This is the 175th #WILTW
The concept of ‘in-reach’ is an inflammatory nidus of debate between hospital teams. If a patient is admitted from an Emergency Department, but no ward bed is available for them, who is responsible for their care? Is it the Emergency Department, as they have initially assessed the patient and will be their physical ‘home’, or the accepting team as they have specialist skills and oversight for the pathway of care needed?
“We can’t do our job if we are looking after your patients as well!” is an argument used by both sides. And as Emergency Department crowding increases, from poor flow through a hospital unable to discharge patients at the rate they are admitted, the tension surrounding “in-reach” increases.
In the UK, emergency medicine is based around providing the first 4 hours of care. This is a wide range of activity from providing critical interventions (management of cardiac arrest) to the simplest of advice (re-direction to a dentist). The aim is to sift and sort, from a large group of undifferentiated patients, those who can safely go home and admit those who require ongoing care. For the latter group, regardless of capacity, the process is initially theoretical (the patient is ‘admitted’) rather than physical (the patient is still in the ‘Emergency Department’). This exposes another issue, that of ‘over-reach’
Emergency Medicine as a specialty excels at “prompt differentiation and initial treatment of the unwell” in the same way that cardiac surgeons excel at operating on hearts and dermatologists excel at managing skin conditions. By definition though it is just the early phases of treatment and interventions, so direct patient contact, the art of medicine, is therefore often time limited. Occasionally I miss the ongoing relationship you develop with patients and their families if you work in hospital and community based specialties. While I often follow up patients on wards you don’t develop a sustained relationship with them in the same way as in-patient teams do. To compensate for this an occasional ‘stay and play’ mentality develops, co-rdinating the second phase of treatments within the Emergency Department. This may be essential if hospital teams are unable to attend the patient themselves but may occur just because I can, rather than I need to.
It is easy to understand why the public and patients would be confused by over-reach. What is the problem with doing this? Isn’t this just good medical practice?
Over-reach in itself reduces the need for in-reach. This promotes behaviour and cultures which may not be beneficial for either ‘side’. Certainly it is vital I don’t over-reach for one patient at the detriment of others. Also as a specialist who merges skills (Paediatric & Emergency) I need to balance the delivery of both.
Do you need to be delivering the care you are giving? This is a question often asked of evidence based practice – are you giving the most effective treatment? However there is a efficiency and equitably component as well. Because you can be delivering something, does it mean you should be?
What have you learnt this week? #WILTW
[Thanks to those at this week’s consultant meeting for inspiring this blog]