Category Archives: General

ED Attendances: Win, lose or draw – Does it matter if England can’t score?

This article was originally submitted to the Christmas BMJ and rejected as it wasn’t ‘interesting enough’. I’d forgotten I’d ever written it but reminded by the following tweet here is the original paper – please take it in the spirit in which it was originally intended!

The idea for the paper came from Ejiro Obakponovwe, who sadly passed away recently having developed ovarian cancer, I am sure she would have been delighted to see the paper released and if you do enjoy it please consider making a donation to a Joyful Joy – a charity she supported.

Presentations to Emergency Departments during a Major Football Championship:

Win, lose or draw – Does it matter if England can’t score?

Abstract:

Hypothesis: Anecdote suggests major sporting events reduce attendance at Emergency Departments. The poor performance of the English national side at this summer’s World Cup raised concerns that this was not occurring when England failed to win.

Objectives: To determine whether England match results during major football championships affect attendance at Emergency Departments

Design: A retrospective descriptive study

Setting: A busy city centre based Emergency Department

Data Sources: Attendances to the Resuscitation, Major, Minor and Paediatric areas were counted for the 8 hour period surrounding kick off time (4 hours either side) of World Cup and European Championship matches England played in events since 2004. These were matched against equivalent days in non-championship years.

Results: On average, the number of attendances to the Emergency Department around kick off on match days was 160 compared to 200 (Ratio 1.25, 95% CI 1.12 to 1.40). This reduction held true when the whole 24 hour period was considered (p=0.035). The trend was observed for categories of Minor (Ratio 1.51 (95% CI 1.28 to 1.77), p<0.0001) and Paediatric (Ratio 1.22 (95% CI 1.04 to 1.43), p=0.015) attendances but not Major (Ratio 0.96 (95% CI 0.82 to 1.12), p=0.578) or Resuscitation (Ratio 1.12 (95% CI 0.76 to 1.66), p=0.570). There was no evidence to suggest a difference in the number of total attendances between matches where England won or lost/drew (p=0.148).

Conclusions: The results indicate that staff in Emergency Departments should not have been concerned about England’s poor performance this summer as it did not increase their workload. Given an overall reduction in attendances the NHS should have an active interest in the England football squad and its management structure to ensure continued presence at World Cups and European Championships.

What is already known on this topic?

Although anecdote strongly supports the theory attendances to Emergency Departments decrease during major sporting events there is evidence to refute this.

Little research has examined the effect on the actual result of the English football team on attendances to Emergency Departments.

What this study adds?

A poor England performance does not appear to affect attendance although the public reduce their Minor or Paediatric attendances during championship matches in which England are playing. However they recognise that serious illness needs treating as demonstrated by the fact Major and Resuscitation area attendances are unaffected.

This may indicate the NHS should be interested in the future fortunes of the England team.

Introduction

Anecdote in Emergency Departments (EDs) often concerns a reduction of attendances when large sporting events are taking place. There is evidence to suggest this is not the case 1,2 and persons presenting with alleged physical assault to EDs may actually increase 3. The staff at the Leicester Royal Infirmary Emergency Department felt negative England performances were affecting attendances during this year’s disappointing World Cup campaign. Previous research in this area has only investigated presentations with alleged assaults when a national team played 4with increases following victories. We postulated that following an England loss attendances for minor injuries may increase in the hours following the game compared to matches in which England won (in the latter case the supporters’ physical pain is compensated by the enjoyment of celebrating).

Methods

The Leicester Royal Infirmary Emergency Department Information System (EDIS) was interrogated for attendance figures from 2004-2010. We extracted attendance data for each England match day (Table One) of the European Championships (Portugal 2004) and the World Cup (Germany 2006, South Africa 2010). Unfortunately England did not qualify for the 2008 European Championships. Attendances were categorised into Resuscitation, Major, Minor and Paediatric Group with the age and time of presentation also noted. Non-match days were identified for comparatives on the same day of the week in the following year (or a year earlier for 2010). Attendances, for the purpose of this study, were counted for the 8 hour period surrounding kick off time (4 hours either side).

Slide1

Poisson regression models, correcting for over dispersion, in SAS version 9.1.3 were used to compare the number of attendances between the 13 match days and the equivalent non-match days, both overall and by categories of Major, Minor, Child and Resuscitation. Poisson regression models also compared the number of attendances in ED on match days between matches where England won to matches where England drew or lost. No identifiable data was requested from the database.

Slide2

Results

Attendance data is demonstrated in Figures One and Two. There were a lower number of attendances in the 8 hour period surrounding match days compared to non-match days (p<0.0001). On average, this was 160 on match days compared to 200 on non-match days (Ratio 1.25, 95% CI 1.12 to 1.40). This trend was observed for categories of Minor and Paediatric attendances but not Major or Resuscitation (Table two). Using a matched pairs t test, there was also a lower average number of attendees in the 24 hours period of a match days compared to non-match days (p=0.035).

Slide3

There was no evidence to suggest a difference in the number of total attendances between matches where England won or lost/drew (p=0.148). This trend was observed for all categories (Table Three).

Slide4

Conclusion

Although there were only 13 available matches (England’s failure to qualify for the 2008 European championship reducing our dataset) it appears actual results impact little on attendance figures. Therefore staff not on shifts during match days should not feel too guilty about watching the match as the result is unlikely to be relevant to the department’s workload. In fact, as our results support the anecdote that attendances decrease, they may feel even less guilty. The general public appear to be able to tolerate the discomfort of a minor illness or injury on match days but perhaps do not feel strongly enough about England’s chances when faced with a more major complaint. The overall reduction in attendances indicates EDs, and perhaps the NHS, should strongly support the English Football Association’s attempts to secure England a strong manager into the next decade as this may well affect attendances and subsequently costs. This would be especially true if England do win the rights to host the 2018 event.

 

Many thanks to Suzanne Rafelt (Medical Statistician) and Patrick Walsh (Medical Student) at the University of Leicester for their initial help with the article.

Please consider making a donation to a Joyful Joy – a charity Ejiro supported.

 

 

How I let @GrangerKate down and what you can do about it..

It was not a particularly busy shift. The patients were not any more sick than other evenings I have worked. I may have been a little more tired than normal, I don’t think I was anymore distracted, but as I walked out of the consulting room I realised I hadn’t #hellomynameis.

I’m pretty thorough by nature. I have always felt my communication skills were at least ok and I certainly think I’ve introduced myself to patients/parents since being a junior doctor. I actually felt everyone else did as well. It wasn’t until Kate Granger‘s #hellomynameis campaign really took off that I realised this might not actually be common practice. It’s interesting what is perceived as common practice or ‘assumed’ to be normal. You would think most people or systems would deliver at the minimum a style of care that at least doesn’t harm people but we know from some tragic events this is not always the case. We know for a fact that there must be pretty huge differences in the way things are done from variation in many healthcare outcomes (atlas of variation in care in children being one example).

It always upset me, and the term upset is correct, when I was a trainee representative for the RCPCH and AoMRC and senior medical leader or educator made a pronouncement on what trainees must be able to do. “It’s ridiculous trainees can’t get their WPBA signed off by consultants. At my hospital there is always a consultant available” Yes – at your hospital perhaps. Your world and training environment is very different from others.

And so I raised a wry smile at this tweet this evening

I’ve never met Partha but he sounds like a pretty awesome bloke. Cruelly overlooked in the HSJ Rising Stars awards he clearly has a great vision and passion for health care. He also seems to insist on calling NHS Change Day – pledge day but I’ll let him off that. It’s worth following the chain this tweet produced. I make no secret of my support for NHS Change Day and I’m happy to accept and defend criticism about it (Partha – I know your weren’t criticising but your tweet was perfect for this blog!). “What’s the point?” is a common question. “You had 3500 people pledge to smile last year. Don’t they do that anyway?” is another. For the answer to the latter reflect on when was the last time you spent an entire shift in public view and at no point looked like you weren’t upset, annoyed, bored or frustrated. How do you think your patients felt when they saw you looking like that?

Yes someone has pledged they want to keep patients safe. And yes this is a fundamental part of a healthcare professional’s role. But, unfortunately, sometimes the healthcare service doesn’t always keep patients safe. Yes – its fairly obvious that you should introduce yourself at the beginning of every consultation. But, unfortunately, even someone who has been supporting #hellomynameis passionately can fall short.

In some ways it is a shame it is ‘change’ and it is ‘day’ because it’s not always about ‘change’ and hopefully its not about one ‘day’. But if you can find a better mechanism that brings the NHS together and say look – lets just think about this – then please let me know. Because until I find one I will continue to support people pledging what they feel is important to them however obvious that might seem to you.

Post Blog Note (23.2.14)

A subsequent comment from @parthaskar following this post deserves mention as it is something I strongly support and given I gave the poor chap no notice about using his original tweet think it is only fair I utilise his wise words!

Harry Potter may have been a leader but Neville Longbottom was the radical one

(apols for advert at start)

I watched the Harry Potter and Deathly Hallows during the christmas holiday period. It first reminded me that I really need to go back and read the books as I am sure they are lots of subplots that I missed. But secondly that Neville gets a pretty raw deal compared to Harry Potter. If I was going to be a hero, Neville Longbottom is the hero I would like to be. Little point in believing I am not a geek. But at least a geek who achieves things, a quiet leader.

Neville Longbottom: So how are we going to get to London?

Harry Potter: Look, it’s not that I don’t appreciate everything you’ve done, all of you, but – but I’ve got you into enough trouble as it is.

[walks past everyone]

Neville Longbottom: Dumbledore’s Army’s supposed to be about doing something real.

[Harry stops turns around to face them]

Neville Longbottom: Or was all that just words to you?

[extract from Harry Potter and the Order of the Phoenix]

The concept of leadership in medicine is pejoratively and passionately pontificated. The impossibility of everyone being a stereotypical ‘leader’ balanced with the importance of all professionals needing to demonstrate ‘leadership’. Harry Potter commonly seen as the former archetype but not everyone can be a ‘Harry’. This is either because they don’t have the subtle instinct to act the right time, are not willing to embrace the negatives or simply weren’t in the right place at the right time. Conversely not everyone sees Neville as a traditional leader but from a hesitant ackward beginning he quietly goes about his business supporting those who need help. He actually has much in common with Harry. Their values and motivations are no different and he ultimately co-ordinates a resistance movement in Harry’s absence. Neville demonstrates true leadership by followership.

Perhaps it is time for us to acknowledge the Neville Longbottom’s of the healthcare system. Those that deliver, sometimes in the absence of guidance, even when everything is stacked against them. The Neville’s appreciate the desire to be involved in creating an effective, high quality healthcare  (it’s not just the Harrys) but acknowledge the system doesn’t give everyone the chance to help deliver it.

If you feel more like a Neville than a Harry then there are things you can do. The School for Healthcare Radicals has opened – an opportunity to learn how to develop yourself, and others, to create change in health and care environments. This school itself has percolated out of NHS Change Day, the 2014 event being now less than two months away. Both are open to all regardless of your profession, grade or place of work. The ideas and pledges you submit are yours and the manner in which you carry them out is up to YOU. But like Neville its likely that you are the type of person who will be delivering more than words…..

On Change, Challenging and Christmas Carols….

Last week I went to see my daughter’s school carol service. A small church in our town hosted pupils singing carols in-between reading the nativity. I was particularly inspired by a nine-year old girl commencing the proceedings with a solo version of “Once in Royal David’s City” but also by the general quality of the readings.  My daughter, barely 4 when she started this year I suspect was not as interested, but over the next few years I hope she will take on board this sign of a very positive culture at the school.

This has been a year of emphasising culture and compassion in healthcare. Francis and Berwick laying down a gauntlet that the status quo is simply an unacceptable path to follow. The mechanisms by which this can occur are still not clear though. This has been clearly illuminated to me as I spend my last few months in medical training. Having recently been appointed as a consultant, to start in spring 2014, I reflect on the current thinking about the need for cultural shifts in the future. My practical skills, clinical reasoning and communication with other health care professionals have been developed during my training to avoid the need to ‘step up’ once in post. However developing and enhancing a culture of quality and compassion in my department will require me to speak up about others practices and be exemplary in my own. As a junior medical professional it is easy, although not necessarily right, to turn a blind eye to others’ terse tones with patients, unnecessary delays providing treatments or passive aggressive overtones in communicating with colleagues. I am not talking about clear breaches of professionalism or causing patient harm but those things which unchecked can lead to the development of ‘acceptability’ of poor practice.

This will be a hard for me.  I am also very aware it really easy to talk about these things on a podium at a conference (or in a blog) but a completely different thing to act on in the clinical work place. I have much to learn from other colleagues but I hope I can be a credible and consistent champion for excellent practice in my trust. On a national level much time has been spent developing medical ‘leaders and managers’. I am still not clear of the definition of these words but I am increasingly aware that management skills and techniques can be learnt and developed but ‘leaders’ are not so easily bred. “Leadership” though is something that any health care professional can display. Demonstrating compassion, empathy and quality of practice, consistently, even if not challenging others sets a tone for a strong culture. Anyone can do this, you just need to remember that you are always potentially being watched. The cynics who challenged the Change Day 2013 “Smile” pledge missed the point:

Yes, it seems like such an obvious thing to do, but do you always do it?

This is a time of year of reflection. For some reason a particular christmas song will remind you of past events and states of mind. The constant repetition of these songs forces an often frank summation of where you have been and where you are going. New Years Resolutions one mechanism of acting these subtle challenges.

I hope in 2014 I can set a similar example to colleagues and patients the pupils of Farndon Fields school showed to their fellow pupils.

Have a great holiday period and New Year…….

Post Blog note:

If you want an mechanism for acting on any healthcare related resolution please do pledge at changeday.nhs.uk and join a social movement of individuals, teams and organisations delivering on what is important to them. Look out for the #100daysofchange listing some of the achievements so far..!

We must never forget what we have failed to do.

Last week I attended the latest King’s Fund Medical Leadership Network/Development event. These bring together a number of clinicians and managers of varying degrees of experience. There is a focus on outcome, rather than just being talking shops, and there is a clear aim to increase the number of those attending who are early in their careers.

One of the talks was from Prof. Rory Shaw, the Medical Director of Health Care UK. This organisation aims to bring NHS healthcare expertise to the world and establish partnerships that will be beneficial for the UK economy. Prof Shaw was quite open about the questions this raises and some of the challenges to be faced. My interest peaked however in respect of NHS expertise in digital healthcare. It is an interesting paradox that many worldwide healthcare services don’t have access to, or any clear plan to develop, some of the initiatives and expertise which exist here. The concept of a universal number, for example,  is something that is taken for granted in the UK but is not present at all in many other healthcare systems. However from my point of view, a young (but potentially naive and impatient) junior doctor, there is nothing particularly brilliant about our digital systems. Very recently I was involved in a case where the failure to have access to the healthcare information of a patient presenting to a paediatric emergency department may well have resulted in harm to the patient. This was not an individuals fault, it was the fault of the absence of an electronic system that can share information about patients throughout the country.

I was pretty vitriolic about this at the conference, and despite furtive glances and frowns from some members of the audience, will remain so about this. It is not an excuse to say we tried that and it didn’t work. The simple fact remains that most members of the public remain extremely surprised that we are unable to access electronic records in one vicinity but not another. Even worse it remains a cause for concern patients can frequent numerous different health care providers  without any of them knowing anything about these visits. This isn’t about being a ‘big brother’; it’s about managing risk for vulnerable patients and ensuring patient safety in a system which harm if often to easy to come by.

What then are we to make of the failure of the National Programme for IT in the NHS? One argument is that we have moved on, the initiative for local solutions and then joined up working more pragmatic and ultimately more achievable. There are still large costs involved though as the governments recent announcement of a £1Billion fund for Emergency Departments emphasises. Appreciating it’s sometimes easier to judge rather than action, I have been working hard locally towards an electronic integrated illness identification system for children (POPS)  which is now used in other centres and could ultimately be used to compare acuity rates between emergency centres. This solution had to bypass NHS IT and is not the safeguarding safety net that is desperately needed.

It is vital that we remember where we have been in the past and what we haven’t achieved. There are many people and organisations passionate about improving the digital infrastructure of the NHS, and Tim Kelsey is clearly keen on making progress. It is likely solutions will eventually been found but we must honest about our past failures. It would be equally disastrous, probably more so,  should further Berwick and Francis reports be needed, but unfortunately history demonstrates we often fail to learn.

Extolling our strengths is fine, acknowledging our failings much the braver thing to do.

Don’t just leave the NHS to the next generation…

As a disproportionate amount of my blogs do, it all starts with a tweet.

https://twitter.com/Modernleader/status/354984152942129152

I unfortunately have a few issues with this concept of “generational” fixing

I think it is ‘our’ problem to fix, but by our I mean everyone in the NHS. The quality, safety and financial issues facing the NHS are not paradigms to be tinkered with, appreciated to be difficult to redress and then passed on like a parcel (not sure anyone would want the music to stop on them). Virtually all journals and health organisations have had a commentary on the reasons why you should listen and engage with junior doctors – the latest from the HSJ “Why junior doctors are innnovation leaders” , but there are many others on [1,2,3]. I’m afraid that will have to suffice as ‘evidence’ the engagement with a future workforce (and not just medical) is a valuable exercise – if you disagree it might be a blog for another time.

The thing that really gets my back up though is the presumption that junior/trainee/developing health care professionals are always given opportunities in change or quality improvement exercises. Need to be clear here: I am not talking about leadership development on a grand scale – not all junior doctors need or desire to have the skills to become operational managers or involved in national projects. I am talking about taking things beyond simple audit (which trainees have experience of in abundance) on to process change, at however small a level, with the purpose of improving quality of care. If you haven’t already done so please do read the blogs from Dr. Partha Kar which cover a wide range of issues. At the centre of many, though, is the notion that nothing will change unless individuals stand up and be counted. You can blame others for current predicaments but no-one will be able make a difference unless YOU do. This philosophy was also espouced at the recent Agents for Change “Speak.Act.Lead” conference. The challenge is how juniors doctors (or any health care professional in training..) can most effectively do this.

For me any health service has a duty to help support its next generation. However, I am not sure how in environments which lack leadership or role models this can really happen. Gilbert and colleagues, in an admittedly regional survey, determined 91.2% of respondents have had ideas for improvement in their workplace; however, only 10.7% have had their ideas for change implemented. Many possibilities for this – ideas actually weren’t any good, junior doctors weren’t persistent or had a poor implementation strategy. I am willing to bet though, having both experienced and heard reports of this, that in a number of cases the barriers were beyond the means of the junior doctor to breakthrough. And more that than there may have been negative influences preventing even initial initiation. I am not naive, anyone at any level may have difficulties with leadership or quality improvement. Junior doctors certainly do not have an monopoly on change challenges but their experiences during training will have profound implications for the future. So I am more than willing to challenge negativity from trainees who feel they can’t get anything done but I must equally fight the lack of opportunity that comes from their seniors and management structures.

This is not universal, many organisations/individuals are clearly supportive, but others aren’t and these outliers won’t be changed by junior doctors alone. I hope I am not a lone voice in this regard [4] as it is not just the next generation that need to Speak, Act and Lead

[1] Coltart C, Cheung R, Ardollino A, et al. Leadership development for early career doctors. Lancet 2012; 379: 1847-1849

[2] Warren O, Carnall R. Medical leadership: why it’s important, what is required, and how we develop it. Postgrad Med J 2011

[3] Involving doctors in Quality Improvement. The Health Foundation

[4] Roland D, Warren O and Klaber R. Engaging with leadership learning in the workplace. The Lancet 2012;380(9841) 563

Top 14 (couldn’t fit in 10!) Tweets from #Quality2013

Would be interested in people’s thoughts on this list – please do comment!