Perspective #WILTW

This is the 129th #WILTW

“The declining level of performance in A&E is a marker of stress across the whole system of health and social care. But performance standards or targets for A&E should not only be viewed as the ‘canary in the mine’ for system-wide pressures. They matter primarily because long waits in A&E affect patient safety and patients’ experience of care.”

The Health Committee report into Emergency Department performance is a no nonsense pragmatic review highlighting safety concerns due to unmet demand, underfunding in social care and too much variation between systems. It highlights the persistent and worsening decline in the four hour target

via Nuffield Trust
via Nuffield Trust

While some will bemoan the creation of the standard, with the resulting gamesmanship and tension between clinicians & managers it produced, it did serve to drive forward changes in staffing and process in Emergency Care. Either way a fall to 85% is uncomfortable and knowing that patients are waiting for prolonged periods is an additional stress for staff in an already demanding environment. There is a feeling that things are getting progressively worse with an associated despair that improvements are not around the corner.

But what if 85% was something to aspire to? I was in Canada this week and delegates at the conference I was speaking at were kind enough to give me a tour around the Toronto Hospital for Sick Children (Sickkids) Emergency Department. I noticed some of the waiting times and found this monthly update from the Ontario Health Ministry.

Note the average time spent in the department. There weren’t any recent comparative target figures available but in 2010-11, 45% patients were admitted from the Sickkids ED with a wait time of less than eight hours, a significant improvement from the 36% recorded the year before (there have not be significant changes in last five years). A consultant recollected they have come onto night shifts with 85 patients still waiting to be seen. For those used to working to a 4 hour target, which Canada does not have, these figures are astounding.

It must be noted Toronto Sickkids is a very busy metropolitan children’s ED. It sees over 75000 patients a year and unlike many UK departments there is no assessment unit to send patients prior to formal admission to the wards; so it is not completely fair to directly compare admission waiting times.

However the perspective this has given me can’t be understated. I must be clear, it is not a case of, “well we’re ok because there is someone much worse..” From what I observed I have no reason to believe the quality of care provided, as measured by other metrics, is no worse than  the UK. In fact the huge numbers of consultants providing on site 24 care with exceptional levels of supervision to junior staff is something to aspire to. They undertake world class research, have a number of extremely impressive training programmes (including  point of care ultrasound) and there is a clear sense of camaraderie between staff.

The dissonance between the waiting times is accentuated by the fact if just children and young persons data is used the average 4 hour target is often 95% or above in the UK. So whatever we may feel about the challenges currently being faced in relation to time based measures these pale into insignificance compared to our North American colleagues. We should continue to strive to improve patient experience by investing appropriately and continually re-examine our approaches to providing emergency care. But we should also be proud of the services we offer. A perspective it is all too easy to lose sight of.

What did you learn this week? #WILTW

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