Study makes case for emergency care reform - The Times - 12/8/2004

Study makes case for emergency care reform
Cynthia Busuttil

The waiting times at St Luke's Hospital's accident and emergency department fall within the criteria established by the United Kingdom's Audit Commission, a study by a medical doctor shows.

The commission's 2001 report said that by 2004 nobody should wait for more than four hours in accident and emergency departments from arrival to admission, transfer or discharge. It said the average waiting times in such a department should fall to 75 minutes.

The study, submitted for a Master's degree in health services management by Tanya Melillo, shows that 96 per cent of cases were dealt with in the first three hours.

In Malta there are no established criteria for waiting times at the emergency department, the hospital services' information and communications department executive head Tonio Bonello said. He said this was because patients who were more seriously ill or injured were seen first while others had to wait accordingly, irrespective of the time they registered at reception.

However, he said, the figures in the thesis were deemed to be very acceptable, especially when comparing them to waiting times in similar departments in hospitals abroad.

The emergency department at St Luke's works on a triage priority system under which those people considered a high emergency are given first priority; those who are an emergency but can wait are given second priority and those not an emergency are given a third priority.

"This is not a first come, first served basis service," Mr Bonello said.

The study shows that the number of people attending the department increased from year to year and went up from 91,110 in 1997 to 118,785 in 2002.

Dr Melillo carried out an in-depth study among 2,592 people on waiting times during a two-week period in September 2002.

The thesis showed that more than 20 per cent of the first priority clients were seen to in the first 30 minutes and about seven per cent after less than an hour. Fewer than five per cent were seen to after an hour and two hours and about one per cent before three hours.

The thesis also indicated that just under half the respondents were not aware of the existence of the triage system. The Medical Association of Malta's general secretary, Martin Balzan, explained that the people who were given third priority did not need to receive treatment by the emergency department. They could be treated at health centres or by a general practitioner.

According to the thesis, an assessment carried out when the patient arrived at the casualty department showed that more than 31,000 cases were third priority but after they were seen by a doctor the number of people whose case was not considered an emergency rose to 35,336.

Mr Bonello emphasised that patients who could be seen by their own doctor or go to a health centre but were instead using the emergency department were clearly increasing the overall waiting-time in any given period. The MAM representative described this as "a problem" and said there was the need to create awareness through an education campaign that non-emergencies should not go to the casualty department.

He insisted that the answer to this situation was not to increase the number of doctors working within the department but to educate people to seek medical treatment elsewhere if their case was not an emergency.

Dr Balzan said violence at the casualty department was usually the result of patients not being aware of the system and, therefore, not understanding why people who arrived after them were seen to before.

He also stressed that the MAM was against closing the Gzira and Floriana health centres during the night as this would create more pressure on the casualty department.

A survey included in the thesis among 30 people shows that 100 per cent of the patients were satisfied after being seen by a doctor. Seventy-seven per cent of those questioned said they were not prepared to pay for the emergency service.

The author of the thesis said that an effective emergency care system must be built on best practice and must meet a number of basic principles, including that the services are designed from the patient's point of view and that patients should receive consistent response. Dr Melillo says a number of changes must take place for the reform of emergency care.

These include the streaming of different categories of patients. Three kinds of services need to be available to meet the needs of four broad groups of patients who go to the department, with patients who require immediate resuscitation and those with major injuries in the first category, patients with less urgent but potentially serious medical or surgical problems who require detailed assessment before a firm decision can be made about their clinical management as the second category.

Patients with moderate illness or minor injuries but who are unlikely to require admission to hospital as the third category and the fourth category made up of patients with "primary care problems".

The author adds that the casualty department needs to be split into three sections to separate the three streams of patients.

Dr Melillo said the first two categories of patients would be seen by senior staff, senior house officers with supervision from senior registrars and a consultant. The third category would be treated by senior house officers, who will consult their senior in case of difficulties, while the last category can be seen separately by a nurse and a family practitioner.

"Reforming emergency care will mean an end to waiting which has, for far too long characterised a patient's experience of emergency care.

It will ensure simplified access to patients and consistent, high quality assessment of their needs. Any increases in resources need to be targeted at specific improvements in waiting times or quality of care," the thesis concludes.

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