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In the UK, there is a national policy that hospitals must adhere to; patients in the Emergency Department must be seen and admitted if necessary within 4 hours. This works in Great Britain because their Emergency Departments work as no more than triage stations. Patients are investigated and admitted under inpatient units whilst still receiving initial treatment. This means that physicians and surgeons have to stabilise their own patients in acute medical units that are separate to ED.
Let's turn our attention to Australia then, specifically at the health network I am working at now. We are now adopting a similar approach here with the "4 hour rule". You can see it boldly and proudly being advertised on our intranet site with the funky and catchy slogan "4 hours will be ours". The first problem is that our hospital hasn't adopted the same approach with stabilising patients as our UK counterparts. ED still holds the dual function of investigating and making the diagnosis then initiating treatment and stabilising the patient prior to referring to the appropriate inpatient unit. Then, if the inpatient unit is too slow to respond, ED reserves the right to ship the patient up to the hospital wards with a "Safe and Timely Care" which basically means if we write up the drug and fluids chart, the doctors on the ward can sort out the rest up there, give us our ED bed now.
I can tell you right now that this 4 hour rule isn't working for sick patients. Sure, simple cases of appendicitis or pneumonia, you can diagnose, treat and refer within four hours but for more complex resuscitation cases, 4 hours just doesn't cut it. Today, a patient came over from ED to ICU with respiratory arrest secondary to opioid narcosis. He had 1600mcg of naloxone, half as IM, half as IV so he was much better. Great news. So he was started on a naloxone infusion as per instructions of the ED toxicologist at a rate of 400mcg per hour. Simple? Let me give you some figures written in the ED nursing notes:
As per Dr. X instructions, naloxone infusion commenced at 400mcg/hour. Naloxone infusion made up with 2g naloxone in 500mL N/Saline commenced infusion at 1mL/hr = 400mcg/hour.
Anyone see a problem with the figures? YES! 1mL/hr is actually only 4mcg/hour so the patient was transferred from ED for 1 hour getting NO naloxone. Now, one might argue that this is a problem with the nurse and the nurse was too stupid to do a simple calculation but you can also make a fairly convincing case that the ED doctor should have reviewed the naloxone infusion AND if there wasn't the 4 hour rule, this would have been picked up earlier instead of the patient being in transit receiving a subtherapeutic dose of naloxone. Who knows? All I know is that if the government wants better care for hospital patients in EDs, putting time pressure on the doctors isn't the answer.
Let's turn our attention to Australia then, specifically at the health network I am working at now. We are now adopting a similar approach here with the "4 hour rule". You can see it boldly and proudly being advertised on our intranet site with the funky and catchy slogan "4 hours will be ours". The first problem is that our hospital hasn't adopted the same approach with stabilising patients as our UK counterparts. ED still holds the dual function of investigating and making the diagnosis then initiating treatment and stabilising the patient prior to referring to the appropriate inpatient unit. Then, if the inpatient unit is too slow to respond, ED reserves the right to ship the patient up to the hospital wards with a "Safe and Timely Care" which basically means if we write up the drug and fluids chart, the doctors on the ward can sort out the rest up there, give us our ED bed now.
I can tell you right now that this 4 hour rule isn't working for sick patients. Sure, simple cases of appendicitis or pneumonia, you can diagnose, treat and refer within four hours but for more complex resuscitation cases, 4 hours just doesn't cut it. Today, a patient came over from ED to ICU with respiratory arrest secondary to opioid narcosis. He had 1600mcg of naloxone, half as IM, half as IV so he was much better. Great news. So he was started on a naloxone infusion as per instructions of the ED toxicologist at a rate of 400mcg per hour. Simple? Let me give you some figures written in the ED nursing notes:
As per Dr. X instructions, naloxone infusion commenced at 400mcg/hour. Naloxone infusion made up with 2g naloxone in 500mL N/Saline commenced infusion at 1mL/hr = 400mcg/hour.
Anyone see a problem with the figures? YES! 1mL/hr is actually only 4mcg/hour so the patient was transferred from ED for 1 hour getting NO naloxone. Now, one might argue that this is a problem with the nurse and the nurse was too stupid to do a simple calculation but you can also make a fairly convincing case that the ED doctor should have reviewed the naloxone infusion AND if there wasn't the 4 hour rule, this would have been picked up earlier instead of the patient being in transit receiving a subtherapeutic dose of naloxone. Who knows? All I know is that if the government wants better care for hospital patients in EDs, putting time pressure on the doctors isn't the answer.
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