96
Injury, 7, 96-100
The inter-related problems of an accident service and the accident emergency department
and
W. H. Rutherford Royal Victoria Hospital, Belfast INTRODUCTION AN ACCIDENT service is the organization of medical personnel and facilities in order to deliver optimal treatment to patients injured in accidents. An accident and emergency department is a contemporary, if clumsy, name for a casualty department. There are considerable problems in organizing either of these entities, and the interests of both overlap, so that any solution for either has implications for the other. ACCIDENT SERVICE Major injuries: in-patients Although it may not be entirely correct to equate major injuries with in-patients, it is approximately correct, and an analysis is possible by concentrating on the statistics of in-patients. The number of specialties involved Tables Z and ZZwere made by analysing the acute admissions of patients with injuries to the surgical wards of the Royal Victoria Hospital, Belfast, and the plastic wards of the Ulster Hospital, Dundonald, for the year 1972. Table Z shows that of all patients with injuries, more were admitted to general surgical wards than to any other. The general surgical admissions were over double the orthopaedic admissions. This explains the resistance of general surgeons to the idea that accidents are primarily the concern of the orthopaedic surgeon. After general and orthopaedic surgery, the next most frequent specialties were plastic and eye surgery, each with over half the number of patients in orthopaedics. Neurosurgery and ear, nose and throat surgery had again approximately half the patients of the previous group. Thoracic surgery and dentistry provided 2 per cent and 1 per cent of the patients, and heart surgery 0.05 per cent.
The amount of trauma within each specialty Table ZZ shows the acute traumatic admissions as a percentage of the total work of the different specialties. It will be seen that this reverses the order of orthopaedics and general surgery, and no doubt explains why orthopaedic surgeons feel that theirs is the major specialty in accident work. The figure of 84 per cent is somewhat false, as the three consultants involved all have beds also in Musgrave Park Hospital, Belfast, and most of their cold orthopaedic cases are admitted to these beds. Even if fractures account for only 50 per cent of their work, however, this is more than three times the percentage of the general surgeons. Accidents provide as many patients for the general surgeon as for the plastic surgeon. It should be remembered that these statistics are for acute admissions only, and that in orthopaedies and plastic surgery, a substantial number of cold admissions may be for the late complications of injury. In Table ZZ, after orthopaedics, general and plastic surgery, come neurosurgery and eye
Table
1.
according
Number of to specialty
General surgery Orthopaedic surgery Plastic surgery Eye surgery Neurosurgery Ear, nose and throat surgery Thoracic surgery Dentistry Heart surgery
admitted
accident
cases
No. of patients
Percentages
822 391 231 221 102
43 21 12 12 5
71 29 22 1
4 2 1 0.05
Rutherford : Accident Services
97
Tab/e I/. Acute accident admissions as a percentage of all admissions by specialty Total patients Orthopaedic surgery General surgery Plastic surgery Neurosurgery Eye surgery Dentistry Thoracic surgery Ear, nose and throatsurgery Heart surgery
466
391
84
5175 1398 851 1787 267
822 231 102 221 22
16 16 13 12 8
575
29
5
1653 287
71 3
4 1
surgery, making the same top five specialties in both tables. The implications of these tables are that every surgical specialty has its quota of traumatic patients. Whatever may be the position in isolated rural areas, it would seem best in large city hospitals that accident cases within each specialty should be cared for by a specialist in that field. One cannot believe that an accident surgeon attempting to cover all fields could give as high a grade of service. In this respect accident surgery appears to bea subject similar to oncology. One would not expect to get oncological surgeons operating on malignant conditions regardless of their anatomical location. Yet unless oncology is recognized as an academic and organizational entity, the likelihood of advances in this field would be small. Similarly, there appear to be strong grounds for promoting the accident service, both as an academic discipline and as an organizational entity. Minor injuries Minor accidents form a large proportion of the work of most casualty departments. During a 4-week period in 1973, a total of 3375 patients were seen at the casualty department of the Royal Victoria Hospital, Belfast. Of these, 1399 had minor injuries. These included wounds, abrasions, bruises, fractures, sprains and burns amongst every other conceivable type of injury. If one counts major and minor injuries together, the most common conditions in which accidents occurred were industrial, domestic and sporting, and in all three, minor injuries were far more common than major. Correct diagnosis and
treatment can save a large amount of morbidity. In a comprehensive accident service, the proper treatment of minor accidents must find a place. The reception, resuscitation and sorting of severe accidents The mortality among the severely injured will to a large extent depend on the speed with which skilled treatment can be organized. There are certain times of the week when it is fairly simple for any doctor working in casualty to get as much senior assistance as he needs. However, there are other times when there is considerable delay in obtaining the help of a senior doctor, and in some cases help is not sought when it should be. Much of what needs to be done for accidents is known, but the knowledge is often not applied because of lack of organization. What is particularly deficient is the participation of sufficiently senior staff immediately the patient arrives. THE ACCIDENT AND EMERGENCY DEPARTMENT Grouping patients by specialty and diagnosis In the Royal Victoria Hospital, Belfast, the accident and emergency department is divided into
SOY0
6%
1290
2%
Specialties of patients in both the ambulance (black) and walking (white) areas.
Fig. 1.
Injury:
98 2
streams; 1 for major or ambulance cases, and 1 for minor or walking cases. In a 4-week survey in 1973 (Rutherford and Maynard, 1975), it was found that 31 per cent of patients were seen in the ambulance area and 69 per cent were seen in the walking area. Fig. 1 shows the specialties of the patients in both areas, Fig. 2 shows the main diagnostic groups for the surgical and medical patients in both areas. It should be understood that because of pressure on beds, general practitioners send patients for acute
200
1
III defined
the British
Journal of Accident Surgery Vol. ~/NO. 2
group of patients. However, neither the nontraumatic surgical patients nor the medical patients can beconsideredasof minor importance. From the point of view of an accident service, it would seem impossible to have a good accident service without having a good casualty department, but from the point of view of an accident surgeon, there is a great deal of work going on in ‘ casualty ’ in which he has neither the wish to become involved nor the ability to participate and do a good job.
Vascular Cordio
Respiratory
Overdose
Mental Illness
Other
l”IL_uhA_ 28%
25%
8%
13%
5%
21%
A
100
III defined
Respiratory
23%
15%
Medical accidents, poisoning
Skin Disease
Other
13%
1196
38%
1
B Fig.
2.
The diagnostic groupings:
A, medical patients, ambulance;
admission to the accident and emergency department for final assessment. Forty-four per cent of the patients in the ambulance area were sent by general practitioners. It will be noted from Fig. 1 that surgical patients form 53 per cent of patients in the ambulance area and 80 per cent in the walking area, whereas medical patients form 43 per cent and 6 per cent respectively. Accidents were responsible for 43 per cent of major surgical cases and 76 per cent of minor ones. This is by far the largest diagnostic
B, medical patients, walking.
Supervision in the accident and emergency department Two solutions have been proposed. The first is that a surgeon concerned with the accident service should be in charge. In some centres this has worked well. If such a consultant is going to make a real contribution, however, he will have to be prepared to spend much of his time in ‘ casualty ‘. Few active surgeons are prepared to do this, but without it, this solution can easily lead to a new form of the absentee landlord.
Rutherford
: Accident
99
Services
The other solution is a consultant whose life will be largely spent in the casualty department. This man would have two main functions. He would be an expert in the resuscitation of all life-threatening emergencies-severe accidents, cardiac arrest, deep coma from any cause, etc. -and he would be a diagnostician, assessing the necessity for hospital admission and deciding on the best unit to send the patient to. In most large hospitals, such a man would have to take a considerable interest in accidents. In the largest hospitals there would be two such men, and if they worked mainly on different shifts, this would go a long way to providing the senior cover at the point of arrival, which is one of the most difficult prerequisites of a good accident service. The remaining sessions of reception duty could be covered by a rota of other surgeons in the accident team. It is sometimes questioned whether such a consultant would be satisfied if denied any patients for whom he had a continuing responsibility. Some men at present in this situation seem reasonably happy. It might be possible that such a consultant would be responsible for acute hand surgery in his department, and for the continuing supervision of cases of mild concussion. He could also be a kind of accident physician, with responsibility for patients with multiple injuries. 300
1
Trauma
Digestive
III defined
G.U.
Other
The Platt Report recommends that the name ‘ casualty service ’ should be altered to ‘ accident and emergency service ‘. Having made this recommendation, the committee promptly gave the title ‘ Accident and Emergency Services ’ to their own report. The original terms of reference were, ‘ To consider the organization of hospital casualty and accident services ‘, and the report is concerned not merely with casualty departments but also with accident services. So one can see that even in the report itself, the phrase ‘ accident and emergency services ’ is sometimes used to denote the work of casualty sometimes to denote accident departments, services and sometimes to include both. This confusing nomenclature has continued in many subsequent publications. There has been a tendency to talk of the accident and emergency department, and of accident services, and if everyone would stick to these words, the debate would be clearer. The word ‘ casualty ’ has proved very difficult to abolish, and there would be much
Other 1,400
1
300
200
100
I 0’ 43%
15%
18%
6%
18%
ln
76%
C Fig.
6%
D
2. cont. C, Surgical patients, ambulance; D, surgical patients, walking.
This might bring him into close contact with the intensive care department and would improve his skills as a resuscitation expert. NOMENCLATURE The term ‘ accident and emergency services ’ was brought into general use by the Platt Report (Platt, 1962). But from the beginning there has been considerable confusion as to its meaning.
to be said for returning to this succinct and unambiguous word. The chief aim in abolishing it was to try to make it clear that the ‘ casualty ’ should be used for accidents and emergencies and not for all ‘ casual ’ complaints. The same aim could be achieved if the notice at the door of the department which was headed either ‘ casualty’ or ‘ casualty department ’ was subheaded ‘ for accidents and emergencies ‘.
100
Injury:
the British Journal
of Accident
Surgery
Vol. ~/NO. 2
The confusion also affects advertisements for jobs in either accident services or accident and emergency departments. It is not very clear what the term ‘accident surgeon ’ means. One would have thought that ‘ orthopaedic surgeon with interest in trauma ‘, ‘ general surgeon with interest in trauma ‘, etc. would be better. And ‘ casualty consultant ’ is clearer than any alternative I can think of. An accident service is an organizational entity, while traumatology or accident surgery is an academic discipline.
It is staffed by a team which reviews achievement and initiates policy. A team presupposes a leader. Such a man will have to take an interest not merely in his own specialty, but in the whole spectrum of accident work. He might well be a general surgeon, a plastic surgeon, a neurosurgeon or an eye surgeon, but the most likely specialties from which he could be drawn are orthopaedics or casualty work. Too often orthopaedic surgeons and casualty consultants have been polarized in their attitudes to each other and to their spheres of work. The
CONCLUSION
way forward standing.
It has been shown that an accident service and an
accident and emergency department are two very different entities. Yet there is a large overlap of interest and the best patient care in both fields is only possible when people involved in one aspect are appreciative of the importance of the other. In discussing these two fields the term ‘ accident services ’ is satisfactory. ‘ Accident and emergency department ’ is in widespread current use, ‘ casualty ’ is clearer. There is no real need for a name for both entities considered together, and the term ‘ accident and emergency services ’ should be abandoned. An accident service is not just a number of specialties which happen to coexist in a hospital. Requests for reprints should be addressed lo: W. H. Rutherford.
Belfast, BT12 6BA.
depends
on fuller
mutual
under-
REFERENCES
Sir Harry (1962) Accident and Emergency Report of Standing Medical Advisory Committee of Central Health Services Council. London, HMSO. RUTHERFORD W. H. and MAYNARD J. S. E. (1975)
PLATT
Services.
An information and Emergency
Recovery System for the Accident Department. Belfast, The Royal
Victoria Hospital.
OBE,
ERG,
Casualty
Department,
Royal
Victoria
Hospital,
Injury, 7, 96-100
The inter-related problems of an accident service and the accident emergency department
and
W. H. Rutherford Royal Victoria Hospital, Belfast INTRODUCTION AN ACCIDENT service is the organization of medical personnel and facilities in order to deliver optimal treatment to patients injured in accidents. An accident and emergency department is a contemporary, if clumsy, name for a casualty department. There are considerable problems in organizing either of these entities, and the interests of both overlap, so that any solution for either has implications for the other. ACCIDENT SERVICE Major injuries: in-patients Although it may not be entirely correct to equate major injuries with in-patients, it is approximately correct, and an analysis is possible by concentrating on the statistics of in-patients. The number of specialties involved Tables Z and ZZwere made by analysing the acute admissions of patients with injuries to the surgical wards of the Royal Victoria Hospital, Belfast, and the plastic wards of the Ulster Hospital, Dundonald, for the year 1972. Table Z shows that of all patients with injuries, more were admitted to general surgical wards than to any other. The general surgical admissions were over double the orthopaedic admissions. This explains the resistance of general surgeons to the idea that accidents are primarily the concern of the orthopaedic surgeon. After general and orthopaedic surgery, the next most frequent specialties were plastic and eye surgery, each with over half the number of patients in orthopaedics. Neurosurgery and ear, nose and throat surgery had again approximately half the patients of the previous group. Thoracic surgery and dentistry provided 2 per cent and 1 per cent of the patients, and heart surgery 0.05 per cent.
The amount of trauma within each specialty Table ZZ shows the acute traumatic admissions as a percentage of the total work of the different specialties. It will be seen that this reverses the order of orthopaedics and general surgery, and no doubt explains why orthopaedic surgeons feel that theirs is the major specialty in accident work. The figure of 84 per cent is somewhat false, as the three consultants involved all have beds also in Musgrave Park Hospital, Belfast, and most of their cold orthopaedic cases are admitted to these beds. Even if fractures account for only 50 per cent of their work, however, this is more than three times the percentage of the general surgeons. Accidents provide as many patients for the general surgeon as for the plastic surgeon. It should be remembered that these statistics are for acute admissions only, and that in orthopaedies and plastic surgery, a substantial number of cold admissions may be for the late complications of injury. In Table ZZ, after orthopaedics, general and plastic surgery, come neurosurgery and eye
Table
1.
according
Number of to specialty
General surgery Orthopaedic surgery Plastic surgery Eye surgery Neurosurgery Ear, nose and throat surgery Thoracic surgery Dentistry Heart surgery
admitted
accident
cases
No. of patients
Percentages
822 391 231 221 102
43 21 12 12 5
71 29 22 1
4 2 1 0.05
Rutherford : Accident Services
97
Tab/e I/. Acute accident admissions as a percentage of all admissions by specialty Total patients Orthopaedic surgery General surgery Plastic surgery Neurosurgery Eye surgery Dentistry Thoracic surgery Ear, nose and throatsurgery Heart surgery
466
391
84
5175 1398 851 1787 267
822 231 102 221 22
16 16 13 12 8
575
29
5
1653 287
71 3
4 1
surgery, making the same top five specialties in both tables. The implications of these tables are that every surgical specialty has its quota of traumatic patients. Whatever may be the position in isolated rural areas, it would seem best in large city hospitals that accident cases within each specialty should be cared for by a specialist in that field. One cannot believe that an accident surgeon attempting to cover all fields could give as high a grade of service. In this respect accident surgery appears to bea subject similar to oncology. One would not expect to get oncological surgeons operating on malignant conditions regardless of their anatomical location. Yet unless oncology is recognized as an academic and organizational entity, the likelihood of advances in this field would be small. Similarly, there appear to be strong grounds for promoting the accident service, both as an academic discipline and as an organizational entity. Minor injuries Minor accidents form a large proportion of the work of most casualty departments. During a 4-week period in 1973, a total of 3375 patients were seen at the casualty department of the Royal Victoria Hospital, Belfast. Of these, 1399 had minor injuries. These included wounds, abrasions, bruises, fractures, sprains and burns amongst every other conceivable type of injury. If one counts major and minor injuries together, the most common conditions in which accidents occurred were industrial, domestic and sporting, and in all three, minor injuries were far more common than major. Correct diagnosis and
treatment can save a large amount of morbidity. In a comprehensive accident service, the proper treatment of minor accidents must find a place. The reception, resuscitation and sorting of severe accidents The mortality among the severely injured will to a large extent depend on the speed with which skilled treatment can be organized. There are certain times of the week when it is fairly simple for any doctor working in casualty to get as much senior assistance as he needs. However, there are other times when there is considerable delay in obtaining the help of a senior doctor, and in some cases help is not sought when it should be. Much of what needs to be done for accidents is known, but the knowledge is often not applied because of lack of organization. What is particularly deficient is the participation of sufficiently senior staff immediately the patient arrives. THE ACCIDENT AND EMERGENCY DEPARTMENT Grouping patients by specialty and diagnosis In the Royal Victoria Hospital, Belfast, the accident and emergency department is divided into
SOY0
6%
1290
2%
Specialties of patients in both the ambulance (black) and walking (white) areas.
Fig. 1.
Injury:
98 2
streams; 1 for major or ambulance cases, and 1 for minor or walking cases. In a 4-week survey in 1973 (Rutherford and Maynard, 1975), it was found that 31 per cent of patients were seen in the ambulance area and 69 per cent were seen in the walking area. Fig. 1 shows the specialties of the patients in both areas, Fig. 2 shows the main diagnostic groups for the surgical and medical patients in both areas. It should be understood that because of pressure on beds, general practitioners send patients for acute
200
1
III defined
the British
Journal of Accident Surgery Vol. ~/NO. 2
group of patients. However, neither the nontraumatic surgical patients nor the medical patients can beconsideredasof minor importance. From the point of view of an accident service, it would seem impossible to have a good accident service without having a good casualty department, but from the point of view of an accident surgeon, there is a great deal of work going on in ‘ casualty ’ in which he has neither the wish to become involved nor the ability to participate and do a good job.
Vascular Cordio
Respiratory
Overdose
Mental Illness
Other
l”IL_uhA_ 28%
25%
8%
13%
5%
21%
A
100
III defined
Respiratory
23%
15%
Medical accidents, poisoning
Skin Disease
Other
13%
1196
38%
1
B Fig.
2.
The diagnostic groupings:
A, medical patients, ambulance;
admission to the accident and emergency department for final assessment. Forty-four per cent of the patients in the ambulance area were sent by general practitioners. It will be noted from Fig. 1 that surgical patients form 53 per cent of patients in the ambulance area and 80 per cent in the walking area, whereas medical patients form 43 per cent and 6 per cent respectively. Accidents were responsible for 43 per cent of major surgical cases and 76 per cent of minor ones. This is by far the largest diagnostic
B, medical patients, walking.
Supervision in the accident and emergency department Two solutions have been proposed. The first is that a surgeon concerned with the accident service should be in charge. In some centres this has worked well. If such a consultant is going to make a real contribution, however, he will have to be prepared to spend much of his time in ‘ casualty ‘. Few active surgeons are prepared to do this, but without it, this solution can easily lead to a new form of the absentee landlord.
Rutherford
: Accident
99
Services
The other solution is a consultant whose life will be largely spent in the casualty department. This man would have two main functions. He would be an expert in the resuscitation of all life-threatening emergencies-severe accidents, cardiac arrest, deep coma from any cause, etc. -and he would be a diagnostician, assessing the necessity for hospital admission and deciding on the best unit to send the patient to. In most large hospitals, such a man would have to take a considerable interest in accidents. In the largest hospitals there would be two such men, and if they worked mainly on different shifts, this would go a long way to providing the senior cover at the point of arrival, which is one of the most difficult prerequisites of a good accident service. The remaining sessions of reception duty could be covered by a rota of other surgeons in the accident team. It is sometimes questioned whether such a consultant would be satisfied if denied any patients for whom he had a continuing responsibility. Some men at present in this situation seem reasonably happy. It might be possible that such a consultant would be responsible for acute hand surgery in his department, and for the continuing supervision of cases of mild concussion. He could also be a kind of accident physician, with responsibility for patients with multiple injuries. 300
1
Trauma
Digestive
III defined
G.U.
Other
The Platt Report recommends that the name ‘ casualty service ’ should be altered to ‘ accident and emergency service ‘. Having made this recommendation, the committee promptly gave the title ‘ Accident and Emergency Services ’ to their own report. The original terms of reference were, ‘ To consider the organization of hospital casualty and accident services ‘, and the report is concerned not merely with casualty departments but also with accident services. So one can see that even in the report itself, the phrase ‘ accident and emergency services ’ is sometimes used to denote the work of casualty sometimes to denote accident departments, services and sometimes to include both. This confusing nomenclature has continued in many subsequent publications. There has been a tendency to talk of the accident and emergency department, and of accident services, and if everyone would stick to these words, the debate would be clearer. The word ‘ casualty ’ has proved very difficult to abolish, and there would be much
Other 1,400
1
300
200
100
I 0’ 43%
15%
18%
6%
18%
ln
76%
C Fig.
6%
D
2. cont. C, Surgical patients, ambulance; D, surgical patients, walking.
This might bring him into close contact with the intensive care department and would improve his skills as a resuscitation expert. NOMENCLATURE The term ‘ accident and emergency services ’ was brought into general use by the Platt Report (Platt, 1962). But from the beginning there has been considerable confusion as to its meaning.
to be said for returning to this succinct and unambiguous word. The chief aim in abolishing it was to try to make it clear that the ‘ casualty ’ should be used for accidents and emergencies and not for all ‘ casual ’ complaints. The same aim could be achieved if the notice at the door of the department which was headed either ‘ casualty’ or ‘ casualty department ’ was subheaded ‘ for accidents and emergencies ‘.
100
Injury:
the British Journal
of Accident
Surgery
Vol. ~/NO. 2
The confusion also affects advertisements for jobs in either accident services or accident and emergency departments. It is not very clear what the term ‘accident surgeon ’ means. One would have thought that ‘ orthopaedic surgeon with interest in trauma ‘, ‘ general surgeon with interest in trauma ‘, etc. would be better. And ‘ casualty consultant ’ is clearer than any alternative I can think of. An accident service is an organizational entity, while traumatology or accident surgery is an academic discipline.
It is staffed by a team which reviews achievement and initiates policy. A team presupposes a leader. Such a man will have to take an interest not merely in his own specialty, but in the whole spectrum of accident work. He might well be a general surgeon, a plastic surgeon, a neurosurgeon or an eye surgeon, but the most likely specialties from which he could be drawn are orthopaedics or casualty work. Too often orthopaedic surgeons and casualty consultants have been polarized in their attitudes to each other and to their spheres of work. The
CONCLUSION
way forward standing.
It has been shown that an accident service and an
accident and emergency department are two very different entities. Yet there is a large overlap of interest and the best patient care in both fields is only possible when people involved in one aspect are appreciative of the importance of the other. In discussing these two fields the term ‘ accident services ’ is satisfactory. ‘ Accident and emergency department ’ is in widespread current use, ‘ casualty ’ is clearer. There is no real need for a name for both entities considered together, and the term ‘ accident and emergency services ’ should be abandoned. An accident service is not just a number of specialties which happen to coexist in a hospital. Requests for reprints should be addressed lo: W. H. Rutherford.
Belfast, BT12 6BA.
depends
on fuller
mutual
under-
REFERENCES
Sir Harry (1962) Accident and Emergency Report of Standing Medical Advisory Committee of Central Health Services Council. London, HMSO. RUTHERFORD W. H. and MAYNARD J. S. E. (1975)
PLATT
Services.
An information and Emergency
Recovery System for the Accident Department. Belfast, The Royal
Victoria Hospital.
OBE,
ERG,
Casualty
Department,
Royal
Victoria
Hospital,
