Editorial

The future of emergency medicine

Training enough emergency doctors

Key to understanding the capacity/ demand issue is a realization that, through haemorrhage of emergency medicine doctors in the last 4 years, we have lost the capacity to see 750 000 patients per annum in the UK, yet attendances and admissions continue to rise inexorably. Some emergency medicine doctors choose other specialties, especially general practice and anaesthetics, but by far the greatest losses arise from emigration. Thus in 2013, the Australasian College of Emergency Medicine discovered over 470 emergency medicine doctors working at registrar grade in the emergency departments of Australasia who had trained in the UK and Ireland. While 95% intended to pursue their emergency medicine career, 92% planned not to do this in the UK. It is thus obvious that the problem does not lie with emergency medicine as a specialty per se. The cost of this ‘trained, brain drain’ is compounded by the expenditure on locums to backfill rotas. Last year in England alone, the NHS spent £150 million on locums in emergency departments. The problem has become a vicious circle in which the unequal and never-ending struggle between capacity and demand exhausts and demoralizes staff who therefore seek alternatives. The problem is not confined to trainees. Last year, 48 consultants also emigrated. Recognition of this issue has led to Health Education England allocating an extra £50 million to increase the number of Acute Care Common Stem 604

(Emergency Medicine) (ACCS EM) posts by 75 per year for the next 3 years. However, unless we can improve retention, we will simply increase the supply of well-trained emergency medicine doctors to the Antipodes.

Keeping emergency doctors in the UK

How can retention be restored and why do UK emergency medicine doctors leave? The answers lie in how we regard emergency departments in the UK and how we treat emergency medicine doctors. The funding structures for emergency departments are rooted in an out-of-date paradigm and ensure that all emergency departments lose money. Consequent underfunding leads to under-resourcing and staff that feel poorly valued. Pressure also arises from the NHS 4-hour operational standard – a target that is dependent upon two key variables; capable and enthusiastic emergency medicine staff and bed availability. Neither is in plentiful supply and often the equation is in negative balance. Tariff and funding reforms are a major priority for the College and indeed without such reforms, the whole infrastructure underpinning emergency care is inadequate for the task. Work–life balance is a major issue affecting recruitment and retention. The College is committed to emergency medicine as a 24/7 specialty but sees no reason why its practitioners should not be treated equitably with those who work few or no evenings, nights and weekends. This is not about salaries or special pleading for emergency medicine – the same is true for all high frequency, high intensity specialties. The College believes that a new contract is required for consultants, trainees and specialty doctors that restores fairness by delivering annual leave entitlements prorata with out-of-hours work. This will deliver a workforce fit for purpose both in terms of number and abilities, to match the needs of the UK patient population. The revenue consequences would actually save money. It cannot be over-emphasized that the combined effects of contractual

arrangements that penalize both acute trusts and emergency medicine clinicians create a toxic synergy.

What is the problem?

Many have called for the 4-hour standard to be relaxed but the College of Emergency Medicine is not among their number. Tempting though it is to regard the standard as a blunt instrument and one which is only a proxy measure for more important metrics such as outcomes, quality of patient experience and resource utilization, it remains the case that these other metrics have yet to have a standardized, readilymeasured data set. The Council of the College recently debated the subject of the 4-hour standard and was unanimous in its support for its retention. Currently fewer than 6% of patients in UK departments remain in the emergency department beyond 4 hours; a figure almost unimaginably better than the situation 15 years ago. Nevertheless, the challenge of ‘exit block’ is a daily event in the emergency departments of the UK. In effect, the resulting prolongation of time in the emergency department is a nosocomial disease with a morbidity and mortality like any other. Over the past few years, there have been a significant number of national bodies, think-tanks and ‘armchair experts’ who contend that many patients attending an emergency department do not need to be there. Quite apart from the implied criticism of millions of patients, the most obvious critique of this opinion is the lack of credible available alternatives afforded to patients. The College Sentinel Sites Study has debunked many of these myths and provided unequivocal evidence that only 15% of patients could be safely redirected from triage. This still represents over two million patients annually and is the basis upon which the College recommends a co-located primary care facility with each emergency department.

The size of the problem

The link between modest percentages and large actual numbers in the previous paragraph is obvious. Those who wish to

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n 2011, the College of Emergency Medicine hosted a ‘crisis conference’ to discuss the mismatch between capacity and demand in the emergency departments of the UK. Then, 1 year ago, the college launched the ‘CEM-10’ (College of Emergency Medicine, 2013), a defining document focused on a concise, clear and constructive set of proposals. Much of the content of the CEM-10 is examined and discussed in the accompanying articles within this themed issue of the journal.

British Journal of Hospital Medicine, November 2014, Vol 75, No 11

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Editorial minimize the scale of the problem in emergency medicine always quote percentages. For example, in the year 2012– 13, attendances at UK emergency departments rose by ‘only’ 1.7%. The explanation that this equates to 240 326 patients is often omitted, as is the corollary that this workload is equivalent to four average-sized emergency departments and a further 80 doctors. While it is clear that the College is winning the arguments, it is salutary that the necessary decisions and corrective actions have yet to be taken. Further delay can only mean that the cadre of the willing and able will be further diminished, the finances of acute trusts further imperiled and the dialogue of disabling recrimination progressed. Set against such a background, it might be concluded that it is surprising that anyone would choose a career in emergency medicine in the UK or Ireland. Fortunately, this is not the case and emergency medicine still offers its practitioners the opportunity to positively influence patient care and outcomes across the spectrum of ages, disease and injury. On a daily basis, the potential to ‘make a difference’ and add ‘years to life and life to years’ is unparalleled. Whether it is in the ‘life saved’ or the

respectful and attentive stewardship of a patient’s final living moments, emergency medicine offers a compelling career for doctors with a wide range of skills. In many countries, emergency medicine is one of the most popular career options; only in the UK has it ranked last for ‘workload’ and ‘work intensity’ as evidenced by the annual General Medical Council training survey for the last 5 years. The College is working with undergraduate bodies, medical schools, deaneries and local education and training boards to remedy this situation and to promote emergency medicine.

KEY POINTS

Themed Issue on emergency medIcIne mergency

edIcIne

Editorial

The future of emergency medicine

edIcIne

hemed ssue on

patients and the staff who in emergency departments that can harm Exit block and crowding create conditions whole hospital is involved is recognizing that it exists and that the look after them. Key to solving exit block in preventing harmful consequences.

College of Emergency Medicine (2013) 10 priorities for resolving the AE crisis. http:// secure.collemergencymed.ac.uk/code/document. asp?ID=7515 (accessed 7 October 2014)

n Recruitment into emergency medicine indicates it is a popular field of medicine. n Retention after year four of training and at consultant level demonstrates that the pressure of work is unsustainable for many. n Demand and capacity are mismatched and the disparity is increasing annually. n Funding of acute care is inadequate; cross-subsidisation from elective care disadvantages acute hospitals. n Contract terms are grossly ill suited to high frequency, high intensity out of hours working.

hemed ssue on

mergency

President College of Emergency Medicine Consultant in Emergency Medicine Musgrove Park Hospital Taunton TA1 5DA ([email protected])

The current system of emergency care provision in the UK is broken and expensive. A more sustainable system will be both

m e A clinical analysis of the emergency I T y department: Better data, better planning: the College of Exit block in the emergenc T I e m T I medicine workforce crisis working practices and Emergency Medicine sentinel sites project recognition and consequences Sustainable What has the 4-hour access Tariffs in emergency care medicine y emergenc in minimizing burnout standard achieved? hemed ssue on

CJ Mann

Conclusions

Themed Issue on emergency medIcIne

Themed Issue on emergency medIcIne

more effective and more efficient. The BJHM has recognized the current problems in emergency medicine and has given voice to the evidence and expert views of the authors of the articles herein. Ignorance of the solutions may have been a credible defence in the past; it no longer is. BJHM

Workforce crises in medicine can be devastating for a specialty, patients and professionals. Emergency medicine and general practice are currently affected but other acute specialties are showing early signs and symptoms of the condition. While symptomatic treatments are helpful, recognition and treatment of the causes is critical.

emergency medIcIne

arrangements that penalize both acute posts (Emergency Medicine) (ACCS EM) This article describes the College of Emergency Medicine’s initial attempt to gather high quality data from trusts and emergency medicine clinicians n 2011, the College of Emergency by 75 per year for the next 3 years. to create a toxic synergy. Medicine hosted a ‘crisis conference’ its own ‘sentinel sites’ rather than relying on more comprehensive national data of dubious quality. Such However, unless we can improve retendiscuss the mismatch between capacity of information is essential to inform and guide the planning of urgent and emergency care services in the future. tion, we will simply increase the supply What is the problem? and demand in the emergency departand The crisis in emergency medicine in the UK well-trained emergency medicine doctors the mergency medicine crosses the boundaries medicine are vital to produce career longevity was no surprise to staff in the specialty, Beniuk et al, 2012; Boyle et al, Many have called for the 4-hour standard ments of the UK. Then, 1 year ago, of pri- increased spiral of pressure Sustainable and satisfying working practices in emergency but was not expected exists when exists (Weiss et al, 2006; the Department of Health. This article explains and workload, amplifying the mary and secondary care, extending by launched the ‘CEM-10’ (College to the Antipodes. success for the individual roblems in urgent and emergency care in the UK are xit block in the emergency department to be relaxed but the College of Emergency statement (International Crowding college from minor symptoms such that a how chronic, systematic under-resourcing A range of strategies is required to ensure investigation 2012). A consensus Few performance Dr Chris Moulton is Consultant in Emergency Medicine, The Royal Bolton crisisprevent is inevitable. premature of emergency care et al, 2013) measures create as much heat and debate as the 4-hour target for emergency injury management to critical care. It has interested If a crisis ‘burnout’. caused (Boylemanagement ensues Medicine, 2013), a defining never far from the news. Everybody has a view on a patient has received his/her initial emergency departments to decompensate, has Medicine is not among their number. of Emergency doctors individual harm and service collapse there Measure in Emergency Departments) emergency and department, Keeping discusses Hospital, Bolton BL4 0JR, Dr Clifford Mann is Consultant in Emergency and works. and emergency actions clear excited the in he/she may definitions that health-care concise, a are necessary to prevent recurrence. in which unless both the causes and the solutions. Most health-care and treatment professionals, policy makers and urgent department relevant departments. This article critically reviews the history, evidence and effectiveness of the 4-hour standard for Tempting though it is to regard the standdocument focused on and the systemoccur resuscitative measures decision to admit identified the emergency in the UK is Medicine, Musgrove Park Hospital, Taunton, and Dr Michelle Tempest is Partner the the public since its inception almost are instituted, followed by agencies have produced one or more reports giving their is a management plan for care and the ard as a blunt instrument and one which constructive set of proposals. Much of 50 years ago. While long-term treatment do patients attending emergency departments. access an appro- shown in Table 1. issues How can retention be restored and why and preventative measures to reduce and Specialist in Healthcare, Candesic Management Consultancy, Londonll NHS emergency emergency medicine is growing and analysis of the situation. The King’s Fund (2014) has even care, including ambulance of the CEM-10 is examined and has been made but the patient cannot medicine do Understanding the of crowding is occupancy – the only a proxy measure for more important content flourishing measure emergency leave? in around simplest career doctors rapid a a The at the Children choosing medicine risk evolved patient octors of relapse. has form a quarter of the workload and The UK emergency the world the last decade has seen the services, is free at the point of use to the major and Emergency medicine in the UK published a list of ‘myths’ about accident and emergency priate hospital bed in a timely manner. of patients in the emergency metrics such as outcomes, quality of patient discussed in the accompanying articles accumulation of whole UK trauma, cardiac and stroke appointed in 1972 so knowing that it is an exciting, stimulating occupying a ratio of the total number The answers lie in how we regard emerit Correspondence to: Dr C Moulton ([email protected]) care is being concentrated in workforce problems within the UK, he 4-hour access standard for patients attending 4 hours in an emergency department, and other devolved population. Over the past 20 years societal, rate. The first 32 consultants were departments. Unfortunately, none of the pundits has remains in the emergency department, experience and resource utilization, within this themed issue of the journal. such that a crisis Aetiology and we the total number of treatment bays. The techni- fewer centres. Contrary to specialty. It can also be stressful in the contributorychallenging on an emergency department and gency departments in the UK and how consultants has tripled in the last of the cal point widely emergency departments creates an enormous in the UK followed shortly afterwards. Failing to nations and over number was factors of professional propagated the reached and in occupancy changes 2013. myth, access to reliable data about emergency care. Weighty Thursday 20 March 2014 were examined by a senior emeremer cubicle cubicle space and usually remains emergency have remains the case that these other metrics altered the care that recent data The physi chaotic environment of the consensus definition defined Guly (2005) noted that the busy, on emergency physioccasionally from emergency departments suggest treat emergency medicine doctors. first three The causal factors for the crisis lie within amount of work and pressure for clinicians and comply with this rule attracted significant financial and decades of emerresil- 10 years alone. Yet the pressures pronouncements are based almost entirely on Hospital gency department doctor. Twelve questions were answeredcould and should be given in the emergency department, only that department trolley. have yet to have a standardized, readilyTraining enough emergency the specialty, gency medicine in the investi and requires good organization and 15% of patients attending could have first attempts to investidepartment or many. Every 100% as crowded. funding structures for emergency departthe UK were managers in thestate NHS. Despite the pressure, the effects administrative penalties. This rule was later amendedthe to acontractual arrangements for health-care characterized been dealt by placed a small upon staff are not unique, cians have steadily risen. The Episode Statistics, a notoriously inaccurate and incom- on a spreadsheet as listed in Table 1. With the exception ofand the pressure these changes are exerting is increasing. Exit block can affect one patient measured data set. The Council of doctors combined with knowledge of live parastaff, the speciality, with its founding ience. The stresses no out-of-date Occupancy were an with in there inin that primary rooted right are the care. in suggested ments bed This the a is in line with the findings in provision of urgent and emergency fathers drawn from a variety valuepatients of the are 4-hour target are incompletely under- 95% target in 2010. The cut-offs of 98% and 95% were many well gate the issue in 1993 plete set of figures. (Hospital Episode Statistics is a the patient’s age, all questions had a yes, no or don’t know In England the Payment by Results system is used to other patient should be able to access and howand College recently debated the subject of Key to understanding the capacity/ care in the UK, of backgrounds. the concept of professional burnout is comparable countries (Australia, New in a timely ambulance off-load times or depression among the however, Over this period digm and ensure that all emergency in its politically led initiatives and societal stoodtoand evaluated. not based on any evidence or even expert opinion. There before andand subsequent years admit Zealand). records-based system of data collection that covers all answer. Physical treatment was defined as a wide-rangingmatch hospital income to activity. Activity is recorded (Burbeck particular concerns of stress patient ward environment for their problem 4-hour standard and was unanimous demand issue is a realization that, through 2 hours from decision expectations. the specialty has developed described regis senior regisas a result of the demands of the job patients, the emer- waiting more than departments lose money. Consequent using a standardized coding framework a pivotal role Crowding in emergency departments is increasingly were plans by Crouch and Cooke (2011), endorsedIndividual by of a Currently fewer medicine docrespondents (72% of consultants and perspectives dictate the weighting of these charge in 201 in retention. the its emergency emerclinician of NHS trusts in England.) Analysis of the data produced by group of procedures ranging from dressings, sutures and for the medicine way. When exit block affects multiple gives support haemorrhage that emergency In is department then trans- Drivers of change fac- gency and urgent care systemet al, 2002; Spickard et al, 2002). aspects of their work Crowding in the leaving the underfunding leads to under-resourcing the within the NHS. The sperecognized a serious health issue; there is an emerging the Department of Health, that this target shouldtors, be but all interplay to explain the current system’s asfunction and trars). They generally evaluated the two main agencies, the NHS Benchmarking Network supplying crutches at one end of the spectrum to intuba intuba-lated into sums of money to be paid to the provider (the Factors gency department becomes crowded. guide of the than 6% of patients in UK departments tors in the last 4 years, we have lost position. were have been heightened in recent years cialty has expanded its role tothese that have driven these changes include: concerns is disrupted. In department a reliable and staff that feel poorly valued. The remedies for the crisis fall into treating include literature demonstrating that crowding in emergency removed and replaced with eight key performance indicaobservation medi- adverse contributors to the environment favourably, although concerns (2012) and the Health and Social Care Information tion, ventilation and defibrillation at the other. All of thesehospital). The amount of money payable – the tariff – is emergency department occurs when flow remain in the emergency department capacity to see 750 000 patients per annum the symp- cine, ambulatory care, rec (College of Emergency Medicine, 2014). as significant in stress recarises from the NHS also training becomes considered been formal Pressure for department prehospital need the estimated the toms of unimaginadepartments is associated with a number of adverse plan was later dropped. tors. The and admissions and care almost by and capacity causes, and developed a analysing how much those activities cost expressed and implementing preventative measCentre (2013), demonstrates the problems. The assertion physical treatments were felt to be unlikely to be provided consequence the beyond 4 hours; a figure in the UK, yet attendances that in General practice availability is large role in rule-out strategiesattractiveness (Heyworth et of the speciality. This has led to a recruitbetween input, 4-hour operational standard – a target ures. The treatment will not rely on for common presentations patient outcomes, including increased mortality (Pines The proponents of the 4-hour access standard claim reduced ognition and avoidance was highlighted in the Keogh report (NHS England, 2013) that 40% of in most UK general practices at the current time. Thedifferent hospitals (the reference cost). inadequate because of a mismatch bly better than the situation 15 years ago. continue to rise inexorably. one agency alone, including low risk a system problem This is particularly true out of hours. and compromised the delivery of effective work-related stress ment crisisembolism, chest pain, pulmonary 2003). In practical Exit block is is dependent upon two key variables; capathatwill require a multidisciplinary partnership This means patients al, 1993). A range of correlates of patients left major (type 1) emergency departments with results were collated and analysed by the independent spe spe- Unfortunately in emergency medicine in England, the arrive deep throughput and output (Asplin et al, Nevertheless, the challenge of ‘exit block’ problem et al, 2009; Guttmann et al, 2011; Plunkett et al, 2011) that it is an intuitive, pragmatic and simple measurebut Some emergency medicine doctors between venous thrombosis and many departments (College of Emergency at hospital without the assessment and reasons: a surge of not a department ble and enthusiastic emergency medicine lonecare the speciality, patients, employers, emergency attendances. Morris et al (2011), Moskop holds acute trust boards to account to improve emeracutein sudden care were identified. detailed conemergency headache no treatment provided a final incentive for the College of cialist healthcare management consultancy, Candesic. Payment by Results system has failed to adequately textual terms, this can happen for a variety of any part ofofthe is a daily event in the emergency departchoose other specialties, especially general commissioners and among others. is in (78%), history that a knowledgeable GP can or radiol- Exit block can occur in Medicine, 2013a). staff and bed availability. Neither the match resources with need, which has health et al (2009) and Schull of boards, the wider NHS and government. dis et al (2004) showed that crowd- gency care. It provides an incentive to improve flow disBy 2002, in a survey with 371 respondents inpatient provide, Emergency Medicine to initiate its own data collection. enjoynew patients (input), staff sickness, laboratory ments of the UK. In effect, the resulting as a result of delayed practice and anaesthetics, but by far is been exacerbated putting a premium The development of new rolesThere is also evidence to show that while being on experienced senior doctors who can available inpatient system. Exit block plentiful supply and often the equation by increased demand (Figure 1). The using a range of validated tools identified ingthat increased fewerto antibiotics for pneumonia and patients through emergency departments. and responsibilities there aretime Results to ogy delays (throughput), or lack of prolongation of time in the emergency greatest losses arise from emigration. Thus result has been make safe decisions physician may not be investigators charge back to the community means as an emergency fill perceived deficiencies in other that were over working able,services may co-exist. with limited or missing information. in negative balance. Tariff and funding a of The malaise affecting emergency medicine analgesia for pain. Bernstein et al (2009) and Fee et al Pressure to achieve the standard was cited by Francis under-resourced emergency departments or to embrace significant adverse psychologi- that 44% had psychological distress levels Method Participating emergency departments are listed in Table chronically 2 beds (exit block). Several of these factors department is a nosocomial disease with in 2013, the Australasian College et al, 2002). new technologies has developed There has been a narrative that 40% and can have Lead and Consultant in Emergency delays most treatments. when there sustainable, reforms are a major priority for the College 470 running on large numbers of expensive Presentation of (2013) as a contributing factor to the poor standards in an uncoordinated of patients ‘inapDr Katherine Henderson is Clinical(2011) showed that crowding the threshold of acceptability (Burbeck A convenience sample of 12 emergency departments in together with the number of new patients who attended A crowded department can be recognized morbidity and mortality like any other. Emergency Medicine discovered over the temporary staff propriately’ come Thomas’ NHS Foundation produce poor long-term career prospects. way, with marked geographicalcalvariations, Guysetand were higher than other effects andsuch to the emergency department, but the and indeed without such reforms, bring new patients at (Press Association, 2014), and requiring Popa al St(2010) showed thatPhysician emergency department care in Stafford Hospital. Critics of the standard The pointcondition has an insidious onset and Medicine in the Emergency Department, that char- Levels of depression of 18% England was selected (Figure 1). At each site, all emergency at each site. There were 3053 patients in total; their age are no free cubicles or even space to Over the past few years, there have been emergency medicine doctors working repeated finan- true figure is closer has been char- is difficult to gain Consultant Emergency burnout is aitwell-recognized syndrome Boyle is also suicidal ideation. Ten in ambulance whole infrastructure underpinning emerconsensus onProfessional to 15%, in line with previous UK acterized crowding adversely impacts on staff, leading to out that it is merely a process measure and does little to by a widespread general malaise. what constitutes Trust, London SE1 7EH and Dr Adrian for groups and 10% reported some a core 4 ‘bail-outs’. This article explores: department patient records for the 24-hour period of and arrival characteristics are shown in Table 3. 3 Table cial into and there are consequent delays a significant number of national bodies, registrar grade in the emergency departSymptoms and emergency medicine Cambridge and Visiting Hospital, by emotional exhaustion (lack of enthusiasm acterized is referred to as gency care is inadequate for the task. service. Further „ Why this has happened. signs (Table 1) progress unless treated, burnout. As a result, most emergency medicine profes- improve quality of care. Mason et al (2010) published in 2012, a survey by the College of Emergency trained in later had changes in the Emergency Department, Addenbrooke’s years who in and ‘armchair experts’ who service lack and Australasia handovers. In the USA this phenomenon of think-tanks ments resulting in an configuration, technologies of cynicism (depersonalisation) Figure 1. Emergency department attendances of consultants in job), feelings Work–life balance is a major issue affectan „ Why this has happened now andthe sional bodies have guidelines on emergency department criticisms of the standard; that it leads to ‘gaming’ and intended workforce – England 1987–2013. From Health the Senior Research Fellow, Cambridge University Medicine had 1077 respondents (70% may be porFigure 1. Map showing the 12 sentinel emergency department sites in England; case mix data. access block (Fatovich et al, 2005). contend that many patients attending and UK and Ireland. While 95% Social Care Information Centre (2014a). trayed as an exciting rapidly evolving accomplishment. The pathway is a spectrum reported that their job department Table 1. by of personal ing recruitment and retention. The College be Signs „ What we need to do to prevent recurrence. and symptoms of a workforce crisis crowding (Affleck et al, 2013; Boyle et al, 2014). The ‘cheating’. Other criticisms described Wilkinson speciality or as a and UK). Over 62% of consultants There is no single definition of emergency emergency department do not need to to pursue their emergency medicine career, ) as a pres speciality still seeking a clear rolethat 12 hospitals Thursday 20 March (Although this article starts from dissatisfaction to disillusionment form because of the presJames Cook is committed to emergency medicine internationally valicritiIt World Health Organization (2006) recognizes timeliness (2007) are that it impairs training and recruitment, 22 000 000 definition. Correspondence to: Dr K Henderson ([email protected] focuses on Payment by Results and is far was unsustainable in its current University crowding but there are a number of there. Quite apart from the implied 92% planned not to do this in the UK. its dis „ New attendance with 51% dis- three major trauma centres A training programme was developed burnout. The incidence in medicine the condition ultimately „ Follow-up attendances 24/7 specialty but sees no reason why obvinot specific examples are from the English as a key component of high quality health care and reduces professional satisfaction,Symptoms and creates an adver- Signs to allow acquisisures of the post. This varied by region, dated scoring systems to identify when cism of millions of patients, the most is thus obvious that the problem does system, the princi- two teaching to 78% in tion of missing competences, depending that in the general population but emergency higher than practitioners should not be treated equitaples discussed are relevant in other systems St James’s patients attendingdepartment emergency departments repeatedly sarial culture between the emergency Stress department and Vacancy rate 20 000 000 on background, satisfaction in south east England climbing medicine as a specialty of this opinion is the lack of burncritique emergency ous recorded with of lie evelevels emergency of no payment.) one children’s or 3053 patients highest few measure the to Medicine, work using secondments to allied specialties has among medicine bly with those who Leeds General to value short waiting times. quality issues potenother inpatient specialties. DataBurnout in Emergency Departments (ICMED) during Northern Ireland (College of Emergency senior regRoyal Bolton credible available alternatives afforded Infirmary per se. not Table 1. International Crowding Measure Attrition from training programmes istrar training. The last two decades and therefore merits particular attention out features nings, nights and weekends. This is is Evolution of emergency medicine tially compromise any evaluation of the standard. One 18 000 000 have seen a rapid 2013a). patients. The College Sentinel Sites Study The cost of this ‘trained, brain drain’ Case mix % % Unhappiness survey of expansion of training posts to supply al, 2012). crowding (Shanafelt about salaries or special pleading for emerand on Twenty years ago The history of the standard of the major difficulties is that the standard is applied Overseas migration of consultants Northern General the et In the United States, the longest running demand for occupational stress for doctors has debunked many of these myths compounded by the expenditure all Comment Birmingham identified such consultant appointments in all emergency Until recently Depressionfrom a specialist Adverse survey gency medicine – the same is true for only Shop-floor practice in Emergency medicine has changed markedly In 2000, the English government was under significant equally to all emergency departments, Children’s 16 000 000 65 years and over 20 20 satisfaction among emergency physicians departments reports provided unequivocal evidence that locums to backfill rotas. Last year over the last Improvement Exit block measures ICMED definitions and then the development of large in emergency medicine and its consequences and Emergency cohort of 1007 physicians, working The Accidentimprove high frequency, high intensity specialties. mil20 years. Previously the clinical model thrombolysis or Increased care in emergency departments, with emergency centre providing stroke multi-consultant Self esteem have that, in a stratified sampling than In practice this means that 10% of pressure to 15% of patients could be safely redirected England alone, the NHS spent £150 is of emergency locum spend the sector regulator for health departments. The numbers of highon and wellbeing, although well described, An emergency department is crowded when less 80.6% in 1999 and team of Monitor, healthapplicants Russells Hall The College believes that a new contract Emergency two medicine was based on filtering and department, or articles regularlytheappearing in the press (Frith, trauma care to a paediatric emergency quality 14 000 000 admitted patients have had a time negative cer- the majority (77.4%) in 1994, for from triage. This still represents over Low job satisfaction referral to inpatient lion on locums in emergency departments. spe16–64 years 59 57 uses 65 minutes as benchmark 90% of patients have left the emergency department from decision to admit to finally leaving2002). higher training posts consistently exceeded services,The coordinated action to address the issues, had little vacancies department emergency medicine had met or required for consultants, trainees and basis specialties to investigate – ‘admit to decide’. government therefore decided to place a even an eye emergency clinic. The published perform-Decreased performance measures up the chal- 77.4% in 2004 felt that Norfolk and million patients annually and is the The problem has become a vicious circle by 2 hours after the admission decision time for this part of the patient journey until 2007. In the decade precedingtainly the UK and Ireland. Combined with boarding time Royal United Norwich However, 33.4% in 1994, cialty doctors that restores fairness a the department of over 120 minutes mandatory problimit on the time patients spent in emergency ance figures do not reflect case-mix,Drwhich 2007inlarge 12 000 000 numbers depart- exceed their expectations. University Kevincreates upon which the College recommends in which the unequal and never-ending Reynard is Consultant in Emergency Medicine prothey have longThe of non-standard posts, such as clinical how of of increased demand upon emergency lenges in 2004 felt that burnout was This is irrespective delivering annual leave entitlements in the Department of Under 16 years each Now in a performance comparidepartments, as ofpart NHS Plan. A Plan for lems with data interpretation andEmergency 21 23 fellows, were estabupon the 31.3% in 1999 and 31% co-located primary care facility with Medicine, struggle between capacity and demand will patients waiting to In practice this means that St James’s University Hospital, Leeds LS9 ward – the go to the lished. These posts provided valuable and Korte, 2008). in recent years this has impacted been waitingAtoPlan mentsexperience rata with out-of-hours work. This 7TF and Dr Ruth Number of patients Boarders are defined as admitted Technological advances, pressure to St Thomas’ is often disprofor Reform (Department of Health, son between trusts. Trust performance Brown 20-bedded emergency department, Investment. 10 000 000 England Sample andspeciality to the young trainees of a significant problem (Cydulka Musgrove Park emergency department. exhausts and demoralizes staff who therereduce inpatient is Consultant in Emergency Medicine, St purpose both in in the the unit is reduced for of the fit service be placed in an inpatient bed. An emergency of training capacity in delivery workforce a by attractiveness by residents Mary’s boarding in the used deliver doctors of Hospital, being are not capable beds, surveys is London 2000). In 2004, the English government introduced a portionately affected by inclusion of data from satellite increased recognition of the dangers of of working on a regis10% two cubicles Interestingly fore seek alternatives. The problem hospitalizadepartment is crowded when there is greater than trar rota until a registrar vacancy became and compromised the safety of an essential emergency the future shown concerning levels of The sample is roughly in line with national proportions of terms of number and abilities, to match tion and increased breadth of medical patients ready to leave to go to a wardrule that 98% of all patients would spend no longer than minor injury units available. influences United States have also Queen Alexandra The size of the problem confined to trainees. Last year, 48 consulttraining have enaCorrespondence to: Dr K Reynard ([email protected]) occupancy of boarders in the emergency department From Boyle et al (2013) department In 2007 specialist training was radically in acute health care. Burnout also attendees. The inclusion of Birmingham Children’s Hospital gives abled emergency medicine study scoring high levels of servicerestructured the needs of the UK patient population. and this by leads to an increase in the risk of burnout, with 42% in one to develop rapidly. DecisionThe link between modest percentages ants also emigrated. Recognition of Dr Adrian Boyle is Consultant Emergency Physician at the Emergency Year and Modernising Medical Careers (Department depersonalisa slight boost to the proportion of under 16-year-olds. = 300 patients quality ofofcare exhaustion or depersonalisaThe revenue consequences would actually paramaking has rightly been pushed towards Evidence Health, large actual numbers in the previous There is a need, burnout with emotional issue has led to Health Education England the front of the Department, Addenbrookes Hospital, Cambridge CB2 2QQ and Visiting Senior medical error (Wallace et al, 2009). save money. It cannot be over-emphasized to recent survey in the United States, out hospital with the key diagnostic and There is surprisingly little published evidence about the to increase Dr Thomas Hughes is Consultant in graph is obvious. Those who wish issues that most tion. In the most therapeutic interEmergency Medicine, Emergency Departmentallocating an extra £50 million Research Fellow, Cambridge University and Professor Suzanne 623 Mason is Professor 612 combined effects of contractual the therefore, to better understand the that ventions Stem Teaching impact the standard. Munro et al (2006) described of Leeds at John Common the Radcliffe point Care Medicine, of first contact – ‘decide to admit’. Hospital, Oxford, OX3 9DU, and Honorary the number of Acute British Journal of Hospital Medicine, of Emergency Medicine at Sheffield University and Honorary Consultant Emergency medicine and produce better supDr Tajek B Hassan is Consultant in Emergency Senior Lecturer November 2014, Vol 75, No 11 Novemberapply 2014, to Volemergency Instead of seeing627 75, No 11 how trusts have had to pour resources into already in Emergency Medicine, University of Oxford, British Journal of Hospital Medicine, November 2014, Vol 75, No 11 British Journal of Hospital Medicine, mainly minor trauma and the occaand satisfying Physician, Northern General Hospital, Sheffield Oxford, Dr Ian Higginson is Hospitals NHS Trust, Leeds LS1 3EX ([email protected]) port strategies that will create sustainable sional major trauma as was the case stretched emergency departments in order to achieve the November 2014, Vol 75, No 11 Consultant in Emergency Medicine, Derriford 20 years ago, emerBritish Journal of Hospital Medicine, Hospital, Plymouth and Dr Clifford working practices. gency departments now see many medical 31/10/2014 19:09 target. One might HMED_2014_75_11_612_616.indd have expected that the 612 standard Mann is Consultant in Emergency Medicine, 304 patients who Correspondence to: Dr A Boyle ([email protected]) Musgrove Park Hospital, Taunton are acutely unwell, a large proportion would have been developed with pilot sites, compared to 617 623 of whom are frail HMED_2014_75_11_627_630.indd 627 31/10/2014 19:09 03/11/2014 09:40 HMED_2014_75_11_623_626.indd 11 and elderly. Correspondence to Dr T Hughes ([email protected]) 29/10/2014 Medicine, November 2014, Vol 75, No

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The articles in this themed issue are available as open access articles from www.magonlinelibrary.com/toc/hmed/current These are provided courtesy of an educational grant from the College of Emergency Medicine This issue is also available free via the BJHM app – download it from iTunes or the Play store BJHM would like to thank Abbott for their support for this issue British Journal of Hospital Medicine, November 2014, Vol 75, No 11

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