Delays At Hospital

First off go and read this. Some of the comments are pretty good as well.

The article has changed somewhat from when I first read it, but it still seems to place a large part of the blame on the ambulance service. The last section tends to stick in the mind, especially the paragraph that reads.

It had failed to meet response time targets and was branded “appalling” and “unacceptable” in a report by a committee of AMs in March this year.

If things are unchanged since I was a nurse on a Medical ward and a Care of the Elderly ward then I can explain exactly why patients are waiting on ambulances for A&E trolleys.

The routine for a patient who needs a trolley and then admission to the hospital goes something like this.

1. Patient calls 999, ambulance turns up, does clever medical stuff and drives them to hospital.

2. Ambulance gives patient to A&E department by putting them on an A&E trolley.

3. A&E department doctor sees the patient, does even cleverer medical stuff, and decides they need admitting.

4. A&E nurse calls the bed manager, bed manager finds the patient a bed on an appropriate ward.

5. A&E transfer the patient to the ward.

6. Patient gets treated on the ward and either goes home or, if unable to return home, is referred to the social workers who arrange a care home/warden controlled place/home care package.

So where is the most common delay? It's at step 6, and this trickles back all the way to step 2.

When a patient cannot return home (for example following a stroke) the social workers need to sort out who is going to fund the care home, they need physiotherapy reports, they need occupational therapy reports, they need to run 'Multidisciplinary team' meetings and they need to do all the other arcane and hidden things that they get paid to do.

Then there needs to be an available place at a care home that the patient and family are happy with. And this all takes time, and so the patient becomes a 'bed-blocker'.

(The record for me when I was a nurse was a patient staying on the ward unnecessarily for six months while funding was sorted out)

Even if the patient can return home but needs assistance, be that daily carers or just a stairlift installation, the delays are much the same.

If the ward beds are full there is no place for a new patient, so the patient stays in A&E taking up a trolley that could have been used by the next patient rolling in by ambulance.

Which means that the A&E department turns into a medical/surgical/psychiatric ward by knocking the wheels off some trolleys and hiring and expensive agency nurse to look after the patients for a few days.

There are other delays, like ward nurses 'not being ready' for a patient even though they have an empty bed, or A&E departments being reluctant to accept new patients because it would impact on their four hour government target. But generally I would say that these are fairly minor and can be fixed by a Matron with a big stick. Or an angry A&E nurse threatening ward nurses with bloody murder…Ahem…

I think that when Mike Cassidy says, “We've experienced some difficulties, maybe one or two days every couple of weeks just when the system overheats a bit and when demand is extremely high for us.”, he is highlighting that this is a cyclical thing, and perhaps people should look into why it is a cycle. Is it because in the hospital social workers and the like vanish at the weekend, leading to a Monday/Tuesday backlog of patients?

However – both the hospital trust and the ambulance service blame the number of 'inappropriate attenders', people who should have gone to their GP for their minor illness. 'Inappropriate attenders' don't block beds – they tend to slow down the transit of people through A&E, but as they seldom need trolleys to lie on they can't really be blamed for making ambulances wait with their patients for trolleys. What 'inappropriate attenders' do is make other minor injury people wait to be seen.

We can blame 'inappropriate attenders' for a lot, I know I do, but in this case their influence is tiny.

What is needed is more social workers, more care homes and more hospital beds with the nurses to staff them. There needs to be a way to move people who no longer need hospital treatment into appropriate placements much faster and there needs to be a streamlining of the discharge into care process.

But that requires money.

And I'm not the minister for health.

16 thoughts on “Delays At Hospital”

  1. I can relate to this. My granddad was in hospital for many weeks following a fall.A couple of days after he died, we received a call to say that a place was finally available at a nursing home.

  2. I still think that the people showing up to the Emergency Room with a cold are the ones who are really screwing up efficiency in that setting. People need to stop using the Emergency Room as a primary care clinic.Dominic A. Carone, Ph.D.

    Founder and Webmaster of and The MedFriendly blog.

  3. In Sufolk it's the same. You stand in A&E watching beds dissapear from cubicles !!! ethier to xray or wards. Result, no where to put our patient. Hour and a half our record, good job the patient slept most of that !!!!Magical

  4. Correct me if i'm wrong… but didn't we used to have places to send people who need a half way house between hospital wards and home? And Matrons we used to have those too right… Hummm I see a possible solution… reverse all the modernisation and actually get back to takeing care of people again!

  5. Do A&E departments in the UK have a specific triage nurse/doc ? In many ED's here in the US if you bring a patient in who has non critical 'walking wounded' type stuff, we take them straight off of our stretcher, and stick them in the waiting room where they are put into the patient triage queue. This keeps the actual ED beds for actual ED patients who need them. It also means that people who call an ambulance because they think it'll get them faster treatment for a minor injury are sorely disappointed.The second question one would ask is whether this is a radical increase in patients leading to an overload of the A&E, or a fundamentally flawed system where all patients are funneled into an underequipped system when other resources (GPs, local clinics etc.) are available but largely unused. In my town we have a fairly nice local Health Center which does have such things as an X-Ray and the ability to triage, but if someone shows up with anything from a cut finger to chest pain, they call 911 and sit in the waiting room until we show up and drive them 30 minutes to the closest emergency department. If I had to guess, I'd say that it is professional liability insurance and lawsuits that prohibit doctors in this kind of facility from carrying out any kind of care – but maybe I'm just being cynical….

  6. I'd also add that defensive medicine is responsible for bed blocking. Like when elderly people with dementia-type illnesses are admitted to hospital with 'confusion'. They then go on to be thoroughtly over-investigated until declared'medically fit for discharge' two weeks later. By which time they've quite likely had a fall or picked up a hospital aquired infection, or simply lost whatever coping skills they may have had prior to admission.

  7. Sorry to detract from the serious points raised by the other comments, but 'clever medical stuff' and 'even cleverer medical stuff' had me giggling for quite some time at work, which I totally needed, so thanks for that. The few times I've had to go to a+e, I have either not had to wait at all, it was in Britain's tiniest* a+e with 1 doc, 2 nurses and 1 patient; me. Or only wait a couple of hours, 1am in Aberdeen, so as a patient top marks from me, as however these are the only 2 times I've visited a+e I'm not qualified to judge. I think even the worlds best heath services probably need more nurses/beds/money and will continue to do so as we live longer and get all these illnesses the human body was never meant to survive long enough to get.*possibly I have made this up

  8. all good points as per, I wouldn't have commented BUT has the layout of this page changed or is it just me? The sidebar seems to have gained weight.

  9. Whatever else, it is clearly totally innappropriate to hold the ambulance service in the least bit responsible for these delays…those concerned have fully discharged their responsibility by turning up, treating the emergency and then arriving with the patient at A & E – after this point it's up to someone else and I cannot but feel the senior Ambulance Manager quoted has done his staff no favours at all by being so defensive…

  10. It really seems to be a case of same sh** different city. The lack of an effective system to move 'bed blockers' on to appropriate care is one big issue. The other, at least her in Melbourne, Australia, is the lack of that appropriate care. With an ageing population that is living longer and longer, we are in a crisis situation. The ripple effect to every other part of the health system is a huge challenge and one that isn't being dealt with very effectively at the moment.Our Ambulance Service has avoided direct blame for high volume 000 calls as a contributing factor – for the moment – but the howls have begun at longer response times (attendance delays) directly related to triage and handover delays at hospitals which have increased from 15-20mins previously to upward of 30mins as the current norm, due, in part to bed blocking.

  11. Its quite maddening when we have an eight minute orcon to make for cat “A” calls when we can be the “only available vehicle” and have to travell across an entire city to get to the patient, we do some ambulance magic, get the patient on board arrive at the A&E dept and thats when our hearts sink, looking up the corridor at the other crews “tied up” with their patients. Not only do you know that it may be a good half hour to be triaged, you also know your patient needs a bed so the patient, the patients family and us the crew join the end of the que knowing that there may be a delay of up to three hours at times. We appologise to the familly as we slowly move up the que, by the time we have a trolley space we feel we have known the familly for years. We hand over, triumphant! but as were leaving passing other crews that have congrgated behind us we get the sneaky feeling were going to be joining the end of the que pretty soon!

    Ironically there “are no problems at the A&E dept” so the finger points at the ambulance service who ” roll over” and admit blame????!!!!

  12. Hello from Wales.. Well, I was shocked to see our humble trust made it onto the world wide web.. Things aren't as rosy in the garden as our bosses make out, with an increase in rapid response vehicles but a decrease in manned ambulances, then response times have improved but the RRV'S are waiting on scene sometimes with seriously ill patients for over an hour ( sometimes dying in front of them..) until a vehicle arrives, then we go back to the hospital and queue again for hours.. the whole system is in meltdown but we all publicly carry on smiling as we head towards the precipice… A lot of the staff on the RRV's have decided it's not for them and have handed the keys back..As for Mr Murray, well there's a rumour he'll jump ship soon…

  13. Does that mean the NHS had best spend some of its scant reserves on getting the message across to the public? I think it would be a good investment.We have access an excellent out of hours, drop in urgent care centre, that is available to the patients of group of 7 GP's surgeries, but how this 'product' has been 'sold' to us has been dismal, people don't really understand what it for (to keep us out of A+E) its hard to find, not sign-posted, poorly lit and tucked away at the back of what looks like an industrial estate.

    Does a 'leading brand' launch a new 'product' by placing one advert?(one press release in the local paper) and does it expect its 'customers' to go and find that information or does it sell itself? (if you happen to go into the surgery you can pick a leaflet, but we have not been sent this information to our homes) or does it promote itself? The NHS has been quick to adopt many commercial practices that make them money, (it annoys me that I have to pay to park at A+E or visit the sick) they would do well to adopt some commercial practices that would better serve their 'customers' the business mantra is tell 'em; tell your patients what is available to them; tell once, tell them twice then tell them again. Its poor communication that is at the root of the problem.

    The NHS is a mad dog chasing its own tail; do you think it will collapse from exhaustion soon

  14. It be time for the A&E to have a separate unit staffed for all walking wounded, set up as a clinic with an old fashioned Nurse with a Sgt. Majors boom voice and a syringe with a horse needle on one lapel a lolly pop on the other. Then hands out a paper gown and sends the customer to the locker room and told strip [regardless if it be adenoid or in-growing toenail problem ], those with neck braces can be shown the television set then be watched for those that can swivel and anchor eyes on the one with a TV neckline. All those with blud then can be processed.

  15. I can beat 6 months – we had a poor lady who'd had a stroke she stayed about a year,'till she died because one geriatrician was resposnsible for the area in which she lived, the other for where she was in hospital and neither would take resposnsibility for her. (It was a long time ago mind you.) Her home remained empty,she would nefer have been able to go back, I don't know if it was private or council but either way someone else could have been living there!

  16. In Norfolk we have M.I.'s (Minor Injury Units) the last 2 times my families need treatment we been to the MI. Advantage to us is easy to get to A&E isn't and short waiting times if at all. The last time was because my wife was suffering pain to her stomach. We got seen right away and they said we can't deal with it, then asked if we had a car and told us to drive to A&E (roughly 40 mins away). We got notes pretreated on arrival at A&E even though it was a Saturday night we seen quickly due to us already attending MI.The thing is the only place I have seen these advertised is at the MI's or the A&E departments themselves. Never in Health handbooks or by NHS direct. Is Norfolk the only place to use them on mass or are they hidden everywhere else to?

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