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Make the Right Call: Ipswich Hospital’s emergency department battles to keep flow of patients moving

18:15 16 June 2014

Paul Morris, Ipswich Hospital

Paul Morris, Ipswich Hospital's Emergency Department charge nurse

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The Emergency Department at Ipswich Hospital is under increasing pressure with 60 extra people attending every day compared to four years ago. Health correspondent Lauren Everitt reports after spending the day in the Emergency Department last Monday.

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Jodie Harris, an emergency nurse practitioner at Ipswich HospitalJodie Harris, an emergency nurse practitioner at Ipswich Hospital

It is nearly 11am and there are already 42 patients awaiting treatment in Ipswich Hospital’s Emergency Department (ED).

And the majority of those are ambulatory – walk-in – patients waiting to see one of the clinicians on duty.

Dr David Hartin, clinical lead for the department explained it’s often busy when the day shift takes over from the night team.

“When we changed shifts we were doing OK before this morning’s spike came in,” he says.

Dr David Hartin, clinical lead for the Emergency Department at Ipswich HospitalDr David Hartin, clinical lead for the Emergency Department at Ipswich Hospital

When a walk-in patient arrives in the department, they are checked in at the main desk before being triaged within 15 minutes.

“In the triage the patients are assessed to see how sick or injured they are,” he explains. “They are then colour-coded in terms of how quickly they should be seen.

“The most serious are red and they will be seen immediately. Orange within 10 minutes, yellow within one hour and green within two hours.”

Having looked through some of the initial triage notes, Dr Hartin reveals some of the complaints.

Make the Right Call

• Earlier this month, the East Anglian Daily Times and the Ipswich Star launched a major campaign to help people make the right decision when it comes to healthcare.

• Entitled Make the Right Call, the 12-week campaign will see the two newspapers teaming up with Ipswich Hospital, West Suffolk Hospital, NHS Ipswich and East Suffolk and NHS West Suffolk Clinical Commissioning Groups (CCGs) and NHS 111 provider, Harmoni, which is now part of Care UK, to encourage people to make the right choice this summer.

• The aim is to help relieve some of the pressures on our hospitals’ emergency departments by pointing people towards other services.

• That could be achieved by self-caring at home with a well-stocked medicine cabinet, seeking advice from a pharmacist, visiting your GP or calling NHS 111 – to get the fastest treatment in the most appropriate location.

They range from falling off a bike the previous week, a boxing injury from the weekend, a twisted ankle from last week suffered after falling down the stairs, having a tick removed and a cold.

According to Dr Hartin, about half of these patients would have gone to their GP if they could.

The ED has two computer systems with screens so the medical team know how many East of England Ambulance Service Trust (EEAST) ambulances are coming in.

The other screen details how many patients have been inputted into the system, what their complaint is and how long they have been waiting.

The team is also ready for incoming ambulances and as of 11am, there were four patients from ambulances – one was fitting, one was a trauma case and two were patients referred from a healthcare professional.

As well as receiving ambulances from EEAST, the ED receives St John Ambulance crews and other private ambulance firms.

“We always know if an EEAST crew is coming in but with the others we don’t always know,” Dr Hartin explains. “If they have concerns they ring us on the red phone and that comes directly from the ambulance crew or control room.

“Before the new treatments came in, a lot would have gone to the wards to be assessed but now they all come into ED.

“Anyone with major trauma, chest pain, sepsis are also the types of calls that are called through to us.”

The ED has to get patients off an ambulance trolley within 15 minutes or face a fine from the commissioners. Those patients are transferred into one of two RATS (Rapid Assessment Teams) bays where they have an initial assessment, receive pain relief or IV fluids if necessary.

Dr Hartin says: “It’s imperative you get people off trolleys as quickly as possible.

“Our new system has been put in place and we are still working on it. It could be better but it has made a difference and put us in the top 10 performing EDs in the country.

“That’s been a result of little changes that have made a big difference – the fact we have more doctors, more nurses, the RATS process.

“There’s no capacity that we would ask the ambulance service to divert patients away from us,” Dr Hartin explains. “On most occasions we have been the receiver of patients from hospitals that are full rather than us diverting them away.

“We have yet to declare a major incident at the trust.”

Some of the more serious patients that were on a bed in the ED including one with gut bleeding, one with chest pain querying a stroke and one with a fractured hip.

It is now noon and there are 50 people waiting for medical treatment -– another 17 patients were added to the waiting list between 11am and noon.

One of the most important aspects of the ED, is ensuring patients are seen within the four-hour target.

Helping ensure that happens is the floor co-ordinator, staff nurse Paul Morris.

Dr Hartin adds: “We can feel the culture has changed. Previously we had to do a lot of pushing to get people onto a ward. Now you can see the results with a gentle pull from the wards to get patients out of the ED.

“There’s got be flow. If we have flow, we perform. If the flow stops for whatever reason, there’s not a lot we can do.

“But it’s all about patient safety then, we forget about the targets. Patient safety comes first here all the time.”

Mr Morris says: “The co-ordinator role works from 10am-10pm but the hours will be extended shortly.

“It’s important to keep the flow going. We don’t want to keep people waiting while they’re ill.

“It’s frustrating not to always be able to deliver that care as efficiently as possible but since our new system was introduced we are not seeing those large delays.”

Dr Hartin explains the department sees a lot of crash victims, equestrian injuries and sports injuries. “As soon as the clocks go forward we get more injuries from motorcycle accidents, misadventure, DIY jobs gone wrong, sports injuries and falls,” he adds. “We have a fairly standard case mix but everyday is different.

“We do have high numbers of elderly people visiting the ED. Elderly people will fall over and it doesn’t matter what time of year and they often have multiple things wrong with them.

“We then have to make a decision over whether to admit them or not.

Emergency nurse practitioner

Jodie Harris is working a shift as an emergency nurse practitioner (ENP) in the ED.

She says patients are triaged within 15 minutes and then categorised as to whether they need to see an ENP or a doctor depending on how severe their case is.

From 8am-1pm, she has treated 12 patients already as well as running a daily clinic.

Some of the ailments have included limb injuries, foot pain and a lady who fell the previous day and had a head injury.

“It’s difficult for patients. If they have a wrist injury they need an X-ray so a lot of the time they will see their GP and end up here anyway,” she explains.

“We see a lot of things such as a common cold, feeling unwell for four weeks, vomiting and diarrhoea for a few days.

“Those things add extra pressures because they have been sitting in the waiting room, in the treatment room and used the toilets which then have to be scrubbed clean.

“Some patients do call NHS 111 and others ring their GP but tell us they wait ages for someone to pick up the phone, explain to the receptionist what the problem is and are then told they are not a priority so you can’t have an appointment.

“So some of those end up in A&E.”

Other problems that are treated by ENPs include insect bites, dog bites and skin infections.

• On Monday, the department saw 250 patients as well as 62 ambulances – above the average weekday attendance of 250 people.

Visits to the ED rise at the weekend with up to 270 patients.

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