accident and Emergency Medicine.
                                                              The way ahead. London: BAEM, 1997.
     make a home visit this would also be arranged         4 Nicholl J, Turner J. Effectiveness of a regional trauma
     from the primary care centre. Where it was felt          system in reducing mortality from major trauma: before
                                                              and after study. BMJ 1997;315:1349-54.
     that the caller warranted emergency care an           5 Dale J, Dolan B. Do patients use minor injury units appro-
     ambulance or a paramedic response vehicle                priately? J Public Health Med 1996;18: 152-6.
                                                           6 Salt P, Clancy M. Implementation of the Ottawa ankle rules
     would be dispatched.                                     by nurses working in an accident and emergency
                                                              department._ Accid Emerg Med 1997;14:363-5.
                                                           7 Secretary of State for Health. The new NHS. London:
     Conclusion                                               Stationery Office, 1997.
     I have given a personal view of some of the           8 Srinivas S, Poole F, Redpath J, et al. Review of a computer
     issues and challenges that face the specialty.           based telephone helpline in the A&E department. Jf Accid
                                                              Emerg Med 1996;13:330-3.
     This is by no means comprehensive and there           9 Dale J, Green J, Reid F, et al. Primary care in the accident
     are many other challenges facing us. I do not            and emergency department: 1. Prospective identification of
                                                              patients. BMJ 1995;311:423-6.
     claim to have any of the answers. However I          10 Murphy AW, Bury G, Gibney D, et al. Randomised control-
     think it is important that we address these              led trial of GP versus usual medical care in an urban acci-
                                                              dent and emergency department: process, outcome, and
     issues and be proactive in determining the               comparative cost. BMJ 1996;312:1 135-42.
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                                  Accident and emergency medicine--the next
                                  25 years.
                                  J Binchy

                                  J Accid Emerg Med 1999 16: 48-54
                                  doi: 10.1136/emj.16.1.48

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