Saturday, 1 June 2013

NHS,The flipside. Emergency Services.

Last week I had another taste of NHS services at Portsmouth's Queen Alexandra Hospital.

So lets start at the beginning. My wife was pretty ill, with a high temperature and no very with it. I Googled the doctors surgery for the out of ours number and it came up with the dreaded 111. Yes, the very number we've been told has a horrendous reputation and was a catastrophe for the Government.

Well, to be honest the 111 service was fine. I explained the wife's symptoms, who by now was adding to the atmosphere of urgency by ranting deliriously in the background. To his credit the 111 operator made (I think) the right call and didn't quibble about bumping the call up the chain to the Triage centre at the AQ Hospital. I got a call back from them within two minutes and explained the symptoms. Quite rightly they first wanted me to bundle her in a car or taxi and take her up to hospital, but as I explained her symptoms we agreed she wasn't fit to travel that way. The bad news was (I was told) that it could take up to 6 hours for the doctor to make his visit. I still didn't relent and said I'd be happy to wait.

Now let me say that my impressions of the 111 service are that it works. I didn't have any expectations, other than I needed my wife to be seen by a GP at home. The 111 operator was professional, asked the correct questions and came up with a reasonable response in that the call would be passed to a medical professional. I was called back so quickly that it took me by surprise. The nurse or doctor calling quite rightly emphasised that my wife would be treated quicker if I could get her to hospital under my own steam, but was quite happy to book a visit by the on-call GP.

The GP arrived within the hour and took about 15 minutes to assess my still delirious wife. He made a few phone calls and booked her into the Medical Assessment Unit at the QA. He also booked an ambulance to take her up there as he was also of the opinion she couldn't be bundled into a car. He wrote us a letter to hand over to the MAU detailing his findings. He diagnosed septicaemia and said she needed IV fluids and antibiotics as quickly as possible.

The ambulance turned up within 30 minutes and she was scooped up and laid out on the stretcher for transport to hospital.

Again, I have no issues thus far. The doctor had arrived in a fair amount of time considering my wife wasn't an emergency case, despite her temperature and delirious state. However, this is where the system falls down. No fault of the 111 service, but a problem with the Emergency Service at the QA and probably most hospitals. The Ambulance crew were already sceptical about her being admitted to the MAU, as it had happened lots of times where they had accepted patients from GP referrals when a bed was not available, hoping a bed would be freed by the time the patient arrives. Of course if bed blocking occurs higher up on the wards, then this isn't possible. It also means that the ED becomes overwhelmed as they can't bump assessed patients up the chain for treatment.

We duly arrived at the QA and as the doctors note had said she was booked in to the MAU, we took her there and guess what, no bed, which means my wife has to start right back at the beginning, to be re-assessed by the ED.

We arrived in the ED to what one nurse described to me as organised chaos. And that's exactly what it was. In a "we've done it many times before" fashion, the scene in ED was about ten trolleys stacked up in the handover area, and at least another twenty trolleys-worth of patients stacked up in the corridor between the reception and the actual ED. Because there weren't enough nurses on staff to cope with that number, the Ambulance staff had to stay behind to manage patients until they could be handed over to ED staff. At one point there were 4 ambulance crews stuck at ED, each crew responsible for 8 patients.

To their credit everyone did their jobs professionally. My wife had hourly observations, so her condition was monitored. By the Ambulance crews for the first hour and then the ED nurses once we'd got to the handover point which was about half way down the corridor and about 2 hours time-wise.

On the second hourly observation it was noted my wife's blood pressure had dropped and by now she was semi-concious. It was decided she needed to be bumped past the falls and sprains and into the smallest Emergency Department I've seen. I didn't count them but there were approximately 10 cubicles in the department and that's being generous.

There were also a couple of side rooms, where my wife was put. The bad news is it was still another 30 minutes or more after she was admitted to the ED proper that a doctor came in and did the self-same tests our GP had done 4 hours earlier and came to the same diagnosis. Appropriately my wife was administered IV Saline and Antibiotics and an two hours later admitted to a ward..

So after all of that, I just wonder what the 111 service is for? It had gone quite smoothly up until the point my Wife needed to be admitted to hospital. Why would the MAU accept her on the phone from the GP but then refuse her 30 minutes later? Especially as it seems to be a regular occurrence according to the Ambulance staff.

Why doesn't the MAU have a holding area where referred patients can be held pending admittance without having to be bumped back down to the ED?

Why then bump her back down the list to ED effectively putting her back to square one where all the GP's observations had to be done all over again proving a waste of his time? Not only that it put her life in danger as the drop in blood pressure was an indication she was going into septic shock?

Why was the ED so pitifully small? For a general hospital serving a large metropolitan area it seemed crazy to have such a small department. Especially if it means Ambulance crews are tied up monitoring patients when they should be attending cases outside the hospital. I would guess 4 Ambulance crews is a large proportion of the crews on hand that day.

So, despite my glowing report the other week about my diagnosis and care after my stroke it seems there is still lots to do in the NHS. It just depends where the money is being spent and what the priorities are. I assume that all depends on what criteria are being monitored by government at any one time.

As an aside, had my wife's blood pressure not dropped, we would have been waiting over 3 hours to get to the ED. Funny that, given the Government's target for ED admission times is 4 hours. Just another indication that in Government when you set limits and measure things, what invariably happens is things are precisely designed to those limits.