What a fortnight.
During what has been described by some (not all) as a ‘crisis’, hospitals around the country have found themselves full to the brim. Patients (and nurses to look after them) have been moved into ‘escalation areas’, meaning that doors which usually open onto sleepy corners or waiting rooms now reveal eccentric looking wards buzzing with activity. Queues of trolleys, a rare scene in most Emergency Departments nowadays, have stretched into corridors. The ideal (arbitrary but for the most part admirable) of being seen, assessed, treated and moved into a bed within four hours has been denied an increasing, though not enormous, proportion of patients. Papers have latched onto the rather dated idea that people who have suffered neither ‘an accident’ nor ‘an emergency’ should not be there. The sense that something exceptional is happening has spread, and even without a major internal incident being formally announced many doctors and nurses changed their usual routine.
It is strangely exhilarating to work through a crisis. People pull together and up their game. You begin to wonder, ‘Shouldn’t we work like this all the time?’ But the energy that a crisis releases is finite. Doctors and nurses can extend themselves for so long, but they cannot maintain a heightened level of activity for too long. Cracks begin to appear. As I paced the wards repeatedly over the last two weeks I observed, in myself and others, some subtle but unwelcome consequences of ‘crisis’ psychology.
‘Crisis’ communicates itself to patients. Those who are aware of what is going on outside the building know that the system in which they find themselves is under pressure. Occasionally this pollutes the patient-doctor relationship. A frail patient awaiting placement [MFFD in the current parlance, Medically Fit For Discharge] looked up at me and said, “I know you need this bed, sorry…” to which the only response could be, “No, this is your bed, and you will be in it as long as you need it. Please don’t worry about that.” However, having just left a bed meeting in which the vital importance of ‘flow’ was again emphasized, I thought privately, ‘Yes, but we do need your bed, for someone waiting in the ED who is acutely ill’. The frustration that we feel in this situation cannot be allowed to communicate itself to the patient. If it does, they will feel as though they have become a burden to the system, and trust will begin to dissolve. We have been there before – it was only a year ago that the idea of ‘death pathways’ being used to free up beds was seriously entertained in the press.
With younger and more robust patients one can be more open about the pressures. During another ward round intended to identify possible discharge I said to several patients, “I saw you this morning, I know, but I’ve come back to see if there is any possibility that we can look after you at home with this chest infection/pain/cellulitis/diarrhoea etc.” A common response was “I would much rather be at home doctor, but I just don’t think I can manage.” Without such a frank approach extra discharges will not be achieved, but the question, once asked, skews the dynamic. It leaves behind the feeling that behind every interaction lies a subtext – how quickly can we get you out? On the one hand we listen and respond to the pressures around us, trying to effect every discharge that we can. At the same time we must maintain the perception and the reality that business – the provision of good care centred around an individual’s needs and no others – continues as usual.
Patients must believe that their best interests are uppermost in our minds, even as we balance the need of the community with the need of the individuals in front of us. Senior doctors have a managerial responsibility to improve the situation and help with patient flow. They cannot bunker down and adopt a wholly myopic view. But they are also the last bastion of defence if and when those pressures threaten to detract from the care that is given. When it comes to crunch, the welfare of the patient in front of you must trump the needs of those queuing to come in. This is what crisis does – it creates hard choices and does not permit right answers.
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