Delays in A&E: Not Just a Matter of Time

23 February 2017

Over the past few weeks there have been numerous stories published on the pressures which A&E Services have come under this winter.  The time taken to be seen initially, as well as the “trolley wait” for admission has been under scrutiny like never before, with reports of significant numbers of patients with waits of between 4-12 hours and even longer. 

For some patients, though, the wait is not just about time, however inconvenient or distressing a long wait may be, but about a narrowing window of opportunity for treating a time critical emergency.  It’s also about whether, once seen, correct advice is given and the next steps in the treatment plan are properly carried through. 

Patients with an infection which has turned into septicaemia, such as meningococcal septicaemia for example, may well respond to antibiotics, but only if they are administered in a timely fashion and before the septicaemia is too far advanced.  With meningitis, time is of the essence not just in being seen initially but in commencing investigations such as a lumbar puncture and blood tests which will allow the correct diagnosis to be made.            

Another area where delays can impact further down the line is where there is need for urgent radiological investigations such as MRI or CT scanning.  As a clinical negligence lawyer it is not uncommon to see cases where early delays in initial care compound an already time critical situation.  Precious time can easily be lost in vascular emergencies, for example, where a clot is blocking the flow of blood and needs to be removed either surgically or through clot busting drugs to restore the blood supply to an area of the body which can only persist for so long before damage is irredeemable, and loss of limb or life occurs. 

The ability to identify those in A&E who truly need urgent care from those who don’t is vital.  But how careful is that triage in A&E when the pressures are so enormous and when the beds may simply not be available?  Indeed, just recently, the Vice President of the Royal College of Emergency Medicine pointed out that we have the lowest number of acute beds per capita in Europe.  It did not surprise me to read recently in the press about a patient who was sent home with paracetamol when in fact she had several tumours on her spine and was found later at home completely incapacitated. 

There is a great danger that not only may those who need urgent attention find that their outcome is poorer because of the wait to be seen but the number of mistakes being made are likely to rise as services are squeezed. 

There is also concern that the people who should be seen in A&E may avoid going because of the current crisis, or may seek primary care and delay being seen by the right people in the right place.  In addition to this, ambulance staff may well be under pressure not to unnecessarily convey patients to hospital and much will rest on paramedics own decision making as to whether the advices given are safe or not.  Directing the right people to the right place make sense, but only where there is appropriate training for those early decision makers and where there is sufficient funding for non-hospital settings. 

Public Health campaigns over recent years have highlighted the need for early intervention in stroke and heart attacks.  But there are, of course, many conditions where reliable and timely assessment in hospital at the outset is vital for both survival and limiting or avoiding poor outcomes. 

It seems that there is a growing consensus on some of the causes of the current crisis in A&E, not least the thorny issue of social care and its impact on exit blocking.  The challenge now is to identify the most effective strategies for tackling these problems.  Sadly, however, until the crisis in A&E is addressed, legal action which revolves around emergency care and avoidable harm is only likely to increase. 

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