Scope of Emergency Services

Emergency Services (Accident and Emergency or as they are popularly known, A&E Departments) exist to save human life in dire and urgent circumstances where every second counts. In 2006/7 6.3 million patients were treated in A&E departments of England alone. Many of these patients have complicated medical or traumatic conditions that require expert knowledge, skill and judgement. Some are so critically ill or so gravely injured that proper care can literally make the difference between life and death. For most patients, their crisis may not be a matter of life or death, but it is no less significant to them and their family.

In the UK, emergency medical responders/technicians (located mainly in major cities) and paramedics are often the first medical professionals to come in to contact with patients in an emergency. They carry a unique and portable set of skills, while at the other end of the ambulance ride are highly specialised A&E units with an sophisticated infrastructure which includes specialist nurses, highly trained doctors, an access to advance clinical investigations panels and critical life support units. The most important link between these two components of the emergency services is the time commonly referred as ‘golden hour’ by the paramedics. The closure of four A&E departments out of nine in the West London would jeopardise this fundamental principle of emergency care. After calling the emergency services, patients currently wait at least 15 minutes, and in most cases more – waiting times of half an hour are common. After these closures, the time between making the emergency call and arriving at hospital, will average one hour. It will be substantially more during rush hours, particularly when the emergency is being transferred to the hospitals such as Northwick Park, Chelsea and Westminster or St Mary’s Paddington. Therefore, the cumulative time from the onset of an acute event (an emergency) to an A&E care facility will certainly hit an unacceptable level.

 

The treatment of myocardial infarction, commonly known as heart attack, is very much time dependant. One third of patients die within first two hours. One study compared groups with total time to treatment of more than 120 minutes against  groups with 120 minutes or less and found mortalities were 4 compared with 0; transfers to a tertiary care facility were 3 compared with 1, respectively (Chughtai H, Ratner D, Pozo M, et al. Prehospital Delay and its Impact on Time to Treatment in ST-elevation Myocardial Infarction. Am J Emerg Med. May 2011;29(4):396-400).

In pulmonary embolism, commonly known as lung clot, 10% of patients die in during the first hour and in a further 30% time delay can result in further complications such as heart failure or even fatality (Wood KE. Major pulmonary embolism: Review of a Pathophysiologic Approach to the Golden Hour of Hemodynamically Significant Pulmonary Embolism. Chest. Mar 2002;121(3):877-905;  Goldhaber SZ, Visani L, De Rosa M. Acute Pulmonary Embolism: Clinical Outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet. Apr 24 1999;353(9162):1386-9).

Similar outcome and principles are applicable in several other acute medical conditions such as breathing difficulties (acute asthma /acute exacerbation of COPD), hypoglycaemia (low glucose levels) and other acute complications i.e. diabetic ketoacidosis in diabetes mellitus, strokes [particularly haemorrhagic strokes / brain hemorrhage (bleeding in the brain)], head injuries and stab or gunshot wounds. These are just few examples where treatment is time dependent: the full list of such conditions is very long.

Similar situations are applicable to emergency maternity units, where time delay, lack of expertise, and complications of delivery can result in children born with disabilities resulting in long-term, expensive care needs.  One relatively common condition is pre-eclampsia/eclampsia which is treatable with urgent care (Liu S, Joseph KS, Liston RM, et al. Incidence, Risk Factors, and Associated Complications of Eclampsia. Obstet Gynecol. Nov 2011;118(5):987-994).

The closure of such units may save little money in the short term, but in the long run children born as result of the complications of these conditions will be far more expensive to look after.

In summary, you can go 10 miles down the road to see a specialist for a stable serious condition but when a serious unstable condition puts your life at risk, you want to get to A&E with a lightning speed.

The Urgent Care Centres

The substitute which the government is offering after closing the four major A&Es in west London are the so called ‘urgent care centres’.  What is an urgent care centre? This is a GP-led service, staffed with few nurses, has access to simple x-ray facilities, but no urgent specialist imaging such as CT scan because the latter need to be requested by a specialist.  These centres are legally forbidden from treating a vast array of serious and life-threatening conditions, including shock, internal bleeding, most types of broken bones, breathing difficulties, accidental injuries, heart attacks, strokes and many more. It will be fair to say that these centres do not have any role in real and life threatening emergencies. Furthermore, they are also banned from treating patients with severe pain resulting from conditions such as sickle cell anaemia. The medical profession has been sceptical about these services since they have started. The risks involved are many:

The College of Emergency Medicine (CEM), which represents A&E doctors, said that it is concerned that "urgent care" centres are acting as a barrier, preventing seriously ill patients from getting the treatment they need.

The President of the CEM, said: "These are worrying examples of things going wrong in urgent care centres.”

In one case, a man who had a stroke was sent home from an urgent care centre because staff could not work out what was wrong. He was eventually admitted to hospital and recovered. In another incident, urgent care centre staff failed to spot that a baby had meningitis. Emergency treatment was delayed but the child made a full recovery. UCCs have been known to miss severe pneumonia, again putting lives at risk.

Serious pulmonary embolism (lung clot) for which guidelines have been issued in the new ‘health and welfare act’ will stay undiagnosed in many cases and will be life threatening as it requires specialist skill and an urgent special type of CT scan which can only follow if a specialist doctors or a specialist team have seen the patient.

There are many more worrying examples - these patients were lucky, but it is easy to see how staff presented with situations outside their area of expertise may reach a diagnosis which could prove damaging to the patient. The risk to the patient presenting with an difficult to diagnose condition is obvious; but asking a care centre to make critical decisions without specialist advice currently available at A&Es risks either sending patients home when they should be in hospital or sending patients to a specialist centre unnecessarily.

It goes without saying that GPs are an essential part of our community medical services, but they lack the breadth and depth of expertise that a current A&E with on-site consultants in a wide range of specialties is able to draw upon - the fear is that if they are running these ‘urgent care centres’ with a pressure to show efficiency, then correct diagnoses and referrals will simply add time to the essential “Golden Hour”; or in the worst cases, cause problems through misdiagnosis of conditions that only a specialist would spot.

Another big worry is that money that should be going into hospital emergency departments is being diverted into these urgent care centres, at a time when financial pressure on the NHS is unprecedented.

These centres did work well alongside the A&E departments: their function as gatekeepers, keeping minor cases from overburdening the A&E did not prevent urgent cases being transferred immediately when necessary. This was an excellent arrangement: any medical emergency cold be taken there confident that it would receive the appropriate response in the shortest possible time, while also ensuring that the high-tech facilities of a modern trauma centre were not being tied up looking after boys with saucepans wedged on their heads.  But stand-alone units are ‘a bad idea’. These centres are working in Europe as well but they are a part of A&E departments. But it must be noted that even when part of A&E department, these centres did not make any economic sense (the cost was over £6,000 daily to save one or two admission).

What it means to close our A&E departments

Closure of four main A&E units will create public confusion, reciprocity challenges, limited professional mobility, impaired consistency and decreased efficiency.

These A&E closures mean that serious diagnostic errors and untreated conditions are likely to become more common. And some patients now face a lot more than an hour’s journey to reach a full hospital A&E department. The important question is whether those – examples described above – who are critically ill will survive this ordeal. The prognosis is not encouraging..

Supporters of the closure claim that the switch to bigger and fewer A&Es will improve patient care by focusing emergency treatment in high-tech ‘centres of excellence’. They miss one important fact: that before these patients can benefit from the services at these centres of excellence, they must survive and reach these centres alive. There is nothing to suggest that this will become more likely under the current proposals.

Furthermore, the definition of ‘centre of excellence’ is not at all clear to the public. Many think and still believe that Hammersmith hospital is a centre of excellence. This hospital invented the heart lung bypass machine, the kidney dialysis machine, produced the world's first test tube baby, and MRI scan. These and many more innovative endeavours shine like a star on the face of this hospital. The health department says that Hammersmith hospital will become a ‘specialist hospital’. But Hammersmith was always a specialist tertiary hospital. Closure of A&E will take away the emergency services and as a consequence a large number of acute beds will close, acute emergency skills will vanish and those who are used to deal with acute emergency cases day and night will disappear from the scene, many other remaining services will shut, all to save money at the expense of human life. One must not forget that the same emergency does arise in the non-acute hospitals (which these hospital will become) inpatients too. The only solution in that situation will be to transfer the patient. Most of these patients admitted in a specialist hospital are already very unwell and if on top of that they develop another critical condition such as heart or kidney failure, the ordeal of transfer to another hospital is highly undesirable from a medical point of view. The plain truth is that many lives will be put at risk. The same applies to Ealing, Central Middlesex and Charing Cross hospitals.

A thought!

In 2007 David Cameron publically promised a ‘bare-knuckle fight’<http://www.guardian.co.uk/uk/2007/aug/20/health.publicservices> to stop A&E and maternity closures. This promise rings very hollow today in the light of experience. Under his watch many Hospitals have actually closed, including Trafford General, Chase Farm in Enfield, North London, King George Hospital in Ilford, East London, and St Cross in Rugby. He gained a seat for Tories in Enfield by saving the Chasing Farm hospital at that time but now that same hospital has lost important services, since the election. He launched ‘Health and Social Care Bill’ from Ealing in April 2012: now that hospital faces A&E and maternity closures. He promised to put doctors in the driving seats and then ignored credible clinical opinions. Since his election in 2010, more than 4000 nurses have lost jobs. We need to tell the Government that we want the promises they made about the NHS kept.

Dr Mansoor A Bhatti

BSc(MedSci) MBBS(Hons) DGIM(Lond) MD(US)

MRCS(Eng) MRCP(UK) MRCP(Lond) PhD(Lond)

Consultant Physician & Gastroenterologist

Twitter