I work in an overcrowded A&E. This winter will be worse than last yearIvy Madziva
Photograph: Jeff J Mitchell/Getty Images
‘Every day now there are more than 10 ambulances waiting outside the emergency department.’
We haven’t expanded our space or staff enough, and nurses and doctors are leaving the department
My emergency department is now always full with patients – mostly seen, diagnosed and treated, but waiting hours for beds in the hospital, which is also full. Poor hospital flow has become a new term for bed blocking and it’s our current priority. The situation has been getting worse since the end of October, and probably won’t now relent until Easter. Everyone I work with thinks this winter is going to be worse for our patients than the last; it already feels as bad as it ever got last year. Every day there are more than 10 ambulances waiting outside, some with patients in them for more than an hour, as everywhere is full. The hospital’s solution over the years has been to add temporary structures outside to create more space. They remind me of a mobile classroom and finding staff for the extra space is already a challenge.
We have already seen more patients into A&E than ever before since April this year. We haven’t expanded our staff or space enough to cope, and our experienced nurses and doctors are leaving the department (or their professions). I’ve gone part-time in an attempt to stay sane. When I started 10 years ago, we used to turn the lights down at night, do some teaching or eat and drink when we needed. The running joke now is that because the nurses don’t have time to have proper breaks, some can go 12 hours without needing to go to the toilet.
On my last shift the nurse in charge was broken. She’d had no break, hadn’t eaten in eight hours and was upset because no one could find any more hospital beds to transfer elderly patients on trolleys to. The only thing that kept her going that day was the new job she had just accepted doing something else.
Often we see patients who needn’t be at hospital. For example, people who couldn’t get to see their GP that day but didn’t know what else to do, or people with unrealistic expectations, like the woman who refused to go home unless we did “some type of scan”.
We also get patients discharged home the day before who come back, like the man who returned after falling and spending all night on his floor. He waited four hours for an ambulance to bring him back to hospital and now has pressure sores. Some patients are ready to go home late at night but we have no transport available until the following day, so they get admitted even though they’re well.
The main focus for the bed management team is to avoid having a patient in the department more than 12 hours after we have decided they need admission (a DTA). We often can’t get patients off ambulances and into the department for a doctor to see and examine them for an hour or two, so the 12-hour clock doesn’t start when they arrive. This means although patients are in the department for more than 12 hours they still don’t become a declared hospital “12 hour DTA” statistic, which hides our problems.
My role most days is to triage the large number of emergency patients – more than I have space for – into a safe space to see them, while trying to make sure the sickest are seen first. When the emergency pre-alert phone goes off, as the senior decision-maker I have to try to find some space for the expected arrival. Everywhere’s full but a space is needed in the next five minutes for a patient who’s critically unwell.
The lead nurse and I put a mark by the name of the least unwell patient in the department: a 90-year-old waiting for the non-existent transport home, in the corridor, and not on a comfortable hospital bed. She’s been there five hours already. Both the lead nurse and I have had our eye on her for some time as the best person to move in case a new patient needs to be put in the resuscitation room.
In the next five minutes she is sent into an area which is currently closed due to poor staffing. The next least sick patient in the department goes into her corridor space, and the next least sick patient in resus then takes their place just in time for the emergency arrival. With 30 seconds to spare we’ve created the space we need, but now have a 90-year-old lady on a trolley, basically in a cupboard.
I trained in emergency medicine to treat sick patients. I’m mostly now a risk manager, my experience enabling me to judge which patient is safest to put into the inappropriate places around my overcrowded and understaffed department.
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