kCCIDENT AND EMERGENCY DEPARTMENT

ORGANISATION ~ND UTILISATION

1

~--

H-328

New Zealand Department of Health

LIBRARY Box 5013 Wellington

73467Accession No

Classification WX 215 [Qj WH

Location 6129378-Y94

ISSN 0548-944X

Department of Health

ACCIDENT AND EMERGENCY DEPARTMENT ORGANISATION AND UTILISATION

SPECIAL REPORT 70

by

B CAllan BSc (Hons) J Reinken PhD

Issued by the Management Services and Research Unit Department of Health Wellington

1984

LIBRARY bull DEPARTMENT OF HEAlrRJ

WELLINGTON

FOREWORD

Over the last twenty years there have been a number of accident and emergency studies in New Zealand hospitals For the most part these have been place and topic specifics This study by Bridget Allan and Judith Reinken is different It begins with an historical review of previous work in the field This is followed by a wide ranging study of accident and emergency services based on field work carried out in a representative sample of hospitals The data are analysed and presented taking account of the relevant international literature The resulting consolidation of knowledge provides a sound basis not only for further research but more importantly for the further development of accident and emergency services

The report provides at least tentative answers to a number of questions regularly asked about accident and emergency services Do general practitioners and accident and emergency departments provide competing services lhe answer appears to be no The public seem to discriminate sensibly between what are for the most part complementary services Is cost a factor in accident and emergency attendance as opposed to a visit to the general practitioner Again the answer appears to be no - cost is not an important factor Are socio-economic status and ethnicity associated with the rate of A amp E attendance Perhaps but distance and other factors concerned with accessibility appear to be more important

The study shows wide variation in the way in which A amp E services are provided in different hospitals This ranges from the size and shape of the physical facilities and the type and level of staffing relative to the workload to the way in which individual patient problems are dealt with Those responsible for the planning and operation of A amp E departments should find these comparisons informative Consideration of the data may perhaps prompt questions which in their answering lead to greater cost effectiveness and to service improvement

As well as providing answers the research raises questions It points yet again to the need in New Zealand for a regional study of accidents and accident services Accidents are a major cause of premature death and morbidity Many organisations are involved in the prevention and treatment of accidents but so far it has not been possible to mount a comprehensive study which includes and integrates all interests Until this is done fragmentation of services is likely to continue

By highlighting access to services the study points up the need for more information about communication and transport patterns in health care delivery Again this is a neglected area of research which could have far reaching implication for the planning and operation of health services

Finally the report raises questions about the interaction between general practitioners and A amp E services That these services are largely complementary is clear but unfortunately the communication between them is often not as good as it could and should be Further research has a contribution here but will not solve the problem Better communication and understanding is needed on both sides

The researchers have provided us with a much needed and timely review of an important and sometimes controversial aspect of health services Theirjete audience

G C Salmond ---shyDeputy Director-General of Health Department of Health

ACKNOWLEDGMENTS

Many people have helped with this study In particular we would like to thank

o John Mills who visited the hospitals drafted the physical characteristics chapter and gave freely of his time and expertise

o the staff of the hospitals visited for sharing their time and thoughts with us

o Desmond Keenan Shelagh McRae and Denis Snelgar for allowing us to use the information they had collected

o Clare Salmond Mike Moore and Sylvia Nichol for their assistance with computer analysis

o readers ofmiddot drafts of this report who offered helpful criticism and suggestion

o the typists and publication staff of the Department of Health

We also acknowledge the Director-General of Health for permission to publish

DISCLAIMER

The views expressed in this report are those of the authors and do not necessarily represent the views of the Department of Health

COPYRIGHT

Provided the source is acknowledged information contained in this report may be freely used by any person

CONTENTS

Page

ACKNOWIEDGEMENTS LIST OF TABLES LIST OF FIGURES

1 INTRODUCTION I

Background Thewider questions of emergency medical services The overseas situation An historical perspective in New Zealand

Interview studies on the utilisation of A amp E departments Record studies on the utili satjon of A amp E departments Studies of the organisation of A amp E departments

Overview of this study Aims Sources of information

References

2 DEFINITIONS 11

The Accident and Emergency department Attendance The hospitals Recording systems References

3 PROCEDURES IN THE ACCIDENT AND EMERGENCY DEPARTMENT 15

Entry Sorting 1 reatmen t Disposal Follow-upcare Admissions Discussion References

4 PHYSICAL CHARACTERISTICS OF ACCIDENT AND EMERGENCY DEPARTMENTS 23

PrinCiples Size Location

Entrances Access to other hospital facilities

Layout Waiting area Examination and treatment area Resuscitation area Operating theatre Plaster room Interview room Reception and records office Staff offices Holding ward

Discussion References

5

6

7

8

STAFFING OF ACCIDENT AND EMERGENCY DEPARTMENTS 35

Medical staffing Senior medical staffing Junior medical staffing Accident and emergency work as a career

Nurse staffing Other staff involved with the A amp E department

Reception and clerical staff Orderlies Social workers Ambulance personnel

Discussion References

PATIENT ATTENDANCE CHARACTERISTICS 55

Overall attendance and trends Age and sex Conditions

Injury conditions Sickness conditions

Recall attendance GP-load

Non-urgent sickness Discussion References

PATIENT ATTI~UDES TO THE ACCIDENT AND EMERGENCY DEPARTMENT AND STAFF ATTITUDES TO THE PATIENTS 75

Reasons for visiting the A amp E department Overseas studies New Zealand studies

Effect of health centres and deputising services on A amp E utilisation A amp E staff views of patients

Overseas studies The New Zealand situation

Discussion References

UTILISATION OF ACCIDENT AND EMERGENCY DEPARTMENTS 91

Comparison of A amp E utilisation among hospital catchment areas Results Effect of general practitioner availability

Factors explaining catchment area variations in A amp E utilisation Method Results of the mUltivariate analyses

Comparison of A amp E use and general practitioner use Discussion References

9 CONCLUSIONS 107

The A amp E department as a hospital department The A amp E department as an emergency service The A amp E department as a primary care service Where from here

APPENDICES

APPENDIX A QUestion sheets 116

APPENDIX B Accident and emergency department records 120

APPENDIX C Statistical analyses of accident and 123 emergency department attendance rates by neighbourhoods

APPENDIX D Childrens use of general practitioners 128 and accident and emergency departments in Wellington

TABLES

Table

1 Proportion of first attendance patients discharged recalled referred or admitted

2 Areas of A amp E department~

3 Area to attendance ratios for adjusted total areas and waiting areas of A amp E departments by first attendance and total attendance

4 Numbers of examination and treatment cubicles or rooms and recommended numbers based on first attendance and total attendance

Medical staffing of A amp E departments

6 Total medical staffing (full-time equivalents) and medical staffing to attendance ratios for first attendance and total attendance

7 Nurse staffing of A amp E departments excluding student nurses and hospital aids

Nurse staffing (full-time equivalents) and nurse staffing to attendance ratios for first attendance and total attendance

Average attendance at A amp E departments 1978-1981

10 Trends in attendance at A amp E departments 1978-1981

11 Proportion of A amp E attendance that was recall attendance

12 Proportion of A amp E attendance that was for sickness

13 Proportion of total A amp E attendance that was for Sickness by policy and age groups

14 Use of general practitioners by first attenders at A amp E departments

15 Reasons for A amp E first attendance from three New Zealand studiesmiddot

Itgt Attendance (mean age-adjusted rates per 1000 per quarter) within each A amp E department catchment area

Page

18

24

25

29

37

39

45

46

56

57

66middot

70

71

77

78

92

(continued)

Table Page

17 Hospital admissionsfor accidental injury (mean 93 age-adjusted rates per 1000 per year) and death due to accidental injury (mean age-adjusted rates per 1000 per year) within each A amp E department catchment area

IB Attendance (mean age-adjusted and neighbourhoodshy 99 adjusted rates per 1000 per quarter) and populationshyto-general practitioner ratio within each A amp E department catchment area

19 Comparison of first attendances for injury at A amp E 101 departments and general practitioners

FIGURES

Figure Page

1 Percentage of total attendance at 58 A amp E departments by age and sex

2 Percentage of total attendance at 59 A amp E departments for sickness and injury conditions by age and sex

3 Injury first attendances by type of injury 6U all ages

4 Injury first attendances by type of injury 61 by age groups

5 Sickness attendances by type of sickness 62 all ages

6 Sickness attendances by type of sickness 63 by age groups

7 Comparison of medical staff availability and 67 level of recall attendance

Comparison of nursing staff availability and 67 level of attendance

9 Location at which accidents happened by those 79 attending the A amp E department or the general practitioner for accidental injury

Use of general practitioners and A amp E departments 131 by Wellington children 1978 (rates per 1000 children per quarter)

1

CHAPTER 1

Introduction

BACKGROUND

This report arises f rom concerns expressed by several groups about the availability especially out of hours of emergency car~ and its provision by Accident and Emergency (A amp E) departments in New Zealand

In _SQe mid 1970 s the people of Porirua were worried that local general -pr-actitioners were not available at nights and weekends and by the delays

involved in travelling to Wellington and Hutt A amp E departments [IJ At the same time the people of North Shore were campaigning to keep their local A amp E department open More recently community groups in Upper Hutt have been pressing for the addition of an A amp E service to a local health centre Overall people are concerned that appropriate care (including facilities such as x-rays) is readily available in emergency situations

General practitioners are another group who have been concerned about A amp E departments in particular about inappropriate uses of A amp E departments A long-standing complaint bas been that patients are using A amp E departments for care which wou~d be better given by a general practitioner and that the A amp E departments retain patients instead of referr ing them back to their general practitioner for follow-up care [2 3J In 1981 the research group of the Wellington Faculty of the Royal NZ College of General Practitioners sponsored a study of children presenting at A amp E departments because they were worried that unnecessary admissions of children to hospital occurred because their parents had bypassed the general practitioners and gone straight to hospital [4J

Also A amp E staff and hospital administrators have been concerned that caring for patients who could have been treated by general practitioners has limited their ability to deal with emergency cases [567]

THE WIDER QUESTIONS OF EMERGENCY MEDICAL SERVICES

Emergency care requires not only the provision of hospital services (the A amp E department with back-up from other hospital facilities) but also the organisation of services outside the hospital and co-ordination between both sets of services Emergency medical services outside the hospital include alarm and communication systems transport systems and first aid services There are important questions for New Zealand within this framework For example what should be the role of general practitioners in on-site emergency care What level of training is appropriate for ambulance officers Should voluntary personnel staff ambulances To what extent is double manning of ambulances required [8910]

In order to limit the study to manageable proportions this report focusses only on the hospital services namely the A amp E department Emergency medical services provided outside hospitals are mentioned only where they impinge noticeably on the A ampE department It is hoped that due attention will be given to the wider questions of emergency medical services in the future (see Chapter 9)

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THE OVERSEAS SITUATION

Concern with emergencymiddot care facilities especially their increasing use has been apparent in other countries for the past thirty years While some articles report on the situation in Canada Australia Sweden France and the USSR most of the literature is about the United States and Britain This section briefly outlines the major themes of the literature and their relevance to New Zealand More specific aspects are covered in the appropriate chapters

Many United States researchers have studied the operations of different emergency rooms exploring patients reasons for using the emergency room their demographic characteristics and their use of the family doctor Often the studies have tried to explain an increasing use of emergency rooms and some have reported on the effectiVeness of measures introduced to reduce thei r use These studies provided models for some of the analyses carried out in this study However the debate in the United States over appropriate methods of funding and staffing for emergency rooms is seldom relevant to New Zealand because of the differences both in philosophy and organisation of medical care in the two countries

The Platt [11] committee on A amp E services in Britain in 1962 was concerned about casual attenders ie patients not in need of urgent attention but wishing to avoid the trouble of attending their general practitioners surgery They also criticised the unsuitable accommodation and the insufficient numbers of senior medical staff supervising Casualty Departments The report recommended changing the name Casualty Service to Accident and Emergency Service (to discourage casual attendance) and rationalising the service by clOSing smaller A amp E units and centralising facilities These recommendations have been partially carried out

However there has been continuing research in Br i tain into the reasons given by patients particularly self-referred patients for their use of A amp E departments and the trade-off between general practitioner and A amp E services There has also been continuing debate over the medical staffing of A amp E departments

The British studies are of some relevance to the New Zealand situation since the organisation of medical care here is similar but no overseas experience can provide a blueprint for New Zealand For example the direct cost to the patient of general practice care in New Zealand raises the possibility of patients attending the A amp E department because it is free whereas the British system of general practitioner funding provides no such incentive

AN HISTORICAL PERSPECTIVE IN NEW ZEALAND

Little is known about the historical development of A amp E services in New Zealand Presumably they followed the British tradition described in the Platt report [11 p23-24)

The word casualty in its proper meaning of a serious injury has a long history It occurs in Shakespeare and Dickens writing in 1837 used casualty ward to describe the ward in a hospital in which accidents were treated Unfortunately the meaning alt~red in the second half of the last century The Nuffield Report (1960) Casualty Services and their Setting

3

gives an interesting quotation from a survey made by the Lancet in 1869 The out-patients at St Bartholomews Hospital are it says divided into two categories They are the middotcasualtymiddot which comprises those who are supposed to require temporary treatment for diseases or injuries of a trifling character and the middotout-patientsmiddot properly so called who after receiving a regular letter of admission are entitled to the advice of the assistant surgeons and physicians for a period of 12 months It is in the casualty division that the increase of numbers has been most marked bullbullbull It is estimated that not less than a thousand patients frequently attend on a Monday or Tuesday morning

Certainly by 1872 vlellingtons private medical practitioners were incensed at the hospitals provision of free treatment for their patients Five hundred outpatients were treated in Wellington that year [12] Separate casualty departments were operating at Wellington Hospital by 1924 [12] at Auckland Hospital by the 1940s [13] and Christchurch Hospital by 1952 [14]

The 1960 Board of Health report [15] on outpatient servicesmiddot expressed concern over the duplication of services by outpatient departments which were also available from general practitioners However it recommended that general hospitals continue to provide a casualty service available at all times

Since the late 1960s a series of New Zealand studies have considered the use of A amp E departments either by interviewing patients or by analysing data drawn from A amp E record systems and the organisation of A amp E departments

Interview studies on the utilisation of A amp E departments

The first interview study was an investigation of first attenders at the Dunedin A amp E department in 1968 by Dixon et al [2] Their results have not been contradicted by any of the later studies

They found that the principal attenders were males aged 15 to 24 who recorded first attendance rates of over 100 per 1000 each year The young men were also the most likely to report having no general practitioner Dixon found that the age and sex pattern of those attending at the A amp E department was nearly converse to the pattern of those attending a general practitioner

Dixon pointed out that the conditions treated at the A amp E department were rarely disease-related rather they were predominantly lacerations and open wounds bruising sprains and strains effects of foreign bodies and fractures The major reason given for attending the department was that it was seen as appropriate

Dixon concluded that the A amp E service was complementary and not competitive to general practice that the public were realistic in regarding it as the only practical and effective primary medical care for accident and emergency injuries and that payment for service did not appear to figure in the decision to attend the department

o

4

TwO interview studies of first attenders at Auckland Hospital A amp E department have been carried out by Hunton in 1972 and Richards in 1975 [16] Both studies included an assessment by the student interviewers and A amp E staff as to the suitability of the patients condition for general practice care 42-43 per cent were considered suitable Richards concluded that public education programmes encouraging people to use their general practitioner prior to attending the A amp E department should be instituted

In 1978 Keenan interviewed patients who had attended Christchurch A amp E department collecting detailed information on the accident or sickness leading to the attendance (unpublished see Chapter 6 and 7) He found the same set of reasons for using A amp E departments as Dixon found the A amp E department was seen as appropriate and accessible

Kljakovic found similar results when interviewing the parents of children attending A amp E departments in the Wellington region in 1978 [4] He also found that in choosing between the general practitioner and the A amp E department parents were more likely to use the service which was closer to the family home Children f rom lower socio-economic status families were more likely than other children to see thei r general practitioner before gOing to the A amp E department

Records studies on the utilisation of A amp E departments

Several studies have gathered data from A amp E records to investigate A amp E utilisation In 1979 Snelgar described the characteristics of people attending Northland Base Hospital A amp E department [17] He found similar results to Dixon apart from a higher proportion of injuries In the same year McRae reviewed all attendances at Waikato Hospital A amp E department and found a similar picture [lB]

Three records studies have looked at the relationship between A amp E use and general practitioner use Maynard looked at Mosgiel residents use of Dunedin A amp E facilities for three years before and three years after the opening of a local health centre [19] No difference was found ~asap

investigated assertions that people from one part of the Wellington Hospital catchment area had suddenly begun to use the A amp E department heavily for conditions that should have been seen by a general practitioner [20] In fact that part of the catchment area had much lower rates of A amp E use than other areas Reinken tested whether the doubling of general practitioner cover in one part of the Wellington region affected A amp E presentation rates differently than in other areas nearby [21] There was no clear evidence that the increased cover had any effect

Studies on the organisation of A amp E departments

As part of a thesis looking at young doctors Salmond examined the work of house surgeons in A amp E departments using a postal questionnaire [22J He concluded that working in an A amp E department was good experience for a house surgeon only if second year house surgeons were deployed in the department the house surgeon was well-supervised by senior medical staff there was a good working relationship with the A amp E chargemiddot nurse and the house surgeon was not over-tired He also suggested that good senior staffing was closely related to effective administration and better service in the A amp E department

5

The Hospital Design and EValuation Unit of the Department of Health prepared a report documenting the planning requirements of New Zealand A amp E departments [23] The report outlined several principles of A amp E design and made detailed recommendations on the facilities rooms and equipment necessary

OVERVIEW OF THIS STUDY

Aims

The aim of this study is to describe A amp E departments in New Zealand Because the material presented in the previous section was collected by different researchers at different times and from different A amp E

departments detailed comparisons across the studies have been difficult To get a more comprehensive picture of A amp E use in New Zealand a systematic investigation was necessary

The specific aims of this report are

o to describe the organisation of A amp E departments by looking at their procedures physical characteristics and staffing patterns

o to describe attendance at A amp E departments including the patients profile and pattern of attendance and the load placed on the departments by patients who would be more appropriately treated by a general practitioner

o to describe the use of A amp E departments by consumers by analysing patients reasons for attending the departments and analysing demographic factors inrelation to A amp E attendance

Sources of information

Information was gathered from three sources

The site visits

Fourteen A amp E departments were visited between May and September 1981 by a Department of Health study team consisting of a medical officer from the Division of Hospitals and a res~arch officer from the Management Services and Research Unit

At each hospital the team examined the facilities and spoke with staff involved with the A amp E department including

o the medical superintendent (and in some hospitals the principal nurse)

o the A amp E officer or medical officer in charge of the A amp E department (where such a position existed and was filled)

o the nurse supervisor andor charge nurse of the A amp E department

o at least one house surgeon working in the A amp E department

6

In some hospitals the team also spoke with other staff members including experienced A amp E staff nurses and hospital social workers

Question sheets were used during interviews so that a comparable body of information was collected at each hospital Interviews were open-ended to allow discussion of local procedures or problems (See Appendix A for question sheets)

Hospitals were carefully selected so that the A amp E departments in the study would represent a cross-section of New Zealand A amp E departments Those selected served a range of communities in both the North and South Islands

o major urban Dunedin)

areas (Auckland Wellington Christchurch and

o provincial centres (Rotorua Taranaki and Timaru)

o predominantly rural areas (Whakatane and Grey)

In centres with more than one A amp E department all were visited so that a complete picture of the services and use could be developed This involved visiting Auckland Green Lane Middlemore and North Shore hospitals in Auckland and Wellington Hutt and Kenepuru hospitals in Wellington

The information gathered in the site visits has been used in describing the organisation of A amp E departments (Chapters 3 4 arid 5)

The A amp E records data collection

On each site visit a sample of 1981 attendances was drawn from the A amp E record system and the following information was recorded for each person age sex presenting condition (sickness or injury) time of presentation residential address and whether the visit was a first attendance for the condition or a recall visit

Exceptions were Christchurch and the three Wellington Hospital Board A amp E departments Comparable data collected by Keenan in Ch ristchurch in 1978 and Allan in Wellington during 1980 were used instead

This information has been used to describe the attendance at A amp E departments (Chapter 6) and for the analysis of demographic factors in relation to attendance (Chapter 8)

The consumer studies

In 1978 Keenan carried out interviews with patients attending Christchurch A amp E department working from a one in eight sample drawn from the A amp E log over a four-week period and gaining a 99 response rate Results from this study have been analysed and compared with the results of the published New Zealand interview studies [2416] Anecdotal material from Kljakovic s study of children attending Wellington A amp E departments has also been included to illustrate the results of the numerical analysis

We realise that in studying only a selection of A amp E departments some local variations may have been missed but we are confident that the broad pattern and major issues in the organisation of A amp E care have been

7

covered Also as the A amp E departments studied serve two-thirds of the population of New Zealand the utilisation patterns discussed in the report are likely to prevail throughout New Zealand We hope that the mater ial presented the conclusions drawn and the questions raised in this report will encourage discussion about the current operation and future developmiant of A amp E departments in NewmiddotZealand

a

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REFERENCES

1 de LACEY A REINKEN J and SALMOND C E - Community attitudes to sickness and health stimulus and response v 3 Community attitudes - Wellington Management Services and Research Unit Dept of Health 1980 p 103-105 (Special report series no 56)

2 DIXON C W Emery G M and SPEARS G F S - Casualty department utilisation survey in NZ Med J - v 71 (1970) p 272-279

3 [Editorial] in G P Journal of the General Practitioner Society no 42 (1981) P 1-2

4 KLJAKOVIC M ALLAN BC and REINKEN J - Why skip the general practitioner and go to the accident and emergency department in NZ Med J - v 93 (1981) P 49-52

5 SKUDDER Paul A McCARROLL James R and WADE Preston A - Hospital emergency facilities and services a survey in Emergency medical services behavioural and planning perspectives edited by John H Noble Jr et ale - New York Behavioural Publications 1973 p 17-35

6 MAYNARD Edward J - The application of epidemiological methods to the evaluation of primary medical care in a health centre environment shyUniversity of Otago 1980 Ph D Thesis Social and Preventive Medicine

7 Hospital misuse brings protest in Taranaki Daily News (1 Sept 1980) bull

8 FAHEY Morgan - The role of the family doctor in disaster and emergency medicine in NZ Family Physician - v 5 no 1 (1978) p 42-44

9 Proceedings of the emergency care seminar Auckland 19-23 March 1979 in NZ Med J - (1980) P 194-196

10 Double manning of ambulances [editorial] in NZ Hosp - v 32 no 3 (1980) p 1

11 Gt Brit Central Health Services Council - Standing Medicine Advisory Committee Accident and emergency services report of the subcommittee - London HMSO 1962 Chaired by Sir Harry Platt

12 BARBER Laurie H and TOWERS Roy J - Wellington Hospital 1847-1976 Wellington Wellington Hospital Board 1976

13 The story of Auckland Hospital 1847-1977 edited by David Scott -Auckland Medical Historical Library Committee of the Royal Australasian College of Physicians in New Zealand 1977 p 35-36

14 BENNETT FO - Hospital on the Avon the story of the Christchurch Hospital 1862-1962 Christchurch North Canterbury Hospital

o Board 1962

9

15 Outpatient services in public hospitals in New Zealand - Wellington Government Printer 196U (Report series Board of Health no 2)

16 RICHARDS J G and WHITE G R - Accident and emergency services at Auckland Hospital in NZ Med J - v 85 (1977) P 272-274

17 SNELGAR Denis - Accident and emergency utilisation study Paper prepared for the Primary Health Care Shadow Service Development Group Northland 1981 (Unpublished)

18 McRAE Shelagh and TOPPING Mark - Casualty attendances one years experience at Waikato Hospital in NZ Med J - v 95 (1982) P 12-14

19 MAYNARD Edward J and DODGE Jeffrey S - Introducing a community health centre at Mosgiel New Zealand effects on use of the hospital accident and emergency department in Med Care - v 21 no 4 (1983) p 379-388

20 KASAP D - Personal communication 1975

21 REINKEN J - Effect of changes in general practitioner cover on accident and emergency utilisation in the Porirua Basin Wellington Management Services and Research Unit Dept of Health 1979 (Unpublished)

22 SALMOND G C - Young doctors an exercise in social research methodology - University of Otago 1970 Ph D Thesis Social and Preventive Medicine p 179-214

23 Accident and emergency departments a study of planning requirements prepared by the Hospital Design and Evaluation Unit - Wellington Department of Health 1973

11

CHAPTER 2

Definitions

lhis chapter provides the definitions of terms used in our study In general our terminology is consistent with the literature However in some areas such as the classification of presenting conditions as sickness or injury or the description of GP-load there is no general consistency and we have developed our own definitions

THE ACCIDENT AND EMERGENCY DEPARTMENT

This name is the one commonly used in New Zealand We have used it in preference to the older description Casualty Depariment [1] and the American description of Emergency Department It is one hospital department which patients can approach without prior notification

Emergencies can be any condition that - in the opinion of the patient their family or whoever assumes the responsibility of bringing the patient to the hospital - requires immediate medical attention

However using such a definition means every case is an emergency In New Zealand A amp E departments patients tend to be classified in a similar way to the description given by the American Hospital Association [2]

o emergencies where delay is harmful and the condition potentially threatens life or function

a urgent cases which require attention within a few hours

o non-urgent cases where the condition is minor or non-acute and does not require the resources of the emergency service

An accident is an unexpected event Accidents which have resulted in attendance at an A amp E department are ones that have caused some trauma whether through shock or other injury The Platt report [1] decided on the term A amp E department in recognition that the real emergencies were a trickle while the accidents were a mighty flood

In general the A amp E department is regarded as part of the hospitals outpatient services and like these in day to day running it provides specific clinics generally for the treatment of traumatic injury x-ray burns dressings plasters and so forth

An accident and emergency patient is a person who is entered in the A amp E log book This can involve a certain amount of error however as some outpatients or discharged patients may return for follow-up care through the A amp E department Also the A amp E department often handles the acute admissions to the hospital

12

ATrENDANCE

A first visit (or first attendance) is the first visit a patient makes for one particular condition

A recall visit is any visit made for one particular condition which is not the first visit for the condition Some recall visits are patient initiated (eg due to pain bleeding infection or an accident to the dressing or plaster) but for the most part revisits are scheduled return visits suggested by A amp E staff

Total attendance is the sum of first visits and recall visits

Inj ury attendances are defined to include the results of trauma (cuts burns fractures sprains strains bruises head injuries multiple injur ies and so forth) as well as foreign bodies in the eye or other orifices and toxic effects whether from accidental or self-poisoning events Late effects of minor injury (pain bleeding abscesses or such) are not included as injury but as sickness

Sickness attendances include collapse (whether stroke coma heart attack or other) shortness of breath abdominal pain general sickness (fever vomiting diarrhoea unwell) mental distress and minor conditions

Non-urgent sicknesses are defined as the minor conditions abdominal pain and general sickness except for preschool children and adults over 65 where the general sickness and abdominal pain conditions can be urgent A amp E staff defined non-urgent sickness less specifically they tended to define it as longstanding or minor sickness

GP-load describes the patients whom A amp E staff feel should have seen a general practitioner It includes patients with longstanding or minor sickness conditions and patients with minor traumatic injury (eg cuts bumps and bruises)

In hours attendance refers to all attendances in the normal working hours of 0800 to 1800 Monday to Friday excluding holidays

Out of hours attendance refers to all other attendances outside the defined normal working hours

In an average week 50 hours fall in the in hours category and 118 hours in the out of hours category If we assume that an average person sleeps eight hours a night then that person is awake for 62 hours in the out of hours category (and all the in hours of course) Thus the out of hours category is 70 per cent of the total time in a week and 55 per cent of the waking time in a week

Minor conditions included abscesses backaches infected wounds or wound pain headache pain (unspecified) earaches eye problems toothaches nosebleeds limb pains We have called it the skin pain or bleeding category in Chapter 6

13

Attendance rates measure the use of A amp E departments for a defined population They express the number of cases from an area over a defined period per 1000 population in that area Rates were obtained by age and sex for sickness and injury and in and out of hours for each census area unit or neighbourhood served by each hospital

THE- HOSPITALS

We grouped hospitals into four types

o urban hospitals (where average annual first attendances at A amp E departments are over 25000 patients)

o provincial hospitals (serving 6000 to 12000 new A amp E patients each year)

o rural hospitals (serving fewer than 6000 new A amp E patients each year)

o suburban hospitals where A amp E departments are not open 24 hours per day North Shore Hospital was open 7 days a week 830 am shy530 pm and Kenepuru Hospital was open 5 days a week 830 am shy430 pm

Most of the A amp E departments visited had a senior position variously called the A amp E officer the A amp E director the senior medical officer or the medical officer in charge For convenience we call this position the A amp E officer

RECORDING SYSTEMS

The log is the record kept at the A amp E department which records some information on every patient who presents It will often give no more than the patients name the date and time of visit

The A amp E record is usually a card and it records basic patient information and case notes It may be held for several years in the A amp E department and may therefore contain information on a series of separate events for anyone patient

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REFERENCES

1 GtBrit Central Health Services Council - Standing Medical Advisory Committee Accident and emergency services report of the sUbcommittee - London HMSO 1962 Chaired by Sir Harry Platt

2 Emergency services the hospital emergency department in an emergency care system Chicago American Hospital Association 1972 p vii-viii

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D

CHAPTER 3

Procedures in the accident and emergency department

In this chapter we begin describing the organisation of A amp E departments by looking at the way they operate We follow the course of a patients care entry to the A amp E department sorting into priority order for care (triage) treatment and follow-up care

ENTRY

Most people presenting at the A amp E department were ambulant (the walking wounded as they are colloquially known) They came through the A amp E departments main entrance to the reception desk where they were first seen by a receptionist or nurse (Exceptions to this occurred in the smaller hospitals where patients presenting at night were first seen by the telephonist who called the nursing staff) Nurses did reception duties at

all the provincial and rural A amp E departments and at two of the urban A amp E departments when receptionists were not on duty (eg lunchtimes nights) bull At times nurses found that having to cover the reception desk interfered with their care of patients

When the receptionists are off duty the nurses do the reception work This can be a nuisance because it interferes with patient care and sometimes patients ring the bell at the reception desk and the staff working in the resuscitation room dont hear it

A amp E nurse

Unless their condition required immediate care the ambulant patients then spent several minutes at the reception desk while their details (eg name address general practitioner complaint) were noted on the A ampE records (See Appendix B for more information on A amp E records) Then they waited in the waiting room until they were called for treatment

A small proportion of patients arrived by ambulance andmiddot at almost all hospitals entered the A amp E department through a separate ambulance entrance In the larger hospitals some nursing staff were stationed in or near the ambulance entrance to care for these patients In other hospitals the staff had often been warned of incoming urgent cases and were standing by when the ambulance arrived As the condition of ambulance patients tended to be urgent they were usually taken straight to a resuscitation or treatment area patients condition permitted or friends or the ambulance driver

Record with the

keeping assist

was ance

carried of thei r

out r

when elativ

the es

SORTING

All A amp E departments operated some triage system to sort the ambulant patients by the urgency of their need for care (Themiddot only exception was Grey A amp E department where there was seldom more than one patient in the department at a time) At most A amp E departments the patients were sorted

16

into urgent and non-urgent categories with urgent cases being seen immediately and non-urgent cases being seen in the order they presented At some of the urban A amp E departments a more complex sorting was done For example

Priority is given in the following order

urgent need very young and very old patients those with general practitioner notes those without general practitioner notes

A lie E nurse

Usually ambulance cases were not triaged since they tended to arrive on their own and required urgent care However several A lie E departments had triage arrangements planned for the arrival of many ambulance cases at once as in a disaster

Sorting was largely a responsibility of the nurses although some A amp E doctors would occasionally check the condition of patients- in the waiting room too The receptionists often played a role in triage as well alerting the nursing staff to urgent cases This happened more in A amp E departments where the physical layout made it difficult for nurses to watch the entrance and the waiting room

The receptionists do tQe basic sorting They have guidelines to follow distressed patients severe cuts or bleeding go straight to the nurses open wounds or eye injuries go directly to a cubicle and are assessed by the nurses patients with abdominal pain or chest pain go on to trolleys and wait in the recovery room This system usually works well although occasionally a fracture patient will not be recognised and will sit in the waiting room

A lie E nurse

In several A lie E departments doctors and nurses stressed the value of an experienced receptionist in recognising and reacting quickly to acutely ill or injured patients

TREATMENT

Almost all the A amp Edepartments visited had a policy that all patients presenting had to be seen by a doctor The doctor did not necessarily have to treat the patient he or she could advise the patient to see a general practitioner Some A amp E doctors commented that by the time they saw the patients it was as easy to treat them as to send them away_ At a few departments the nurses (and occasionally the receptionist) could advise the patient that the department was not an appropriate place for their condition and that they should see a general practitioner This was usually done in consultation with the A E doctor but at times the nurses acted on their own initiative In these places a triage system similar to that reported by Weinerman et al [1] where patients were assigned to the appropriate service inside or outsidemiddot the hospital appeared to be operating

7

The assessment of patients the ordering of tests andmiddot the supervision of treatment were usually seen ~s medical functions The nurses would prepare patients for treatment (removing dressings) and carry out urgent first aid measures (stem bleeding start gastric lavage or cardio-pulmonary resuscitation) Generally however a nurse would only initiate treatment if the patients condition was urgent and a doctor was not available or was already busy with another emergency Exceptions to this situation occurred in some hospitals with A amp E nurse training programmes and in some smaller hospitals where the doctor is on call rather than working in the A amp E department In these departments experienced nurses could order tests such as x-rays and initiate treatments such as suturing and removing foreign bodies from eyes

In most A amp E departments nurses would perform some treatments under a doctors supervision However the range of treatments nurses were allowed to perform varied considerably among hospitals At some hospitals nurses sutured after training but at others they never sutured

The nurses do not suture although they would like to There are four reasons for this there is no full-time A amp E officer so good standards of sutur ing could not be maintained there could be medico-legal problems if a nurse sutured a cut which was more complicated than it looked eg with tendon involvement the nurses have enough to do at present and if they start suturing they will be expected to do it always and the young doctors need to learn suturing as part of their training

Principal nurse

Electrocardiograms were taken by nurses in some A amp E departments by technicians at others Taking blood samples was a doctors job in some departments but was done by nurses in others Similarly gastric lavage using a def ibrillator and plaster work were done by nurses in some departments Most A amp E nurses would maintain intra-venous drips but only nurses with special training WOUld insert them

Some nurses expressed frustration at restrictions on the treatments they were allowed to perform However several sen~or nurses stressed that they had to select carefully the nurses they allowed to perform more difficult treatments

We are very selective about choosing the nurses to do triage suturing and the more complicated procedures This seems to have been successful weve had no problems with nurses undertaking treatment theyre not competent to provide

A amp E senior nurse

I make sure the nurses understand they can be dangerous people If theyre not aware of their limitations theyre not suitable for A amp E work

A amp E senior nurse o

Also one department which had comparatively few nurses discouraged them from increasing the range of treatments they performed so that their workload did not become overwhelming

18

For diagnosis the A amp E departments made heavy use of the x-ray departments (The Design and Evaluation Unit study [21 estimated that 30 per cent of A amp E attenders had an x-ray during their visit) Some A amp E departments found their arrangements with the x-ray department very convenient with an x-ray machine aVailable 24 hours a day in or close to the A amp E department and with patients and x-ray films or reports returning within an hour At other hospitals arrangements Were less convenient in some places reporting bac k of x-rays took two or three hours delaying patients considerably while in others the x-ray departmentmiddot was located on a different floor from the A amp E ~epartment causing difficulties in transporting and accompanying patients there

Little use was made of the laboratory services other than for blood and urine tests and arrangements were generally satisfactory However in many hospitals x-ray and laboratory staff had to be called in to perform tests out of hours and because of the expense involved these out of hours tests were discouraged Some house surgeons found this a difficult situation

I I m caught between contradictory pressures the orthopaedic surgeons say that x-rays are necessary for proper diagnosis and the hospital board is trying to limit out of hours x-rays to save money

House surgeon

DISPOSAL

After treating the patient the A amp E doctor decides on the appropriate disposal discharging from care arranging follow-up treatment by referring to another source of care or recalling to the A amp E department or admitting the patient Information on disposal was only readily available from three A amp E departments The most common disposal pattern was in fact discharging from care with 40 to 55 per cent of patients making a first Visit being discharged

TABLE I PROPORTION OF FIRST ATTENDANCE PATIENrs DISCHARGED RECALLED REFERRED OR ADMITTED

Discharged Recalled Referred to Admitted Other First to A amp E GP Specialist attendance

Clinic tallied

Waikato l 393 132 222 99 134 19 25 707 Green Lane2 550 220 110 40 80 Unknown Taranaki 41 5 268 73 103 116 24 164

1 From McRaes study of Waikato A amp E departmen~ in 1979 2 From a study carried out by Green Lane A amp E department

19

FOLLOW-UP CARE

The decision to be made on follow-up care was usually between re~alling to the A amp E department or referring back to the patient I s general practitioner Some A amp E departments also referred patients (especially children) to district nurses or patients with work 1n]uries to an occupational health nurse or clinic Many departments referred fracture patients to orthopaedic clinics held in the hospital outpatients department and one A amp E department which was very short of space referred patients needing redressings to the outpatients department

There were large differences in referral practices (see Table 1) Between 13 and 27 per cent of first attenders were recalled to the A amp E department for follow-up care while 15 to 30 per cent were referred elsewhere either to a general practitioner or to a specialist clinic Also recall attendances expressed as a proportion of total attendances varied considerably among the A amp E departments from 10 per cent to 50 per cent (see Chapter 6 Table 11) and clearly reflected different follow-up practices

All of the urban and two of the provincial A amp E departments had a policy of referring most patients requiring follow-up care to a general practitioner and of keeping recall visits as low as possible This was similar to general policy in both Britain and the United States which appears to discourage re-at tendance at A amp E departments [34] However in the suburban rural and other provincial A amp E departments the decision on follow-up care was left to the judgement of the A amp E doctor

In practice however the choice to refer or to recall was reiated to several factors First the decision related to characteristics of the patients If the patients had serious wounds or burns or injuries which could develop complications they were usually recalled They were also recalled if the A amp E staff thought they would not receive appropriate care at home or they would not see a general practitioner for follow-up care Patients living a long way from the hospital were usually referred to their general practitioner At some A amp E departments patients were given the choice of referral or recall according to A amp E staff comments most chose to return to theA amp E department

The patients prefer to come back to the hospital Money is not a factor in this because the ACC pays for accident treatment at the general practitioner

A amp E nurse

Second there were general practitioner factors If the local general practitioners were unhappy about the A amp E department recalling patients or if a general practitioner had referred the patient to the department originally the A amp E doctors would refemiddotr rather than recall However if the A amp E doctors thought that the general practitioner did not have the facilities and in some cases the ability to provide follow-up care (eg for serious woundS eye injuries) they would recall the patient

Some GPs dont like following up care initiated by the A amp E department or dont have the necessary facilities so I tend not to send patients back to them

A amp E officer

20

Im more likely to refer a patient back to a GP who is reliable

House surgeon

Third many of the house surgeons said they would recall patients if they were interested in the condition or if they were worried about their diagnosis and treatment and wanted to see the outcome Several medical superintendents noted that recalling under these circumstances was acceptable because it comprised part of the house surgeons training

Fourth the workload of the A amp E department sometimes affected the follow-up decision with very busy departments actively discouraging recalls And finally there was the philosophy of A amp E medicine held by the A amp E doctor In one department where the A amp E officer considered it an ethical duty to see any treatment initiated through to a successful conclusion almost all patients who needed follow-up care were recalled At two other departments the A amp E officers stressed the importance of being able to deal efficiently with any emergencies presenting they kept recalls low so that the department was not clogged with extra patients Other A amp E doctors thought that the general practitioner could provide better continuity of care than the A amp E department so they referred as many patients as possible

When referring patients to the general practitionermiddot most of the A amp E doctors made a verbal recommendation to the patient and then relied on the patient to attend the general practitioner They would only write a formal referral letter if the patients condition was serious In several A amp E departments however greater efforts were made to inform the patient t s general practitioner Three departments gave referred patients cyclostyled forms with details of diagnosis and treatment to be passed to their general practitioner while the Whakatane department sent a copy of the A amp E record form to each patients general practitioner

ADMISSIONS

Table I suggests that between a and 14 per cent of all first attendances were admitted to the hospitals Admissions could well be higher for children Kljakovic [5] found that 20 per cent of the children presenting at the Wellington Hospital Board A amp E departments were admitted

The A amp E departments were involved in several different pathways for the admission of acutely ill or injured patients (Scheduled admissions did not involve the A amp E department at any of the hospitals visited) Self-referred patients could be admitted directly from the A amp E department to the wards or could be cared for in a holding (or acute admitting) ward before going to the wards

There was considerable variation among the hospitals as to which members of the medical staff were able to admit patients At some of the urban hospitals only the registrars could admit while at others the A amp E doctor could admit if the registrar was delayed and unable to assess the patient quickly At some of the provincial and one of the urban hospitals the A amp E doctor could admit in consultation with the admitting officer or appropriate registrar while at-another urban hospital and the rural A amp E departments the A amp E doctors regularly admitted patients

21

Hospitals with lower levels of bed occupancy were more likely to allow A amp E doctors to admit Senior A amp E doctors were more likely to play a role in admissions (actually admitting patients or advising the registrar) than house surgeons

Some patients referred by a general practitioner for acute admission also passed through the A amp E department At one hospital the general practitioners rang the A amp E officer to arrange for all acute admissions and all such GP-referred patients were seen first in the A amp E department However more usually the general practitioners rang the appropriate registrar to make arrangements and the registrar decided whether to admit the patient directly to the wards or through the A amp E department The involvement of A amp E staff with patients requiring admission ranged from almost none (where the patient went directly from the A amp E department to the ward or specialist unit) to a full initial assessment including tests (often undertaken at the request of the registrar responsible for the patient) bull

Generally the A amp E doctors were satisfied with the admission procedures However at one hospital where the A amp E doctors could not admit patients waiting for admission tended to clog the department The doctorselt that if they had admission rights the situation would be remedied

DISCUSSION

There were few differences among the A amp E departments in the reception and sorting of patients However there were differences in some aspects of treatment follow-up care and admission procedures

lhe role of the A amp E nurses in treatment varied considerably with some departments allowing nurses to initiate and perform many treatments and other departments allowing little autonomy Careful training and selection were essential before nurses increased their responsibility for treatment bull

Policies on follow-up care differed among the departments with the urban and provincial departments generally referring patients to general practitioners and the rural and suburban departments leaving the referral decision to the A amp E doctor In practice however the differences were less clear-cut with several factors other than the patient I s condition affecting the follow-up care decisions These factors included the A amp E staffs communicat ion with local general practitioners the inexperience and training needs of house surgeons the workload of the department and the senior A amp E doctors philosophy with regard to A amp E medicine

The A amp E departments also differed considerably in thei r procedures for acute admissions At some hospitals the A amp E doctor could admit an A amp E patient while at others the patient had to be held in the department until admitted by a registrar Also at some hospitals patients referred by general practitioners for acute admission were seen in the A amp E department before going to a ward While having to hold patients sometimes caused

clogging in the department A amp E staff were generally satisfied with the procedures

22

REfERENCES

1 WEINERMAN E Richard RUfZEN S Robert and PEARSON David shyEffects of medical -triage- in hospital emergency service in Public health reports - v 80 no 5 (May 1965) p 389-399

2 Accident and emergency departments a study of planning requirements prepared by the Hospital Design and Evaluation Unit - Wellington Department of Health 1973

3 Accident and emergency services - Gt Brit National Health Service memorandum HM (68)83

4 Emergency department organisation and management edited by AL Jenkins - St Louis Hosby 1975

5 KLJAKOVIC M ALLAN B C and REINKEN J - Why skip the general practitioner and go to the accident and emergency department in NZ Med J - v 93 (1981) P 49-52

23

CHAPTER 4

Phy~i~~1 c~~raft~rhtics of accident and emergency departments

This chapter describes the physical characteristics of A amp E departments their overall size location and layout as well as specific areas within the departments It discusses the effects of the physical characteristlcs on the organisation and functioning of the A amp E departments Our investigation worked from the detailed base established in bullAccident and emergency departments a studY of planning r~quirements a report prepared by the Hospital Design and Evaluation gnit Departmellt of HeCilth [1]

PRINCIPLES

The 1973 Hospital Design and Evaluation Unit (DEU) report [l] outlined the following principles to be applied in designing A amp E departments

o the A amp E department must be patients seeking emergency care

ready to receive and deal with

o the A amp E department mus~ be able load within a reasonable period

to cope with an average i

busy

o the A amp E department must be capable of adaptation to exceptional situations arising from major accidents ltgtrqther disasters

o the layout should be simple easily unqerstood and compact

o the layout and procedures should facilitate easy flow of patients through the department

o spaces should be multipurpose to give greatest versatility

o p~tient ~ovew~n~ should be minimised )

priv~cy for patientsshould be provided as far as is practicable andconsistent with the need for supervisi0rt

SIZE

There was considerable variation in the total sizes of the A amp E -a~1-ftment~ vi~ited witll floor areas ranging from 250 sql1a~e metres to 2115 ~guare m~ties (see Table 2) Eight of the 14 departments visited had i

hhid1pgw~fd~oracUte admitting ward However even wt)en ~he area of th~ f~ ~ bull ~middotc1~A~- _ ~ - bull bull ~

AampE department WCiS adjusted for the presence of a holding ward this I~1-getv~-rH~tion in irea reniained

24

TABLE 2 AREAS OF A amp E DEPARTMENTS

Total area Holding ward Adjusted total Waiting room area areal area

sqm sqm sqm sqm

Full-time departments

Urban Auckland 2 115 225 1 890 55 Middlemore 1 045 140 905 50 Green Lane 960 240 720 70 Wellington 575 190 385 75 Hutt 270 270 30 Christchurch 470 470 40 Dunedin 635 90 545 20

Provincial Rotorua 515 20 495 90 Taranaki Base 720 90 630 40 Timaru 605 70 535 80

Rural Whakatane 430 430 20 Grey 310 310 15

Part-time departments

Suburban North Shore 255 255 30 Kenepuru 540 540 30

1 Adjusted total area = total area minus holding ward area Considerable sharing with outpatients department

The area of the A amp E department was not closely related to the attendance (see Table 3) Obviously there is a certain minimum size for an A amp E department since certain facilities are essential regardless of the attendance served Thus as would be expected the rural and to a lesser extent the provincial A amp E departments had high area to attendance ratios However even within the group of urban A amp E departments there was a fourfold difference in the total area to attendance ratio

The design at Auckland~ laid out along several corridors with many separate consulting and treatment rooms possibly contributed to its high ratio At Wellington Hutt and Christchurch hospitals staff commented on their difficulties working in cramped conditions The lack of space often forced staff to work under extreme pressure to move patients through the departments very quickly

25

TABLE 3 AREA TO ATTENDANCE RATIOS FOR ADJUSTED TOTAL AREAS 1 AND WAITING AREAS OF A amp E DEPARTMENTS BY FIRST ATTENDANCE2 AND TOTAL ATTENDANCE 2

Adjusted total area to attendance ratio Waiting area to to attendance ratio

Sqm per 1000 Sqm per 1000 Sqm per 1000 first attendance total attendance total attendance pa p a p a

Full-time departments ~

Urban Auckland 323 291 08 Middlemore 232 157 09 Green Lane 3 230 168 16 Wellington 80 69 13 Hutt 82 63 07 Christchurch 76 64 05 Dunedin 200 143 05

Provincial Rotorua 404 293 53 Taranaki Base 609 399 25 Timaru 466 266 403

Rural Whakatane 718 490 23 Grey 805 61 2 30

Part-time departments

Suburban I INorth Shore 272 148 17

Kenepuru 924 597 33

1 Adjusted total area = total area minus holding ward area

2 See Table 9 for attendance figures used in calculations

3 Considerable sharing with outpatients department

Spearman rank correlations [2] of adjusted total area with

( a) first attendance r = 0310 p gt 010 Not significant ( b) total attendance r = 0297 pgt 010 Not significant

26

LOCATION

There is broad agreement that the A amp E department should be located on the ground floor well signposted and easily accessible to ambulatory patients and ambulances The ambulance entrance should be able to handle several ambulances at once and should have adequate turning space It should be projected from the weather and screened from the view of the other A amp E department patients

The A amp E department should also be located as closely as possible to radiology facilities (either the x-ray department itself or a branch) The A amp E department and the outpatients department can share some facilities and provide additional staff and accommodation in an emergen~y

situation if they are sited together Acute patient care areas (operating theatres intensive care unitsmiddot and cardiac care units) and laboratory services should also be readily accessible from the A amp E department [134]

Entrances

Almost all of the A amp E departments visited were on the ground floor of the hospital and were well signposted Generally access for ambulatory patients was good apart from two hospitals where they had to walk up steps to enter the building o

Few departments had ambulance access which could cope with a shuttle of ambulances bringing mass casualties from a disaster There w~s little relation between the size of the department or the population served and the ease of ambulance flow Indeed those departments with a relatively low probability of being involved in a mass casualty situation had good ambulance flow (eg Whakatane) while those with a greater possibility had relatively poor ambulance access (eg Wellington) Several departments had particularly poor a~bulance flow with only a one-lane access Three departments had good drive-straight-through access while at the rest ambulances had to reverse However there were advantages to some of the bull reversing I situations in that the bays into which the ambulances had to reverse were more likely to give the patient protection from the weather All the A amp E departments visited had separate ambulance entrances which in all but three cases guaranteed screening of ambulance patients from public view

Access to other hospital facilities

In many of the hospitals the A amp E department was adjacent to the outpatients department or to the orthopaedic outpatients section When this occurred the plaster room and x-ray facilities were usually shared and waiting areas and the records office were sometimes shared In the smaller hospitals both departments often shared the nursing staff

The access to the x-ray department ranged from excellent in places which had x-ray facilities immediately adjacent to the A amp E department to very poor where the patient had to be transported hundreds of metres and to a different floor The time taken for the A amp E doctor to get the result of the x-ray varied from five minutes to over two hours though the physical separation of the two departments was only one of the factors which affected this

27

Access to acute care facilities was similarly variable In Christchurch the intensive care unit was adjacent to the A amp E department while in Rotorua it was at the other end of the hospital In many cases additions or alterations to the hospital buildings and changes of function of certain areas have meant that the A amp E department no longer bears the same physical relationship to other hospital departments as was originally the case

LAYOUT

Several studies have concluded that the A amp Edepartment should be designed so that there is an orderly progression of patients from registration to examination to investigations if necessary to treatment and to referral admission or discharge Staff time and effort is best conserved by a compact plan with waiting areas and treatment areas easily accessible and supervised However the need for easy supervision has to be balanced by consideration of the patients privacy Two basic A amp E plans have evolved

o a radial plan where the waiting examination and treatment rooms are arranged on the perimeter of the departmentmiddot with the nurses station doctors room and records office in the centre

o a linear plan where the examination and treatment rooms are arranged down each side of a corridor with the waiting area records office and staff offices at one end [145]

Many of the A amp E departments visited had a linear layout with the largest Auckland being arranged along several corridors In these departments staff often commented that their overall view of the patients was not good and a considerable amount of walking was needed to supervise them Middlemore A amp E department and the treatment areas of several other departments had radial layouts which staff found very satisfactory Generally the A amp E staff prefer red open plan layouts using curtained cubicles rather than enclosed rooms Staff (especially nursing staff) often commented that their department would be better if certain walls or partitions were removed to give easier surveillance of the department as a whole However staff also commented on the relative lack of privacy for patients being examined or treated and noted that some private rooms were needed for instance for obstetric or paediatric patients

Waiting area

There is general agreement that the waiting area should be adjacent to the reception desk easily visible to the receptionist and if possible overlooked by the nurses office or station It should be a cheerful comfortable area with toys provided for children and a range of magazines and books Public toiletspublic telephones and arrangements for refreshments are also needed [146]

The size of the waiting area varied considerably among the A amp E departments visited (refer back tomiddot Table 2) Again this variation bore little relationship to the workload of the department (see Table 3) Some waiting areas were clearly too small and this put pressure on the staff to deal with patients quickly in order to clear the waiting room

28

Staff comments suggested that not only the size of the waiting area but also its design affected its crowding Basically square rooms with seats around the edges had fewer problems than corridor-style rooms with only one row of seats

In all the A amp E departments visited the waiting areas were adjacent to the reception area Sometimes they were visible from the nurses office or work area but where this was not possible the nurses relied on the receptionists to alert them to urgent cases or checked the wai Hng area often themselves

Facilities in waiting areas varied from nothing but seats to areas in which there were hot and cold drink dispensing machines a childrens play area with toys and health-related poster and pamphlet displays Some had a TV set or a tropical fish tank Most staff were agreed that a pleasant atmosphere in the waiting room was important and adVerse comments about the waiting area were made by staff in departments which lacked this In some departments staff commented that vandalism made it difficult to retain facilities and a pleasant atmosphere

Examination and treatment area

The examination and treatment area provides for the needs of all A amp E patients other than those with serious conditions requiring the resuscitation room or those needing special facilities such as plastering Because special purpose areas are frequently under-utilised flexibility is a key requi rement Hence multipurpose cubicles with standardised equipment are usually recommended The cubicles must be big enough to give easy access for patients (not necessarily walking) to accommodate eqUipment and to give staff enough room to work Curtained cubicles are generally sufficient but at least one enclosed cubicle is required for patients needing extra privacy or for light control in eye examinations A cubicle especially set up for children (with appropriately-sized equipment toys and posters) is also desirable [1346]

Most of themiddot A ~ E departments visited had curtained cubicles in the examination and treatment area with perhaps one or two enclosed cubicles or rooms as well Four A amp E departments only had separate rooms for treatment Curtained cubicles made for ease of access while separate rooms did present some difficulties in manoeuvering patient trolleys and wheelchairs In one case it was impossible to get a patient trolley into the room at all and the room was consequently little used

Curtained cubicles did afford greater flexibility in use and did provide more room to work but had the disadvantage of being considerably less private than rooms Surveillance was easier in departments with curtains than those withmiddot walls and doors In the Auckland A amp E department treatment rooms doors had been removed in the interests of improved surveillance Staff in this department commented that its rigid design could lead to difficulties in accommodating a large number of patients in a disaster

The DEU report [1] recommended that the number of cubicles required by an A amp E department was NIlS where N is the anticipated average number of new patients per day It noted that in A amp E departments with few new patients per day a minimum of two cubicles should be provided It also recommended that the flow of recalled patients should be regulated so that they did not greatly affect the need for cubicles

29

As can be seen from Table 4 most departments had enough cubicles to cope with their first attendance workload Even applying the DEU recommendation of N18 to their total attendance most of the departments had an adequate number of cubicles The exceptions were Hutt Christchurch and Dunedin

TABLE 4 NUMBERS OF EXAMINATION AND TREATMENT CUBICLES OR ROOMS AND RECOMMENDED NUMBERS l BASED ON FIRST ATTENDANCE 2 AND TOTAL ATTENDANCE 2

Actual number of DEU recommended numbers (minimum of 2) cubiclesrooms based on

first attendance total attendance pa pa

Full-time departments

Urban Auckland 13 89 99 Middlemore 9 59 88

Green Lane 7 40 65 Wellington 10 73 85 Hutt 4 51 66 Christchurch 7 94 11 2 Dunedin 3 41 58

Provincial Rotorua 4 2 26 Taranaki Base 4 2 24 Timaru 6 2 31

Rural Whakatane 3 2 2 Grey 3 2 2

Part-time departments

Suburban North Shore3 8 22 37 Kenepuru3 6 22 30

1 Based on DEU report [l which recommended NIS cubicles where N average number of new patients per day ie N6750 where N = average first attendance pa

2 See Table 9 for attendance figures used in calculations

3 Recommended numbers increased to adjust for North Shore and Kenepuru treating their attendance numbers in part-time rather than full-time hours

30

Resuscitation area

The resusciation area is used for the immediate life--saving treatment of seriously injured or sick patients It is the acute treatment area in contrast to the examination and treatment area which is used for relatively minor procedures In making its recommendations about the resuscitation area the DEU report [I] balanced the probability of the A amp E department having to treat multiple accident victims with the comparative rarity of use of resuscitation rooms It recommended that a resuscitation room of suff icient size to deal with two patients concurrently be provided in all A amp E departments It also noted that the ambulance entrance and resuscitation area should be located as close together as possible

Most of the departments visited had purpose-built resuscitation rooms of varying size and with varying degrees of sophistication in equipment Some had x-ray facilities in the resuscitat ion area and in those that did not its absence was regarded as a serious impediment to the efficient care of severe trauma

In four of the seven urban A amp E departments the resuscitation rooms were regarded by the staff as being too small The comment was made in one urban department that because of the small size of the resuscitation area patients sometimes had to be moved out of the area before it was felt clinically desirable to do so in order to accommodate incoming patients In the rural and prOVincial A amp E departments the resuscitation rooms wereshyadequate for the demands placed on them

Most resuscitation rooms were sited close to the ambulance entrance and afforded good access to stretcher patients However in three A amp E departments patients had to be moved some distance and in another department up one floor by lift

Operating theatre

In discussing provision of operating theatres in the A amp E departments the DEU report [1] noted that

o most surgery done is minor requires only local anaesthesia and could be done within adequately designed cubicles

o the A amp E department is not a proper place for general anaesthesia

o using A amp Etheatres for day surgery tends to block other A amp E facilities and staff causin~ delay in treating A amp E patients

The report concluded that special facilities appear to be justified only if there is a clear intention of widening the scope of accident surgery in the departments

bullMinor ops theatres of varying sizes and equipped to varying standards were available in many departments Very variable use was made of such theatres - never in some departments to daily in others It was used less in departments with very heavy workloads and where the medical staff were not satisfied that sufficiently sterile conditions could be maintained In one department the theatre was only used for day surgery cases

31

Plaster room

In the plaster room casts are applied and removed and fractures and dislocations can be manipulated The DEU report [1] noted that the plaster room could be an integral part of the A amp E department or shared with the orthopaedic department or belonging entirely to the latter It recommended that the plaster room be close to the A amp E department and the x-ray department

Most departments had a separate plaster room available In many cases this was shared with an adjacent orthopaedic outpatients or fracture clinic Th~ staff generally found the plaste~-rooms satisfactory although two particularly narrow rooms were difficult to work in

Interview room

The DEU report [l] recommended that A amp E departments in medium-sized and larger hospitals should have a small interview room where a patient IS

relatives could talk with A amp E staff the police or others

No A amp E department had a room specifically designated as an interview room for bereaved or distressed relatives although one A amp E department shared such a room with another department In most departments one of the staff off ices was generally used for this purpose In departments where staff offices were small or crowded the lack of an interview room was seen as a serious flaw in departmental layout

Reception and records office

The reception desk should be immediately visible to ambulant patients arriving at the A amp E department and it is desirable for the receptionist to be aware of what is happening at the ambulance entrance as well The current A amp E records should be held at the reception desk or nearby [1]

In the A ampE departments visited the reception desk was usually well-placed for dealing with ambulant patients but in only four cases did it overlook the ambulance entrance In two departments the reception desk was some distance from the treatment area (separated by a waiting room or outpatients room) and the nursing staff found it difficult to oversee incoming patients Current A amp E records were held at the reception desk in all but one of the departments visited The amount of space available in relation to the throughput of patients was a major factor in determining the length of time records could be kept within the department This in turn affected the ease and therefore speed of record retrieval

Staff offices

These ranged from non existent to very cramped spaces serving many other functions to pleasant specifically designated and relatively quiet areas The latter offices are conducive to good staff morale and being a place for exchange of views and experiences could be expected to contribute quite markedly to the overall effectiveness and eff iciency of the department

32

Holding ward

The DEU report [1] said that holding beds should be used primarily for A amp E patients requiring a period of observation prior to a decision about admission or for those who could be expected to go home after a rest period The report noted that using holding beds as recovery beds for day patients for arranged admissions or for pre-admission clinics was not desirable

Most of the urban and provincial A amp E departments visited had holding or acute admitting wards These holding wards were used mainly for assessing patients requiring acute admission but in some hospitals were also used for observing patients (eg with suspected concussion) and for holding night admissions till the morning to save disturbing the wards Neither of the rural A amp E departments had a holding ward although one had an I A amp E admission procedure where a patient could be admitted for up to 24 hours for observation without the need for full admission procedures In the A amp E departments with holding wards a patient staying for more than four hours was formally admitted

Our study showed that the A amp E departments had some problems using holding wards properly In two A amp E departments holding wards were little used at night because nursing levels were too low to staff them safely In another department the beds were used for patients recovering from day surgery and even for some pre-ar ranged admissions At times general practitioner-referred admissions could also clog the holding wards

DISCUSSION

Most of the A amp E departments were generally adequate in size location and layout The exceptions were Christchurch and Butt where conditions were very cramped with particularly limited examination and treatment areas and poor layout We understand that improvements are planned at Hutt and that recent extensions have improved the Christchurch department considerably but at the time of our visits staff in both these departments were working under extreme pressure because of the physical conditions

Despite the general adequacy of the departments almost all had some flaw which affected their operation and inconvenienced staff and patients Major flaws found in several A amp E departments included

o ambulance access unsuitable for a shuttle of ambulances in a disaster

o difficult access to the x-ray department

o resuscitation room too small for easy treatment of more than one patient at a time

o no interview room for relatives of patients

33

REFERENCES

1 Accident and emergency departments a study of planning requirements prepared by the Hospital Design and Evaluation Unit - Wellington Department of Health 1973

2 SIEGEL Sydney - Nonparametric statistics for the behavioural sciences - Tokyo McGraw-Hill Kogakusha 1956 p 202-213

3 Emergency services the hospital emergency department in an emergency care system Chicago American Hospital Association 1972 p 44-49

4 Emer~ency department organisation and management edited by A L Jenkins - St Louis Mosby 1975 p 8-16

5 Design of departments in Br Med J - v 2 (1979) p 1204-7

6 McKINLAY Robin - The care of children in New Zealand hospitals -Aucklandmiddot National Childrens Health Research Foundation 1982 p 79-80

35

CHAPTER 5

Staffing of accident and emergency departments

This chapter describes the staffing both medical and nursing looking at their numbers and experience their previous training and the training they receive in the A amp E department and their satisfaction with their work and conditions We also describe the clerical and reception staff and briefly the involvement of other workers (orderlies social workers and ambulance personnel) in the departments

MEDICAL STAFFING

Senior medical staffing

Organising appropriate medical staffing for hospital emergency services is a prQblem in many countries [1] The variety of staffing arrangements in A amp E departments within many countries suggests that none have established a generally satisfactory pattern of medical staffing

The Platt report [2] found that in Br itish A amp E departments the great majority of patients were seen by junior staff only and that supervision of the A amp E departments by conSUltants was often little more than nominal The committee recommended that

o the junior medical staff should be adequately supervised by consultants

o a consultant orthopaedic surgeon should normally be in charge of theA amp E unit

o an accident and emergency unit should have at least three consultant surgeons each giving a substantial part of their time to this work

o the primary task of general practitioners in emergency services is to deal with minor accidents and emergencies at any time of the day or night (by organising a rota to answer emergency calls within their practice by working sessions in A amp E departments or by attending cottage hospitals at short notice for emergency calls) bull

Since then some progress has been made but standards continue to lag behind those recommended [34] There has been considerable debate over the appropriate staffing arrangements for A amp E departments Some hospitals have implemented the Platt report recommendations others have appointed a full-time A amp E specialist others have employed a full-time non-specialist doctor and some have employed general practitioners

Despite the various systems there is a consensus in both the United States and Britain that experienced medical staffmiddot are essential in the A amp E department They are necessary for prompt effective treatment of emergency conditions for efficient running of the departments and for adequate supervision of the junior doctors employed [23567 p 17-23]

36

Similar concerns have been expressed in New Zealand since the Board of Health report on outpatient services in 1960 [8] This report recommended that general hospitals continue to provide a casualty service available at all times and staffed by experiencedmedical officers

Salmond [9] found that when a senior A amp E officer directed the department A amp E work was handled more efficiently and house surgeons were more closely supervised and supported He suggested that one senior member of the hospital staff (ideally a full-time A amp E officer) should accept full responsibility for the overall supervision of A amp E services

Most of the A amp E departments that we visited had an A amp E officer The position was vacant at both Wellington and Hutt hospitals at the time of our visit while at North Shore Hospital responsibility for the A amp E department was shared by two senior doctors The A amp E departments of the rural hospitals had no senior medical staff

In A amp E departments with heavy workloads additional experienced doctors were often employed as deputy A amp E officers usually medical officer special scale or as Medical Reserve Scheme registrars (see Table 5) There was no general practitioner staffing of any of the Aamp E departments visited although general practitioners had been part-time staff of some of themiddot smaller A amp E departments in previous years One medical superintendent commented that since very few general practitioners could be classified as specialists they could only be paid as medical officers special scale This low level of payment acted as a disincentive to general practitioner recruitment

The A amp E officers usually worked normal office hours (830 am - 430 pm or 9 am - 5 pm weekdays) apart from two who worked part-time covering morning periods If additional experienced doctors were employed they usually covered evening periods (eg 5 pm - 10 pm) and weekend day shifts

There was a wide range of experience among the A amp E officers Half of the senior A amp E doctors had a general practice background and these doctors often had specific surgical medical pharmacological or Armed Forces medical experience as well Several A amp E officers had primarily a surgical background while others had a considerable range of hospital experience In hospitals where the A amp E officers had a general practice background the Medical Superintendent or the A amp E officer often stressed the suitability of this background for A amp E work

An extensive general practitioner background is useful in dealing with the multitude of problems seen in an Accident and Emergency department An orthopaedic or surgical background is not as necessary because of the good backup from the specialties And staff who have only had hospital experience particularly junior staff can lack skills in general assessment and triage

A amp E officer

In other hospitals staff stressed that an orthopaedic and surgical background was very valuable as was experience in dealing with specific types of injury such as soft tissue wounds

37

TABLE 5 MEDICAL STAFFING OF A amp E DEPARTMENTS

Full-time departments

Urban Auckland Middlemore Green Lane Wellington2

Hutt2

Christchurch Dunedin

Provincial Rotorua Taranaki Base Timaru

Rural Whakatane Grey

Part-time departments

Suburban North Shore Kenepuru

Senior medical staffing

Number of full-time equivalents

A amp E officer ( including deputies) 25 15 I 16

I 2

I 03 I

2 05

Registrar

06

1 1

House surgeons

Number on Number A amp E runs covering

some shifts in A amp E deptl

6 2-3 6 2 5 I 5 4 2-3 5 2 2

All on rotating basis 1 3 1 2

5 on rotating basis 4 on rotating basis

None in A amp E dept 4 on rotating basis

1 On general relieving duties 2 Senior A amp E position vacant at time of visit

Junior medical staffing

The issues

Junior medical staffing of A amp E departments has concerned many commentators in the United States Britain and New Zealand The Platt report [2] noted that recently qualified staff when serving in the casualty department undertake responsibility which they would not have in the wards or outpatient clinics

38

In 1960 the New Zealand Board of Health report [8] on out-patient services deplored the staffing of casualty departments by I relatively inexperienced men [sic] and suggested that these staff I should be regarded more as assistants under supervision and training than responsible officers in the outpatients departments The undesirability of staffing A amp E departments with first year house surgeons (or pre-registration doctors) has been reiterated since Junior doctors are often unsure when to ask for advice or help and are sometimes unwilling to admit that they are over-tired and unable to cope [91011)

The report on the working conditions of New Zealand resident medical officers [12] noted the heavy load carried by house surgeons working long shifts in A amp E departments It also commented that when house surgeons are required to look after the A amp E department while carrying out ward duties inadequate cover of the A amp E department could result

The New Zealand situation

The urban A amp E departments had between two and six house surgeons working on three month A amp E runs and in several of these hospitals another one to three house surgeons on general relieving duties covered some A amp E shifts There were more house surgeons in A amp E departments with heavier workloads or with fewer senior medical staff The provincial and rural departments did not usually have house surgeons working on specific A amp E runs rather the A amp E department was covered by all (or most) of the house surgeons in the hospital on a rotatng basis Of the two suburban A amp E departments Kenepuru was covered by the house surgeons on a rotating basis while North Shore did not have any house surgeons because there was no inpatient or consultative backup available (see Table 5)

The total medical staffing of the departments (senior A amp E doctors and house surgeons together) ranged from 10 to 100 full-time equivalents and was closely related to the attendance at the departments (see Table 6) The provincial and rural A amp E departments had higher medical staff to attendance ratios because they had to provide a 24-hour service regardless of the size of the attendance

Each A amp E department visited rostered its house surgeons differently depending on the availability of senior medical staff the workload of the department and the house surgeons other duties In the urban departments house surgeons worked between 45 and 60 hours a week on shifts usually 8 to 12 hours long Many of the house surgeons working in these departments complained about long shifts and suggested that more staff were needed to reduce the shift lengths Split shifts were also unpopular

The most worrying aspect of the staff ing arrangements in bhe Accident and Emergency department is the long hours We need another house surgeon to reduce the hours on some shifts and to proviae another pair of hands in busy periods (eg Friday and Saturday night Sunday afternoon)

House surgeon

39

TABLE 6 TOTAL MEDICAL STAFFING (FULL-TIME EQUIVALENTS) AND MEDICAL STAFFING TO ATTENDANCE RATIOS FOR FIRST ATTENDANCE I AND TOTAL ATTENDANCE 1

Total medical Total medical staffing to staffing attendance ratio

FTE per FTE per 10000 first 10000 total

Full-time attendance attendance equivalents p a pa

Full-time departments

Urban

Auckland2 100 17 15 Middlemore2 91 23 16 Green Lane2 65 25 15 Wellington 66 14 12 Hutt2 55 17 13 Christchurch 70 11 10 Dunedin2 60 22 16

Provincial Rotorua 42 34 25 Taranaki Base2 28 27 18 Timaru 22 19 11

Rural Whakatane3 15 25 17 Grey 10 26 20

Part-time departments

Suburban North Shore 20 21 12 Kenepuru3 20 34 22

1 See Table 9 for attendance figures used in calculations 2 FTE estimated since A amp E department partially covered by house

surgeons on general relieving duties 3 FTE estimated since A amp E department covered by house surgeons on

rotating basis

Spearman rank correlations [131 of total medical staffing with

(a) first attendance r = 0953 p lt 001 (b) total attendance r = 0933 p 001

In the provincial and rural hospitals house surgeons were often on call for long shifts over nights and weekends They were usually covering a ward or the whole hospital at the same time and simultaneous demands from the wards and the A amp E department sometimes caused problems However

40

these house surgeons generally found their rostering satisfactory despite the long hours on call perhaps because the actual work required in the A amp E department was comparatively light

An ordinary week night is usually quiet after midnight thered be three to five calls and Id have to get up once on average Weekend nights are busier but I usually get at least two or three hours sleep

House surgeon

Several house surgeons were irritated that while they worked more intensively on A amp E runs than on ward runs they spent fewer hours on-call and consequently they were paid less

Supervision by senior medical staff

In the larger A amp F departments house surgeons worked with the senior medical staff on most day and some evening shifts only on night shifts (and some evening shifts) were house surgeons the sole medical staff in a department By contrast in the smaller and part-time departments house surgeons covered the department alone seldom working with any senior A amp E medical staff

Several nurses commented that the A amp E department ran less efficiently outside normal working hours because the house surgeons inexperience meant assessment and treatment times were longer and tests were used more often than when the A amp E officer was present

Many senior medical staff in the urban A amp E departments were concerned at the lack of supervision for house surgeons outside normal working hours and so would have Ii ked more senior A amp E staff Several of the house surgeons were also concerned although others enjoyed the autonomy they had and were not concerned about working without supervision

I am not happy with house surgeons managing the A amp E department on their own They only have a three month shift in the department and often most of this time is spent learning how to do A amp E wor k The house surgeons can have problems deciding when to call a registrar to treat a patient and there can be delays in obtaining a registrar The A amp E department needs full-time trained medical staff on duty 24 hours a day to give proper supervision to the house surgeons and to run an efficient department

A amp E officer

On night shift I can feel rather alone if something goes wrong

House surgeon

I enjoy the variety of work and the independence I have to treat most patients as I see fit

House surgeon

41 _A

Arraflgements for consultative backup and support when senior A amp E staff were not on duty varied from hospital to hospital according to hospital size n urban hospitals the house surgeons would usually call on the appropriate registrar and the acute admitting or specialist teams for emergencymiddot cases In some places the house surgeons could calIon the consultant if a registrar was unavailable but this was usually seen as a last resort call In the provincial and rural hospitals the house surgeons would call on the appropriate senior doctor who was available This was usually one of the cQnsultants or a registrar if any were employed by the hospital The A amp E Qfficer might occasionally be called and in hospitals without an A~amp E oHicer th~ medical superintendent would also provid~ backup

Generally house surgeons were happy with the support they received A physically compact hospital was mentioned several times as facilitating ~ ~ fast back-up Howeve( in some hospitals there could be considerable delays in 9etting surgical and orthopaedic registrars to the A amp E department usually because they were in theatre Also at two hospitals backup in the minor specialties was considered inadequate bull

Use of first year house surgeons

Urban and suburban hospitals had a policy of using second year house surgeons as much as possible in the A amp E department and of using first year house surgeons only in their second six months This policy was generally butmiddot not always carried out For example the on-call arrangements of some urban A amp E departments resulted in inexperienced first year house surgeons working in the department In the smaller hospitals also the limited pool of house surgeons available tended to result in more first year house surgeons working in the department

The hospital could not provide cover for the A amp E department without using first year house surgeons However there are always senior staff and the medical registrar readily available as backup

Medical superintendent

When direct supervision was limited first year house surgeons did find A amp E work difficult

Training

The training received by the house surgeons in the A amp E departments varied greatly Two hospitals ran half-day or one-day orientation courses before -house surgeons started in the department Three A amp E departments ran weekly or fortnightly training sessions on specific conditions while another department ran sessions on an irregular basis However house surgeons often missed training sessions because they were treating pat~entsln more than half tmiddothe A amp E departments no formal training was giVen and house surgeons were taught on-the-job when senior A amp E staff were available This teaching placed a considerable load on senior staff

The three-monthly changeover of house surgeons is frustrating and the first month with new house surgeons is very demanding because they have little confidence or competence

A amp E officer

H-328

New Zealand Department of Health

LIBRARY Box 5013 Wellington

73467Accession No

Classification WX 215 [Qj WH

Location 6129378-Y94

ISSN 0548-944X

Department of Health

ACCIDENT AND EMERGENCY DEPARTMENT ORGANISATION AND UTILISATION

SPECIAL REPORT 70

by

B CAllan BSc (Hons) J Reinken PhD

Issued by the Management Services and Research Unit Department of Health Wellington

1984

LIBRARY bull DEPARTMENT OF HEAlrRJ

WELLINGTON

FOREWORD

Over the last twenty years there have been a number of accident and emergency studies in New Zealand hospitals For the most part these have been place and topic specifics This study by Bridget Allan and Judith Reinken is different It begins with an historical review of previous work in the field This is followed by a wide ranging study of accident and emergency services based on field work carried out in a representative sample of hospitals The data are analysed and presented taking account of the relevant international literature The resulting consolidation of knowledge provides a sound basis not only for further research but more importantly for the further development of accident and emergency services

The report provides at least tentative answers to a number of questions regularly asked about accident and emergency services Do general practitioners and accident and emergency departments provide competing services lhe answer appears to be no The public seem to discriminate sensibly between what are for the most part complementary services Is cost a factor in accident and emergency attendance as opposed to a visit to the general practitioner Again the answer appears to be no - cost is not an important factor Are socio-economic status and ethnicity associated with the rate of A amp E attendance Perhaps but distance and other factors concerned with accessibility appear to be more important

The study shows wide variation in the way in which A amp E services are provided in different hospitals This ranges from the size and shape of the physical facilities and the type and level of staffing relative to the workload to the way in which individual patient problems are dealt with Those responsible for the planning and operation of A amp E departments should find these comparisons informative Consideration of the data may perhaps prompt questions which in their answering lead to greater cost effectiveness and to service improvement

As well as providing answers the research raises questions It points yet again to the need in New Zealand for a regional study of accidents and accident services Accidents are a major cause of premature death and morbidity Many organisations are involved in the prevention and treatment of accidents but so far it has not been possible to mount a comprehensive study which includes and integrates all interests Until this is done fragmentation of services is likely to continue

By highlighting access to services the study points up the need for more information about communication and transport patterns in health care delivery Again this is a neglected area of research which could have far reaching implication for the planning and operation of health services

Finally the report raises questions about the interaction between general practitioners and A amp E services That these services are largely complementary is clear but unfortunately the communication between them is often not as good as it could and should be Further research has a contribution here but will not solve the problem Better communication and understanding is needed on both sides

The researchers have provided us with a much needed and timely review of an important and sometimes controversial aspect of health services Theirjete audience

G C Salmond ---shyDeputy Director-General of Health Department of Health

ACKNOWLEDGMENTS

Many people have helped with this study In particular we would like to thank

o John Mills who visited the hospitals drafted the physical characteristics chapter and gave freely of his time and expertise

o the staff of the hospitals visited for sharing their time and thoughts with us

o Desmond Keenan Shelagh McRae and Denis Snelgar for allowing us to use the information they had collected

o Clare Salmond Mike Moore and Sylvia Nichol for their assistance with computer analysis

o readers ofmiddot drafts of this report who offered helpful criticism and suggestion

o the typists and publication staff of the Department of Health

We also acknowledge the Director-General of Health for permission to publish

DISCLAIMER

The views expressed in this report are those of the authors and do not necessarily represent the views of the Department of Health

COPYRIGHT

Provided the source is acknowledged information contained in this report may be freely used by any person

CONTENTS

Page

ACKNOWIEDGEMENTS LIST OF TABLES LIST OF FIGURES

1 INTRODUCTION I

Background Thewider questions of emergency medical services The overseas situation An historical perspective in New Zealand

Interview studies on the utilisation of A amp E departments Record studies on the utili satjon of A amp E departments Studies of the organisation of A amp E departments

Overview of this study Aims Sources of information

References

2 DEFINITIONS 11

The Accident and Emergency department Attendance The hospitals Recording systems References

3 PROCEDURES IN THE ACCIDENT AND EMERGENCY DEPARTMENT 15

Entry Sorting 1 reatmen t Disposal Follow-upcare Admissions Discussion References

4 PHYSICAL CHARACTERISTICS OF ACCIDENT AND EMERGENCY DEPARTMENTS 23

PrinCiples Size Location

Entrances Access to other hospital facilities

Layout Waiting area Examination and treatment area Resuscitation area Operating theatre Plaster room Interview room Reception and records office Staff offices Holding ward

Discussion References

5

6

7

8

STAFFING OF ACCIDENT AND EMERGENCY DEPARTMENTS 35

Medical staffing Senior medical staffing Junior medical staffing Accident and emergency work as a career

Nurse staffing Other staff involved with the A amp E department

Reception and clerical staff Orderlies Social workers Ambulance personnel

Discussion References

PATIENT ATTENDANCE CHARACTERISTICS 55

Overall attendance and trends Age and sex Conditions

Injury conditions Sickness conditions

Recall attendance GP-load

Non-urgent sickness Discussion References

PATIENT ATTI~UDES TO THE ACCIDENT AND EMERGENCY DEPARTMENT AND STAFF ATTITUDES TO THE PATIENTS 75

Reasons for visiting the A amp E department Overseas studies New Zealand studies

Effect of health centres and deputising services on A amp E utilisation A amp E staff views of patients

Overseas studies The New Zealand situation

Discussion References

UTILISATION OF ACCIDENT AND EMERGENCY DEPARTMENTS 91

Comparison of A amp E utilisation among hospital catchment areas Results Effect of general practitioner availability

Factors explaining catchment area variations in A amp E utilisation Method Results of the mUltivariate analyses

Comparison of A amp E use and general practitioner use Discussion References

9 CONCLUSIONS 107

The A amp E department as a hospital department The A amp E department as an emergency service The A amp E department as a primary care service Where from here

APPENDICES

APPENDIX A QUestion sheets 116

APPENDIX B Accident and emergency department records 120

APPENDIX C Statistical analyses of accident and 123 emergency department attendance rates by neighbourhoods

APPENDIX D Childrens use of general practitioners 128 and accident and emergency departments in Wellington

TABLES

Table

1 Proportion of first attendance patients discharged recalled referred or admitted

2 Areas of A amp E department~

3 Area to attendance ratios for adjusted total areas and waiting areas of A amp E departments by first attendance and total attendance

4 Numbers of examination and treatment cubicles or rooms and recommended numbers based on first attendance and total attendance

Medical staffing of A amp E departments

6 Total medical staffing (full-time equivalents) and medical staffing to attendance ratios for first attendance and total attendance

7 Nurse staffing of A amp E departments excluding student nurses and hospital aids

Nurse staffing (full-time equivalents) and nurse staffing to attendance ratios for first attendance and total attendance

Average attendance at A amp E departments 1978-1981

10 Trends in attendance at A amp E departments 1978-1981

11 Proportion of A amp E attendance that was recall attendance

12 Proportion of A amp E attendance that was for sickness

13 Proportion of total A amp E attendance that was for Sickness by policy and age groups

14 Use of general practitioners by first attenders at A amp E departments

15 Reasons for A amp E first attendance from three New Zealand studiesmiddot

Itgt Attendance (mean age-adjusted rates per 1000 per quarter) within each A amp E department catchment area

Page

18

24

25

29

37

39

45

46

56

57

66middot

70

71

77

78

92

(continued)

Table Page

17 Hospital admissionsfor accidental injury (mean 93 age-adjusted rates per 1000 per year) and death due to accidental injury (mean age-adjusted rates per 1000 per year) within each A amp E department catchment area

IB Attendance (mean age-adjusted and neighbourhoodshy 99 adjusted rates per 1000 per quarter) and populationshyto-general practitioner ratio within each A amp E department catchment area

19 Comparison of first attendances for injury at A amp E 101 departments and general practitioners

FIGURES

Figure Page

1 Percentage of total attendance at 58 A amp E departments by age and sex

2 Percentage of total attendance at 59 A amp E departments for sickness and injury conditions by age and sex

3 Injury first attendances by type of injury 6U all ages

4 Injury first attendances by type of injury 61 by age groups

5 Sickness attendances by type of sickness 62 all ages

6 Sickness attendances by type of sickness 63 by age groups

7 Comparison of medical staff availability and 67 level of recall attendance

Comparison of nursing staff availability and 67 level of attendance

9 Location at which accidents happened by those 79 attending the A amp E department or the general practitioner for accidental injury

Use of general practitioners and A amp E departments 131 by Wellington children 1978 (rates per 1000 children per quarter)

1

CHAPTER 1

Introduction

BACKGROUND

This report arises f rom concerns expressed by several groups about the availability especially out of hours of emergency car~ and its provision by Accident and Emergency (A amp E) departments in New Zealand

In _SQe mid 1970 s the people of Porirua were worried that local general -pr-actitioners were not available at nights and weekends and by the delays

involved in travelling to Wellington and Hutt A amp E departments [IJ At the same time the people of North Shore were campaigning to keep their local A amp E department open More recently community groups in Upper Hutt have been pressing for the addition of an A amp E service to a local health centre Overall people are concerned that appropriate care (including facilities such as x-rays) is readily available in emergency situations

General practitioners are another group who have been concerned about A amp E departments in particular about inappropriate uses of A amp E departments A long-standing complaint bas been that patients are using A amp E departments for care which wou~d be better given by a general practitioner and that the A amp E departments retain patients instead of referr ing them back to their general practitioner for follow-up care [2 3J In 1981 the research group of the Wellington Faculty of the Royal NZ College of General Practitioners sponsored a study of children presenting at A amp E departments because they were worried that unnecessary admissions of children to hospital occurred because their parents had bypassed the general practitioners and gone straight to hospital [4J

Also A amp E staff and hospital administrators have been concerned that caring for patients who could have been treated by general practitioners has limited their ability to deal with emergency cases [567]

THE WIDER QUESTIONS OF EMERGENCY MEDICAL SERVICES

Emergency care requires not only the provision of hospital services (the A amp E department with back-up from other hospital facilities) but also the organisation of services outside the hospital and co-ordination between both sets of services Emergency medical services outside the hospital include alarm and communication systems transport systems and first aid services There are important questions for New Zealand within this framework For example what should be the role of general practitioners in on-site emergency care What level of training is appropriate for ambulance officers Should voluntary personnel staff ambulances To what extent is double manning of ambulances required [8910]

In order to limit the study to manageable proportions this report focusses only on the hospital services namely the A amp E department Emergency medical services provided outside hospitals are mentioned only where they impinge noticeably on the A ampE department It is hoped that due attention will be given to the wider questions of emergency medical services in the future (see Chapter 9)

2

THE OVERSEAS SITUATION

Concern with emergencymiddot care facilities especially their increasing use has been apparent in other countries for the past thirty years While some articles report on the situation in Canada Australia Sweden France and the USSR most of the literature is about the United States and Britain This section briefly outlines the major themes of the literature and their relevance to New Zealand More specific aspects are covered in the appropriate chapters

Many United States researchers have studied the operations of different emergency rooms exploring patients reasons for using the emergency room their demographic characteristics and their use of the family doctor Often the studies have tried to explain an increasing use of emergency rooms and some have reported on the effectiVeness of measures introduced to reduce thei r use These studies provided models for some of the analyses carried out in this study However the debate in the United States over appropriate methods of funding and staffing for emergency rooms is seldom relevant to New Zealand because of the differences both in philosophy and organisation of medical care in the two countries

The Platt [11] committee on A amp E services in Britain in 1962 was concerned about casual attenders ie patients not in need of urgent attention but wishing to avoid the trouble of attending their general practitioners surgery They also criticised the unsuitable accommodation and the insufficient numbers of senior medical staff supervising Casualty Departments The report recommended changing the name Casualty Service to Accident and Emergency Service (to discourage casual attendance) and rationalising the service by clOSing smaller A amp E units and centralising facilities These recommendations have been partially carried out

However there has been continuing research in Br i tain into the reasons given by patients particularly self-referred patients for their use of A amp E departments and the trade-off between general practitioner and A amp E services There has also been continuing debate over the medical staffing of A amp E departments

The British studies are of some relevance to the New Zealand situation since the organisation of medical care here is similar but no overseas experience can provide a blueprint for New Zealand For example the direct cost to the patient of general practice care in New Zealand raises the possibility of patients attending the A amp E department because it is free whereas the British system of general practitioner funding provides no such incentive

AN HISTORICAL PERSPECTIVE IN NEW ZEALAND

Little is known about the historical development of A amp E services in New Zealand Presumably they followed the British tradition described in the Platt report [11 p23-24)

The word casualty in its proper meaning of a serious injury has a long history It occurs in Shakespeare and Dickens writing in 1837 used casualty ward to describe the ward in a hospital in which accidents were treated Unfortunately the meaning alt~red in the second half of the last century The Nuffield Report (1960) Casualty Services and their Setting

3

gives an interesting quotation from a survey made by the Lancet in 1869 The out-patients at St Bartholomews Hospital are it says divided into two categories They are the middotcasualtymiddot which comprises those who are supposed to require temporary treatment for diseases or injuries of a trifling character and the middotout-patientsmiddot properly so called who after receiving a regular letter of admission are entitled to the advice of the assistant surgeons and physicians for a period of 12 months It is in the casualty division that the increase of numbers has been most marked bullbullbull It is estimated that not less than a thousand patients frequently attend on a Monday or Tuesday morning

Certainly by 1872 vlellingtons private medical practitioners were incensed at the hospitals provision of free treatment for their patients Five hundred outpatients were treated in Wellington that year [12] Separate casualty departments were operating at Wellington Hospital by 1924 [12] at Auckland Hospital by the 1940s [13] and Christchurch Hospital by 1952 [14]

The 1960 Board of Health report [15] on outpatient servicesmiddot expressed concern over the duplication of services by outpatient departments which were also available from general practitioners However it recommended that general hospitals continue to provide a casualty service available at all times

Since the late 1960s a series of New Zealand studies have considered the use of A amp E departments either by interviewing patients or by analysing data drawn from A amp E record systems and the organisation of A amp E departments

Interview studies on the utilisation of A amp E departments

The first interview study was an investigation of first attenders at the Dunedin A amp E department in 1968 by Dixon et al [2] Their results have not been contradicted by any of the later studies

They found that the principal attenders were males aged 15 to 24 who recorded first attendance rates of over 100 per 1000 each year The young men were also the most likely to report having no general practitioner Dixon found that the age and sex pattern of those attending at the A amp E department was nearly converse to the pattern of those attending a general practitioner

Dixon pointed out that the conditions treated at the A amp E department were rarely disease-related rather they were predominantly lacerations and open wounds bruising sprains and strains effects of foreign bodies and fractures The major reason given for attending the department was that it was seen as appropriate

Dixon concluded that the A amp E service was complementary and not competitive to general practice that the public were realistic in regarding it as the only practical and effective primary medical care for accident and emergency injuries and that payment for service did not appear to figure in the decision to attend the department

o

4

TwO interview studies of first attenders at Auckland Hospital A amp E department have been carried out by Hunton in 1972 and Richards in 1975 [16] Both studies included an assessment by the student interviewers and A amp E staff as to the suitability of the patients condition for general practice care 42-43 per cent were considered suitable Richards concluded that public education programmes encouraging people to use their general practitioner prior to attending the A amp E department should be instituted

In 1978 Keenan interviewed patients who had attended Christchurch A amp E department collecting detailed information on the accident or sickness leading to the attendance (unpublished see Chapter 6 and 7) He found the same set of reasons for using A amp E departments as Dixon found the A amp E department was seen as appropriate and accessible

Kljakovic found similar results when interviewing the parents of children attending A amp E departments in the Wellington region in 1978 [4] He also found that in choosing between the general practitioner and the A amp E department parents were more likely to use the service which was closer to the family home Children f rom lower socio-economic status families were more likely than other children to see thei r general practitioner before gOing to the A amp E department

Records studies on the utilisation of A amp E departments

Several studies have gathered data from A amp E records to investigate A amp E utilisation In 1979 Snelgar described the characteristics of people attending Northland Base Hospital A amp E department [17] He found similar results to Dixon apart from a higher proportion of injuries In the same year McRae reviewed all attendances at Waikato Hospital A amp E department and found a similar picture [lB]

Three records studies have looked at the relationship between A amp E use and general practitioner use Maynard looked at Mosgiel residents use of Dunedin A amp E facilities for three years before and three years after the opening of a local health centre [19] No difference was found ~asap

investigated assertions that people from one part of the Wellington Hospital catchment area had suddenly begun to use the A amp E department heavily for conditions that should have been seen by a general practitioner [20] In fact that part of the catchment area had much lower rates of A amp E use than other areas Reinken tested whether the doubling of general practitioner cover in one part of the Wellington region affected A amp E presentation rates differently than in other areas nearby [21] There was no clear evidence that the increased cover had any effect

Studies on the organisation of A amp E departments

As part of a thesis looking at young doctors Salmond examined the work of house surgeons in A amp E departments using a postal questionnaire [22J He concluded that working in an A amp E department was good experience for a house surgeon only if second year house surgeons were deployed in the department the house surgeon was well-supervised by senior medical staff there was a good working relationship with the A amp E chargemiddot nurse and the house surgeon was not over-tired He also suggested that good senior staffing was closely related to effective administration and better service in the A amp E department

5

The Hospital Design and EValuation Unit of the Department of Health prepared a report documenting the planning requirements of New Zealand A amp E departments [23] The report outlined several principles of A amp E design and made detailed recommendations on the facilities rooms and equipment necessary

OVERVIEW OF THIS STUDY

Aims

The aim of this study is to describe A amp E departments in New Zealand Because the material presented in the previous section was collected by different researchers at different times and from different A amp E

departments detailed comparisons across the studies have been difficult To get a more comprehensive picture of A amp E use in New Zealand a systematic investigation was necessary

The specific aims of this report are

o to describe the organisation of A amp E departments by looking at their procedures physical characteristics and staffing patterns

o to describe attendance at A amp E departments including the patients profile and pattern of attendance and the load placed on the departments by patients who would be more appropriately treated by a general practitioner

o to describe the use of A amp E departments by consumers by analysing patients reasons for attending the departments and analysing demographic factors inrelation to A amp E attendance

Sources of information

Information was gathered from three sources

The site visits

Fourteen A amp E departments were visited between May and September 1981 by a Department of Health study team consisting of a medical officer from the Division of Hospitals and a res~arch officer from the Management Services and Research Unit

At each hospital the team examined the facilities and spoke with staff involved with the A amp E department including

o the medical superintendent (and in some hospitals the principal nurse)

o the A amp E officer or medical officer in charge of the A amp E department (where such a position existed and was filled)

o the nurse supervisor andor charge nurse of the A amp E department

o at least one house surgeon working in the A amp E department

6

In some hospitals the team also spoke with other staff members including experienced A amp E staff nurses and hospital social workers

Question sheets were used during interviews so that a comparable body of information was collected at each hospital Interviews were open-ended to allow discussion of local procedures or problems (See Appendix A for question sheets)

Hospitals were carefully selected so that the A amp E departments in the study would represent a cross-section of New Zealand A amp E departments Those selected served a range of communities in both the North and South Islands

o major urban Dunedin)

areas (Auckland Wellington Christchurch and

o provincial centres (Rotorua Taranaki and Timaru)

o predominantly rural areas (Whakatane and Grey)

In centres with more than one A amp E department all were visited so that a complete picture of the services and use could be developed This involved visiting Auckland Green Lane Middlemore and North Shore hospitals in Auckland and Wellington Hutt and Kenepuru hospitals in Wellington

The information gathered in the site visits has been used in describing the organisation of A amp E departments (Chapters 3 4 arid 5)

The A amp E records data collection

On each site visit a sample of 1981 attendances was drawn from the A amp E record system and the following information was recorded for each person age sex presenting condition (sickness or injury) time of presentation residential address and whether the visit was a first attendance for the condition or a recall visit

Exceptions were Christchurch and the three Wellington Hospital Board A amp E departments Comparable data collected by Keenan in Ch ristchurch in 1978 and Allan in Wellington during 1980 were used instead

This information has been used to describe the attendance at A amp E departments (Chapter 6) and for the analysis of demographic factors in relation to attendance (Chapter 8)

The consumer studies

In 1978 Keenan carried out interviews with patients attending Christchurch A amp E department working from a one in eight sample drawn from the A amp E log over a four-week period and gaining a 99 response rate Results from this study have been analysed and compared with the results of the published New Zealand interview studies [2416] Anecdotal material from Kljakovic s study of children attending Wellington A amp E departments has also been included to illustrate the results of the numerical analysis

We realise that in studying only a selection of A amp E departments some local variations may have been missed but we are confident that the broad pattern and major issues in the organisation of A amp E care have been

7

covered Also as the A amp E departments studied serve two-thirds of the population of New Zealand the utilisation patterns discussed in the report are likely to prevail throughout New Zealand We hope that the mater ial presented the conclusions drawn and the questions raised in this report will encourage discussion about the current operation and future developmiant of A amp E departments in NewmiddotZealand

a

8

REFERENCES

1 de LACEY A REINKEN J and SALMOND C E - Community attitudes to sickness and health stimulus and response v 3 Community attitudes - Wellington Management Services and Research Unit Dept of Health 1980 p 103-105 (Special report series no 56)

2 DIXON C W Emery G M and SPEARS G F S - Casualty department utilisation survey in NZ Med J - v 71 (1970) p 272-279

3 [Editorial] in G P Journal of the General Practitioner Society no 42 (1981) P 1-2

4 KLJAKOVIC M ALLAN BC and REINKEN J - Why skip the general practitioner and go to the accident and emergency department in NZ Med J - v 93 (1981) P 49-52

5 SKUDDER Paul A McCARROLL James R and WADE Preston A - Hospital emergency facilities and services a survey in Emergency medical services behavioural and planning perspectives edited by John H Noble Jr et ale - New York Behavioural Publications 1973 p 17-35

6 MAYNARD Edward J - The application of epidemiological methods to the evaluation of primary medical care in a health centre environment shyUniversity of Otago 1980 Ph D Thesis Social and Preventive Medicine

7 Hospital misuse brings protest in Taranaki Daily News (1 Sept 1980) bull

8 FAHEY Morgan - The role of the family doctor in disaster and emergency medicine in NZ Family Physician - v 5 no 1 (1978) p 42-44

9 Proceedings of the emergency care seminar Auckland 19-23 March 1979 in NZ Med J - (1980) P 194-196

10 Double manning of ambulances [editorial] in NZ Hosp - v 32 no 3 (1980) p 1

11 Gt Brit Central Health Services Council - Standing Medicine Advisory Committee Accident and emergency services report of the subcommittee - London HMSO 1962 Chaired by Sir Harry Platt

12 BARBER Laurie H and TOWERS Roy J - Wellington Hospital 1847-1976 Wellington Wellington Hospital Board 1976

13 The story of Auckland Hospital 1847-1977 edited by David Scott -Auckland Medical Historical Library Committee of the Royal Australasian College of Physicians in New Zealand 1977 p 35-36

14 BENNETT FO - Hospital on the Avon the story of the Christchurch Hospital 1862-1962 Christchurch North Canterbury Hospital

o Board 1962

9

15 Outpatient services in public hospitals in New Zealand - Wellington Government Printer 196U (Report series Board of Health no 2)

16 RICHARDS J G and WHITE G R - Accident and emergency services at Auckland Hospital in NZ Med J - v 85 (1977) P 272-274

17 SNELGAR Denis - Accident and emergency utilisation study Paper prepared for the Primary Health Care Shadow Service Development Group Northland 1981 (Unpublished)

18 McRAE Shelagh and TOPPING Mark - Casualty attendances one years experience at Waikato Hospital in NZ Med J - v 95 (1982) P 12-14

19 MAYNARD Edward J and DODGE Jeffrey S - Introducing a community health centre at Mosgiel New Zealand effects on use of the hospital accident and emergency department in Med Care - v 21 no 4 (1983) p 379-388

20 KASAP D - Personal communication 1975

21 REINKEN J - Effect of changes in general practitioner cover on accident and emergency utilisation in the Porirua Basin Wellington Management Services and Research Unit Dept of Health 1979 (Unpublished)

22 SALMOND G C - Young doctors an exercise in social research methodology - University of Otago 1970 Ph D Thesis Social and Preventive Medicine p 179-214

23 Accident and emergency departments a study of planning requirements prepared by the Hospital Design and Evaluation Unit - Wellington Department of Health 1973

11

CHAPTER 2

Definitions

lhis chapter provides the definitions of terms used in our study In general our terminology is consistent with the literature However in some areas such as the classification of presenting conditions as sickness or injury or the description of GP-load there is no general consistency and we have developed our own definitions

THE ACCIDENT AND EMERGENCY DEPARTMENT

This name is the one commonly used in New Zealand We have used it in preference to the older description Casualty Depariment [1] and the American description of Emergency Department It is one hospital department which patients can approach without prior notification

Emergencies can be any condition that - in the opinion of the patient their family or whoever assumes the responsibility of bringing the patient to the hospital - requires immediate medical attention

However using such a definition means every case is an emergency In New Zealand A amp E departments patients tend to be classified in a similar way to the description given by the American Hospital Association [2]

o emergencies where delay is harmful and the condition potentially threatens life or function

a urgent cases which require attention within a few hours

o non-urgent cases where the condition is minor or non-acute and does not require the resources of the emergency service

An accident is an unexpected event Accidents which have resulted in attendance at an A amp E department are ones that have caused some trauma whether through shock or other injury The Platt report [1] decided on the term A amp E department in recognition that the real emergencies were a trickle while the accidents were a mighty flood

In general the A amp E department is regarded as part of the hospitals outpatient services and like these in day to day running it provides specific clinics generally for the treatment of traumatic injury x-ray burns dressings plasters and so forth

An accident and emergency patient is a person who is entered in the A amp E log book This can involve a certain amount of error however as some outpatients or discharged patients may return for follow-up care through the A amp E department Also the A amp E department often handles the acute admissions to the hospital

12

ATrENDANCE

A first visit (or first attendance) is the first visit a patient makes for one particular condition

A recall visit is any visit made for one particular condition which is not the first visit for the condition Some recall visits are patient initiated (eg due to pain bleeding infection or an accident to the dressing or plaster) but for the most part revisits are scheduled return visits suggested by A amp E staff

Total attendance is the sum of first visits and recall visits

Inj ury attendances are defined to include the results of trauma (cuts burns fractures sprains strains bruises head injuries multiple injur ies and so forth) as well as foreign bodies in the eye or other orifices and toxic effects whether from accidental or self-poisoning events Late effects of minor injury (pain bleeding abscesses or such) are not included as injury but as sickness

Sickness attendances include collapse (whether stroke coma heart attack or other) shortness of breath abdominal pain general sickness (fever vomiting diarrhoea unwell) mental distress and minor conditions

Non-urgent sicknesses are defined as the minor conditions abdominal pain and general sickness except for preschool children and adults over 65 where the general sickness and abdominal pain conditions can be urgent A amp E staff defined non-urgent sickness less specifically they tended to define it as longstanding or minor sickness

GP-load describes the patients whom A amp E staff feel should have seen a general practitioner It includes patients with longstanding or minor sickness conditions and patients with minor traumatic injury (eg cuts bumps and bruises)

In hours attendance refers to all attendances in the normal working hours of 0800 to 1800 Monday to Friday excluding holidays

Out of hours attendance refers to all other attendances outside the defined normal working hours

In an average week 50 hours fall in the in hours category and 118 hours in the out of hours category If we assume that an average person sleeps eight hours a night then that person is awake for 62 hours in the out of hours category (and all the in hours of course) Thus the out of hours category is 70 per cent of the total time in a week and 55 per cent of the waking time in a week

Minor conditions included abscesses backaches infected wounds or wound pain headache pain (unspecified) earaches eye problems toothaches nosebleeds limb pains We have called it the skin pain or bleeding category in Chapter 6

13

Attendance rates measure the use of A amp E departments for a defined population They express the number of cases from an area over a defined period per 1000 population in that area Rates were obtained by age and sex for sickness and injury and in and out of hours for each census area unit or neighbourhood served by each hospital

THE- HOSPITALS

We grouped hospitals into four types

o urban hospitals (where average annual first attendances at A amp E departments are over 25000 patients)

o provincial hospitals (serving 6000 to 12000 new A amp E patients each year)

o rural hospitals (serving fewer than 6000 new A amp E patients each year)

o suburban hospitals where A amp E departments are not open 24 hours per day North Shore Hospital was open 7 days a week 830 am shy530 pm and Kenepuru Hospital was open 5 days a week 830 am shy430 pm

Most of the A amp E departments visited had a senior position variously called the A amp E officer the A amp E director the senior medical officer or the medical officer in charge For convenience we call this position the A amp E officer

RECORDING SYSTEMS

The log is the record kept at the A amp E department which records some information on every patient who presents It will often give no more than the patients name the date and time of visit

The A amp E record is usually a card and it records basic patient information and case notes It may be held for several years in the A amp E department and may therefore contain information on a series of separate events for anyone patient

14

REFERENCES

1 GtBrit Central Health Services Council - Standing Medical Advisory Committee Accident and emergency services report of the sUbcommittee - London HMSO 1962 Chaired by Sir Harry Platt

2 Emergency services the hospital emergency department in an emergency care system Chicago American Hospital Association 1972 p vii-viii

15

D

CHAPTER 3

Procedures in the accident and emergency department

In this chapter we begin describing the organisation of A amp E departments by looking at the way they operate We follow the course of a patients care entry to the A amp E department sorting into priority order for care (triage) treatment and follow-up care

ENTRY

Most people presenting at the A amp E department were ambulant (the walking wounded as they are colloquially known) They came through the A amp E departments main entrance to the reception desk where they were first seen by a receptionist or nurse (Exceptions to this occurred in the smaller hospitals where patients presenting at night were first seen by the telephonist who called the nursing staff) Nurses did reception duties at

all the provincial and rural A amp E departments and at two of the urban A amp E departments when receptionists were not on duty (eg lunchtimes nights) bull At times nurses found that having to cover the reception desk interfered with their care of patients

When the receptionists are off duty the nurses do the reception work This can be a nuisance because it interferes with patient care and sometimes patients ring the bell at the reception desk and the staff working in the resuscitation room dont hear it

A amp E nurse

Unless their condition required immediate care the ambulant patients then spent several minutes at the reception desk while their details (eg name address general practitioner complaint) were noted on the A ampE records (See Appendix B for more information on A amp E records) Then they waited in the waiting room until they were called for treatment

A small proportion of patients arrived by ambulance andmiddot at almost all hospitals entered the A amp E department through a separate ambulance entrance In the larger hospitals some nursing staff were stationed in or near the ambulance entrance to care for these patients In other hospitals the staff had often been warned of incoming urgent cases and were standing by when the ambulance arrived As the condition of ambulance patients tended to be urgent they were usually taken straight to a resuscitation or treatment area patients condition permitted or friends or the ambulance driver

Record with the

keeping assist

was ance

carried of thei r

out r

when elativ

the es

SORTING

All A amp E departments operated some triage system to sort the ambulant patients by the urgency of their need for care (Themiddot only exception was Grey A amp E department where there was seldom more than one patient in the department at a time) At most A amp E departments the patients were sorted

16

into urgent and non-urgent categories with urgent cases being seen immediately and non-urgent cases being seen in the order they presented At some of the urban A amp E departments a more complex sorting was done For example

Priority is given in the following order

urgent need very young and very old patients those with general practitioner notes those without general practitioner notes

A lie E nurse

Usually ambulance cases were not triaged since they tended to arrive on their own and required urgent care However several A lie E departments had triage arrangements planned for the arrival of many ambulance cases at once as in a disaster

Sorting was largely a responsibility of the nurses although some A amp E doctors would occasionally check the condition of patients- in the waiting room too The receptionists often played a role in triage as well alerting the nursing staff to urgent cases This happened more in A amp E departments where the physical layout made it difficult for nurses to watch the entrance and the waiting room

The receptionists do tQe basic sorting They have guidelines to follow distressed patients severe cuts or bleeding go straight to the nurses open wounds or eye injuries go directly to a cubicle and are assessed by the nurses patients with abdominal pain or chest pain go on to trolleys and wait in the recovery room This system usually works well although occasionally a fracture patient will not be recognised and will sit in the waiting room

A lie E nurse

In several A lie E departments doctors and nurses stressed the value of an experienced receptionist in recognising and reacting quickly to acutely ill or injured patients

TREATMENT

Almost all the A amp Edepartments visited had a policy that all patients presenting had to be seen by a doctor The doctor did not necessarily have to treat the patient he or she could advise the patient to see a general practitioner Some A amp E doctors commented that by the time they saw the patients it was as easy to treat them as to send them away_ At a few departments the nurses (and occasionally the receptionist) could advise the patient that the department was not an appropriate place for their condition and that they should see a general practitioner This was usually done in consultation with the A E doctor but at times the nurses acted on their own initiative In these places a triage system similar to that reported by Weinerman et al [1] where patients were assigned to the appropriate service inside or outsidemiddot the hospital appeared to be operating

7

The assessment of patients the ordering of tests andmiddot the supervision of treatment were usually seen ~s medical functions The nurses would prepare patients for treatment (removing dressings) and carry out urgent first aid measures (stem bleeding start gastric lavage or cardio-pulmonary resuscitation) Generally however a nurse would only initiate treatment if the patients condition was urgent and a doctor was not available or was already busy with another emergency Exceptions to this situation occurred in some hospitals with A amp E nurse training programmes and in some smaller hospitals where the doctor is on call rather than working in the A amp E department In these departments experienced nurses could order tests such as x-rays and initiate treatments such as suturing and removing foreign bodies from eyes

In most A amp E departments nurses would perform some treatments under a doctors supervision However the range of treatments nurses were allowed to perform varied considerably among hospitals At some hospitals nurses sutured after training but at others they never sutured

The nurses do not suture although they would like to There are four reasons for this there is no full-time A amp E officer so good standards of sutur ing could not be maintained there could be medico-legal problems if a nurse sutured a cut which was more complicated than it looked eg with tendon involvement the nurses have enough to do at present and if they start suturing they will be expected to do it always and the young doctors need to learn suturing as part of their training

Principal nurse

Electrocardiograms were taken by nurses in some A amp E departments by technicians at others Taking blood samples was a doctors job in some departments but was done by nurses in others Similarly gastric lavage using a def ibrillator and plaster work were done by nurses in some departments Most A amp E nurses would maintain intra-venous drips but only nurses with special training WOUld insert them

Some nurses expressed frustration at restrictions on the treatments they were allowed to perform However several sen~or nurses stressed that they had to select carefully the nurses they allowed to perform more difficult treatments

We are very selective about choosing the nurses to do triage suturing and the more complicated procedures This seems to have been successful weve had no problems with nurses undertaking treatment theyre not competent to provide

A amp E senior nurse

I make sure the nurses understand they can be dangerous people If theyre not aware of their limitations theyre not suitable for A amp E work

A amp E senior nurse o

Also one department which had comparatively few nurses discouraged them from increasing the range of treatments they performed so that their workload did not become overwhelming

18

For diagnosis the A amp E departments made heavy use of the x-ray departments (The Design and Evaluation Unit study [21 estimated that 30 per cent of A amp E attenders had an x-ray during their visit) Some A amp E departments found their arrangements with the x-ray department very convenient with an x-ray machine aVailable 24 hours a day in or close to the A amp E department and with patients and x-ray films or reports returning within an hour At other hospitals arrangements Were less convenient in some places reporting bac k of x-rays took two or three hours delaying patients considerably while in others the x-ray departmentmiddot was located on a different floor from the A amp E ~epartment causing difficulties in transporting and accompanying patients there

Little use was made of the laboratory services other than for blood and urine tests and arrangements were generally satisfactory However in many hospitals x-ray and laboratory staff had to be called in to perform tests out of hours and because of the expense involved these out of hours tests were discouraged Some house surgeons found this a difficult situation

I I m caught between contradictory pressures the orthopaedic surgeons say that x-rays are necessary for proper diagnosis and the hospital board is trying to limit out of hours x-rays to save money

House surgeon

DISPOSAL

After treating the patient the A amp E doctor decides on the appropriate disposal discharging from care arranging follow-up treatment by referring to another source of care or recalling to the A amp E department or admitting the patient Information on disposal was only readily available from three A amp E departments The most common disposal pattern was in fact discharging from care with 40 to 55 per cent of patients making a first Visit being discharged

TABLE I PROPORTION OF FIRST ATTENDANCE PATIENrs DISCHARGED RECALLED REFERRED OR ADMITTED

Discharged Recalled Referred to Admitted Other First to A amp E GP Specialist attendance

Clinic tallied

Waikato l 393 132 222 99 134 19 25 707 Green Lane2 550 220 110 40 80 Unknown Taranaki 41 5 268 73 103 116 24 164

1 From McRaes study of Waikato A amp E departmen~ in 1979 2 From a study carried out by Green Lane A amp E department

19

FOLLOW-UP CARE

The decision to be made on follow-up care was usually between re~alling to the A amp E department or referring back to the patient I s general practitioner Some A amp E departments also referred patients (especially children) to district nurses or patients with work 1n]uries to an occupational health nurse or clinic Many departments referred fracture patients to orthopaedic clinics held in the hospital outpatients department and one A amp E department which was very short of space referred patients needing redressings to the outpatients department

There were large differences in referral practices (see Table 1) Between 13 and 27 per cent of first attenders were recalled to the A amp E department for follow-up care while 15 to 30 per cent were referred elsewhere either to a general practitioner or to a specialist clinic Also recall attendances expressed as a proportion of total attendances varied considerably among the A amp E departments from 10 per cent to 50 per cent (see Chapter 6 Table 11) and clearly reflected different follow-up practices

All of the urban and two of the provincial A amp E departments had a policy of referring most patients requiring follow-up care to a general practitioner and of keeping recall visits as low as possible This was similar to general policy in both Britain and the United States which appears to discourage re-at tendance at A amp E departments [34] However in the suburban rural and other provincial A amp E departments the decision on follow-up care was left to the judgement of the A amp E doctor

In practice however the choice to refer or to recall was reiated to several factors First the decision related to characteristics of the patients If the patients had serious wounds or burns or injuries which could develop complications they were usually recalled They were also recalled if the A amp E staff thought they would not receive appropriate care at home or they would not see a general practitioner for follow-up care Patients living a long way from the hospital were usually referred to their general practitioner At some A amp E departments patients were given the choice of referral or recall according to A amp E staff comments most chose to return to theA amp E department

The patients prefer to come back to the hospital Money is not a factor in this because the ACC pays for accident treatment at the general practitioner

A amp E nurse

Second there were general practitioner factors If the local general practitioners were unhappy about the A amp E department recalling patients or if a general practitioner had referred the patient to the department originally the A amp E doctors would refemiddotr rather than recall However if the A amp E doctors thought that the general practitioner did not have the facilities and in some cases the ability to provide follow-up care (eg for serious woundS eye injuries) they would recall the patient

Some GPs dont like following up care initiated by the A amp E department or dont have the necessary facilities so I tend not to send patients back to them

A amp E officer

20

Im more likely to refer a patient back to a GP who is reliable

House surgeon

Third many of the house surgeons said they would recall patients if they were interested in the condition or if they were worried about their diagnosis and treatment and wanted to see the outcome Several medical superintendents noted that recalling under these circumstances was acceptable because it comprised part of the house surgeons training

Fourth the workload of the A amp E department sometimes affected the follow-up decision with very busy departments actively discouraging recalls And finally there was the philosophy of A amp E medicine held by the A amp E doctor In one department where the A amp E officer considered it an ethical duty to see any treatment initiated through to a successful conclusion almost all patients who needed follow-up care were recalled At two other departments the A amp E officers stressed the importance of being able to deal efficiently with any emergencies presenting they kept recalls low so that the department was not clogged with extra patients Other A amp E doctors thought that the general practitioner could provide better continuity of care than the A amp E department so they referred as many patients as possible

When referring patients to the general practitionermiddot most of the A amp E doctors made a verbal recommendation to the patient and then relied on the patient to attend the general practitioner They would only write a formal referral letter if the patients condition was serious In several A amp E departments however greater efforts were made to inform the patient t s general practitioner Three departments gave referred patients cyclostyled forms with details of diagnosis and treatment to be passed to their general practitioner while the Whakatane department sent a copy of the A amp E record form to each patients general practitioner

ADMISSIONS

Table I suggests that between a and 14 per cent of all first attendances were admitted to the hospitals Admissions could well be higher for children Kljakovic [5] found that 20 per cent of the children presenting at the Wellington Hospital Board A amp E departments were admitted

The A amp E departments were involved in several different pathways for the admission of acutely ill or injured patients (Scheduled admissions did not involve the A amp E department at any of the hospitals visited) Self-referred patients could be admitted directly from the A amp E department to the wards or could be cared for in a holding (or acute admitting) ward before going to the wards

There was considerable variation among the hospitals as to which members of the medical staff were able to admit patients At some of the urban hospitals only the registrars could admit while at others the A amp E doctor could admit if the registrar was delayed and unable to assess the patient quickly At some of the provincial and one of the urban hospitals the A amp E doctor could admit in consultation with the admitting officer or appropriate registrar while at-another urban hospital and the rural A amp E departments the A amp E doctors regularly admitted patients

21

Hospitals with lower levels of bed occupancy were more likely to allow A amp E doctors to admit Senior A amp E doctors were more likely to play a role in admissions (actually admitting patients or advising the registrar) than house surgeons

Some patients referred by a general practitioner for acute admission also passed through the A amp E department At one hospital the general practitioners rang the A amp E officer to arrange for all acute admissions and all such GP-referred patients were seen first in the A amp E department However more usually the general practitioners rang the appropriate registrar to make arrangements and the registrar decided whether to admit the patient directly to the wards or through the A amp E department The involvement of A amp E staff with patients requiring admission ranged from almost none (where the patient went directly from the A amp E department to the ward or specialist unit) to a full initial assessment including tests (often undertaken at the request of the registrar responsible for the patient) bull

Generally the A amp E doctors were satisfied with the admission procedures However at one hospital where the A amp E doctors could not admit patients waiting for admission tended to clog the department The doctorselt that if they had admission rights the situation would be remedied

DISCUSSION

There were few differences among the A amp E departments in the reception and sorting of patients However there were differences in some aspects of treatment follow-up care and admission procedures

lhe role of the A amp E nurses in treatment varied considerably with some departments allowing nurses to initiate and perform many treatments and other departments allowing little autonomy Careful training and selection were essential before nurses increased their responsibility for treatment bull

Policies on follow-up care differed among the departments with the urban and provincial departments generally referring patients to general practitioners and the rural and suburban departments leaving the referral decision to the A amp E doctor In practice however the differences were less clear-cut with several factors other than the patient I s condition affecting the follow-up care decisions These factors included the A amp E staffs communicat ion with local general practitioners the inexperience and training needs of house surgeons the workload of the department and the senior A amp E doctors philosophy with regard to A amp E medicine

The A amp E departments also differed considerably in thei r procedures for acute admissions At some hospitals the A amp E doctor could admit an A amp E patient while at others the patient had to be held in the department until admitted by a registrar Also at some hospitals patients referred by general practitioners for acute admission were seen in the A amp E department before going to a ward While having to hold patients sometimes caused

clogging in the department A amp E staff were generally satisfied with the procedures

22

REfERENCES

1 WEINERMAN E Richard RUfZEN S Robert and PEARSON David shyEffects of medical -triage- in hospital emergency service in Public health reports - v 80 no 5 (May 1965) p 389-399

2 Accident and emergency departments a study of planning requirements prepared by the Hospital Design and Evaluation Unit - Wellington Department of Health 1973

3 Accident and emergency services - Gt Brit National Health Service memorandum HM (68)83

4 Emergency department organisation and management edited by AL Jenkins - St Louis Hosby 1975

5 KLJAKOVIC M ALLAN B C and REINKEN J - Why skip the general practitioner and go to the accident and emergency department in NZ Med J - v 93 (1981) P 49-52

23

CHAPTER 4

Phy~i~~1 c~~raft~rhtics of accident and emergency departments

This chapter describes the physical characteristics of A amp E departments their overall size location and layout as well as specific areas within the departments It discusses the effects of the physical characteristlcs on the organisation and functioning of the A amp E departments Our investigation worked from the detailed base established in bullAccident and emergency departments a studY of planning r~quirements a report prepared by the Hospital Design and Evaluation gnit Departmellt of HeCilth [1]

PRINCIPLES

The 1973 Hospital Design and Evaluation Unit (DEU) report [l] outlined the following principles to be applied in designing A amp E departments

o the A amp E department must be patients seeking emergency care

ready to receive and deal with

o the A amp E department mus~ be able load within a reasonable period

to cope with an average i

busy

o the A amp E department must be capable of adaptation to exceptional situations arising from major accidents ltgtrqther disasters

o the layout should be simple easily unqerstood and compact

o the layout and procedures should facilitate easy flow of patients through the department

o spaces should be multipurpose to give greatest versatility

o p~tient ~ovew~n~ should be minimised )

priv~cy for patientsshould be provided as far as is practicable andconsistent with the need for supervisi0rt

SIZE

There was considerable variation in the total sizes of the A amp E -a~1-ftment~ vi~ited witll floor areas ranging from 250 sql1a~e metres to 2115 ~guare m~ties (see Table 2) Eight of the 14 departments visited had i

hhid1pgw~fd~oracUte admitting ward However even wt)en ~he area of th~ f~ ~ bull ~middotc1~A~- _ ~ - bull bull ~

AampE department WCiS adjusted for the presence of a holding ward this I~1-getv~-rH~tion in irea reniained

24

TABLE 2 AREAS OF A amp E DEPARTMENTS

Total area Holding ward Adjusted total Waiting room area areal area

sqm sqm sqm sqm

Full-time departments

Urban Auckland 2 115 225 1 890 55 Middlemore 1 045 140 905 50 Green Lane 960 240 720 70 Wellington 575 190 385 75 Hutt 270 270 30 Christchurch 470 470 40 Dunedin 635 90 545 20

Provincial Rotorua 515 20 495 90 Taranaki Base 720 90 630 40 Timaru 605 70 535 80

Rural Whakatane 430 430 20 Grey 310 310 15

Part-time departments

Suburban North Shore 255 255 30 Kenepuru 540 540 30

1 Adjusted total area = total area minus holding ward area Considerable sharing with outpatients department

The area of the A amp E department was not closely related to the attendance (see Table 3) Obviously there is a certain minimum size for an A amp E department since certain facilities are essential regardless of the attendance served Thus as would be expected the rural and to a lesser extent the provincial A amp E departments had high area to attendance ratios However even within the group of urban A amp E departments there was a fourfold difference in the total area to attendance ratio

The design at Auckland~ laid out along several corridors with many separate consulting and treatment rooms possibly contributed to its high ratio At Wellington Hutt and Christchurch hospitals staff commented on their difficulties working in cramped conditions The lack of space often forced staff to work under extreme pressure to move patients through the departments very quickly

25

TABLE 3 AREA TO ATTENDANCE RATIOS FOR ADJUSTED TOTAL AREAS 1 AND WAITING AREAS OF A amp E DEPARTMENTS BY FIRST ATTENDANCE2 AND TOTAL ATTENDANCE 2

Adjusted total area to attendance ratio Waiting area to to attendance ratio

Sqm per 1000 Sqm per 1000 Sqm per 1000 first attendance total attendance total attendance pa p a p a

Full-time departments ~

Urban Auckland 323 291 08 Middlemore 232 157 09 Green Lane 3 230 168 16 Wellington 80 69 13 Hutt 82 63 07 Christchurch 76 64 05 Dunedin 200 143 05

Provincial Rotorua 404 293 53 Taranaki Base 609 399 25 Timaru 466 266 403

Rural Whakatane 718 490 23 Grey 805 61 2 30

Part-time departments

Suburban I INorth Shore 272 148 17

Kenepuru 924 597 33

1 Adjusted total area = total area minus holding ward area

2 See Table 9 for attendance figures used in calculations

3 Considerable sharing with outpatients department

Spearman rank correlations [2] of adjusted total area with

( a) first attendance r = 0310 p gt 010 Not significant ( b) total attendance r = 0297 pgt 010 Not significant

26

LOCATION

There is broad agreement that the A amp E department should be located on the ground floor well signposted and easily accessible to ambulatory patients and ambulances The ambulance entrance should be able to handle several ambulances at once and should have adequate turning space It should be projected from the weather and screened from the view of the other A amp E department patients

The A amp E department should also be located as closely as possible to radiology facilities (either the x-ray department itself or a branch) The A amp E department and the outpatients department can share some facilities and provide additional staff and accommodation in an emergen~y

situation if they are sited together Acute patient care areas (operating theatres intensive care unitsmiddot and cardiac care units) and laboratory services should also be readily accessible from the A amp E department [134]

Entrances

Almost all of the A amp E departments visited were on the ground floor of the hospital and were well signposted Generally access for ambulatory patients was good apart from two hospitals where they had to walk up steps to enter the building o

Few departments had ambulance access which could cope with a shuttle of ambulances bringing mass casualties from a disaster There w~s little relation between the size of the department or the population served and the ease of ambulance flow Indeed those departments with a relatively low probability of being involved in a mass casualty situation had good ambulance flow (eg Whakatane) while those with a greater possibility had relatively poor ambulance access (eg Wellington) Several departments had particularly poor a~bulance flow with only a one-lane access Three departments had good drive-straight-through access while at the rest ambulances had to reverse However there were advantages to some of the bull reversing I situations in that the bays into which the ambulances had to reverse were more likely to give the patient protection from the weather All the A amp E departments visited had separate ambulance entrances which in all but three cases guaranteed screening of ambulance patients from public view

Access to other hospital facilities

In many of the hospitals the A amp E department was adjacent to the outpatients department or to the orthopaedic outpatients section When this occurred the plaster room and x-ray facilities were usually shared and waiting areas and the records office were sometimes shared In the smaller hospitals both departments often shared the nursing staff

The access to the x-ray department ranged from excellent in places which had x-ray facilities immediately adjacent to the A amp E department to very poor where the patient had to be transported hundreds of metres and to a different floor The time taken for the A amp E doctor to get the result of the x-ray varied from five minutes to over two hours though the physical separation of the two departments was only one of the factors which affected this

27

Access to acute care facilities was similarly variable In Christchurch the intensive care unit was adjacent to the A amp E department while in Rotorua it was at the other end of the hospital In many cases additions or alterations to the hospital buildings and changes of function of certain areas have meant that the A amp E department no longer bears the same physical relationship to other hospital departments as was originally the case

LAYOUT

Several studies have concluded that the A amp Edepartment should be designed so that there is an orderly progression of patients from registration to examination to investigations if necessary to treatment and to referral admission or discharge Staff time and effort is best conserved by a compact plan with waiting areas and treatment areas easily accessible and supervised However the need for easy supervision has to be balanced by consideration of the patients privacy Two basic A amp E plans have evolved

o a radial plan where the waiting examination and treatment rooms are arranged on the perimeter of the departmentmiddot with the nurses station doctors room and records office in the centre

o a linear plan where the examination and treatment rooms are arranged down each side of a corridor with the waiting area records office and staff offices at one end [145]

Many of the A amp E departments visited had a linear layout with the largest Auckland being arranged along several corridors In these departments staff often commented that their overall view of the patients was not good and a considerable amount of walking was needed to supervise them Middlemore A amp E department and the treatment areas of several other departments had radial layouts which staff found very satisfactory Generally the A amp E staff prefer red open plan layouts using curtained cubicles rather than enclosed rooms Staff (especially nursing staff) often commented that their department would be better if certain walls or partitions were removed to give easier surveillance of the department as a whole However staff also commented on the relative lack of privacy for patients being examined or treated and noted that some private rooms were needed for instance for obstetric or paediatric patients

Waiting area

There is general agreement that the waiting area should be adjacent to the reception desk easily visible to the receptionist and if possible overlooked by the nurses office or station It should be a cheerful comfortable area with toys provided for children and a range of magazines and books Public toiletspublic telephones and arrangements for refreshments are also needed [146]

The size of the waiting area varied considerably among the A amp E departments visited (refer back tomiddot Table 2) Again this variation bore little relationship to the workload of the department (see Table 3) Some waiting areas were clearly too small and this put pressure on the staff to deal with patients quickly in order to clear the waiting room

28

Staff comments suggested that not only the size of the waiting area but also its design affected its crowding Basically square rooms with seats around the edges had fewer problems than corridor-style rooms with only one row of seats

In all the A amp E departments visited the waiting areas were adjacent to the reception area Sometimes they were visible from the nurses office or work area but where this was not possible the nurses relied on the receptionists to alert them to urgent cases or checked the wai Hng area often themselves

Facilities in waiting areas varied from nothing but seats to areas in which there were hot and cold drink dispensing machines a childrens play area with toys and health-related poster and pamphlet displays Some had a TV set or a tropical fish tank Most staff were agreed that a pleasant atmosphere in the waiting room was important and adVerse comments about the waiting area were made by staff in departments which lacked this In some departments staff commented that vandalism made it difficult to retain facilities and a pleasant atmosphere

Examination and treatment area

The examination and treatment area provides for the needs of all A amp E patients other than those with serious conditions requiring the resuscitation room or those needing special facilities such as plastering Because special purpose areas are frequently under-utilised flexibility is a key requi rement Hence multipurpose cubicles with standardised equipment are usually recommended The cubicles must be big enough to give easy access for patients (not necessarily walking) to accommodate eqUipment and to give staff enough room to work Curtained cubicles are generally sufficient but at least one enclosed cubicle is required for patients needing extra privacy or for light control in eye examinations A cubicle especially set up for children (with appropriately-sized equipment toys and posters) is also desirable [1346]

Most of themiddot A ~ E departments visited had curtained cubicles in the examination and treatment area with perhaps one or two enclosed cubicles or rooms as well Four A amp E departments only had separate rooms for treatment Curtained cubicles made for ease of access while separate rooms did present some difficulties in manoeuvering patient trolleys and wheelchairs In one case it was impossible to get a patient trolley into the room at all and the room was consequently little used

Curtained cubicles did afford greater flexibility in use and did provide more room to work but had the disadvantage of being considerably less private than rooms Surveillance was easier in departments with curtains than those withmiddot walls and doors In the Auckland A amp E department treatment rooms doors had been removed in the interests of improved surveillance Staff in this department commented that its rigid design could lead to difficulties in accommodating a large number of patients in a disaster

The DEU report [1] recommended that the number of cubicles required by an A amp E department was NIlS where N is the anticipated average number of new patients per day It noted that in A amp E departments with few new patients per day a minimum of two cubicles should be provided It also recommended that the flow of recalled patients should be regulated so that they did not greatly affect the need for cubicles

29

As can be seen from Table 4 most departments had enough cubicles to cope with their first attendance workload Even applying the DEU recommendation of N18 to their total attendance most of the departments had an adequate number of cubicles The exceptions were Hutt Christchurch and Dunedin

TABLE 4 NUMBERS OF EXAMINATION AND TREATMENT CUBICLES OR ROOMS AND RECOMMENDED NUMBERS l BASED ON FIRST ATTENDANCE 2 AND TOTAL ATTENDANCE 2

Actual number of DEU recommended numbers (minimum of 2) cubiclesrooms based on

first attendance total attendance pa pa

Full-time departments

Urban Auckland 13 89 99 Middlemore 9 59 88

Green Lane 7 40 65 Wellington 10 73 85 Hutt 4 51 66 Christchurch 7 94 11 2 Dunedin 3 41 58

Provincial Rotorua 4 2 26 Taranaki Base 4 2 24 Timaru 6 2 31

Rural Whakatane 3 2 2 Grey 3 2 2

Part-time departments

Suburban North Shore3 8 22 37 Kenepuru3 6 22 30

1 Based on DEU report [l which recommended NIS cubicles where N average number of new patients per day ie N6750 where N = average first attendance pa

2 See Table 9 for attendance figures used in calculations

3 Recommended numbers increased to adjust for North Shore and Kenepuru treating their attendance numbers in part-time rather than full-time hours

30

Resuscitation area

The resusciation area is used for the immediate life--saving treatment of seriously injured or sick patients It is the acute treatment area in contrast to the examination and treatment area which is used for relatively minor procedures In making its recommendations about the resuscitation area the DEU report [I] balanced the probability of the A amp E department having to treat multiple accident victims with the comparative rarity of use of resuscitation rooms It recommended that a resuscitation room of suff icient size to deal with two patients concurrently be provided in all A amp E departments It also noted that the ambulance entrance and resuscitation area should be located as close together as possible

Most of the departments visited had purpose-built resuscitation rooms of varying size and with varying degrees of sophistication in equipment Some had x-ray facilities in the resuscitat ion area and in those that did not its absence was regarded as a serious impediment to the efficient care of severe trauma

In four of the seven urban A amp E departments the resuscitation rooms were regarded by the staff as being too small The comment was made in one urban department that because of the small size of the resuscitation area patients sometimes had to be moved out of the area before it was felt clinically desirable to do so in order to accommodate incoming patients In the rural and prOVincial A amp E departments the resuscitation rooms wereshyadequate for the demands placed on them

Most resuscitation rooms were sited close to the ambulance entrance and afforded good access to stretcher patients However in three A amp E departments patients had to be moved some distance and in another department up one floor by lift

Operating theatre

In discussing provision of operating theatres in the A amp E departments the DEU report [1] noted that

o most surgery done is minor requires only local anaesthesia and could be done within adequately designed cubicles

o the A amp E department is not a proper place for general anaesthesia

o using A amp Etheatres for day surgery tends to block other A amp E facilities and staff causin~ delay in treating A amp E patients

The report concluded that special facilities appear to be justified only if there is a clear intention of widening the scope of accident surgery in the departments

bullMinor ops theatres of varying sizes and equipped to varying standards were available in many departments Very variable use was made of such theatres - never in some departments to daily in others It was used less in departments with very heavy workloads and where the medical staff were not satisfied that sufficiently sterile conditions could be maintained In one department the theatre was only used for day surgery cases

31

Plaster room

In the plaster room casts are applied and removed and fractures and dislocations can be manipulated The DEU report [1] noted that the plaster room could be an integral part of the A amp E department or shared with the orthopaedic department or belonging entirely to the latter It recommended that the plaster room be close to the A amp E department and the x-ray department

Most departments had a separate plaster room available In many cases this was shared with an adjacent orthopaedic outpatients or fracture clinic Th~ staff generally found the plaste~-rooms satisfactory although two particularly narrow rooms were difficult to work in

Interview room

The DEU report [l] recommended that A amp E departments in medium-sized and larger hospitals should have a small interview room where a patient IS

relatives could talk with A amp E staff the police or others

No A amp E department had a room specifically designated as an interview room for bereaved or distressed relatives although one A amp E department shared such a room with another department In most departments one of the staff off ices was generally used for this purpose In departments where staff offices were small or crowded the lack of an interview room was seen as a serious flaw in departmental layout

Reception and records office

The reception desk should be immediately visible to ambulant patients arriving at the A amp E department and it is desirable for the receptionist to be aware of what is happening at the ambulance entrance as well The current A amp E records should be held at the reception desk or nearby [1]

In the A ampE departments visited the reception desk was usually well-placed for dealing with ambulant patients but in only four cases did it overlook the ambulance entrance In two departments the reception desk was some distance from the treatment area (separated by a waiting room or outpatients room) and the nursing staff found it difficult to oversee incoming patients Current A amp E records were held at the reception desk in all but one of the departments visited The amount of space available in relation to the throughput of patients was a major factor in determining the length of time records could be kept within the department This in turn affected the ease and therefore speed of record retrieval

Staff offices

These ranged from non existent to very cramped spaces serving many other functions to pleasant specifically designated and relatively quiet areas The latter offices are conducive to good staff morale and being a place for exchange of views and experiences could be expected to contribute quite markedly to the overall effectiveness and eff iciency of the department

32

Holding ward

The DEU report [1] said that holding beds should be used primarily for A amp E patients requiring a period of observation prior to a decision about admission or for those who could be expected to go home after a rest period The report noted that using holding beds as recovery beds for day patients for arranged admissions or for pre-admission clinics was not desirable

Most of the urban and provincial A amp E departments visited had holding or acute admitting wards These holding wards were used mainly for assessing patients requiring acute admission but in some hospitals were also used for observing patients (eg with suspected concussion) and for holding night admissions till the morning to save disturbing the wards Neither of the rural A amp E departments had a holding ward although one had an I A amp E admission procedure where a patient could be admitted for up to 24 hours for observation without the need for full admission procedures In the A amp E departments with holding wards a patient staying for more than four hours was formally admitted

Our study showed that the A amp E departments had some problems using holding wards properly In two A amp E departments holding wards were little used at night because nursing levels were too low to staff them safely In another department the beds were used for patients recovering from day surgery and even for some pre-ar ranged admissions At times general practitioner-referred admissions could also clog the holding wards

DISCUSSION

Most of the A amp E departments were generally adequate in size location and layout The exceptions were Christchurch and Butt where conditions were very cramped with particularly limited examination and treatment areas and poor layout We understand that improvements are planned at Hutt and that recent extensions have improved the Christchurch department considerably but at the time of our visits staff in both these departments were working under extreme pressure because of the physical conditions

Despite the general adequacy of the departments almost all had some flaw which affected their operation and inconvenienced staff and patients Major flaws found in several A amp E departments included

o ambulance access unsuitable for a shuttle of ambulances in a disaster

o difficult access to the x-ray department

o resuscitation room too small for easy treatment of more than one patient at a time

o no interview room for relatives of patients

33

REFERENCES

1 Accident and emergency departments a study of planning requirements prepared by the Hospital Design and Evaluation Unit - Wellington Department of Health 1973

2 SIEGEL Sydney - Nonparametric statistics for the behavioural sciences - Tokyo McGraw-Hill Kogakusha 1956 p 202-213

3 Emergency services the hospital emergency department in an emergency care system Chicago American Hospital Association 1972 p 44-49

4 Emer~ency department organisation and management edited by A L Jenkins - St Louis Mosby 1975 p 8-16

5 Design of departments in Br Med J - v 2 (1979) p 1204-7

6 McKINLAY Robin - The care of children in New Zealand hospitals -Aucklandmiddot National Childrens Health Research Foundation 1982 p 79-80

35

CHAPTER 5

Staffing of accident and emergency departments

This chapter describes the staffing both medical and nursing looking at their numbers and experience their previous training and the training they receive in the A amp E department and their satisfaction with their work and conditions We also describe the clerical and reception staff and briefly the involvement of other workers (orderlies social workers and ambulance personnel) in the departments

MEDICAL STAFFING

Senior medical staffing

Organising appropriate medical staffing for hospital emergency services is a prQblem in many countries [1] The variety of staffing arrangements in A amp E departments within many countries suggests that none have established a generally satisfactory pattern of medical staffing

The Platt report [2] found that in Br itish A amp E departments the great majority of patients were seen by junior staff only and that supervision of the A amp E departments by conSUltants was often little more than nominal The committee recommended that

o the junior medical staff should be adequately supervised by consultants

o a consultant orthopaedic surgeon should normally be in charge of theA amp E unit

o an accident and emergency unit should have at least three consultant surgeons each giving a substantial part of their time to this work

o the primary task of general practitioners in emergency services is to deal with minor accidents and emergencies at any time of the day or night (by organising a rota to answer emergency calls within their practice by working sessions in A amp E departments or by attending cottage hospitals at short notice for emergency calls) bull

Since then some progress has been made but standards continue to lag behind those recommended [34] There has been considerable debate over the appropriate staffing arrangements for A amp E departments Some hospitals have implemented the Platt report recommendations others have appointed a full-time A amp E specialist others have employed a full-time non-specialist doctor and some have employed general practitioners

Despite the various systems there is a consensus in both the United States and Britain that experienced medical staffmiddot are essential in the A amp E department They are necessary for prompt effective treatment of emergency conditions for efficient running of the departments and for adequate supervision of the junior doctors employed [23567 p 17-23]

36

Similar concerns have been expressed in New Zealand since the Board of Health report on outpatient services in 1960 [8] This report recommended that general hospitals continue to provide a casualty service available at all times and staffed by experiencedmedical officers

Salmond [9] found that when a senior A amp E officer directed the department A amp E work was handled more efficiently and house surgeons were more closely supervised and supported He suggested that one senior member of the hospital staff (ideally a full-time A amp E officer) should accept full responsibility for the overall supervision of A amp E services

Most of the A amp E departments that we visited had an A amp E officer The position was vacant at both Wellington and Hutt hospitals at the time of our visit while at North Shore Hospital responsibility for the A amp E department was shared by two senior doctors The A amp E departments of the rural hospitals had no senior medical staff

In A amp E departments with heavy workloads additional experienced doctors were often employed as deputy A amp E officers usually medical officer special scale or as Medical Reserve Scheme registrars (see Table 5) There was no general practitioner staffing of any of the Aamp E departments visited although general practitioners had been part-time staff of some of themiddot smaller A amp E departments in previous years One medical superintendent commented that since very few general practitioners could be classified as specialists they could only be paid as medical officers special scale This low level of payment acted as a disincentive to general practitioner recruitment

The A amp E officers usually worked normal office hours (830 am - 430 pm or 9 am - 5 pm weekdays) apart from two who worked part-time covering morning periods If additional experienced doctors were employed they usually covered evening periods (eg 5 pm - 10 pm) and weekend day shifts

There was a wide range of experience among the A amp E officers Half of the senior A amp E doctors had a general practice background and these doctors often had specific surgical medical pharmacological or Armed Forces medical experience as well Several A amp E officers had primarily a surgical background while others had a considerable range of hospital experience In hospitals where the A amp E officers had a general practice background the Medical Superintendent or the A amp E officer often stressed the suitability of this background for A amp E work

An extensive general practitioner background is useful in dealing with the multitude of problems seen in an Accident and Emergency department An orthopaedic or surgical background is not as necessary because of the good backup from the specialties And staff who have only had hospital experience particularly junior staff can lack skills in general assessment and triage

A amp E officer

In other hospitals staff stressed that an orthopaedic and surgical background was very valuable as was experience in dealing with specific types of injury such as soft tissue wounds

37

TABLE 5 MEDICAL STAFFING OF A amp E DEPARTMENTS

Full-time departments

Urban Auckland Middlemore Green Lane Wellington2

Hutt2

Christchurch Dunedin

Provincial Rotorua Taranaki Base Timaru

Rural Whakatane Grey

Part-time departments

Suburban North Shore Kenepuru

Senior medical staffing

Number of full-time equivalents

A amp E officer ( including deputies) 25 15 I 16

I 2

I 03 I

2 05

Registrar

06

1 1

House surgeons

Number on Number A amp E runs covering

some shifts in A amp E deptl

6 2-3 6 2 5 I 5 4 2-3 5 2 2

All on rotating basis 1 3 1 2

5 on rotating basis 4 on rotating basis

None in A amp E dept 4 on rotating basis

1 On general relieving duties 2 Senior A amp E position vacant at time of visit

Junior medical staffing

The issues

Junior medical staffing of A amp E departments has concerned many commentators in the United States Britain and New Zealand The Platt report [2] noted that recently qualified staff when serving in the casualty department undertake responsibility which they would not have in the wards or outpatient clinics

38

In 1960 the New Zealand Board of Health report [8] on out-patient services deplored the staffing of casualty departments by I relatively inexperienced men [sic] and suggested that these staff I should be regarded more as assistants under supervision and training than responsible officers in the outpatients departments The undesirability of staffing A amp E departments with first year house surgeons (or pre-registration doctors) has been reiterated since Junior doctors are often unsure when to ask for advice or help and are sometimes unwilling to admit that they are over-tired and unable to cope [91011)

The report on the working conditions of New Zealand resident medical officers [12] noted the heavy load carried by house surgeons working long shifts in A amp E departments It also commented that when house surgeons are required to look after the A amp E department while carrying out ward duties inadequate cover of the A amp E department could result

The New Zealand situation

The urban A amp E departments had between two and six house surgeons working on three month A amp E runs and in several of these hospitals another one to three house surgeons on general relieving duties covered some A amp E shifts There were more house surgeons in A amp E departments with heavier workloads or with fewer senior medical staff The provincial and rural departments did not usually have house surgeons working on specific A amp E runs rather the A amp E department was covered by all (or most) of the house surgeons in the hospital on a rotatng basis Of the two suburban A amp E departments Kenepuru was covered by the house surgeons on a rotating basis while North Shore did not have any house surgeons because there was no inpatient or consultative backup available (see Table 5)

The total medical staffing of the departments (senior A amp E doctors and house surgeons together) ranged from 10 to 100 full-time equivalents and was closely related to the attendance at the departments (see Table 6) The provincial and rural A amp E departments had higher medical staff to attendance ratios because they had to provide a 24-hour service regardless of the size of the attendance

Each A amp E department visited rostered its house surgeons differently depending on the availability of senior medical staff the workload of the department and the house surgeons other duties In the urban departments house surgeons worked between 45 and 60 hours a week on shifts usually 8 to 12 hours long Many of the house surgeons working in these departments complained about long shifts and suggested that more staff were needed to reduce the shift lengths Split shifts were also unpopular

The most worrying aspect of the staff ing arrangements in bhe Accident and Emergency department is the long hours We need another house surgeon to reduce the hours on some shifts and to proviae another pair of hands in busy periods (eg Friday and Saturday night Sunday afternoon)

House surgeon

39

TABLE 6 TOTAL MEDICAL STAFFING (FULL-TIME EQUIVALENTS) AND MEDICAL STAFFING TO ATTENDANCE RATIOS FOR FIRST ATTENDANCE I AND TOTAL ATTENDANCE 1

Total medical Total medical staffing to staffing attendance ratio

FTE per FTE per 10000 first 10000 total

Full-time attendance attendance equivalents p a pa

Full-time departments

Urban

Auckland2 100 17 15 Middlemore2 91 23 16 Green Lane2 65 25 15 Wellington 66 14 12 Hutt2 55 17 13 Christchurch 70 11 10 Dunedin2 60 22 16

Provincial Rotorua 42 34 25 Taranaki Base2 28 27 18 Timaru 22 19 11

Rural Whakatane3 15 25 17 Grey 10 26 20

Part-time departments

Suburban North Shore 20 21 12 Kenepuru3 20 34 22

1 See Table 9 for attendance figures used in calculations 2 FTE estimated since A amp E department partially covered by house

surgeons on general relieving duties 3 FTE estimated since A amp E department covered by house surgeons on

rotating basis

Spearman rank correlations [131 of total medical staffing with

(a) first attendance r = 0953 p lt 001 (b) total attendance r = 0933 p 001

In the provincial and rural hospitals house surgeons were often on call for long shifts over nights and weekends They were usually covering a ward or the whole hospital at the same time and simultaneous demands from the wards and the A amp E department sometimes caused problems However

40

these house surgeons generally found their rostering satisfactory despite the long hours on call perhaps because the actual work required in the A amp E department was comparatively light

An ordinary week night is usually quiet after midnight thered be three to five calls and Id have to get up once on average Weekend nights are busier but I usually get at least two or three hours sleep

House surgeon

Several house surgeons were irritated that while they worked more intensively on A amp E runs than on ward runs they spent fewer hours on-call and consequently they were paid less

Supervision by senior medical staff

In the larger A amp F departments house surgeons worked with the senior medical staff on most day and some evening shifts only on night shifts (and some evening shifts) were house surgeons the sole medical staff in a department By contrast in the smaller and part-time departments house surgeons covered the department alone seldom working with any senior A amp E medical staff

Several nurses commented that the A amp E department ran less efficiently outside normal working hours because the house surgeons inexperience meant assessment and treatment times were longer and tests were used more often than when the A amp E officer was present

Many senior medical staff in the urban A amp E departments were concerned at the lack of supervision for house surgeons outside normal working hours and so would have Ii ked more senior A amp E staff Several of the house surgeons were also concerned although others enjoyed the autonomy they had and were not concerned about working without supervision

I am not happy with house surgeons managing the A amp E department on their own They only have a three month shift in the department and often most of this time is spent learning how to do A amp E wor k The house surgeons can have problems deciding when to call a registrar to treat a patient and there can be delays in obtaining a registrar The A amp E department needs full-time trained medical staff on duty 24 hours a day to give proper supervision to the house surgeons and to run an efficient department

A amp E officer

On night shift I can feel rather alone if something goes wrong

House surgeon

I enjoy the variety of work and the independence I have to treat most patients as I see fit

House surgeon

41 _A

Arraflgements for consultative backup and support when senior A amp E staff were not on duty varied from hospital to hospital according to hospital size n urban hospitals the house surgeons would usually call on the appropriate registrar and the acute admitting or specialist teams for emergencymiddot cases In some places the house surgeons could calIon the consultant if a registrar was unavailable but this was usually seen as a last resort call In the provincial and rural hospitals the house surgeons would call on the appropriate senior doctor who was available This was usually one of the cQnsultants or a registrar if any were employed by the hospital The A amp E Qfficer might occasionally be called and in hospitals without an A~amp E oHicer th~ medical superintendent would also provid~ backup

Generally house surgeons were happy with the support they received A physically compact hospital was mentioned several times as facilitating ~ ~ fast back-up Howeve( in some hospitals there could be considerable delays in 9etting surgical and orthopaedic registrars to the A amp E department usually because they were in theatre Also at two hospitals backup in the minor specialties was considered inadequate bull

Use of first year house surgeons

Urban and suburban hospitals had a policy of using second year house surgeons as much as possible in the A amp E department and of using first year house surgeons only in their second six months This policy was generally butmiddot not always carried out For example the on-call arrangements of some urban A amp E departments resulted in inexperienced first year house surgeons working in the department In the smaller hospitals also the limited pool of house surgeons available tended to result in more first year house surgeons working in the department

The hospital could not provide cover for the A amp E department without using first year house surgeons However there are always senior staff and the medical registrar readily available as backup

Medical superintendent

When direct supervision was limited first year house surgeons did find A amp E work difficult

Training

The training received by the house surgeons in the A amp E departments varied greatly Two hospitals ran half-day or one-day orientation courses before -house surgeons started in the department Three A amp E departments ran weekly or fortnightly training sessions on specific conditions while another department ran sessions on an irregular basis However house surgeons often missed training sessions because they were treating pat~entsln more than half tmiddothe A amp E departments no formal training was giVen and house surgeons were taught on-the-job when senior A amp E staff were available This teaching placed a considerable load on senior staff

The three-monthly changeover of house surgeons is frustrating and the first month with new house surgeons is very demanding because they have little confidence or competence

A amp E officer

ISSN 0548-944X

Department of Health

ACCIDENT AND EMERGENCY DEPARTMENT ORGANISATION AND UTILISATION

SPECIAL REPORT 70

by

B CAllan BSc (Hons) J Reinken PhD

Issued by the Management Services and Research Unit Department of Health Wellington

1984

LIBRARY bull DEPARTMENT OF HEAlrRJ

WELLINGTON

FOREWORD

Over the last twenty years there have been a number of accident and emergency studies in New Zealand hospitals For the most part these have been place and topic specifics This study by Bridget Allan and Judith Reinken is different It begins with an historical review of previous work in the field This is followed by a wide ranging study of accident and emergency services based on field work carried out in a representative sample of hospitals The data are analysed and presented taking account of the relevant international literature The resulting consolidation of knowledge provides a sound basis not only for further research but more importantly for the further development of accident and emergency services

The report provides at least tentative answers to a number of questions regularly asked about accident and emergency services Do general practitioners and accident and emergency departments provide competing services lhe answer appears to be no The public seem to discriminate sensibly between what are for the most part complementary services Is cost a factor in accident and emergency attendance as opposed to a visit to the general practitioner Again the answer appears to be no - cost is not an important factor Are socio-economic status and ethnicity associated with the rate of A amp E attendance Perhaps but distance and other factors concerned with accessibility appear to be more important

The study shows wide variation in the way in which A amp E services are provided in different hospitals This ranges from the size and shape of the physical facilities and the type and level of staffing relative to the workload to the way in which individual patient problems are dealt with Those responsible for the planning and operation of A amp E departments should find these comparisons informative Consideration of the data may perhaps prompt questions which in their answering lead to greater cost effectiveness and to service improvement

As well as providing answers the research raises questions It points yet again to the need in New Zealand for a regional study of accidents and accident services Accidents are a major cause of premature death and morbidity Many organisations are involved in the prevention and treatment of accidents but so far it has not been possible to mount a comprehensive study which includes and integrates all interests Until this is done fragmentation of services is likely to continue

By highlighting access to services the study points up the need for more information about communication and transport patterns in health care delivery Again this is a neglected area of research which could have far reaching implication for the planning and operation of health services

Finally the report raises questions about the interaction between general practitioners and A amp E services That these services are largely complementary is clear but unfortunately the communication between them is often not as good as it could and should be Further research has a contribution here but will not solve the problem Better communication and understanding is needed on both sides

The researchers have provided us with a much needed and timely review of an important and sometimes controversial aspect of health services Theirjete audience

G C Salmond ---shyDeputy Director-General of Health Department of Health

ACKNOWLEDGMENTS

Many people have helped with this study In particular we would like to thank

o John Mills who visited the hospitals drafted the physical characteristics chapter and gave freely of his time and expertise

o the staff of the hospitals visited for sharing their time and thoughts with us

o Desmond Keenan Shelagh McRae and Denis Snelgar for allowing us to use the information they had collected

o Clare Salmond Mike Moore and Sylvia Nichol for their assistance with computer analysis

o readers ofmiddot drafts of this report who offered helpful criticism and suggestion

o the typists and publication staff of the Department of Health

We also acknowledge the Director-General of Health for permission to publish

DISCLAIMER

The views expressed in this report are those of the authors and do not necessarily represent the views of the Department of Health

COPYRIGHT

Provided the source is acknowledged information contained in this report may be freely used by any person

CONTENTS

Page

ACKNOWIEDGEMENTS LIST OF TABLES LIST OF FIGURES

1 INTRODUCTION I

Background Thewider questions of emergency medical services The overseas situation An historical perspective in New Zealand

Interview studies on the utilisation of A amp E departments Record studies on the utili satjon of A amp E departments Studies of the organisation of A amp E departments

Overview of this study Aims Sources of information

References

2 DEFINITIONS 11

The Accident and Emergency department Attendance The hospitals Recording systems References

3 PROCEDURES IN THE ACCIDENT AND EMERGENCY DEPARTMENT 15

Entry Sorting 1 reatmen t Disposal Follow-upcare Admissions Discussion References

4 PHYSICAL CHARACTERISTICS OF ACCIDENT AND EMERGENCY DEPARTMENTS 23

PrinCiples Size Location

Entrances Access to other hospital facilities

Layout Waiting area Examination and treatment area Resuscitation area Operating theatre Plaster room Interview room Reception and records office Staff offices Holding ward

Discussion References

5

6

7

8

STAFFING OF ACCIDENT AND EMERGENCY DEPARTMENTS 35

Medical staffing Senior medical staffing Junior medical staffing Accident and emergency work as a career

Nurse staffing Other staff involved with the A amp E department

Reception and clerical staff Orderlies Social workers Ambulance personnel

Discussion References

PATIENT ATTENDANCE CHARACTERISTICS 55

Overall attendance and trends Age and sex Conditions

Injury conditions Sickness conditions

Recall attendance GP-load

Non-urgent sickness Discussion References

PATIENT ATTI~UDES TO THE ACCIDENT AND EMERGENCY DEPARTMENT AND STAFF ATTITUDES TO THE PATIENTS 75

Reasons for visiting the A amp E department Overseas studies New Zealand studies

Effect of health centres and deputising services on A amp E utilisation A amp E staff views of patients

Overseas studies The New Zealand situation

Discussion References

UTILISATION OF ACCIDENT AND EMERGENCY DEPARTMENTS 91

Comparison of A amp E utilisation among hospital catchment areas Results Effect of general practitioner availability

Factors explaining catchment area variations in A amp E utilisation Method Results of the mUltivariate analyses

Comparison of A amp E use and general practitioner use Discussion References

9 CONCLUSIONS 107

The A amp E department as a hospital department The A amp E department as an emergency service The A amp E department as a primary care service Where from here

APPENDICES

APPENDIX A QUestion sheets 116

APPENDIX B Accident and emergency department records 120

APPENDIX C Statistical analyses of accident and 123 emergency department attendance rates by neighbourhoods

APPENDIX D Childrens use of general practitioners 128 and accident and emergency departments in Wellington

TABLES

Table

1 Proportion of first attendance patients discharged recalled referred or admitted

2 Areas of A amp E department~

3 Area to attendance ratios for adjusted total areas and waiting areas of A amp E departments by first attendance and total attendance

4 Numbers of examination and treatment cubicles or rooms and recommended numbers based on first attendance and total attendance

Medical staffing of A amp E departments

6 Total medical staffing (full-time equivalents) and medical staffing to attendance ratios for first attendance and total attendance

7 Nurse staffing of A amp E departments excluding student nurses and hospital aids

Nurse staffing (full-time equivalents) and nurse staffing to attendance ratios for first attendance and total attendance

Average attendance at A amp E departments 1978-1981

10 Trends in attendance at A amp E departments 1978-1981

11 Proportion of A amp E attendance that was recall attendance

12 Proportion of A amp E attendance that was for sickness

13 Proportion of total A amp E attendance that was for Sickness by policy and age groups

14 Use of general practitioners by first attenders at A amp E departments

15 Reasons for A amp E first attendance from three New Zealand studiesmiddot

Itgt Attendance (mean age-adjusted rates per 1000 per quarter) within each A amp E department catchment area

Page

18

24

25

29

37

39

45

46

56

57

66middot

70

71

77

78

92

(continued)

Table Page

17 Hospital admissionsfor accidental injury (mean 93 age-adjusted rates per 1000 per year) and death due to accidental injury (mean age-adjusted rates per 1000 per year) within each A amp E department catchment area

IB Attendance (mean age-adjusted and neighbourhoodshy 99 adjusted rates per 1000 per quarter) and populationshyto-general practitioner ratio within each A amp E department catchment area

19 Comparison of first attendances for injury at A amp E 101 departments and general practitioners

FIGURES

Figure Page

1 Percentage of total attendance at 58 A amp E departments by age and sex

2 Percentage of total attendance at 59 A amp E departments for sickness and injury conditions by age and sex

3 Injury first attendances by type of injury 6U all ages

4 Injury first attendances by type of injury 61 by age groups

5 Sickness attendances by type of sickness 62 all ages

6 Sickness attendances by type of sickness 63 by age groups

7 Comparison of medical staff availability and 67 level of recall attendance

Comparison of nursing staff availability and 67 level of attendance

9 Location at which accidents happened by those 79 attending the A amp E department or the general practitioner for accidental injury

Use of general practitioners and A amp E departments 131 by Wellington children 1978 (rates per 1000 children per quarter)

1

CHAPTER 1

Introduction

BACKGROUND

This report arises f rom concerns expressed by several groups about the availability especially out of hours of emergency car~ and its provision by Accident and Emergency (A amp E) departments in New Zealand

In _SQe mid 1970 s the people of Porirua were worried that local general -pr-actitioners were not available at nights and weekends and by the delays

involved in travelling to Wellington and Hutt A amp E departments [IJ At the same time the people of North Shore were campaigning to keep their local A amp E department open More recently community groups in Upper Hutt have been pressing for the addition of an A amp E service to a local health centre Overall people are concerned that appropriate care (including facilities such as x-rays) is readily available in emergency situations

General practitioners are another group who have been concerned about A amp E departments in particular about inappropriate uses of A amp E departments A long-standing complaint bas been that patients are using A amp E departments for care which wou~d be better given by a general practitioner and that the A amp E departments retain patients instead of referr ing them back to their general practitioner for follow-up care [2 3J In 1981 the research group of the Wellington Faculty of the Royal NZ College of General Practitioners sponsored a study of children presenting at A amp E departments because they were worried that unnecessary admissions of children to hospital occurred because their parents had bypassed the general practitioners and gone straight to hospital [4J

Also A amp E staff and hospital administrators have been concerned that caring for patients who could have been treated by general practitioners has limited their ability to deal with emergency cases [567]

THE WIDER QUESTIONS OF EMERGENCY MEDICAL SERVICES

Emergency care requires not only the provision of hospital services (the A amp E department with back-up from other hospital facilities) but also the organisation of services outside the hospital and co-ordination between both sets of services Emergency medical services outside the hospital include alarm and communication systems transport systems and first aid services There are important questions for New Zealand within this framework For example what should be the role of general practitioners in on-site emergency care What level of training is appropriate for ambulance officers Should voluntary personnel staff ambulances To what extent is double manning of ambulances required [8910]

In order to limit the study to manageable proportions this report focusses only on the hospital services namely the A amp E department Emergency medical services provided outside hospitals are mentioned only where they impinge noticeably on the A ampE department It is hoped that due attention will be given to the wider questions of emergency medical services in the future (see Chapter 9)

2

THE OVERSEAS SITUATION

Concern with emergencymiddot care facilities especially their increasing use has been apparent in other countries for the past thirty years While some articles report on the situation in Canada Australia Sweden France and the USSR most of the literature is about the United States and Britain This section briefly outlines the major themes of the literature and their relevance to New Zealand More specific aspects are covered in the appropriate chapters

Many United States researchers have studied the operations of different emergency rooms exploring patients reasons for using the emergency room their demographic characteristics and their use of the family doctor Often the studies have tried to explain an increasing use of emergency rooms and some have reported on the effectiVeness of measures introduced to reduce thei r use These studies provided models for some of the analyses carried out in this study However the debate in the United States over appropriate methods of funding and staffing for emergency rooms is seldom relevant to New Zealand because of the differences both in philosophy and organisation of medical care in the two countries

The Platt [11] committee on A amp E services in Britain in 1962 was concerned about casual attenders ie patients not in need of urgent attention but wishing to avoid the trouble of attending their general practitioners surgery They also criticised the unsuitable accommodation and the insufficient numbers of senior medical staff supervising Casualty Departments The report recommended changing the name Casualty Service to Accident and Emergency Service (to discourage casual attendance) and rationalising the service by clOSing smaller A amp E units and centralising facilities These recommendations have been partially carried out

However there has been continuing research in Br i tain into the reasons given by patients particularly self-referred patients for their use of A amp E departments and the trade-off between general practitioner and A amp E services There has also been continuing debate over the medical staffing of A amp E departments

The British studies are of some relevance to the New Zealand situation since the organisation of medical care here is similar but no overseas experience can provide a blueprint for New Zealand For example the direct cost to the patient of general practice care in New Zealand raises the possibility of patients attending the A amp E department because it is free whereas the British system of general practitioner funding provides no such incentive

AN HISTORICAL PERSPECTIVE IN NEW ZEALAND

Little is known about the historical development of A amp E services in New Zealand Presumably they followed the British tradition described in the Platt report [11 p23-24)

The word casualty in its proper meaning of a serious injury has a long history It occurs in Shakespeare and Dickens writing in 1837 used casualty ward to describe the ward in a hospital in which accidents were treated Unfortunately the meaning alt~red in the second half of the last century The Nuffield Report (1960) Casualty Services and their Setting

3

gives an interesting quotation from a survey made by the Lancet in 1869 The out-patients at St Bartholomews Hospital are it says divided into two categories They are the middotcasualtymiddot which comprises those who are supposed to require temporary treatment for diseases or injuries of a trifling character and the middotout-patientsmiddot properly so called who after receiving a regular letter of admission are entitled to the advice of the assistant surgeons and physicians for a period of 12 months It is in the casualty division that the increase of numbers has been most marked bullbullbull It is estimated that not less than a thousand patients frequently attend on a Monday or Tuesday morning

Certainly by 1872 vlellingtons private medical practitioners were incensed at the hospitals provision of free treatment for their patients Five hundred outpatients were treated in Wellington that year [12] Separate casualty departments were operating at Wellington Hospital by 1924 [12] at Auckland Hospital by the 1940s [13] and Christchurch Hospital by 1952 [14]

The 1960 Board of Health report [15] on outpatient servicesmiddot expressed concern over the duplication of services by outpatient departments which were also available from general practitioners However it recommended that general hospitals continue to provide a casualty service available at all times

Since the late 1960s a series of New Zealand studies have considered the use of A amp E departments either by interviewing patients or by analysing data drawn from A amp E record systems and the organisation of A amp E departments

Interview studies on the utilisation of A amp E departments

The first interview study was an investigation of first attenders at the Dunedin A amp E department in 1968 by Dixon et al [2] Their results have not been contradicted by any of the later studies

They found that the principal attenders were males aged 15 to 24 who recorded first attendance rates of over 100 per 1000 each year The young men were also the most likely to report having no general practitioner Dixon found that the age and sex pattern of those attending at the A amp E department was nearly converse to the pattern of those attending a general practitioner

Dixon pointed out that the conditions treated at the A amp E department were rarely disease-related rather they were predominantly lacerations and open wounds bruising sprains and strains effects of foreign bodies and fractures The major reason given for attending the department was that it was seen as appropriate

Dixon concluded that the A amp E service was complementary and not competitive to general practice that the public were realistic in regarding it as the only practical and effective primary medical care for accident and emergency injuries and that payment for service did not appear to figure in the decision to attend the department

o

4

TwO interview studies of first attenders at Auckland Hospital A amp E department have been carried out by Hunton in 1972 and Richards in 1975 [16] Both studies included an assessment by the student interviewers and A amp E staff as to the suitability of the patients condition for general practice care 42-43 per cent were considered suitable Richards concluded that public education programmes encouraging people to use their general practitioner prior to attending the A amp E department should be instituted

In 1978 Keenan interviewed patients who had attended Christchurch A amp E department collecting detailed information on the accident or sickness leading to the attendance (unpublished see Chapter 6 and 7) He found the same set of reasons for using A amp E departments as Dixon found the A amp E department was seen as appropriate and accessible

Kljakovic found similar results when interviewing the parents of children attending A amp E departments in the Wellington region in 1978 [4] He also found that in choosing between the general practitioner and the A amp E department parents were more likely to use the service which was closer to the family home Children f rom lower socio-economic status families were more likely than other children to see thei r general practitioner before gOing to the A amp E department

Records studies on the utilisation of A amp E departments

Several studies have gathered data from A amp E records to investigate A amp E utilisation In 1979 Snelgar described the characteristics of people attending Northland Base Hospital A amp E department [17] He found similar results to Dixon apart from a higher proportion of injuries In the same year McRae reviewed all attendances at Waikato Hospital A amp E department and found a similar picture [lB]

Three records studies have looked at the relationship between A amp E use and general practitioner use Maynard looked at Mosgiel residents use of Dunedin A amp E facilities for three years before and three years after the opening of a local health centre [19] No difference was found ~asap

investigated assertions that people from one part of the Wellington Hospital catchment area had suddenly begun to use the A amp E department heavily for conditions that should have been seen by a general practitioner [20] In fact that part of the catchment area had much lower rates of A amp E use than other areas Reinken tested whether the doubling of general practitioner cover in one part of the Wellington region affected A amp E presentation rates differently than in other areas nearby [21] There was no clear evidence that the increased cover had any effect

Studies on the organisation of A amp E departments

As part of a thesis looking at young doctors Salmond examined the work of house surgeons in A amp E departments using a postal questionnaire [22J He concluded that working in an A amp E department was good experience for a house surgeon only if second year house surgeons were deployed in the department the house surgeon was well-supervised by senior medical staff there was a good working relationship with the A amp E chargemiddot nurse and the house surgeon was not over-tired He also suggested that good senior staffing was closely related to effective administration and better service in the A amp E department

5

The Hospital Design and EValuation Unit of the Department of Health prepared a report documenting the planning requirements of New Zealand A amp E departments [23] The report outlined several principles of A amp E design and made detailed recommendations on the facilities rooms and equipment necessary

OVERVIEW OF THIS STUDY

Aims

The aim of this study is to describe A amp E departments in New Zealand Because the material presented in the previous section was collected by different researchers at different times and from different A amp E

departments detailed comparisons across the studies have been difficult To get a more comprehensive picture of A amp E use in New Zealand a systematic investigation was necessary

The specific aims of this report are

o to describe the organisation of A amp E departments by looking at their procedures physical characteristics and staffing patterns

o to describe attendance at A amp E departments including the patients profile and pattern of attendance and the load placed on the departments by patients who would be more appropriately treated by a general practitioner

o to describe the use of A amp E departments by consumers by analysing patients reasons for attending the departments and analysing demographic factors inrelation to A amp E attendance

Sources of information

Information was gathered from three sources

The site visits

Fourteen A amp E departments were visited between May and September 1981 by a Department of Health study team consisting of a medical officer from the Division of Hospitals and a res~arch officer from the Management Services and Research Unit

At each hospital the team examined the facilities and spoke with staff involved with the A amp E department including

o the medical superintendent (and in some hospitals the principal nurse)

o the A amp E officer or medical officer in charge of the A amp E department (where such a position existed and was filled)

o the nurse supervisor andor charge nurse of the A amp E department

o at least one house surgeon working in the A amp E department

6

In some hospitals the team also spoke with other staff members including experienced A amp E staff nurses and hospital social workers

Question sheets were used during interviews so that a comparable body of information was collected at each hospital Interviews were open-ended to allow discussion of local procedures or problems (See Appendix A for question sheets)

Hospitals were carefully selected so that the A amp E departments in the study would represent a cross-section of New Zealand A amp E departments Those selected served a range of communities in both the North and South Islands

o major urban Dunedin)

areas (Auckland Wellington Christchurch and

o provincial centres (Rotorua Taranaki and Timaru)

o predominantly rural areas (Whakatane and Grey)

In centres with more than one A amp E department all were visited so that a complete picture of the services and use could be developed This involved visiting Auckland Green Lane Middlemore and North Shore hospitals in Auckland and Wellington Hutt and Kenepuru hospitals in Wellington

The information gathered in the site visits has been used in describing the organisation of A amp E departments (Chapters 3 4 arid 5)

The A amp E records data collection

On each site visit a sample of 1981 attendances was drawn from the A amp E record system and the following information was recorded for each person age sex presenting condition (sickness or injury) time of presentation residential address and whether the visit was a first attendance for the condition or a recall visit

Exceptions were Christchurch and the three Wellington Hospital Board A amp E departments Comparable data collected by Keenan in Ch ristchurch in 1978 and Allan in Wellington during 1980 were used instead

This information has been used to describe the attendance at A amp E departments (Chapter 6) and for the analysis of demographic factors in relation to attendance (Chapter 8)

The consumer studies

In 1978 Keenan carried out interviews with patients attending Christchurch A amp E department working from a one in eight sample drawn from the A amp E log over a four-week period and gaining a 99 response rate Results from this study have been analysed and compared with the results of the published New Zealand interview studies [2416] Anecdotal material from Kljakovic s study of children attending Wellington A amp E departments has also been included to illustrate the results of the numerical analysis

We realise that in studying only a selection of A amp E departments some local variations may have been missed but we are confident that the broad pattern and major issues in the organisation of A amp E care have been

7

covered Also as the A amp E departments studied serve two-thirds of the population of New Zealand the utilisation patterns discussed in the report are likely to prevail throughout New Zealand We hope that the mater ial presented the conclusions drawn and the questions raised in this report will encourage discussion about the current operation and future developmiant of A amp E departments in NewmiddotZealand

a

8

REFERENCES

1 de LACEY A REINKEN J and SALMOND C E - Community attitudes to sickness and health stimulus and response v 3 Community attitudes - Wellington Management Services and Research Unit Dept of Health 1980 p 103-105 (Special report series no 56)

2 DIXON C W Emery G M and SPEARS G F S - Casualty department utilisation survey in NZ Med J - v 71 (1970) p 272-279

3 [Editorial] in G P Journal of the General Practitioner Society no 42 (1981) P 1-2

4 KLJAKOVIC M ALLAN BC and REINKEN J - Why skip the general practitioner and go to the accident and emergency department in NZ Med J - v 93 (1981) P 49-52

5 SKUDDER Paul A McCARROLL James R and WADE Preston A - Hospital emergency facilities and services a survey in Emergency medical services behavioural and planning perspectives edited by John H Noble Jr et ale - New York Behavioural Publications 1973 p 17-35

6 MAYNARD Edward J - The application of epidemiological methods to the evaluation of primary medical care in a health centre environment shyUniversity of Otago 1980 Ph D Thesis Social and Preventive Medicine

7 Hospital misuse brings protest in Taranaki Daily News (1 Sept 1980) bull

8 FAHEY Morgan - The role of the family doctor in disaster and emergency medicine in NZ Family Physician - v 5 no 1 (1978) p 42-44

9 Proceedings of the emergency care seminar Auckland 19-23 March 1979 in NZ Med J - (1980) P 194-196

10 Double manning of ambulances [editorial] in NZ Hosp - v 32 no 3 (1980) p 1

11 Gt Brit Central Health Services Council - Standing Medicine Advisory Committee Accident and emergency services report of the subcommittee - London HMSO 1962 Chaired by Sir Harry Platt

12 BARBER Laurie H and TOWERS Roy J - Wellington Hospital 1847-1976 Wellington Wellington Hospital Board 1976

13 The story of Auckland Hospital 1847-1977 edited by David Scott -Auckland Medical Historical Library Committee of the Royal Australasian College of Physicians in New Zealand 1977 p 35-36

14 BENNETT FO - Hospital on the Avon the story of the Christchurch Hospital 1862-1962 Christchurch North Canterbury Hospital

o Board 1962

9

15 Outpatient services in public hospitals in New Zealand - Wellington Government Printer 196U (Report series Board of Health no 2)

16 RICHARDS J G and WHITE G R - Accident and emergency services at Auckland Hospital in NZ Med J - v 85 (1977) P 272-274

17 SNELGAR Denis - Accident and emergency utilisation study Paper prepared for the Primary Health Care Shadow Service Development Group Northland 1981 (Unpublished)

18 McRAE Shelagh and TOPPING Mark - Casualty attendances one years experience at Waikato Hospital in NZ Med J - v 95 (1982) P 12-14

19 MAYNARD Edward J and DODGE Jeffrey S - Introducing a community health centre at Mosgiel New Zealand effects on use of the hospital accident and emergency department in Med Care - v 21 no 4 (1983) p 379-388

20 KASAP D - Personal communication 1975

21 REINKEN J - Effect of changes in general practitioner cover on accident and emergency utilisation in the Porirua Basin Wellington Management Services and Research Unit Dept of Health 1979 (Unpublished)

22 SALMOND G C - Young doctors an exercise in social research methodology - University of Otago 1970 Ph D Thesis Social and Preventive Medicine p 179-214

23 Accident and emergency departments a study of planning requirements prepared by the Hospital Design and Evaluation Unit - Wellington Department of Health 1973

11

CHAPTER 2

Definitions

lhis chapter provides the definitions of terms used in our study In general our terminology is consistent with the literature However in some areas such as the classification of presenting conditions as sickness or injury or the description of GP-load there is no general consistency and we have developed our own definitions

THE ACCIDENT AND EMERGENCY DEPARTMENT

This name is the one commonly used in New Zealand We have used it in preference to the older description Casualty Depariment [1] and the American description of Emergency Department It is one hospital department which patients can approach without prior notification

Emergencies can be any condition that - in the opinion of the patient their family or whoever assumes the responsibility of bringing the patient to the hospital - requires immediate medical attention

However using such a definition means every case is an emergency In New Zealand A amp E departments patients tend to be classified in a similar way to the description given by the American Hospital Association [2]

o emergencies where delay is harmful and the condition potentially threatens life or function

a urgent cases which require attention within a few hours

o non-urgent cases where the condition is minor or non-acute and does not require the resources of the emergency service

An accident is an unexpected event Accidents which have resulted in attendance at an A amp E department are ones that have caused some trauma whether through shock or other injury The Platt report [1] decided on the term A amp E department in recognition that the real emergencies were a trickle while the accidents were a mighty flood

In general the A amp E department is regarded as part of the hospitals outpatient services and like these in day to day running it provides specific clinics generally for the treatment of traumatic injury x-ray burns dressings plasters and so forth

An accident and emergency patient is a person who is entered in the A amp E log book This can involve a certain amount of error however as some outpatients or discharged patients may return for follow-up care through the A amp E department Also the A amp E department often handles the acute admissions to the hospital

12

ATrENDANCE

A first visit (or first attendance) is the first visit a patient makes for one particular condition

A recall visit is any visit made for one particular condition which is not the first visit for the condition Some recall visits are patient initiated (eg due to pain bleeding infection or an accident to the dressing or plaster) but for the most part revisits are scheduled return visits suggested by A amp E staff

Total attendance is the sum of first visits and recall visits

Inj ury attendances are defined to include the results of trauma (cuts burns fractures sprains strains bruises head injuries multiple injur ies and so forth) as well as foreign bodies in the eye or other orifices and toxic effects whether from accidental or self-poisoning events Late effects of minor injury (pain bleeding abscesses or such) are not included as injury but as sickness

Sickness attendances include collapse (whether stroke coma heart attack or other) shortness of breath abdominal pain general sickness (fever vomiting diarrhoea unwell) mental distress and minor conditions

Non-urgent sicknesses are defined as the minor conditions abdominal pain and general sickness except for preschool children and adults over 65 where the general sickness and abdominal pain conditions can be urgent A amp E staff defined non-urgent sickness less specifically they tended to define it as longstanding or minor sickness

GP-load describes the patients whom A amp E staff feel should have seen a general practitioner It includes patients with longstanding or minor sickness conditions and patients with minor traumatic injury (eg cuts bumps and bruises)

In hours attendance refers to all attendances in the normal working hours of 0800 to 1800 Monday to Friday excluding holidays

Out of hours attendance refers to all other attendances outside the defined normal working hours

In an average week 50 hours fall in the in hours category and 118 hours in the out of hours category If we assume that an average person sleeps eight hours a night then that person is awake for 62 hours in the out of hours category (and all the in hours of course) Thus the out of hours category is 70 per cent of the total time in a week and 55 per cent of the waking time in a week

Minor conditions included abscesses backaches infected wounds or wound pain headache pain (unspecified) earaches eye problems toothaches nosebleeds limb pains We have called it the skin pain or bleeding category in Chapter 6

13

Attendance rates measure the use of A amp E departments for a defined population They express the number of cases from an area over a defined period per 1000 population in that area Rates were obtained by age and sex for sickness and injury and in and out of hours for each census area unit or neighbourhood served by each hospital

THE- HOSPITALS

We grouped hospitals into four types

o urban hospitals (where average annual first attendances at A amp E departments are over 25000 patients)

o provincial hospitals (serving 6000 to 12000 new A amp E patients each year)

o rural hospitals (serving fewer than 6000 new A amp E patients each year)

o suburban hospitals where A amp E departments are not open 24 hours per day North Shore Hospital was open 7 days a week 830 am shy530 pm and Kenepuru Hospital was open 5 days a week 830 am shy430 pm

Most of the A amp E departments visited had a senior position variously called the A amp E officer the A amp E director the senior medical officer or the medical officer in charge For convenience we call this position the A amp E officer

RECORDING SYSTEMS

The log is the record kept at the A amp E department which records some information on every patient who presents It will often give no more than the patients name the date and time of visit

The A amp E record is usually a card and it records basic patient information and case notes It may be held for several years in the A amp E department and may therefore contain information on a series of separate events for anyone patient

14

REFERENCES

1 GtBrit Central Health Services Council - Standing Medical Advisory Committee Accident and emergency services report of the sUbcommittee - London HMSO 1962 Chaired by Sir Harry Platt

2 Emergency services the hospital emergency department in an emergency care system Chicago American Hospital Association 1972 p vii-viii

15

D

CHAPTER 3

Procedures in the accident and emergency department

In this chapter we begin describing the organisation of A amp E departments by looking at the way they operate We follow the course of a patients care entry to the A amp E department sorting into priority order for care (triage) treatment and follow-up care

ENTRY

Most people presenting at the A amp E department were ambulant (the walking wounded as they are colloquially known) They came through the A amp E departments main entrance to the reception desk where they were first seen by a receptionist or nurse (Exceptions to this occurred in the smaller hospitals where patients presenting at night were first seen by the telephonist who called the nursing staff) Nurses did reception duties at

all the provincial and rural A amp E departments and at two of the urban A amp E departments when receptionists were not on duty (eg lunchtimes nights) bull At times nurses found that having to cover the reception desk interfered with their care of patients

When the receptionists are off duty the nurses do the reception work This can be a nuisance because it interferes with patient care and sometimes patients ring the bell at the reception desk and the staff working in the resuscitation room dont hear it

A amp E nurse

Unless their condition required immediate care the ambulant patients then spent several minutes at the reception desk while their details (eg name address general practitioner complaint) were noted on the A ampE records (See Appendix B for more information on A amp E records) Then they waited in the waiting room until they were called for treatment

A small proportion of patients arrived by ambulance andmiddot at almost all hospitals entered the A amp E department through a separate ambulance entrance In the larger hospitals some nursing staff were stationed in or near the ambulance entrance to care for these patients In other hospitals the staff had often been warned of incoming urgent cases and were standing by when the ambulance arrived As the condition of ambulance patients tended to be urgent they were usually taken straight to a resuscitation or treatment area patients condition permitted or friends or the ambulance driver

Record with the

keeping assist

was ance

carried of thei r

out r

when elativ

the es

SORTING

All A amp E departments operated some triage system to sort the ambulant patients by the urgency of their need for care (Themiddot only exception was Grey A amp E department where there was seldom more than one patient in the department at a time) At most A amp E departments the patients were sorted

16

into urgent and non-urgent categories with urgent cases being seen immediately and non-urgent cases being seen in the order they presented At some of the urban A amp E departments a more complex sorting was done For example

Priority is given in the following order

urgent need very young and very old patients those with general practitioner notes those without general practitioner notes

A lie E nurse

Usually ambulance cases were not triaged since they tended to arrive on their own and required urgent care However several A lie E departments had triage arrangements planned for the arrival of many ambulance cases at once as in a disaster

Sorting was largely a responsibility of the nurses although some A amp E doctors would occasionally check the condition of patients- in the waiting room too The receptionists often played a role in triage as well alerting the nursing staff to urgent cases This happened more in A amp E departments where the physical layout made it difficult for nurses to watch the entrance and the waiting room

The receptionists do tQe basic sorting They have guidelines to follow distressed patients severe cuts or bleeding go straight to the nurses open wounds or eye injuries go directly to a cubicle and are assessed by the nurses patients with abdominal pain or chest pain go on to trolleys and wait in the recovery room This system usually works well although occasionally a fracture patient will not be recognised and will sit in the waiting room

A lie E nurse

In several A lie E departments doctors and nurses stressed the value of an experienced receptionist in recognising and reacting quickly to acutely ill or injured patients

TREATMENT

Almost all the A amp Edepartments visited had a policy that all patients presenting had to be seen by a doctor The doctor did not necessarily have to treat the patient he or she could advise the patient to see a general practitioner Some A amp E doctors commented that by the time they saw the patients it was as easy to treat them as to send them away_ At a few departments the nurses (and occasionally the receptionist) could advise the patient that the department was not an appropriate place for their condition and that they should see a general practitioner This was usually done in consultation with the A E doctor but at times the nurses acted on their own initiative In these places a triage system similar to that reported by Weinerman et al [1] where patients were assigned to the appropriate service inside or outsidemiddot the hospital appeared to be operating

7

The assessment of patients the ordering of tests andmiddot the supervision of treatment were usually seen ~s medical functions The nurses would prepare patients for treatment (removing dressings) and carry out urgent first aid measures (stem bleeding start gastric lavage or cardio-pulmonary resuscitation) Generally however a nurse would only initiate treatment if the patients condition was urgent and a doctor was not available or was already busy with another emergency Exceptions to this situation occurred in some hospitals with A amp E nurse training programmes and in some smaller hospitals where the doctor is on call rather than working in the A amp E department In these departments experienced nurses could order tests such as x-rays and initiate treatments such as suturing and removing foreign bodies from eyes

In most A amp E departments nurses would perform some treatments under a doctors supervision However the range of treatments nurses were allowed to perform varied considerably among hospitals At some hospitals nurses sutured after training but at others they never sutured

The nurses do not suture although they would like to There are four reasons for this there is no full-time A amp E officer so good standards of sutur ing could not be maintained there could be medico-legal problems if a nurse sutured a cut which was more complicated than it looked eg with tendon involvement the nurses have enough to do at present and if they start suturing they will be expected to do it always and the young doctors need to learn suturing as part of their training

Principal nurse

Electrocardiograms were taken by nurses in some A amp E departments by technicians at others Taking blood samples was a doctors job in some departments but was done by nurses in others Similarly gastric lavage using a def ibrillator and plaster work were done by nurses in some departments Most A amp E nurses would maintain intra-venous drips but only nurses with special training WOUld insert them

Some nurses expressed frustration at restrictions on the treatments they were allowed to perform However several sen~or nurses stressed that they had to select carefully the nurses they allowed to perform more difficult treatments

We are very selective about choosing the nurses to do triage suturing and the more complicated procedures This seems to have been successful weve had no problems with nurses undertaking treatment theyre not competent to provide

A amp E senior nurse

I make sure the nurses understand they can be dangerous people If theyre not aware of their limitations theyre not suitable for A amp E work

A amp E senior nurse o

Also one department which had comparatively few nurses discouraged them from increasing the range of treatments they performed so that their workload did not become overwhelming

18

For diagnosis the A amp E departments made heavy use of the x-ray departments (The Design and Evaluation Unit study [21 estimated that 30 per cent of A amp E attenders had an x-ray during their visit) Some A amp E departments found their arrangements with the x-ray department very convenient with an x-ray machine aVailable 24 hours a day in or close to the A amp E department and with patients and x-ray films or reports returning within an hour At other hospitals arrangements Were less convenient in some places reporting bac k of x-rays took two or three hours delaying patients considerably while in others the x-ray departmentmiddot was located on a different floor from the A amp E ~epartment causing difficulties in transporting and accompanying patients there

Little use was made of the laboratory services other than for blood and urine tests and arrangements were generally satisfactory However in many hospitals x-ray and laboratory staff had to be called in to perform tests out of hours and because of the expense involved these out of hours tests were discouraged Some house surgeons found this a difficult situation

I I m caught between contradictory pressures the orthopaedic surgeons say that x-rays are necessary for proper diagnosis and the hospital board is trying to limit out of hours x-rays to save money

House surgeon

DISPOSAL

After treating the patient the A amp E doctor decides on the appropriate disposal discharging from care arranging follow-up treatment by referring to another source of care or recalling to the A amp E department or admitting the patient Information on disposal was only readily available from three A amp E departments The most common disposal pattern was in fact discharging from care with 40 to 55 per cent of patients making a first Visit being discharged

TABLE I PROPORTION OF FIRST ATTENDANCE PATIENrs DISCHARGED RECALLED REFERRED OR ADMITTED

Discharged Recalled Referred to Admitted Other First to A amp E GP Specialist attendance

Clinic tallied

Waikato l 393 132 222 99 134 19 25 707 Green Lane2 550 220 110 40 80 Unknown Taranaki 41 5 268 73 103 116 24 164

1 From McRaes study of Waikato A amp E departmen~ in 1979 2 From a study carried out by Green Lane A amp E department

19

FOLLOW-UP CARE

The decision to be made on follow-up care was usually between re~alling to the A amp E department or referring back to the patient I s general practitioner Some A amp E departments also referred patients (especially children) to district nurses or patients with work 1n]uries to an occupational health nurse or clinic Many departments referred fracture patients to orthopaedic clinics held in the hospital outpatients department and one A amp E department which was very short of space referred patients needing redressings to the outpatients department

There were large differences in referral practices (see Table 1) Between 13 and 27 per cent of first attenders were recalled to the A amp E department for follow-up care while 15 to 30 per cent were referred elsewhere either to a general practitioner or to a specialist clinic Also recall attendances expressed as a proportion of total attendances varied considerably among the A amp E departments from 10 per cent to 50 per cent (see Chapter 6 Table 11) and clearly reflected different follow-up practices

All of the urban and two of the provincial A amp E departments had a policy of referring most patients requiring follow-up care to a general practitioner and of keeping recall visits as low as possible This was similar to general policy in both Britain and the United States which appears to discourage re-at tendance at A amp E departments [34] However in the suburban rural and other provincial A amp E departments the decision on follow-up care was left to the judgement of the A amp E doctor

In practice however the choice to refer or to recall was reiated to several factors First the decision related to characteristics of the patients If the patients had serious wounds or burns or injuries which could develop complications they were usually recalled They were also recalled if the A amp E staff thought they would not receive appropriate care at home or they would not see a general practitioner for follow-up care Patients living a long way from the hospital were usually referred to their general practitioner At some A amp E departments patients were given the choice of referral or recall according to A amp E staff comments most chose to return to theA amp E department

The patients prefer to come back to the hospital Money is not a factor in this because the ACC pays for accident treatment at the general practitioner

A amp E nurse

Second there were general practitioner factors If the local general practitioners were unhappy about the A amp E department recalling patients or if a general practitioner had referred the patient to the department originally the A amp E doctors would refemiddotr rather than recall However if the A amp E doctors thought that the general practitioner did not have the facilities and in some cases the ability to provide follow-up care (eg for serious woundS eye injuries) they would recall the patient

Some GPs dont like following up care initiated by the A amp E department or dont have the necessary facilities so I tend not to send patients back to them

A amp E officer

20

Im more likely to refer a patient back to a GP who is reliable

House surgeon

Third many of the house surgeons said they would recall patients if they were interested in the condition or if they were worried about their diagnosis and treatment and wanted to see the outcome Several medical superintendents noted that recalling under these circumstances was acceptable because it comprised part of the house surgeons training

Fourth the workload of the A amp E department sometimes affected the follow-up decision with very busy departments actively discouraging recalls And finally there was the philosophy of A amp E medicine held by the A amp E doctor In one department where the A amp E officer considered it an ethical duty to see any treatment initiated through to a successful conclusion almost all patients who needed follow-up care were recalled At two other departments the A amp E officers stressed the importance of being able to deal efficiently with any emergencies presenting they kept recalls low so that the department was not clogged with extra patients Other A amp E doctors thought that the general practitioner could provide better continuity of care than the A amp E department so they referred as many patients as possible

When referring patients to the general practitionermiddot most of the A amp E doctors made a verbal recommendation to the patient and then relied on the patient to attend the general practitioner They would only write a formal referral letter if the patients condition was serious In several A amp E departments however greater efforts were made to inform the patient t s general practitioner Three departments gave referred patients cyclostyled forms with details of diagnosis and treatment to be passed to their general practitioner while the Whakatane department sent a copy of the A amp E record form to each patients general practitioner

ADMISSIONS

Table I suggests that between a and 14 per cent of all first attendances were admitted to the hospitals Admissions could well be higher for children Kljakovic [5] found that 20 per cent of the children presenting at the Wellington Hospital Board A amp E departments were admitted

The A amp E departments were involved in several different pathways for the admission of acutely ill or injured patients (Scheduled admissions did not involve the A amp E department at any of the hospitals visited) Self-referred patients could be admitted directly from the A amp E department to the wards or could be cared for in a holding (or acute admitting) ward before going to the wards

There was considerable variation among the hospitals as to which members of the medical staff were able to admit patients At some of the urban hospitals only the registrars could admit while at others the A amp E doctor could admit if the registrar was delayed and unable to assess the patient quickly At some of the provincial and one of the urban hospitals the A amp E doctor could admit in consultation with the admitting officer or appropriate registrar while at-another urban hospital and the rural A amp E departments the A amp E doctors regularly admitted patients

21

Hospitals with lower levels of bed occupancy were more likely to allow A amp E doctors to admit Senior A amp E doctors were more likely to play a role in admissions (actually admitting patients or advising the registrar) than house surgeons

Some patients referred by a general practitioner for acute admission also passed through the A amp E department At one hospital the general practitioners rang the A amp E officer to arrange for all acute admissions and all such GP-referred patients were seen first in the A amp E department However more usually the general practitioners rang the appropriate registrar to make arrangements and the registrar decided whether to admit the patient directly to the wards or through the A amp E department The involvement of A amp E staff with patients requiring admission ranged from almost none (where the patient went directly from the A amp E department to the ward or specialist unit) to a full initial assessment including tests (often undertaken at the request of the registrar responsible for the patient) bull

Generally the A amp E doctors were satisfied with the admission procedures However at one hospital where the A amp E doctors could not admit patients waiting for admission tended to clog the department The doctorselt that if they had admission rights the situation would be remedied

DISCUSSION

There were few differences among the A amp E departments in the reception and sorting of patients However there were differences in some aspects of treatment follow-up care and admission procedures

lhe role of the A amp E nurses in treatment varied considerably with some departments allowing nurses to initiate and perform many treatments and other departments allowing little autonomy Careful training and selection were essential before nurses increased their responsibility for treatment bull

Policies on follow-up care differed among the departments with the urban and provincial departments generally referring patients to general practitioners and the rural and suburban departments leaving the referral decision to the A amp E doctor In practice however the differences were less clear-cut with several factors other than the patient I s condition affecting the follow-up care decisions These factors included the A amp E staffs communicat ion with local general practitioners the inexperience and training needs of house surgeons the workload of the department and the senior A amp E doctors philosophy with regard to A amp E medicine

The A amp E departments also differed considerably in thei r procedures for acute admissions At some hospitals the A amp E doctor could admit an A amp E patient while at others the patient had to be held in the department until admitted by a registrar Also at some hospitals patients referred by general practitioners for acute admission were seen in the A amp E department before going to a ward While having to hold patients sometimes caused

clogging in the department A amp E staff were generally satisfied with the procedures

22

REfERENCES

1 WEINERMAN E Richard RUfZEN S Robert and PEARSON David shyEffects of medical -triage- in hospital emergency service in Public health reports - v 80 no 5 (May 1965) p 389-399

2 Accident and emergency departments a study of planning requirements prepared by the Hospital Design and Evaluation Unit - Wellington Department of Health 1973

3 Accident and emergency services - Gt Brit National Health Service memorandum HM (68)83

4 Emergency department organisation and management edited by AL Jenkins - St Louis Hosby 1975

5 KLJAKOVIC M ALLAN B C and REINKEN J - Why skip the general practitioner and go to the accident and emergency department in NZ Med J - v 93 (1981) P 49-52

23

CHAPTER 4

Phy~i~~1 c~~raft~rhtics of accident and emergency departments

This chapter describes the physical characteristics of A amp E departments their overall size location and layout as well as specific areas within the departments It discusses the effects of the physical characteristlcs on the organisation and functioning of the A amp E departments Our investigation worked from the detailed base established in bullAccident and emergency departments a studY of planning r~quirements a report prepared by the Hospital Design and Evaluation gnit Departmellt of HeCilth [1]

PRINCIPLES

The 1973 Hospital Design and Evaluation Unit (DEU) report [l] outlined the following principles to be applied in designing A amp E departments

o the A amp E department must be patients seeking emergency care

ready to receive and deal with

o the A amp E department mus~ be able load within a reasonable period

to cope with an average i

busy

o the A amp E department must be capable of adaptation to exceptional situations arising from major accidents ltgtrqther disasters

o the layout should be simple easily unqerstood and compact

o the layout and procedures should facilitate easy flow of patients through the department

o spaces should be multipurpose to give greatest versatility

o p~tient ~ovew~n~ should be minimised )

priv~cy for patientsshould be provided as far as is practicable andconsistent with the need for supervisi0rt

SIZE

There was considerable variation in the total sizes of the A amp E -a~1-ftment~ vi~ited witll floor areas ranging from 250 sql1a~e metres to 2115 ~guare m~ties (see Table 2) Eight of the 14 departments visited had i

hhid1pgw~fd~oracUte admitting ward However even wt)en ~he area of th~ f~ ~ bull ~middotc1~A~- _ ~ - bull bull ~

AampE department WCiS adjusted for the presence of a holding ward this I~1-getv~-rH~tion in irea reniained

24

TABLE 2 AREAS OF A amp E DEPARTMENTS

Total area Holding ward Adjusted total Waiting room area areal area

sqm sqm sqm sqm

Full-time departments

Urban Auckland 2 115 225 1 890 55 Middlemore 1 045 140 905 50 Green Lane 960 240 720 70 Wellington 575 190 385 75 Hutt 270 270 30 Christchurch 470 470 40 Dunedin 635 90 545 20

Provincial Rotorua 515 20 495 90 Taranaki Base 720 90 630 40 Timaru 605 70 535 80

Rural Whakatane 430 430 20 Grey 310 310 15

Part-time departments

Suburban North Shore 255 255 30 Kenepuru 540 540 30

1 Adjusted total area = total area minus holding ward area Considerable sharing with outpatients department

The area of the A amp E department was not closely related to the attendance (see Table 3) Obviously there is a certain minimum size for an A amp E department since certain facilities are essential regardless of the attendance served Thus as would be expected the rural and to a lesser extent the provincial A amp E departments had high area to attendance ratios However even within the group of urban A amp E departments there was a fourfold difference in the total area to attendance ratio

The design at Auckland~ laid out along several corridors with many separate consulting and treatment rooms possibly contributed to its high ratio At Wellington Hutt and Christchurch hospitals staff commented on their difficulties working in cramped conditions The lack of space often forced staff to work under extreme pressure to move patients through the departments very quickly

25

TABLE 3 AREA TO ATTENDANCE RATIOS FOR ADJUSTED TOTAL AREAS 1 AND WAITING AREAS OF A amp E DEPARTMENTS BY FIRST ATTENDANCE2 AND TOTAL ATTENDANCE 2

Adjusted total area to attendance ratio Waiting area to to attendance ratio

Sqm per 1000 Sqm per 1000 Sqm per 1000 first attendance total attendance total attendance pa p a p a

Full-time departments ~

Urban Auckland 323 291 08 Middlemore 232 157 09 Green Lane 3 230 168 16 Wellington 80 69 13 Hutt 82 63 07 Christchurch 76 64 05 Dunedin 200 143 05

Provincial Rotorua 404 293 53 Taranaki Base 609 399 25 Timaru 466 266 403

Rural Whakatane 718 490 23 Grey 805 61 2 30

Part-time departments

Suburban I INorth Shore 272 148 17

Kenepuru 924 597 33

1 Adjusted total area = total area minus holding ward area

2 See Table 9 for attendance figures used in calculations

3 Considerable sharing with outpatients department

Spearman rank correlations [2] of adjusted total area with

( a) first attendance r = 0310 p gt 010 Not significant ( b) total attendance r = 0297 pgt 010 Not significant

26

LOCATION

There is broad agreement that the A amp E department should be located on the ground floor well signposted and easily accessible to ambulatory patients and ambulances The ambulance entrance should be able to handle several ambulances at once and should have adequate turning space It should be projected from the weather and screened from the view of the other A amp E department patients

The A amp E department should also be located as closely as possible to radiology facilities (either the x-ray department itself or a branch) The A amp E department and the outpatients department can share some facilities and provide additional staff and accommodation in an emergen~y

situation if they are sited together Acute patient care areas (operating theatres intensive care unitsmiddot and cardiac care units) and laboratory services should also be readily accessible from the A amp E department [134]

Entrances

Almost all of the A amp E departments visited were on the ground floor of the hospital and were well signposted Generally access for ambulatory patients was good apart from two hospitals where they had to walk up steps to enter the building o

Few departments had ambulance access which could cope with a shuttle of ambulances bringing mass casualties from a disaster There w~s little relation between the size of the department or the population served and the ease of ambulance flow Indeed those departments with a relatively low probability of being involved in a mass casualty situation had good ambulance flow (eg Whakatane) while those with a greater possibility had relatively poor ambulance access (eg Wellington) Several departments had particularly poor a~bulance flow with only a one-lane access Three departments had good drive-straight-through access while at the rest ambulances had to reverse However there were advantages to some of the bull reversing I situations in that the bays into which the ambulances had to reverse were more likely to give the patient protection from the weather All the A amp E departments visited had separate ambulance entrances which in all but three cases guaranteed screening of ambulance patients from public view

Access to other hospital facilities

In many of the hospitals the A amp E department was adjacent to the outpatients department or to the orthopaedic outpatients section When this occurred the plaster room and x-ray facilities were usually shared and waiting areas and the records office were sometimes shared In the smaller hospitals both departments often shared the nursing staff

The access to the x-ray department ranged from excellent in places which had x-ray facilities immediately adjacent to the A amp E department to very poor where the patient had to be transported hundreds of metres and to a different floor The time taken for the A amp E doctor to get the result of the x-ray varied from five minutes to over two hours though the physical separation of the two departments was only one of the factors which affected this

27

Access to acute care facilities was similarly variable In Christchurch the intensive care unit was adjacent to the A amp E department while in Rotorua it was at the other end of the hospital In many cases additions or alterations to the hospital buildings and changes of function of certain areas have meant that the A amp E department no longer bears the same physical relationship to other hospital departments as was originally the case

LAYOUT

Several studies have concluded that the A amp Edepartment should be designed so that there is an orderly progression of patients from registration to examination to investigations if necessary to treatment and to referral admission or discharge Staff time and effort is best conserved by a compact plan with waiting areas and treatment areas easily accessible and supervised However the need for easy supervision has to be balanced by consideration of the patients privacy Two basic A amp E plans have evolved

o a radial plan where the waiting examination and treatment rooms are arranged on the perimeter of the departmentmiddot with the nurses station doctors room and records office in the centre

o a linear plan where the examination and treatment rooms are arranged down each side of a corridor with the waiting area records office and staff offices at one end [145]

Many of the A amp E departments visited had a linear layout with the largest Auckland being arranged along several corridors In these departments staff often commented that their overall view of the patients was not good and a considerable amount of walking was needed to supervise them Middlemore A amp E department and the treatment areas of several other departments had radial layouts which staff found very satisfactory Generally the A amp E staff prefer red open plan layouts using curtained cubicles rather than enclosed rooms Staff (especially nursing staff) often commented that their department would be better if certain walls or partitions were removed to give easier surveillance of the department as a whole However staff also commented on the relative lack of privacy for patients being examined or treated and noted that some private rooms were needed for instance for obstetric or paediatric patients

Waiting area

There is general agreement that the waiting area should be adjacent to the reception desk easily visible to the receptionist and if possible overlooked by the nurses office or station It should be a cheerful comfortable area with toys provided for children and a range of magazines and books Public toiletspublic telephones and arrangements for refreshments are also needed [146]

The size of the waiting area varied considerably among the A amp E departments visited (refer back tomiddot Table 2) Again this variation bore little relationship to the workload of the department (see Table 3) Some waiting areas were clearly too small and this put pressure on the staff to deal with patients quickly in order to clear the waiting room

28

Staff comments suggested that not only the size of the waiting area but also its design affected its crowding Basically square rooms with seats around the edges had fewer problems than corridor-style rooms with only one row of seats

In all the A amp E departments visited the waiting areas were adjacent to the reception area Sometimes they were visible from the nurses office or work area but where this was not possible the nurses relied on the receptionists to alert them to urgent cases or checked the wai Hng area often themselves

Facilities in waiting areas varied from nothing but seats to areas in which there were hot and cold drink dispensing machines a childrens play area with toys and health-related poster and pamphlet displays Some had a TV set or a tropical fish tank Most staff were agreed that a pleasant atmosphere in the waiting room was important and adVerse comments about the waiting area were made by staff in departments which lacked this In some departments staff commented that vandalism made it difficult to retain facilities and a pleasant atmosphere

Examination and treatment area

The examination and treatment area provides for the needs of all A amp E patients other than those with serious conditions requiring the resuscitation room or those needing special facilities such as plastering Because special purpose areas are frequently under-utilised flexibility is a key requi rement Hence multipurpose cubicles with standardised equipment are usually recommended The cubicles must be big enough to give easy access for patients (not necessarily walking) to accommodate eqUipment and to give staff enough room to work Curtained cubicles are generally sufficient but at least one enclosed cubicle is required for patients needing extra privacy or for light control in eye examinations A cubicle especially set up for children (with appropriately-sized equipment toys and posters) is also desirable [1346]

Most of themiddot A ~ E departments visited had curtained cubicles in the examination and treatment area with perhaps one or two enclosed cubicles or rooms as well Four A amp E departments only had separate rooms for treatment Curtained cubicles made for ease of access while separate rooms did present some difficulties in manoeuvering patient trolleys and wheelchairs In one case it was impossible to get a patient trolley into the room at all and the room was consequently little used

Curtained cubicles did afford greater flexibility in use and did provide more room to work but had the disadvantage of being considerably less private than rooms Surveillance was easier in departments with curtains than those withmiddot walls and doors In the Auckland A amp E department treatment rooms doors had been removed in the interests of improved surveillance Staff in this department commented that its rigid design could lead to difficulties in accommodating a large number of patients in a disaster

The DEU report [1] recommended that the number of cubicles required by an A amp E department was NIlS where N is the anticipated average number of new patients per day It noted that in A amp E departments with few new patients per day a minimum of two cubicles should be provided It also recommended that the flow of recalled patients should be regulated so that they did not greatly affect the need for cubicles

29

As can be seen from Table 4 most departments had enough cubicles to cope with their first attendance workload Even applying the DEU recommendation of N18 to their total attendance most of the departments had an adequate number of cubicles The exceptions were Hutt Christchurch and Dunedin

TABLE 4 NUMBERS OF EXAMINATION AND TREATMENT CUBICLES OR ROOMS AND RECOMMENDED NUMBERS l BASED ON FIRST ATTENDANCE 2 AND TOTAL ATTENDANCE 2

Actual number of DEU recommended numbers (minimum of 2) cubiclesrooms based on

first attendance total attendance pa pa

Full-time departments

Urban Auckland 13 89 99 Middlemore 9 59 88

Green Lane 7 40 65 Wellington 10 73 85 Hutt 4 51 66 Christchurch 7 94 11 2 Dunedin 3 41 58

Provincial Rotorua 4 2 26 Taranaki Base 4 2 24 Timaru 6 2 31

Rural Whakatane 3 2 2 Grey 3 2 2

Part-time departments

Suburban North Shore3 8 22 37 Kenepuru3 6 22 30

1 Based on DEU report [l which recommended NIS cubicles where N average number of new patients per day ie N6750 where N = average first attendance pa

2 See Table 9 for attendance figures used in calculations

3 Recommended numbers increased to adjust for North Shore and Kenepuru treating their attendance numbers in part-time rather than full-time hours

30

Resuscitation area

The resusciation area is used for the immediate life--saving treatment of seriously injured or sick patients It is the acute treatment area in contrast to the examination and treatment area which is used for relatively minor procedures In making its recommendations about the resuscitation area the DEU report [I] balanced the probability of the A amp E department having to treat multiple accident victims with the comparative rarity of use of resuscitation rooms It recommended that a resuscitation room of suff icient size to deal with two patients concurrently be provided in all A amp E departments It also noted that the ambulance entrance and resuscitation area should be located as close together as possible

Most of the departments visited had purpose-built resuscitation rooms of varying size and with varying degrees of sophistication in equipment Some had x-ray facilities in the resuscitat ion area and in those that did not its absence was regarded as a serious impediment to the efficient care of severe trauma

In four of the seven urban A amp E departments the resuscitation rooms were regarded by the staff as being too small The comment was made in one urban department that because of the small size of the resuscitation area patients sometimes had to be moved out of the area before it was felt clinically desirable to do so in order to accommodate incoming patients In the rural and prOVincial A amp E departments the resuscitation rooms wereshyadequate for the demands placed on them

Most resuscitation rooms were sited close to the ambulance entrance and afforded good access to stretcher patients However in three A amp E departments patients had to be moved some distance and in another department up one floor by lift

Operating theatre

In discussing provision of operating theatres in the A amp E departments the DEU report [1] noted that

o most surgery done is minor requires only local anaesthesia and could be done within adequately designed cubicles

o the A amp E department is not a proper place for general anaesthesia

o using A amp Etheatres for day surgery tends to block other A amp E facilities and staff causin~ delay in treating A amp E patients

The report concluded that special facilities appear to be justified only if there is a clear intention of widening the scope of accident surgery in the departments

bullMinor ops theatres of varying sizes and equipped to varying standards were available in many departments Very variable use was made of such theatres - never in some departments to daily in others It was used less in departments with very heavy workloads and where the medical staff were not satisfied that sufficiently sterile conditions could be maintained In one department the theatre was only used for day surgery cases

31

Plaster room

In the plaster room casts are applied and removed and fractures and dislocations can be manipulated The DEU report [1] noted that the plaster room could be an integral part of the A amp E department or shared with the orthopaedic department or belonging entirely to the latter It recommended that the plaster room be close to the A amp E department and the x-ray department

Most departments had a separate plaster room available In many cases this was shared with an adjacent orthopaedic outpatients or fracture clinic Th~ staff generally found the plaste~-rooms satisfactory although two particularly narrow rooms were difficult to work in

Interview room

The DEU report [l] recommended that A amp E departments in medium-sized and larger hospitals should have a small interview room where a patient IS

relatives could talk with A amp E staff the police or others

No A amp E department had a room specifically designated as an interview room for bereaved or distressed relatives although one A amp E department shared such a room with another department In most departments one of the staff off ices was generally used for this purpose In departments where staff offices were small or crowded the lack of an interview room was seen as a serious flaw in departmental layout

Reception and records office

The reception desk should be immediately visible to ambulant patients arriving at the A amp E department and it is desirable for the receptionist to be aware of what is happening at the ambulance entrance as well The current A amp E records should be held at the reception desk or nearby [1]

In the A ampE departments visited the reception desk was usually well-placed for dealing with ambulant patients but in only four cases did it overlook the ambulance entrance In two departments the reception desk was some distance from the treatment area (separated by a waiting room or outpatients room) and the nursing staff found it difficult to oversee incoming patients Current A amp E records were held at the reception desk in all but one of the departments visited The amount of space available in relation to the throughput of patients was a major factor in determining the length of time records could be kept within the department This in turn affected the ease and therefore speed of record retrieval

Staff offices

These ranged from non existent to very cramped spaces serving many other functions to pleasant specifically designated and relatively quiet areas The latter offices are conducive to good staff morale and being a place for exchange of views and experiences could be expected to contribute quite markedly to the overall effectiveness and eff iciency of the department

32

Holding ward

The DEU report [1] said that holding beds should be used primarily for A amp E patients requiring a period of observation prior to a decision about admission or for those who could be expected to go home after a rest period The report noted that using holding beds as recovery beds for day patients for arranged admissions or for pre-admission clinics was not desirable

Most of the urban and provincial A amp E departments visited had holding or acute admitting wards These holding wards were used mainly for assessing patients requiring acute admission but in some hospitals were also used for observing patients (eg with suspected concussion) and for holding night admissions till the morning to save disturbing the wards Neither of the rural A amp E departments had a holding ward although one had an I A amp E admission procedure where a patient could be admitted for up to 24 hours for observation without the need for full admission procedures In the A amp E departments with holding wards a patient staying for more than four hours was formally admitted

Our study showed that the A amp E departments had some problems using holding wards properly In two A amp E departments holding wards were little used at night because nursing levels were too low to staff them safely In another department the beds were used for patients recovering from day surgery and even for some pre-ar ranged admissions At times general practitioner-referred admissions could also clog the holding wards

DISCUSSION

Most of the A amp E departments were generally adequate in size location and layout The exceptions were Christchurch and Butt where conditions were very cramped with particularly limited examination and treatment areas and poor layout We understand that improvements are planned at Hutt and that recent extensions have improved the Christchurch department considerably but at the time of our visits staff in both these departments were working under extreme pressure because of the physical conditions

Despite the general adequacy of the departments almost all had some flaw which affected their operation and inconvenienced staff and patients Major flaws found in several A amp E departments included

o ambulance access unsuitable for a shuttle of ambulances in a disaster

o difficult access to the x-ray department

o resuscitation room too small for easy treatment of more than one patient at a time

o no interview room for relatives of patients

33

REFERENCES

1 Accident and emergency departments a study of planning requirements prepared by the Hospital Design and Evaluation Unit - Wellington Department of Health 1973

2 SIEGEL Sydney - Nonparametric statistics for the behavioural sciences - Tokyo McGraw-Hill Kogakusha 1956 p 202-213

3 Emergency services the hospital emergency department in an emergency care system Chicago American Hospital Association 1972 p 44-49

4 Emer~ency department organisation and management edited by A L Jenkins - St Louis Mosby 1975 p 8-16

5 Design of departments in Br Med J - v 2 (1979) p 1204-7

6 McKINLAY Robin - The care of children in New Zealand hospitals -Aucklandmiddot National Childrens Health Research Foundation 1982 p 79-80

35

CHAPTER 5

Staffing of accident and emergency departments

This chapter describes the staffing both medical and nursing looking at their numbers and experience their previous training and the training they receive in the A amp E department and their satisfaction with their work and conditions We also describe the clerical and reception staff and briefly the involvement of other workers (orderlies social workers and ambulance personnel) in the departments

MEDICAL STAFFING

Senior medical staffing

Organising appropriate medical staffing for hospital emergency services is a prQblem in many countries [1] The variety of staffing arrangements in A amp E departments within many countries suggests that none have established a generally satisfactory pattern of medical staffing

The Platt report [2] found that in Br itish A amp E departments the great majority of patients were seen by junior staff only and that supervision of the A amp E departments by conSUltants was often little more than nominal The committee recommended that

o the junior medical staff should be adequately supervised by consultants

o a consultant orthopaedic surgeon should normally be in charge of theA amp E unit

o an accident and emergency unit should have at least three consultant surgeons each giving a substantial part of their time to this work

o the primary task of general practitioners in emergency services is to deal with minor accidents and emergencies at any time of the day or night (by organising a rota to answer emergency calls within their practice by working sessions in A amp E departments or by attending cottage hospitals at short notice for emergency calls) bull

Since then some progress has been made but standards continue to lag behind those recommended [34] There has been considerable debate over the appropriate staffing arrangements for A amp E departments Some hospitals have implemented the Platt report recommendations others have appointed a full-time A amp E specialist others have employed a full-time non-specialist doctor and some have employed general practitioners

Despite the various systems there is a consensus in both the United States and Britain that experienced medical staffmiddot are essential in the A amp E department They are necessary for prompt effective treatment of emergency conditions for efficient running of the departments and for adequate supervision of the junior doctors employed [23567 p 17-23]

36

Similar concerns have been expressed in New Zealand since the Board of Health report on outpatient services in 1960 [8] This report recommended that general hospitals continue to provide a casualty service available at all times and staffed by experiencedmedical officers

Salmond [9] found that when a senior A amp E officer directed the department A amp E work was handled more efficiently and house surgeons were more closely supervised and supported He suggested that one senior member of the hospital staff (ideally a full-time A amp E officer) should accept full responsibility for the overall supervision of A amp E services

Most of the A amp E departments that we visited had an A amp E officer The position was vacant at both Wellington and Hutt hospitals at the time of our visit while at North Shore Hospital responsibility for the A amp E department was shared by two senior doctors The A amp E departments of the rural hospitals had no senior medical staff

In A amp E departments with heavy workloads additional experienced doctors were often employed as deputy A amp E officers usually medical officer special scale or as Medical Reserve Scheme registrars (see Table 5) There was no general practitioner staffing of any of the Aamp E departments visited although general practitioners had been part-time staff of some of themiddot smaller A amp E departments in previous years One medical superintendent commented that since very few general practitioners could be classified as specialists they could only be paid as medical officers special scale This low level of payment acted as a disincentive to general practitioner recruitment

The A amp E officers usually worked normal office hours (830 am - 430 pm or 9 am - 5 pm weekdays) apart from two who worked part-time covering morning periods If additional experienced doctors were employed they usually covered evening periods (eg 5 pm - 10 pm) and weekend day shifts

There was a wide range of experience among the A amp E officers Half of the senior A amp E doctors had a general practice background and these doctors often had specific surgical medical pharmacological or Armed Forces medical experience as well Several A amp E officers had primarily a surgical background while others had a considerable range of hospital experience In hospitals where the A amp E officers had a general practice background the Medical Superintendent or the A amp E officer often stressed the suitability of this background for A amp E work

An extensive general practitioner background is useful in dealing with the multitude of problems seen in an Accident and Emergency department An orthopaedic or surgical background is not as necessary because of the good backup from the specialties And staff who have only had hospital experience particularly junior staff can lack skills in general assessment and triage

A amp E officer

In other hospitals staff stressed that an orthopaedic and surgical background was very valuable as was experience in dealing with specific types of injury such as soft tissue wounds

37

TABLE 5 MEDICAL STAFFING OF A amp E DEPARTMENTS

Full-time departments

Urban Auckland Middlemore Green Lane Wellington2

Hutt2

Christchurch Dunedin

Provincial Rotorua Taranaki Base Timaru

Rural Whakatane Grey

Part-time departments

Suburban North Shore Kenepuru

Senior medical staffing

Number of full-time equivalents

A amp E officer ( including deputies) 25 15 I 16

I 2

I 03 I

2 05

Registrar

06

1 1

House surgeons

Number on Number A amp E runs covering

some shifts in A amp E deptl

6 2-3 6 2 5 I 5 4 2-3 5 2 2

All on rotating basis 1 3 1 2

5 on rotating basis 4 on rotating basis

None in A amp E dept 4 on rotating basis

1 On general relieving duties 2 Senior A amp E position vacant at time of visit

Junior medical staffing

The issues

Junior medical staffing of A amp E departments has concerned many commentators in the United States Britain and New Zealand The Platt report [2] noted that recently qualified staff when serving in the casualty department undertake responsibility which they would not have in the wards or outpatient clinics

38

In 1960 the New Zealand Board of Health report [8] on out-patient services deplored the staffing of casualty departments by I relatively inexperienced men [sic] and suggested that these staff I should be regarded more as assistants under supervision and training than responsible officers in the outpatients departments The undesirability of staffing A amp E departments with first year house surgeons (or pre-registration doctors) has been reiterated since Junior doctors are often unsure when to ask for advice or help and are sometimes unwilling to admit that they are over-tired and unable to cope [91011)

The report on the working conditions of New Zealand resident medical officers [12] noted the heavy load carried by house surgeons working long shifts in A amp E departments It also commented that when house surgeons are required to look after the A amp E department while carrying out ward duties inadequate cover of the A amp E department could result

The New Zealand situation

The urban A amp E departments had between two and six house surgeons working on three month A amp E runs and in several of these hospitals another one to three house surgeons on general relieving duties covered some A amp E shifts There were more house surgeons in A amp E departments with heavier workloads or with fewer senior medical staff The provincial and rural departments did not usually have house surgeons working on specific A amp E runs rather the A amp E department was covered by all (or most) of the house surgeons in the hospital on a rotatng basis Of the two suburban A amp E departments Kenepuru was covered by the house surgeons on a rotating basis while North Shore did not have any house surgeons because there was no inpatient or consultative backup available (see Table 5)

The total medical staffing of the departments (senior A amp E doctors and house surgeons together) ranged from 10 to 100 full-time equivalents and was closely related to the attendance at the departments (see Table 6) The provincial and rural A amp E departments had higher medical staff to attendance ratios because they had to provide a 24-hour service regardless of the size of the attendance

Each A amp E department visited rostered its house surgeons differently depending on the availability of senior medical staff the workload of the department and the house surgeons other duties In the urban departments house surgeons worked between 45 and 60 hours a week on shifts usually 8 to 12 hours long Many of the house surgeons working in these departments complained about long shifts and suggested that more staff were needed to reduce the shift lengths Split shifts were also unpopular

The most worrying aspect of the staff ing arrangements in bhe Accident and Emergency department is the long hours We need another house surgeon to reduce the hours on some shifts and to proviae another pair of hands in busy periods (eg Friday and Saturday night Sunday afternoon)

House surgeon

39

TABLE 6 TOTAL MEDICAL STAFFING (FULL-TIME EQUIVALENTS) AND MEDICAL STAFFING TO ATTENDANCE RATIOS FOR FIRST ATTENDANCE I AND TOTAL ATTENDANCE 1

Total medical Total medical staffing to staffing attendance ratio

FTE per FTE per 10000 first 10000 total

Full-time attendance attendance equivalents p a pa

Full-time departments

Urban

Auckland2 100 17 15 Middlemore2 91 23 16 Green Lane2 65 25 15 Wellington 66 14 12 Hutt2 55 17 13 Christchurch 70 11 10 Dunedin2 60 22 16

Provincial Rotorua 42 34 25 Taranaki Base2 28 27 18 Timaru 22 19 11

Rural Whakatane3 15 25 17 Grey 10 26 20

Part-time departments

Suburban North Shore 20 21 12 Kenepuru3 20 34 22

1 See Table 9 for attendance figures used in calculations 2 FTE estimated since A amp E department partially covered by house

surgeons on general relieving duties 3 FTE estimated since A amp E department covered by house surgeons on

rotating basis

Spearman rank correlations [131 of total medical staffing with

(a) first attendance r = 0953 p lt 001 (b) total attendance r = 0933 p 001

In the provincial and rural hospitals house surgeons were often on call for long shifts over nights and weekends They were usually covering a ward or the whole hospital at the same time and simultaneous demands from the wards and the A amp E department sometimes caused problems However

40

these house surgeons generally found their rostering satisfactory despite the long hours on call perhaps because the actual work required in the A amp E department was comparatively light

An ordinary week night is usually quiet after midnight thered be three to five calls and Id have to get up once on average Weekend nights are busier but I usually get at least two or three hours sleep

House surgeon

Several house surgeons were irritated that while they worked more intensively on A amp E runs than on ward runs they spent fewer hours on-call and consequently they were paid less

Supervision by senior medical staff

In the larger A amp F departments house surgeons worked with the senior medical staff on most day and some evening shifts only on night shifts (and some evening shifts) were house surgeons the sole medical staff in a department By contrast in the smaller and part-time departments house surgeons covered the department alone seldom working with any senior A amp E medical staff

Several nurses commented that the A amp E department ran less efficiently outside normal working hours because the house surgeons inexperience meant assessment and treatment times were longer and tests were used more often than when the A amp E officer was present

Many senior medical staff in the urban A amp E departments were concerned at the lack of supervision for house surgeons outside normal working hours and so would have Ii ked more senior A amp E staff Several of the house surgeons were also concerned although others enjoyed the autonomy they had and were not concerned about working without supervision

I am not happy with house surgeons managing the A amp E department on their own They only have a three month shift in the department and often most of this time is spent learning how to do A amp E wor k The house surgeons can have problems deciding when to call a registrar to treat a patient and there can be delays in obtaining a registrar The A amp E department needs full-time trained medical staff on duty 24 hours a day to give proper supervision to the house surgeons and to run an efficient department

A amp E officer

On night shift I can feel rather alone if something goes wrong

House surgeon

I enjoy the variety of work and the independence I have to treat most patients as I see fit

House surgeon

41 _A

Arraflgements for consultative backup and support when senior A amp E staff were not on duty varied from hospital to hospital according to hospital size n urban hospitals the house surgeons would usually call on the appropriate registrar and the acute admitting or specialist teams for emergencymiddot cases In some places the house surgeons could calIon the consultant if a registrar was unavailable but this was usually seen as a last resort call In the provincial and rural hospitals the house surgeons would call on the appropriate senior doctor who was available This was usually one of the cQnsultants or a registrar if any were employed by the hospital The A amp E Qfficer might occasionally be called and in hospitals without an A~amp E oHicer th~ medical superintendent would also provid~ backup

Generally house surgeons were happy with the support they received A physically compact hospital was mentioned several times as facilitating ~ ~ fast back-up Howeve( in some hospitals there could be considerable delays in 9etting surgical and orthopaedic registrars to the A amp E department usually because they were in theatre Also at two hospitals backup in the minor specialties was considered inadequate bull

Use of first year house surgeons

Urban and suburban hospitals had a policy of using second year house surgeons as much as possible in the A amp E department and of using first year house surgeons only in their second six months This policy was generally butmiddot not always carried out For example the on-call arrangements of some urban A amp E departments resulted in inexperienced first year house surgeons working in the department In the smaller hospitals also the limited pool of house surgeons available tended to result in more first year house surgeons working in the department

The hospital could not provide cover for the A amp E department without using first year house surgeons However there are always senior staff and the medical registrar readily available as backup

Medical superintendent

When direct supervision was limited first year house surgeons did find A amp E work difficult

Training

The training received by the house surgeons in the A amp E departments varied greatly Two hospitals ran half-day or one-day orientation courses before -house surgeons started in the department Three A amp E departments ran weekly or fortnightly training sessions on specific conditions while another department ran sessions on an irregular basis However house surgeons often missed training sessions because they were treating pat~entsln more than half tmiddothe A amp E departments no formal training was giVen and house surgeons were taught on-the-job when senior A amp E staff were available This teaching placed a considerable load on senior staff

The three-monthly changeover of house surgeons is frustrating and the first month with new house surgeons is very demanding because they have little confidence or competence

A amp E officer

FOREWORD

Over the last twenty years there have been a number of accident and emergency studies in New Zealand hospitals For the most part these have been place and topic specifics This study by Bridget Allan and Judith Reinken is different It begins with an historical review of previous work in the field This is followed by a wide ranging study of accident and emergency services based on field work carried out in a representative sample of hospitals The data are analysed and presented taking account of the relevant international literature The resulting consolidation of knowledge provides a sound basis not only for further research but more importantly for the further development of accident and emergency services

The report provides at least tentative answers to a number of questions regularly asked about accident and emergency services Do general practitioners and accident and emergency departments provide competing services lhe answer appears to be no The public seem to discriminate sensibly between what are for the most part complementary services Is cost a factor in accident and emergency attendance as opposed to a visit to the general practitioner Again the answer appears to be no - cost is not an important factor Are socio-economic status and ethnicity associated with the rate of A amp E attendance Perhaps but distance and other factors concerned with accessibility appear to be more important

The study shows wide variation in the way in which A amp E services are provided in different hospitals This ranges from the size and shape of the physical facilities and the type and level of staffing relative to the workload to the way in which individual patient problems are dealt with Those responsible for the planning and operation of A amp E departments should find these comparisons informative Consideration of the data may perhaps prompt questions which in their answering lead to greater cost effectiveness and to service improvement

As well as providing answers the research raises questions It points yet again to the need in New Zealand for a regional study of accidents and accident services Accidents are a major cause of premature death and morbidity Many organisations are involved in the prevention and treatment of accidents but so far it has not been possible to mount a comprehensive study which includes and integrates all interests Until this is done fragmentation of services is likely to continue

By highlighting access to services the study points up the need for more information about communication and transport patterns in health care delivery Again this is a neglected area of research which could have far reaching implication for the planning and operation of health services

Finally the report raises questions about the interaction between general practitioners and A amp E services That these services are largely complementary is clear but unfortunately the communication between them is often not as good as it could and should be Further research has a contribution here but will not solve the problem Better communication and understanding is needed on both sides

The researchers have provided us with a much needed and timely review of an important and sometimes controversial aspect of health services Theirjete audience

G C Salmond ---shyDeputy Director-General of Health Department of Health

ACKNOWLEDGMENTS

Many people have helped with this study In particular we would like to thank

o John Mills who visited the hospitals drafted the physical characteristics chapter and gave freely of his time and expertise

o the staff of the hospitals visited for sharing their time and thoughts with us

o Desmond Keenan Shelagh McRae and Denis Snelgar for allowing us to use the information they had collected

o Clare Salmond Mike Moore and Sylvia Nichol for their assistance with computer analysis

o readers ofmiddot drafts of this report who offered helpful criticism and suggestion

o the typists and publication staff of the Department of Health

We also acknowledge the Director-General of Health for permission to publish

DISCLAIMER

The views expressed in this report are those of the authors and do not necessarily represent the views of the Department of Health

COPYRIGHT

Provided the source is acknowledged information contained in this report may be freely used by any person

CONTENTS

Page

ACKNOWIEDGEMENTS LIST OF TABLES LIST OF FIGURES

1 INTRODUCTION I

Background Thewider questions of emergency medical services The overseas situation An historical perspective in New Zealand

Interview studies on the utilisation of A amp E departments Record studies on the utili satjon of A amp E departments Studies of the organisation of A amp E departments

Overview of this study Aims Sources of information

References

2 DEFINITIONS 11

The Accident and Emergency department Attendance The hospitals Recording systems References

3 PROCEDURES IN THE ACCIDENT AND EMERGENCY DEPARTMENT 15

Entry Sorting 1 reatmen t Disposal Follow-upcare Admissions Discussion References

4 PHYSICAL CHARACTERISTICS OF ACCIDENT AND EMERGENCY DEPARTMENTS 23

PrinCiples Size Location

Entrances Access to other hospital facilities

Layout Waiting area Examination and treatment area Resuscitation area Operating theatre Plaster room Interview room Reception and records office Staff offices Holding ward

Discussion References

5

6

7

8

STAFFING OF ACCIDENT AND EMERGENCY DEPARTMENTS 35

Medical staffing Senior medical staffing Junior medical staffing Accident and emergency work as a career

Nurse staffing Other staff involved with the A amp E department

Reception and clerical staff Orderlies Social workers Ambulance personnel

Discussion References

PATIENT ATTENDANCE CHARACTERISTICS 55

Overall attendance and trends Age and sex Conditions

Injury conditions Sickness conditions

Recall attendance GP-load

Non-urgent sickness Discussion References

PATIENT ATTI~UDES TO THE ACCIDENT AND EMERGENCY DEPARTMENT AND STAFF ATTITUDES TO THE PATIENTS 75

Reasons for visiting the A amp E department Overseas studies New Zealand studies

Effect of health centres and deputising services on A amp E utilisation A amp E staff views of patients

Overseas studies The New Zealand situation

Discussion References

UTILISATION OF ACCIDENT AND EMERGENCY DEPARTMENTS 91

Comparison of A amp E utilisation among hospital catchment areas Results Effect of general practitioner availability

Factors explaining catchment area variations in A amp E utilisation Method Results of the mUltivariate analyses

Comparison of A amp E use and general practitioner use Discussion References

9 CONCLUSIONS 107

The A amp E department as a hospital department The A amp E department as an emergency service The A amp E department as a primary care service Where from here

APPENDICES

APPENDIX A QUestion sheets 116

APPENDIX B Accident and emergency department records 120

APPENDIX C Statistical analyses of accident and 123 emergency department attendance rates by neighbourhoods

APPENDIX D Childrens use of general practitioners 128 and accident and emergency departments in Wellington

TABLES

Table

1 Proportion of first attendance patients discharged recalled referred or admitted

2 Areas of A amp E department~

3 Area to attendance ratios for adjusted total areas and waiting areas of A amp E departments by first attendance and total attendance

4 Numbers of examination and treatment cubicles or rooms and recommended numbers based on first attendance and total attendance

Medical staffing of A amp E departments

6 Total medical staffing (full-time equivalents) and medical staffing to attendance ratios for first attendance and total attendance

7 Nurse staffing of A amp E departments excluding student nurses and hospital aids

Nurse staffing (full-time equivalents) and nurse staffing to attendance ratios for first attendance and total attendance

Average attendance at A amp E departments 1978-1981

10 Trends in attendance at A amp E departments 1978-1981

11 Proportion of A amp E attendance that was recall attendance

12 Proportion of A amp E attendance that was for sickness

13 Proportion of total A amp E attendance that was for Sickness by policy and age groups

14 Use of general practitioners by first attenders at A amp E departments

15 Reasons for A amp E first attendance from three New Zealand studiesmiddot

Itgt Attendance (mean age-adjusted rates per 1000 per quarter) within each A amp E department catchment area

Page

18

24

25

29

37

39

45

46

56

57

66middot

70

71

77

78

92

(continued)

Table Page

17 Hospital admissionsfor accidental injury (mean 93 age-adjusted rates per 1000 per year) and death due to accidental injury (mean age-adjusted rates per 1000 per year) within each A amp E department catchment area

IB Attendance (mean age-adjusted and neighbourhoodshy 99 adjusted rates per 1000 per quarter) and populationshyto-general practitioner ratio within each A amp E department catchment area

19 Comparison of first attendances for injury at A amp E 101 departments and general practitioners

FIGURES

Figure Page

1 Percentage of total attendance at 58 A amp E departments by age and sex

2 Percentage of total attendance at 59 A amp E departments for sickness and injury conditions by age and sex

3 Injury first attendances by type of injury 6U all ages

4 Injury first attendances by type of injury 61 by age groups

5 Sickness attendances by type of sickness 62 all ages

6 Sickness attendances by type of sickness 63 by age groups

7 Comparison of medical staff availability and 67 level of recall attendance

Comparison of nursing staff availability and 67 level of attendance

9 Location at which accidents happened by those 79 attending the A amp E department or the general practitioner for accidental injury

Use of general practitioners and A amp E departments 131 by Wellington children 1978 (rates per 1000 children per quarter)

1

CHAPTER 1

Introduction

BACKGROUND

This report arises f rom concerns expressed by several groups about the availability especially out of hours of emergency car~ and its provision by Accident and Emergency (A amp E) departments in New Zealand

In _SQe mid 1970 s the people of Porirua were worried that local general -pr-actitioners were not available at nights and weekends and by the delays

involved in travelling to Wellington and Hutt A amp E departments [IJ At the same time the people of North Shore were campaigning to keep their local A amp E department open More recently community groups in Upper Hutt have been pressing for the addition of an A amp E service to a local health centre Overall people are concerned that appropriate care (including facilities such as x-rays) is readily available in emergency situations

General practitioners are another group who have been concerned about A amp E departments in particular about inappropriate uses of A amp E departments A long-standing complaint bas been that patients are using A amp E departments for care which wou~d be better given by a general practitioner and that the A amp E departments retain patients instead of referr ing them back to their general practitioner for follow-up care [2 3J In 1981 the research group of the Wellington Faculty of the Royal NZ College of General Practitioners sponsored a study of children presenting at A amp E departments because they were worried that unnecessary admissions of children to hospital occurred because their parents had bypassed the general practitioners and gone straight to hospital [4J

Also A amp E staff and hospital administrators have been concerned that caring for patients who could have been treated by general practitioners has limited their ability to deal with emergency cases [567]

THE WIDER QUESTIONS OF EMERGENCY MEDICAL SERVICES

Emergency care requires not only the provision of hospital services (the A amp E department with back-up from other hospital facilities) but also the organisation of services outside the hospital and co-ordination between both sets of services Emergency medical services outside the hospital include alarm and communication systems transport systems and first aid services There are important questions for New Zealand within this framework For example what should be the role of general practitioners in on-site emergency care What level of training is appropriate for ambulance officers Should voluntary personnel staff ambulances To what extent is double manning of ambulances required [8910]

In order to limit the study to manageable proportions this report focusses only on the hospital services namely the A amp E department Emergency medical services provided outside hospitals are mentioned only where they impinge noticeably on the A ampE department It is hoped that due attention will be given to the wider questions of emergency medical services in the future (see Chapter 9)

2

THE OVERSEAS SITUATION

Concern with emergencymiddot care facilities especially their increasing use has been apparent in other countries for the past thirty years While some articles report on the situation in Canada Australia Sweden France and the USSR most of the literature is about the United States and Britain This section briefly outlines the major themes of the literature and their relevance to New Zealand More specific aspects are covered in the appropriate chapters

Many United States researchers have studied the operations of different emergency rooms exploring patients reasons for using the emergency room their demographic characteristics and their use of the family doctor Often the studies have tried to explain an increasing use of emergency rooms and some have reported on the effectiVeness of measures introduced to reduce thei r use These studies provided models for some of the analyses carried out in this study However the debate in the United States over appropriate methods of funding and staffing for emergency rooms is seldom relevant to New Zealand because of the differences both in philosophy and organisation of medical care in the two countries

The Platt [11] committee on A amp E services in Britain in 1962 was concerned about casual attenders ie patients not in need of urgent attention but wishing to avoid the trouble of attending their general practitioners surgery They also criticised the unsuitable accommodation and the insufficient numbers of senior medical staff supervising Casualty Departments The report recommended changing the name Casualty Service to Accident and Emergency Service (to discourage casual attendance) and rationalising the service by clOSing smaller A amp E units and centralising facilities These recommendations have been partially carried out

However there has been continuing research in Br i tain into the reasons given by patients particularly self-referred patients for their use of A amp E departments and the trade-off between general practitioner and A amp E services There has also been continuing debate over the medical staffing of A amp E departments

The British studies are of some relevance to the New Zealand situation since the organisation of medical care here is similar but no overseas experience can provide a blueprint for New Zealand For example the direct cost to the patient of general practice care in New Zealand raises the possibility of patients attending the A amp E department because it is free whereas the British system of general practitioner funding provides no such incentive

AN HISTORICAL PERSPECTIVE IN NEW ZEALAND

Little is known about the historical development of A amp E services in New Zealand Presumably they followed the British tradition described in the Platt report [11 p23-24)

The word casualty in its proper meaning of a serious injury has a long history It occurs in Shakespeare and Dickens writing in 1837 used casualty ward to describe the ward in a hospital in which accidents were treated Unfortunately the meaning alt~red in the second half of the last century The Nuffield Report (1960) Casualty Services and their Setting

3

gives an interesting quotation from a survey made by the Lancet in 1869 The out-patients at St Bartholomews Hospital are it says divided into two categories They are the middotcasualtymiddot which comprises those who are supposed to require temporary treatment for diseases or injuries of a trifling character and the middotout-patientsmiddot properly so called who after receiving a regular letter of admission are entitled to the advice of the assistant surgeons and physicians for a period of 12 months It is in the casualty division that the increase of numbers has been most marked bullbullbull It is estimated that not less than a thousand patients frequently attend on a Monday or Tuesday morning

Certainly by 1872 vlellingtons private medical practitioners were incensed at the hospitals provision of free treatment for their patients Five hundred outpatients were treated in Wellington that year [12] Separate casualty departments were operating at Wellington Hospital by 1924 [12] at Auckland Hospital by the 1940s [13] and Christchurch Hospital by 1952 [14]

The 1960 Board of Health report [15] on outpatient servicesmiddot expressed concern over the duplication of services by outpatient departments which were also available from general practitioners However it recommended that general hospitals continue to provide a casualty service available at all times

Since the late 1960s a series of New Zealand studies have considered the use of A amp E departments either by interviewing patients or by analysing data drawn from A amp E record systems and the organisation of A amp E departments

Interview studies on the utilisation of A amp E departments

The first interview study was an investigation of first attenders at the Dunedin A amp E department in 1968 by Dixon et al [2] Their results have not been contradicted by any of the later studies

They found that the principal attenders were males aged 15 to 24 who recorded first attendance rates of over 100 per 1000 each year The young men were also the most likely to report having no general practitioner Dixon found that the age and sex pattern of those attending at the A amp E department was nearly converse to the pattern of those attending a general practitioner

Dixon pointed out that the conditions treated at the A amp E department were rarely disease-related rather they were predominantly lacerations and open wounds bruising sprains and strains effects of foreign bodies and fractures The major reason given for attending the department was that it was seen as appropriate

Dixon concluded that the A amp E service was complementary and not competitive to general practice that the public were realistic in regarding it as the only practical and effective primary medical care for accident and emergency injuries and that payment for service did not appear to figure in the decision to attend the department

o

4

TwO interview studies of first attenders at Auckland Hospital A amp E department have been carried out by Hunton in 1972 and Richards in 1975 [16] Both studies included an assessment by the student interviewers and A amp E staff as to the suitability of the patients condition for general practice care 42-43 per cent were considered suitable Richards concluded that public education programmes encouraging people to use their general practitioner prior to attending the A amp E department should be instituted

In 1978 Keenan interviewed patients who had attended Christchurch A amp E department collecting detailed information on the accident or sickness leading to the attendance (unpublished see Chapter 6 and 7) He found the same set of reasons for using A amp E departments as Dixon found the A amp E department was seen as appropriate and accessible

Kljakovic found similar results when interviewing the parents of children attending A amp E departments in the Wellington region in 1978 [4] He also found that in choosing between the general practitioner and the A amp E department parents were more likely to use the service which was closer to the family home Children f rom lower socio-economic status families were more likely than other children to see thei r general practitioner before gOing to the A amp E department

Records studies on the utilisation of A amp E departments

Several studies have gathered data from A amp E records to investigate A amp E utilisation In 1979 Snelgar described the characteristics of people attending Northland Base Hospital A amp E department [17] He found similar results to Dixon apart from a higher proportion of injuries In the same year McRae reviewed all attendances at Waikato Hospital A amp E department and found a similar picture [lB]

Three records studies have looked at the relationship between A amp E use and general practitioner use Maynard looked at Mosgiel residents use of Dunedin A amp E facilities for three years before and three years after the opening of a local health centre [19] No difference was found ~asap

investigated assertions that people from one part of the Wellington Hospital catchment area had suddenly begun to use the A amp E department heavily for conditions that should have been seen by a general practitioner [20] In fact that part of the catchment area had much lower rates of A amp E use than other areas Reinken tested whether the doubling of general practitioner cover in one part of the Wellington region affected A amp E presentation rates differently than in other areas nearby [21] There was no clear evidence that the increased cover had any effect

Studies on the organisation of A amp E departments

As part of a thesis looking at young doctors Salmond examined the work of house surgeons in A amp E departments using a postal questionnaire [22J He concluded that working in an A amp E department was good experience for a house surgeon only if second year house surgeons were deployed in the department the house surgeon was well-supervised by senior medical staff there was a good working relationship with the A amp E chargemiddot nurse and the house surgeon was not over-tired He also suggested that good senior staffing was closely related to effective administration and better service in the A amp E department

5

The Hospital Design and EValuation Unit of the Department of Health prepared a report documenting the planning requirements of New Zealand A amp E departments [23] The report outlined several principles of A amp E design and made detailed recommendations on the facilities rooms and equipment necessary

OVERVIEW OF THIS STUDY

Aims

The aim of this study is to describe A amp E departments in New Zealand Because the material presented in the previous section was collected by different researchers at different times and from different A amp E

departments detailed comparisons across the studies have been difficult To get a more comprehensive picture of A amp E use in New Zealand a systematic investigation was necessary

The specific aims of this report are

o to describe the organisation of A amp E departments by looking at their procedures physical characteristics and staffing patterns

o to describe attendance at A amp E departments including the patients profile and pattern of attendance and the load placed on the departments by patients who would be more appropriately treated by a general practitioner

o to describe the use of A amp E departments by consumers by analysing patients reasons for attending the departments and analysing demographic factors inrelation to A amp E attendance

Sources of information

Information was gathered from three sources

The site visits

Fourteen A amp E departments were visited between May and September 1981 by a Department of Health study team consisting of a medical officer from the Division of Hospitals and a res~arch officer from the Management Services and Research Unit

At each hospital the team examined the facilities and spoke with staff involved with the A amp E department including

o the medical superintendent (and in some hospitals the principal nurse)

o the A amp E officer or medical officer in charge of the A amp E department (where such a position existed and was filled)

o the nurse supervisor andor charge nurse of the A amp E department

o at least one house surgeon working in the A amp E department

6

In some hospitals the team also spoke with other staff members including experienced A amp E staff nurses and hospital social workers

Question sheets were used during interviews so that a comparable body of information was collected at each hospital Interviews were open-ended to allow discussion of local procedures or problems (See Appendix A for question sheets)

Hospitals were carefully selected so that the A amp E departments in the study would represent a cross-section of New Zealand A amp E departments Those selected served a range of communities in both the North and South Islands

o major urban Dunedin)

areas (Auckland Wellington Christchurch and

o provincial centres (Rotorua Taranaki and Timaru)

o predominantly rural areas (Whakatane and Grey)

In centres with more than one A amp E department all were visited so that a complete picture of the services and use could be developed This involved visiting Auckland Green Lane Middlemore and North Shore hospitals in Auckland and Wellington Hutt and Kenepuru hospitals in Wellington

The information gathered in the site visits has been used in describing the organisation of A amp E departments (Chapters 3 4 arid 5)

The A amp E records data collection

On each site visit a sample of 1981 attendances was drawn from the A amp E record system and the following information was recorded for each person age sex presenting condition (sickness or injury) time of presentation residential address and whether the visit was a first attendance for the condition or a recall visit

Exceptions were Christchurch and the three Wellington Hospital Board A amp E departments Comparable data collected by Keenan in Ch ristchurch in 1978 and Allan in Wellington during 1980 were used instead

This information has been used to describe the attendance at A amp E departments (Chapter 6) and for the analysis of demographic factors in relation to attendance (Chapter 8)

The consumer studies

In 1978 Keenan carried out interviews with patients attending Christchurch A amp E department working from a one in eight sample drawn from the A amp E log over a four-week period and gaining a 99 response rate Results from this study have been analysed and compared with the results of the published New Zealand interview studies [2416] Anecdotal material from Kljakovic s study of children attending Wellington A amp E departments has also been included to illustrate the results of the numerical analysis

We realise that in studying only a selection of A amp E departments some local variations may have been missed but we are confident that the broad pattern and major issues in the organisation of A amp E care have been

7

covered Also as the A amp E departments studied serve two-thirds of the population of New Zealand the utilisation patterns discussed in the report are likely to prevail throughout New Zealand We hope that the mater ial presented the conclusions drawn and the questions raised in this report will encourage discussion about the current operation and future developmiant of A amp E departments in NewmiddotZealand

a

8

REFERENCES

1 de LACEY A REINKEN J and SALMOND C E - Community attitudes to sickness and health stimulus and response v 3 Community attitudes - Wellington Management Services and Research Unit Dept of Health 1980 p 103-105 (Special report series no 56)

2 DIXON C W Emery G M and SPEARS G F S - Casualty department utilisation survey in NZ Med J - v 71 (1970) p 272-279

3 [Editorial] in G P Journal of the General Practitioner Society no 42 (1981) P 1-2

4 KLJAKOVIC M ALLAN BC and REINKEN J - Why skip the general practitioner and go to the accident and emergency department in NZ Med J - v 93 (1981) P 49-52

5 SKUDDER Paul A McCARROLL James R and WADE Preston A - Hospital emergency facilities and services a survey in Emergency medical services behavioural and planning perspectives edited by John H Noble Jr et ale - New York Behavioural Publications 1973 p 17-35

6 MAYNARD Edward J - The application of epidemiological methods to the evaluation of primary medical care in a health centre environment shyUniversity of Otago 1980 Ph D Thesis Social and Preventive Medicine

7 Hospital misuse brings protest in Taranaki Daily News (1 Sept 1980) bull

8 FAHEY Morgan - The role of the family doctor in disaster and emergency medicine in NZ Family Physician - v 5 no 1 (1978) p 42-44

9 Proceedings of the emergency care seminar Auckland 19-23 March 1979 in NZ Med J - (1980) P 194-196

10 Double manning of ambulances [editorial] in NZ Hosp - v 32 no 3 (1980) p 1

11 Gt Brit Central Health Services Council - Standing Medicine Advisory Committee Accident and emergency services report of the subcommittee - London HMSO 1962 Chaired by Sir Harry Platt

12 BARBER Laurie H and TOWERS Roy J - Wellington Hospital 1847-1976 Wellington Wellington Hospital Board 1976

13 The story of Auckland Hospital 1847-1977 edited by David Scott -Auckland Medical Historical Library Committee of the Royal Australasian College of Physicians in New Zealand 1977 p 35-36

14 BENNETT FO - Hospital on the Avon the story of the Christchurch Hospital 1862-1962 Christchurch North Canterbury Hospital

o Board 1962

9

15 Outpatient services in public hospitals in New Zealand - Wellington Government Printer 196U (Report series Board of Health no 2)

16 RICHARDS J G and WHITE G R - Accident and emergency services at Auckland Hospital in NZ Med J - v 85 (1977) P 272-274

17 SNELGAR Denis - Accident and emergency utilisation study Paper prepared for the Primary Health Care Shadow Service Development Group Northland 1981 (Unpublished)

18 McRAE Shelagh and TOPPING Mark - Casualty attendances one years experience at Waikato Hospital in NZ Med J - v 95 (1982) P 12-14

19 MAYNARD Edward J and DODGE Jeffrey S - Introducing a community health centre at Mosgiel New Zealand effects on use of the hospital accident and emergency department in Med Care - v 21 no 4 (1983) p 379-388

20 KASAP D - Personal communication 1975

21 REINKEN J - Effect of changes in general practitioner cover on accident and emergency utilisation in the Porirua Basin Wellington Management Services and Research Unit Dept of Health 1979 (Unpublished)

22 SALMOND G C - Young doctors an exercise in social research methodology - University of Otago 1970 Ph D Thesis Social and Preventive Medicine p 179-214

23 Accident and emergency departments a study of planning requirements prepared by the Hospital Design and Evaluation Unit - Wellington Department of Health 1973

11

CHAPTER 2

Definitions

lhis chapter provides the definitions of terms used in our study In general our terminology is consistent with the literature However in some areas such as the classification of presenting conditions as sickness or injury or the description of GP-load there is no general consistency and we have developed our own definitions

THE ACCIDENT AND EMERGENCY DEPARTMENT

This name is the one commonly used in New Zealand We have used it in preference to the older description Casualty Depariment [1] and the American description of Emergency Department It is one hospital department which patients can approach without prior notification

Emergencies can be any condition that - in the opinion of the patient their family or whoever assumes the responsibility of bringing the patient to the hospital - requires immediate medical attention

However using such a definition means every case is an emergency In New Zealand A amp E departments patients tend to be classified in a similar way to the description given by the American Hospital Association [2]

o emergencies where delay is harmful and the condition potentially threatens life or function

a urgent cases which require attention within a few hours

o non-urgent cases where the condition is minor or non-acute and does not require the resources of the emergency service

An accident is an unexpected event Accidents which have resulted in attendance at an A amp E department are ones that have caused some trauma whether through shock or other injury The Platt report [1] decided on the term A amp E department in recognition that the real emergencies were a trickle while the accidents were a mighty flood

In general the A amp E department is regarded as part of the hospitals outpatient services and like these in day to day running it provides specific clinics generally for the treatment of traumatic injury x-ray burns dressings plasters and so forth

An accident and emergency patient is a person who is entered in the A amp E log book This can involve a certain amount of error however as some outpatients or discharged patients may return for follow-up care through the A amp E department Also the A amp E department often handles the acute admissions to the hospital

12

ATrENDANCE

A first visit (or first attendance) is the first visit a patient makes for one particular condition

A recall visit is any visit made for one particular condition which is not the first visit for the condition Some recall visits are patient initiated (eg due to pain bleeding infection or an accident to the dressing or plaster) but for the most part revisits are scheduled return visits suggested by A amp E staff

Total attendance is the sum of first visits and recall visits

Inj ury attendances are defined to include the results of trauma (cuts burns fractures sprains strains bruises head injuries multiple injur ies and so forth) as well as foreign bodies in the eye or other orifices and toxic effects whether from accidental or self-poisoning events Late effects of minor injury (pain bleeding abscesses or such) are not included as injury but as sickness

Sickness attendances include collapse (whether stroke coma heart attack or other) shortness of breath abdominal pain general sickness (fever vomiting diarrhoea unwell) mental distress and minor conditions

Non-urgent sicknesses are defined as the minor conditions abdominal pain and general sickness except for preschool children and adults over 65 where the general sickness and abdominal pain conditions can be urgent A amp E staff defined non-urgent sickness less specifically they tended to define it as longstanding or minor sickness

GP-load describes the patients whom A amp E staff feel should have seen a general practitioner It includes patients with longstanding or minor sickness conditions and patients with minor traumatic injury (eg cuts bumps and bruises)

In hours attendance refers to all attendances in the normal working hours of 0800 to 1800 Monday to Friday excluding holidays

Out of hours attendance refers to all other attendances outside the defined normal working hours

In an average week 50 hours fall in the in hours category and 118 hours in the out of hours category If we assume that an average person sleeps eight hours a night then that person is awake for 62 hours in the out of hours category (and all the in hours of course) Thus the out of hours category is 70 per cent of the total time in a week and 55 per cent of the waking time in a week

Minor conditions included abscesses backaches infected wounds or wound pain headache pain (unspecified) earaches eye problems toothaches nosebleeds limb pains We have called it the skin pain or bleeding category in Chapter 6

13

Attendance rates measure the use of A amp E departments for a defined population They express the number of cases from an area over a defined period per 1000 population in that area Rates were obtained by age and sex for sickness and injury and in and out of hours for each census area unit or neighbourhood served by each hospital

THE- HOSPITALS

We grouped hospitals into four types

o urban hospitals (where average annual first attendances at A amp E departments are over 25000 patients)

o provincial hospitals (serving 6000 to 12000 new A amp E patients each year)

o rural hospitals (serving fewer than 6000 new A amp E patients each year)

o suburban hospitals where A amp E departments are not open 24 hours per day North Shore Hospital was open 7 days a week 830 am shy530 pm and Kenepuru Hospital was open 5 days a week 830 am shy430 pm

Most of the A amp E departments visited had a senior position variously called the A amp E officer the A amp E director the senior medical officer or the medical officer in charge For convenience we call this position the A amp E officer

RECORDING SYSTEMS

The log is the record kept at the A amp E department which records some information on every patient who presents It will often give no more than the patients name the date and time of visit

The A amp E record is usually a card and it records basic patient information and case notes It may be held for several years in the A amp E department and may therefore contain information on a series of separate events for anyone patient

14

REFERENCES

1 GtBrit Central Health Services Council - Standing Medical Advisory Committee Accident and emergency services report of the sUbcommittee - London HMSO 1962 Chaired by Sir Harry Platt

2 Emergency services the hospital emergency department in an emergency care system Chicago American Hospital Association 1972 p vii-viii

15

D

CHAPTER 3

Procedures in the accident and emergency department

In this chapter we begin describing the organisation of A amp E departments by looking at the way they operate We follow the course of a patients care entry to the A amp E department sorting into priority order for care (triage) treatment and follow-up care

ENTRY

Most people presenting at the A amp E department were ambulant (the walking wounded as they are colloquially known) They came through the A amp E departments main entrance to the reception desk where they were first seen by a receptionist or nurse (Exceptions to this occurred in the smaller hospitals where patients presenting at night were first seen by the telephonist who called the nursing staff) Nurses did reception duties at

all the provincial and rural A amp E departments and at two of the urban A amp E departments when receptionists were not on duty (eg lunchtimes nights) bull At times nurses found that having to cover the reception desk interfered with their care of patients

When the receptionists are off duty the nurses do the reception work This can be a nuisance because it interferes with patient care and sometimes patients ring the bell at the reception desk and the staff working in the resuscitation room dont hear it

A amp E nurse

Unless their condition required immediate care the ambulant patients then spent several minutes at the reception desk while their details (eg name address general practitioner complaint) were noted on the A ampE records (See Appendix B for more information on A amp E records) Then they waited in the waiting room until they were called for treatment

A small proportion of patients arrived by ambulance andmiddot at almost all hospitals entered the A amp E department through a separate ambulance entrance In the larger hospitals some nursing staff were stationed in or near the ambulance entrance to care for these patients In other hospitals the staff had often been warned of incoming urgent cases and were standing by when the ambulance arrived As the condition of ambulance patients tended to be urgent they were usually taken straight to a resuscitation or treatment area patients condition permitted or friends or the ambulance driver

Record with the

keeping assist

was ance

carried of thei r

out r

when elativ

the es

SORTING

All A amp E departments operated some triage system to sort the ambulant patients by the urgency of their need for care (Themiddot only exception was Grey A amp E department where there was seldom more than one patient in the department at a time) At most A amp E departments the patients were sorted

16

into urgent and non-urgent categories with urgent cases being seen immediately and non-urgent cases being seen in the order they presented At some of the urban A amp E departments a more complex sorting was done For example

Priority is given in the following order

urgent need very young and very old patients those with general practitioner notes those without general practitioner notes

A lie E nurse

Usually ambulance cases were not triaged since they tended to arrive on their own and required urgent care However several A lie E departments had triage arrangements planned for the arrival of many ambulance cases at once as in a disaster

Sorting was largely a responsibility of the nurses although some A amp E doctors would occasionally check the condition of patients- in the waiting room too The receptionists often played a role in triage as well alerting the nursing staff to urgent cases This happened more in A amp E departments where the physical layout made it difficult for nurses to watch the entrance and the waiting room

The receptionists do tQe basic sorting They have guidelines to follow distressed patients severe cuts or bleeding go straight to the nurses open wounds or eye injuries go directly to a cubicle and are assessed by the nurses patients with abdominal pain or chest pain go on to trolleys and wait in the recovery room This system usually works well although occasionally a fracture patient will not be recognised and will sit in the waiting room

A lie E nurse

In several A lie E departments doctors and nurses stressed the value of an experienced receptionist in recognising and reacting quickly to acutely ill or injured patients

TREATMENT

Almost all the A amp Edepartments visited had a policy that all patients presenting had to be seen by a doctor The doctor did not necessarily have to treat the patient he or she could advise the patient to see a general practitioner Some A amp E doctors commented that by the time they saw the patients it was as easy to treat them as to send them away_ At a few departments the nurses (and occasionally the receptionist) could advise the patient that the department was not an appropriate place for their condition and that they should see a general practitioner This was usually done in consultation with the A E doctor but at times the nurses acted on their own initiative In these places a triage system similar to that reported by Weinerman et al [1] where patients were assigned to the appropriate service inside or outsidemiddot the hospital appeared to be operating

7

The assessment of patients the ordering of tests andmiddot the supervision of treatment were usually seen ~s medical functions The nurses would prepare patients for treatment (removing dressings) and carry out urgent first aid measures (stem bleeding start gastric lavage or cardio-pulmonary resuscitation) Generally however a nurse would only initiate treatment if the patients condition was urgent and a doctor was not available or was already busy with another emergency Exceptions to this situation occurred in some hospitals with A amp E nurse training programmes and in some smaller hospitals where the doctor is on call rather than working in the A amp E department In these departments experienced nurses could order tests such as x-rays and initiate treatments such as suturing and removing foreign bodies from eyes

In most A amp E departments nurses would perform some treatments under a doctors supervision However the range of treatments nurses were allowed to perform varied considerably among hospitals At some hospitals nurses sutured after training but at others they never sutured

The nurses do not suture although they would like to There are four reasons for this there is no full-time A amp E officer so good standards of sutur ing could not be maintained there could be medico-legal problems if a nurse sutured a cut which was more complicated than it looked eg with tendon involvement the nurses have enough to do at present and if they start suturing they will be expected to do it always and the young doctors need to learn suturing as part of their training

Principal nurse

Electrocardiograms were taken by nurses in some A amp E departments by technicians at others Taking blood samples was a doctors job in some departments but was done by nurses in others Similarly gastric lavage using a def ibrillator and plaster work were done by nurses in some departments Most A amp E nurses would maintain intra-venous drips but only nurses with special training WOUld insert them

Some nurses expressed frustration at restrictions on the treatments they were allowed to perform However several sen~or nurses stressed that they had to select carefully the nurses they allowed to perform more difficult treatments

We are very selective about choosing the nurses to do triage suturing and the more complicated procedures This seems to have been successful weve had no problems with nurses undertaking treatment theyre not competent to provide

A amp E senior nurse

I make sure the nurses understand they can be dangerous people If theyre not aware of their limitations theyre not suitable for A amp E work

A amp E senior nurse o

Also one department which had comparatively few nurses discouraged them from increasing the range of treatments they performed so that their workload did not become overwhelming

18

For diagnosis the A amp E departments made heavy use of the x-ray departments (The Design and Evaluation Unit study [21 estimated that 30 per cent of A amp E attenders had an x-ray during their visit) Some A amp E departments found their arrangements with the x-ray department very convenient with an x-ray machine aVailable 24 hours a day in or close to the A amp E department and with patients and x-ray films or reports returning within an hour At other hospitals arrangements Were less convenient in some places reporting bac k of x-rays took two or three hours delaying patients considerably while in others the x-ray departmentmiddot was located on a different floor from the A amp E ~epartment causing difficulties in transporting and accompanying patients there

Little use was made of the laboratory services other than for blood and urine tests and arrangements were generally satisfactory However in many hospitals x-ray and laboratory staff had to be called in to perform tests out of hours and because of the expense involved these out of hours tests were discouraged Some house surgeons found this a difficult situation

I I m caught between contradictory pressures the orthopaedic surgeons say that x-rays are necessary for proper diagnosis and the hospital board is trying to limit out of hours x-rays to save money

House surgeon

DISPOSAL

After treating the patient the A amp E doctor decides on the appropriate disposal discharging from care arranging follow-up treatment by referring to another source of care or recalling to the A amp E department or admitting the patient Information on disposal was only readily available from three A amp E departments The most common disposal pattern was in fact discharging from care with 40 to 55 per cent of patients making a first Visit being discharged

TABLE I PROPORTION OF FIRST ATTENDANCE PATIENrs DISCHARGED RECALLED REFERRED OR ADMITTED

Discharged Recalled Referred to Admitted Other First to A amp E GP Specialist attendance

Clinic tallied

Waikato l 393 132 222 99 134 19 25 707 Green Lane2 550 220 110 40 80 Unknown Taranaki 41 5 268 73 103 116 24 164

1 From McRaes study of Waikato A amp E departmen~ in 1979 2 From a study carried out by Green Lane A amp E department

19

FOLLOW-UP CARE

The decision to be made on follow-up care was usually between re~alling to the A amp E department or referring back to the patient I s general practitioner Some A amp E departments also referred patients (especially children) to district nurses or patients with work 1n]uries to an occupational health nurse or clinic Many departments referred fracture patients to orthopaedic clinics held in the hospital outpatients department and one A amp E department which was very short of space referred patients needing redressings to the outpatients department

There were large differences in referral practices (see Table 1) Between 13 and 27 per cent of first attenders were recalled to the A amp E department for follow-up care while 15 to 30 per cent were referred elsewhere either to a general practitioner or to a specialist clinic Also recall attendances expressed as a proportion of total attendances varied considerably among the A amp E departments from 10 per cent to 50 per cent (see Chapter 6 Table 11) and clearly reflected different follow-up practices

All of the urban and two of the provincial A amp E departments had a policy of referring most patients requiring follow-up care to a general practitioner and of keeping recall visits as low as possible This was similar to general policy in both Britain and the United States which appears to discourage re-at tendance at A amp E departments [34] However in the suburban rural and other provincial A amp E departments the decision on follow-up care was left to the judgement of the A amp E doctor

In practice however the choice to refer or to recall was reiated to several factors First the decision related to characteristics of the patients If the patients had serious wounds or burns or injuries which could develop complications they were usually recalled They were also recalled if the A amp E staff thought they would not receive appropriate care at home or they would not see a general practitioner for follow-up care Patients living a long way from the hospital were usually referred to their general practitioner At some A amp E departments patients were given the choice of referral or recall according to A amp E staff comments most chose to return to theA amp E department

The patients prefer to come back to the hospital Money is not a factor in this because the ACC pays for accident treatment at the general practitioner

A amp E nurse

Second there were general practitioner factors If the local general practitioners were unhappy about the A amp E department recalling patients or if a general practitioner had referred the patient to the department originally the A amp E doctors would refemiddotr rather than recall However if the A amp E doctors thought that the general practitioner did not have the facilities and in some cases the ability to provide follow-up care (eg for serious woundS eye injuries) they would recall the patient

Some GPs dont like following up care initiated by the A amp E department or dont have the necessary facilities so I tend not to send patients back to them

A amp E officer

20

Im more likely to refer a patient back to a GP who is reliable

House surgeon

Third many of the house surgeons said they would recall patients if they were interested in the condition or if they were worried about their diagnosis and treatment and wanted to see the outcome Several medical superintendents noted that recalling under these circumstances was acceptable because it comprised part of the house surgeons training

Fourth the workload of the A amp E department sometimes affected the follow-up decision with very busy departments actively discouraging recalls And finally there was the philosophy of A amp E medicine held by the A amp E doctor In one department where the A amp E officer considered it an ethical duty to see any treatment initiated through to a successful conclusion almost all patients who needed follow-up care were recalled At two other departments the A amp E officers stressed the importance of being able to deal efficiently with any emergencies presenting they kept recalls low so that the department was not clogged with extra patients Other A amp E doctors thought that the general practitioner could provide better continuity of care than the A amp E department so they referred as many patients as possible

When referring patients to the general practitionermiddot most of the A amp E doctors made a verbal recommendation to the patient and then relied on the patient to attend the general practitioner They would only write a formal referral letter if the patients condition was serious In several A amp E departments however greater efforts were made to inform the patient t s general practitioner Three departments gave referred patients cyclostyled forms with details of diagnosis and treatment to be passed to their general practitioner while the Whakatane department sent a copy of the A amp E record form to each patients general practitioner

ADMISSIONS

Table I suggests that between a and 14 per cent of all first attendances were admitted to the hospitals Admissions could well be higher for children Kljakovic [5] found that 20 per cent of the children presenting at the Wellington Hospital Board A amp E departments were admitted

The A amp E departments were involved in several different pathways for the admission of acutely ill or injured patients (Scheduled admissions did not involve the A amp E department at any of the hospitals visited) Self-referred patients could be admitted directly from the A amp E department to the wards or could be cared for in a holding (or acute admitting) ward before going to the wards

There was considerable variation among the hospitals as to which members of the medical staff were able to admit patients At some of the urban hospitals only the registrars could admit while at others the A amp E doctor could admit if the registrar was delayed and unable to assess the patient quickly At some of the provincial and one of the urban hospitals the A amp E doctor could admit in consultation with the admitting officer or appropriate registrar while at-another urban hospital and the rural A amp E departments the A amp E doctors regularly admitted patients

21

Hospitals with lower levels of bed occupancy were more likely to allow A amp E doctors to admit Senior A amp E doctors were more likely to play a role in admissions (actually admitting patients or advising the registrar) than house surgeons

Some patients referred by a general practitioner for acute admission also passed through the A amp E department At one hospital the general practitioners rang the A amp E officer to arrange for all acute admissions and all such GP-referred patients were seen first in the A amp E department However more usually the general practitioners rang the appropriate registrar to make arrangements and the registrar decided whether to admit the patient directly to the wards or through the A amp E department The involvement of A amp E staff with patients requiring admission ranged from almost none (where the patient went directly from the A amp E department to the ward or specialist unit) to a full initial assessment including tests (often undertaken at the request of the registrar responsible for the patient) bull

Generally the A amp E doctors were satisfied with the admission procedures However at one hospital where the A amp E doctors could not admit patients waiting for admission tended to clog the department The doctorselt that if they had admission rights the situation would be remedied

DISCUSSION

There were few differences among the A amp E departments in the reception and sorting of patients However there were differences in some aspects of treatment follow-up care and admission procedures

lhe role of the A amp E nurses in treatment varied considerably with some departments allowing nurses to initiate and perform many treatments and other departments allowing little autonomy Careful training and selection were essential before nurses increased their responsibility for treatment bull

Policies on follow-up care differed among the departments with the urban and provincial departments generally referring patients to general practitioners and the rural and suburban departments leaving the referral decision to the A amp E doctor In practice however the differences were less clear-cut with several factors other than the patient I s condition affecting the follow-up care decisions These factors included the A amp E staffs communicat ion with local general practitioners the inexperience and training needs of house surgeons the workload of the department and the senior A amp E doctors philosophy with regard to A amp E medicine

The A amp E departments also differed considerably in thei r procedures for acute admissions At some hospitals the A amp E doctor could admit an A amp E patient while at others the patient had to be held in the department until admitted by a registrar Also at some hospitals patients referred by general practitioners for acute admission were seen in the A amp E department before going to a ward While having to hold patients sometimes caused

clogging in the department A amp E staff were generally satisfied with the procedures

22

REfERENCES

1 WEINERMAN E Richard RUfZEN S Robert and PEARSON David shyEffects of medical -triage- in hospital emergency service in Public health reports - v 80 no 5 (May 1965) p 389-399

2 Accident and emergency departments a study of planning requirements prepared by the Hospital Design and Evaluation Unit - Wellington Department of Health 1973

3 Accident and emergency services - Gt Brit National Health Service memorandum HM (68)83

4 Emergency department organisation and management edited by AL Jenkins - St Louis Hosby 1975

5 KLJAKOVIC M ALLAN B C and REINKEN J - Why skip the general practitioner and go to the accident and emergency department in NZ Med J - v 93 (1981) P 49-52

23

CHAPTER 4

Phy~i~~1 c~~raft~rhtics of accident and emergency departments

This chapter describes the physical characteristics of A amp E departments their overall size location and layout as well as specific areas within the departments It discusses the effects of the physical characteristlcs on the organisation and functioning of the A amp E departments Our investigation worked from the detailed base established in bullAccident and emergency departments a studY of planning r~quirements a report prepared by the Hospital Design and Evaluation gnit Departmellt of HeCilth [1]

PRINCIPLES

The 1973 Hospital Design and Evaluation Unit (DEU) report [l] outlined the following principles to be applied in designing A amp E departments

o the A amp E department must be patients seeking emergency care

ready to receive and deal with

o the A amp E department mus~ be able load within a reasonable period

to cope with an average i

busy

o the A amp E department must be capable of adaptation to exceptional situations arising from major accidents ltgtrqther disasters

o the layout should be simple easily unqerstood and compact

o the layout and procedures should facilitate easy flow of patients through the department

o spaces should be multipurpose to give greatest versatility

o p~tient ~ovew~n~ should be minimised )

priv~cy for patientsshould be provided as far as is practicable andconsistent with the need for supervisi0rt

SIZE

There was considerable variation in the total sizes of the A amp E -a~1-ftment~ vi~ited witll floor areas ranging from 250 sql1a~e metres to 2115 ~guare m~ties (see Table 2) Eight of the 14 departments visited had i

hhid1pgw~fd~oracUte admitting ward However even wt)en ~he area of th~ f~ ~ bull ~middotc1~A~- _ ~ - bull bull ~

AampE department WCiS adjusted for the presence of a holding ward this I~1-getv~-rH~tion in irea reniained

24

TABLE 2 AREAS OF A amp E DEPARTMENTS

Total area Holding ward Adjusted total Waiting room area areal area

sqm sqm sqm sqm

Full-time departments

Urban Auckland 2 115 225 1 890 55 Middlemore 1 045 140 905 50 Green Lane 960 240 720 70 Wellington 575 190 385 75 Hutt 270 270 30 Christchurch 470 470 40 Dunedin 635 90 545 20

Provincial Rotorua 515 20 495 90 Taranaki Base 720 90 630 40 Timaru 605 70 535 80

Rural Whakatane 430 430 20 Grey 310 310 15

Part-time departments

Suburban North Shore 255 255 30 Kenepuru 540 540 30

1 Adjusted total area = total area minus holding ward area Considerable sharing with outpatients department

The area of the A amp E department was not closely related to the attendance (see Table 3) Obviously there is a certain minimum size for an A amp E department since certain facilities are essential regardless of the attendance served Thus as would be expected the rural and to a lesser extent the provincial A amp E departments had high area to attendance ratios However even within the group of urban A amp E departments there was a fourfold difference in the total area to attendance ratio

The design at Auckland~ laid out along several corridors with many separate consulting and treatment rooms possibly contributed to its high ratio At Wellington Hutt and Christchurch hospitals staff commented on their difficulties working in cramped conditions The lack of space often forced staff to work under extreme pressure to move patients through the departments very quickly

25

TABLE 3 AREA TO ATTENDANCE RATIOS FOR ADJUSTED TOTAL AREAS 1 AND WAITING AREAS OF A amp E DEPARTMENTS BY FIRST ATTENDANCE2 AND TOTAL ATTENDANCE 2

Adjusted total area to attendance ratio Waiting area to to attendance ratio

Sqm per 1000 Sqm per 1000 Sqm per 1000 first attendance total attendance total attendance pa p a p a

Full-time departments ~

Urban Auckland 323 291 08 Middlemore 232 157 09 Green Lane 3 230 168 16 Wellington 80 69 13 Hutt 82 63 07 Christchurch 76 64 05 Dunedin 200 143 05

Provincial Rotorua 404 293 53 Taranaki Base 609 399 25 Timaru 466 266 403

Rural Whakatane 718 490 23 Grey 805 61 2 30

Part-time departments

Suburban I INorth Shore 272 148 17

Kenepuru 924 597 33

1 Adjusted total area = total area minus holding ward area

2 See Table 9 for attendance figures used in calculations

3 Considerable sharing with outpatients department

Spearman rank correlations [2] of adjusted total area with

( a) first attendance r = 0310 p gt 010 Not significant ( b) total attendance r = 0297 pgt 010 Not significant

26

LOCATION

There is broad agreement that the A amp E department should be located on the ground floor well signposted and easily accessible to ambulatory patients and ambulances The ambulance entrance should be able to handle several ambulances at once and should have adequate turning space It should be projected from the weather and screened from the view of the other A amp E department patients

The A amp E department should also be located as closely as possible to radiology facilities (either the x-ray department itself or a branch) The A amp E department and the outpatients department can share some facilities and provide additional staff and accommodation in an emergen~y

situation if they are sited together Acute patient care areas (operating theatres intensive care unitsmiddot and cardiac care units) and laboratory services should also be readily accessible from the A amp E department [134]

Entrances

Almost all of the A amp E departments visited were on the ground floor of the hospital and were well signposted Generally access for ambulatory patients was good apart from two hospitals where they had to walk up steps to enter the building o

Few departments had ambulance access which could cope with a shuttle of ambulances bringing mass casualties from a disaster There w~s little relation between the size of the department or the population served and the ease of ambulance flow Indeed those departments with a relatively low probability of being involved in a mass casualty situation had good ambulance flow (eg Whakatane) while those with a greater possibility had relatively poor ambulance access (eg Wellington) Several departments had particularly poor a~bulance flow with only a one-lane access Three departments had good drive-straight-through access while at the rest ambulances had to reverse However there were advantages to some of the bull reversing I situations in that the bays into which the ambulances had to reverse were more likely to give the patient protection from the weather All the A amp E departments visited had separate ambulance entrances which in all but three cases guaranteed screening of ambulance patients from public view

Access to other hospital facilities

In many of the hospitals the A amp E department was adjacent to the outpatients department or to the orthopaedic outpatients section When this occurred the plaster room and x-ray facilities were usually shared and waiting areas and the records office were sometimes shared In the smaller hospitals both departments often shared the nursing staff

The access to the x-ray department ranged from excellent in places which had x-ray facilities immediately adjacent to the A amp E department to very poor where the patient had to be transported hundreds of metres and to a different floor The time taken for the A amp E doctor to get the result of the x-ray varied from five minutes to over two hours though the physical separation of the two departments was only one of the factors which affected this

27

Access to acute care facilities was similarly variable In Christchurch the intensive care unit was adjacent to the A amp E department while in Rotorua it was at the other end of the hospital In many cases additions or alterations to the hospital buildings and changes of function of certain areas have meant that the A amp E department no longer bears the same physical relationship to other hospital departments as was originally the case

LAYOUT

Several studies have concluded that the A amp Edepartment should be designed so that there is an orderly progression of patients from registration to examination to investigations if necessary to treatment and to referral admission or discharge Staff time and effort is best conserved by a compact plan with waiting areas and treatment areas easily accessible and supervised However the need for easy supervision has to be balanced by consideration of the patients privacy Two basic A amp E plans have evolved

o a radial plan where the waiting examination and treatment rooms are arranged on the perimeter of the departmentmiddot with the nurses station doctors room and records office in the centre

o a linear plan where the examination and treatment rooms are arranged down each side of a corridor with the waiting area records office and staff offices at one end [145]

Many of the A amp E departments visited had a linear layout with the largest Auckland being arranged along several corridors In these departments staff often commented that their overall view of the patients was not good and a considerable amount of walking was needed to supervise them Middlemore A amp E department and the treatment areas of several other departments had radial layouts which staff found very satisfactory Generally the A amp E staff prefer red open plan layouts using curtained cubicles rather than enclosed rooms Staff (especially nursing staff) often commented that their department would be better if certain walls or partitions were removed to give easier surveillance of the department as a whole However staff also commented on the relative lack of privacy for patients being examined or treated and noted that some private rooms were needed for instance for obstetric or paediatric patients

Waiting area

There is general agreement that the waiting area should be adjacent to the reception desk easily visible to the receptionist and if possible overlooked by the nurses office or station It should be a cheerful comfortable area with toys provided for children and a range of magazines and books Public toiletspublic telephones and arrangements for refreshments are also needed [146]

The size of the waiting area varied considerably among the A amp E departments visited (refer back tomiddot Table 2) Again this variation bore little relationship to the workload of the department (see Table 3) Some waiting areas were clearly too small and this put pressure on the staff to deal with patients quickly in order to clear the waiting room

28

Staff comments suggested that not only the size of the waiting area but also its design affected its crowding Basically square rooms with seats around the edges had fewer problems than corridor-style rooms with only one row of seats

In all the A amp E departments visited the waiting areas were adjacent to the reception area Sometimes they were visible from the nurses office or work area but where this was not possible the nurses relied on the receptionists to alert them to urgent cases or checked the wai Hng area often themselves

Facilities in waiting areas varied from nothing but seats to areas in which there were hot and cold drink dispensing machines a childrens play area with toys and health-related poster and pamphlet displays Some had a TV set or a tropical fish tank Most staff were agreed that a pleasant atmosphere in the waiting room was important and adVerse comments about the waiting area were made by staff in departments which lacked this In some departments staff commented that vandalism made it difficult to retain facilities and a pleasant atmosphere

Examination and treatment area

The examination and treatment area provides for the needs of all A amp E patients other than those with serious conditions requiring the resuscitation room or those needing special facilities such as plastering Because special purpose areas are frequently under-utilised flexibility is a key requi rement Hence multipurpose cubicles with standardised equipment are usually recommended The cubicles must be big enough to give easy access for patients (not necessarily walking) to accommodate eqUipment and to give staff enough room to work Curtained cubicles are generally sufficient but at least one enclosed cubicle is required for patients needing extra privacy or for light control in eye examinations A cubicle especially set up for children (with appropriately-sized equipment toys and posters) is also desirable [1346]

Most of themiddot A ~ E departments visited had curtained cubicles in the examination and treatment area with perhaps one or two enclosed cubicles or rooms as well Four A amp E departments only had separate rooms for treatment Curtained cubicles made for ease of access while separate rooms did present some difficulties in manoeuvering patient trolleys and wheelchairs In one case it was impossible to get a patient trolley into the room at all and the room was consequently little used

Curtained cubicles did afford greater flexibility in use and did provide more room to work but had the disadvantage of being considerably less private than rooms Surveillance was easier in departments with curtains than those withmiddot walls and doors In the Auckland A amp E department treatment rooms doors had been removed in the interests of improved surveillance Staff in this department commented that its rigid design could lead to difficulties in accommodating a large number of patients in a disaster

The DEU report [1] recommended that the number of cubicles required by an A amp E department was NIlS where N is the anticipated average number of new patients per day It noted that in A amp E departments with few new patients per day a minimum of two cubicles should be provided It also recommended that the flow of recalled patients should be regulated so that they did not greatly affect the need for cubicles

29

As can be seen from Table 4 most departments had enough cubicles to cope with their first attendance workload Even applying the DEU recommendation of N18 to their total attendance most of the departments had an adequate number of cubicles The exceptions were Hutt Christchurch and Dunedin

TABLE 4 NUMBERS OF EXAMINATION AND TREATMENT CUBICLES OR ROOMS AND RECOMMENDED NUMBERS l BASED ON FIRST ATTENDANCE 2 AND TOTAL ATTENDANCE 2

Actual number of DEU recommended numbers (minimum of 2) cubiclesrooms based on

first attendance total attendance pa pa

Full-time departments

Urban Auckland 13 89 99 Middlemore 9 59 88

Green Lane 7 40 65 Wellington 10 73 85 Hutt 4 51 66 Christchurch 7 94 11 2 Dunedin 3 41 58

Provincial Rotorua 4 2 26 Taranaki Base 4 2 24 Timaru 6 2 31

Rural Whakatane 3 2 2 Grey 3 2 2

Part-time departments

Suburban North Shore3 8 22 37 Kenepuru3 6 22 30

1 Based on DEU report [l which recommended NIS cubicles where N average number of new patients per day ie N6750 where N = average first attendance pa

2 See Table 9 for attendance figures used in calculations

3 Recommended numbers increased to adjust for North Shore and Kenepuru treating their attendance numbers in part-time rather than full-time hours

30

Resuscitation area

The resusciation area is used for the immediate life--saving treatment of seriously injured or sick patients It is the acute treatment area in contrast to the examination and treatment area which is used for relatively minor procedures In making its recommendations about the resuscitation area the DEU report [I] balanced the probability of the A amp E department having to treat multiple accident victims with the comparative rarity of use of resuscitation rooms It recommended that a resuscitation room of suff icient size to deal with two patients concurrently be provided in all A amp E departments It also noted that the ambulance entrance and resuscitation area should be located as close together as possible

Most of the departments visited had purpose-built resuscitation rooms of varying size and with varying degrees of sophistication in equipment Some had x-ray facilities in the resuscitat ion area and in those that did not its absence was regarded as a serious impediment to the efficient care of severe trauma

In four of the seven urban A amp E departments the resuscitation rooms were regarded by the staff as being too small The comment was made in one urban department that because of the small size of the resuscitation area patients sometimes had to be moved out of the area before it was felt clinically desirable to do so in order to accommodate incoming patients In the rural and prOVincial A amp E departments the resuscitation rooms wereshyadequate for the demands placed on them

Most resuscitation rooms were sited close to the ambulance entrance and afforded good access to stretcher patients However in three A amp E departments patients had to be moved some distance and in another department up one floor by lift

Operating theatre

In discussing provision of operating theatres in the A amp E departments the DEU report [1] noted that

o most surgery done is minor requires only local anaesthesia and could be done within adequately designed cubicles

o the A amp E department is not a proper place for general anaesthesia

o using A amp Etheatres for day surgery tends to block other A amp E facilities and staff causin~ delay in treating A amp E patients

The report concluded that special facilities appear to be justified only if there is a clear intention of widening the scope of accident surgery in the departments

bullMinor ops theatres of varying sizes and equipped to varying standards were available in many departments Very variable use was made of such theatres - never in some departments to daily in others It was used less in departments with very heavy workloads and where the medical staff were not satisfied that sufficiently sterile conditions could be maintained In one department the theatre was only used for day surgery cases

31

Plaster room

In the plaster room casts are applied and removed and fractures and dislocations can be manipulated The DEU report [1] noted that the plaster room could be an integral part of the A amp E department or shared with the orthopaedic department or belonging entirely to the latter It recommended that the plaster room be close to the A amp E department and the x-ray department

Most departments had a separate plaster room available In many cases this was shared with an adjacent orthopaedic outpatients or fracture clinic Th~ staff generally found the plaste~-rooms satisfactory although two particularly narrow rooms were difficult to work in

Interview room

The DEU report [l] recommended that A amp E departments in medium-sized and larger hospitals should have a small interview room where a patient IS

relatives could talk with A amp E staff the police or others

No A amp E department had a room specifically designated as an interview room for bereaved or distressed relatives although one A amp E department shared such a room with another department In most departments one of the staff off ices was generally used for this purpose In departments where staff offices were small or crowded the lack of an interview room was seen as a serious flaw in departmental layout

Reception and records office

The reception desk should be immediately visible to ambulant patients arriving at the A amp E department and it is desirable for the receptionist to be aware of what is happening at the ambulance entrance as well The current A amp E records should be held at the reception desk or nearby [1]

In the A ampE departments visited the reception desk was usually well-placed for dealing with ambulant patients but in only four cases did it overlook the ambulance entrance In two departments the reception desk was some distance from the treatment area (separated by a waiting room or outpatients room) and the nursing staff found it difficult to oversee incoming patients Current A amp E records were held at the reception desk in all but one of the departments visited The amount of space available in relation to the throughput of patients was a major factor in determining the length of time records could be kept within the department This in turn affected the ease and therefore speed of record retrieval

Staff offices

These ranged from non existent to very cramped spaces serving many other functions to pleasant specifically designated and relatively quiet areas The latter offices are conducive to good staff morale and being a place for exchange of views and experiences could be expected to contribute quite markedly to the overall effectiveness and eff iciency of the department

32

Holding ward

The DEU report [1] said that holding beds should be used primarily for A amp E patients requiring a period of observation prior to a decision about admission or for those who could be expected to go home after a rest period The report noted that using holding beds as recovery beds for day patients for arranged admissions or for pre-admission clinics was not desirable

Most of the urban and provincial A amp E departments visited had holding or acute admitting wards These holding wards were used mainly for assessing patients requiring acute admission but in some hospitals were also used for observing patients (eg with suspected concussion) and for holding night admissions till the morning to save disturbing the wards Neither of the rural A amp E departments had a holding ward although one had an I A amp E admission procedure where a patient could be admitted for up to 24 hours for observation without the need for full admission procedures In the A amp E departments with holding wards a patient staying for more than four hours was formally admitted

Our study showed that the A amp E departments had some problems using holding wards properly In two A amp E departments holding wards were little used at night because nursing levels were too low to staff them safely In another department the beds were used for patients recovering from day surgery and even for some pre-ar ranged admissions At times general practitioner-referred admissions could also clog the holding wards

DISCUSSION

Most of the A amp E departments were generally adequate in size location and layout The exceptions were Christchurch and Butt where conditions were very cramped with particularly limited examination and treatment areas and poor layout We understand that improvements are planned at Hutt and that recent extensions have improved the Christchurch department considerably but at the time of our visits staff in both these departments were working under extreme pressure because of the physical conditions

Despite the general adequacy of the departments almost all had some flaw which affected their operation and inconvenienced staff and patients Major flaws found in several A amp E departments included

o ambulance access unsuitable for a shuttle of ambulances in a disaster

o difficult access to the x-ray department

o resuscitation room too small for easy treatment of more than one patient at a time

o no interview room for relatives of patients

33

REFERENCES

1 Accident and emergency departments a study of planning requirements prepared by the Hospital Design and Evaluation Unit - Wellington Department of Health 1973

2 SIEGEL Sydney - Nonparametric statistics for the behavioural sciences - Tokyo McGraw-Hill Kogakusha 1956 p 202-213

3 Emergency services the hospital emergency department in an emergency care system Chicago American Hospital Association 1972 p 44-49

4 Emer~ency department organisation and management edited by A L Jenkins - St Louis Mosby 1975 p 8-16

5 Design of departments in Br Med J - v 2 (1979) p 1204-7

6 McKINLAY Robin - The care of children in New Zealand hospitals -Aucklandmiddot National Childrens Health Research Foundation 1982 p 79-80

35

CHAPTER 5

Staffing of accident and emergency departments

This chapter describes the staffing both medical and nursing looking at their numbers and experience their previous training and the training they receive in the A amp E department and their satisfaction with their work and conditions We also describe the clerical and reception staff and briefly the involvement of other workers (orderlies social workers and ambulance personnel) in the departments

MEDICAL STAFFING

Senior medical staffing

Organising appropriate medical staffing for hospital emergency services is a prQblem in many countries [1] The variety of staffing arrangements in A amp E departments within many countries suggests that none have established a generally satisfactory pattern of medical staffing

The Platt report [2] found that in Br itish A amp E departments the great majority of patients were seen by junior staff only and that supervision of the A amp E departments by conSUltants was often little more than nominal The committee recommended that

o the junior medical staff should be adequately supervised by consultants

o a consultant orthopaedic surgeon should normally be in charge of theA amp E unit

o an accident and emergency unit should have at least three consultant surgeons each giving a substantial part of their time to this work

o the primary task of general practitioners in emergency services is to deal with minor accidents and emergencies at any time of the day or night (by organising a rota to answer emergency calls within their practice by working sessions in A amp E departments or by attending cottage hospitals at short notice for emergency calls) bull

Since then some progress has been made but standards continue to lag behind those recommended [34] There has been considerable debate over the appropriate staffing arrangements for A amp E departments Some hospitals have implemented the Platt report recommendations others have appointed a full-time A amp E specialist others have employed a full-time non-specialist doctor and some have employed general practitioners

Despite the various systems there is a consensus in both the United States and Britain that experienced medical staffmiddot are essential in the A amp E department They are necessary for prompt effective treatment of emergency conditions for efficient running of the departments and for adequate supervision of the junior doctors employed [23567 p 17-23]

36

Similar concerns have been expressed in New Zealand since the Board of Health report on outpatient services in 1960 [8] This report recommended that general hospitals continue to provide a casualty service available at all times and staffed by experiencedmedical officers

Salmond [9] found that when a senior A amp E officer directed the department A amp E work was handled more efficiently and house surgeons were more closely supervised and supported He suggested that one senior member of the hospital staff (ideally a full-time A amp E officer) should accept full responsibility for the overall supervision of A amp E services

Most of the A amp E departments that we visited had an A amp E officer The position was vacant at both Wellington and Hutt hospitals at the time of our visit while at North Shore Hospital responsibility for the A amp E department was shared by two senior doctors The A amp E departments of the rural hospitals had no senior medical staff

In A amp E departments with heavy workloads additional experienced doctors were often employed as deputy A amp E officers usually medical officer special scale or as Medical Reserve Scheme registrars (see Table 5) There was no general practitioner staffing of any of the Aamp E departments visited although general practitioners had been part-time staff of some of themiddot smaller A amp E departments in previous years One medical superintendent commented that since very few general practitioners could be classified as specialists they could only be paid as medical officers special scale This low level of payment acted as a disincentive to general practitioner recruitment

The A amp E officers usually worked normal office hours (830 am - 430 pm or 9 am - 5 pm weekdays) apart from two who worked part-time covering morning periods If additional experienced doctors were employed they usually covered evening periods (eg 5 pm - 10 pm) and weekend day shifts

There was a wide range of experience among the A amp E officers Half of the senior A amp E doctors had a general practice background and these doctors often had specific surgical medical pharmacological or Armed Forces medical experience as well Several A amp E officers had primarily a surgical background while others had a considerable range of hospital experience In hospitals where the A amp E officers had a general practice background the Medical Superintendent or the A amp E officer often stressed the suitability of this background for A amp E work

An extensive general practitioner background is useful in dealing with the multitude of problems seen in an Accident and Emergency department An orthopaedic or surgical background is not as necessary because of the good backup from the specialties And staff who have only had hospital experience particularly junior staff can lack skills in general assessment and triage

A amp E officer

In other hospitals staff stressed that an orthopaedic and surgical background was very valuable as was experience in dealing with specific types of injury such as soft tissue wounds

37

TABLE 5 MEDICAL STAFFING OF A amp E DEPARTMENTS

Full-time departments

Urban Auckland Middlemore Green Lane Wellington2

Hutt2

Christchurch Dunedin

Provincial Rotorua Taranaki Base Timaru

Rural Whakatane Grey

Part-time departments

Suburban North Shore Kenepuru

Senior medical staffing

Number of full-time equivalents

A amp E officer ( including deputies) 25 15 I 16

I 2

I 03 I

2 05

Registrar

06

1 1

House surgeons

Number on Number A amp E runs covering

some shifts in A amp E deptl

6 2-3 6 2 5 I 5 4 2-3 5 2 2

All on rotating basis 1 3 1 2

5 on rotating basis 4 on rotating basis

None in A amp E dept 4 on rotating basis

1 On general relieving duties 2 Senior A amp E position vacant at time of visit

Junior medical staffing

The issues

Junior medical staffing of A amp E departments has concerned many commentators in the United States Britain and New Zealand The Platt report [2] noted that recently qualified staff when serving in the casualty department undertake responsibility which they would not have in the wards or outpatient clinics

38

In 1960 the New Zealand Board of Health report [8] on out-patient services deplored the staffing of casualty departments by I relatively inexperienced men [sic] and suggested that these staff I should be regarded more as assistants under supervision and training than responsible officers in the outpatients departments The undesirability of staffing A amp E departments with first year house surgeons (or pre-registration doctors) has been reiterated since Junior doctors are often unsure when to ask for advice or help and are sometimes unwilling to admit that they are over-tired and unable to cope [91011)

The report on the working conditions of New Zealand resident medical officers [12] noted the heavy load carried by house surgeons working long shifts in A amp E departments It also commented that when house surgeons are required to look after the A amp E department while carrying out ward duties inadequate cover of the A amp E department could result

The New Zealand situation

The urban A amp E departments had between two and six house surgeons working on three month A amp E runs and in several of these hospitals another one to three house surgeons on general relieving duties covered some A amp E shifts There were more house surgeons in A amp E departments with heavier workloads or with fewer senior medical staff The provincial and rural departments did not usually have house surgeons working on specific A amp E runs rather the A amp E department was covered by all (or most) of the house surgeons in the hospital on a rotatng basis Of the two suburban A amp E departments Kenepuru was covered by the house surgeons on a rotating basis while North Shore did not have any house surgeons because there was no inpatient or consultative backup available (see Table 5)

The total medical staffing of the departments (senior A amp E doctors and house surgeons together) ranged from 10 to 100 full-time equivalents and was closely related to the attendance at the departments (see Table 6) The provincial and rural A amp E departments had higher medical staff to attendance ratios because they had to provide a 24-hour service regardless of the size of the attendance

Each A amp E department visited rostered its house surgeons differently depending on the availability of senior medical staff the workload of the department and the house surgeons other duties In the urban departments house surgeons worked between 45 and 60 hours a week on shifts usually 8 to 12 hours long Many of the house surgeons working in these departments complained about long shifts and suggested that more staff were needed to reduce the shift lengths Split shifts were also unpopular

The most worrying aspect of the staff ing arrangements in bhe Accident and Emergency department is the long hours We need another house surgeon to reduce the hours on some shifts and to proviae another pair of hands in busy periods (eg Friday and Saturday night Sunday afternoon)

House surgeon

39

TABLE 6 TOTAL MEDICAL STAFFING (FULL-TIME EQUIVALENTS) AND MEDICAL STAFFING TO ATTENDANCE RATIOS FOR FIRST ATTENDANCE I AND TOTAL ATTENDANCE 1

Total medical Total medical staffing to staffing attendance ratio

FTE per FTE per 10000 first 10000 total

Full-time attendance attendance equivalents p a pa

Full-time departments

Urban

Auckland2 100 17 15 Middlemore2 91 23 16 Green Lane2 65 25 15 Wellington 66 14 12 Hutt2 55 17 13 Christchurch 70 11 10 Dunedin2 60 22 16

Provincial Rotorua 42 34 25 Taranaki Base2 28 27 18 Timaru 22 19 11

Rural Whakatane3 15 25 17 Grey 10 26 20

Part-time departments

Suburban North Shore 20 21 12 Kenepuru3 20 34 22

1 See Table 9 for attendance figures used in calculations 2 FTE estimated since A amp E department partially covered by house

surgeons on general relieving duties 3 FTE estimated since A amp E department covered by house surgeons on

rotating basis

Spearman rank correlations [131 of total medical staffing with

(a) first attendance r = 0953 p lt 001 (b) total attendance r = 0933 p 001

In the provincial and rural hospitals house surgeons were often on call for long shifts over nights and weekends They were usually covering a ward or the whole hospital at the same time and simultaneous demands from the wards and the A amp E department sometimes caused problems However

40

these house surgeons generally found their rostering satisfactory despite the long hours on call perhaps because the actual work required in the A amp E department was comparatively light

An ordinary week night is usually quiet after midnight thered be three to five calls and Id have to get up once on average Weekend nights are busier but I usually get at least two or three hours sleep

House surgeon

Several house surgeons were irritated that while they worked more intensively on A amp E runs than on ward runs they spent fewer hours on-call and consequently they were paid less

Supervision by senior medical staff

In the larger A amp F departments house surgeons worked with the senior medical staff on most day and some evening shifts only on night shifts (and some evening shifts) were house surgeons the sole medical staff in a department By contrast in the smaller and part-time departments house surgeons covered the department alone seldom working with any senior A amp E medical staff

Several nurses commented that the A amp E department ran less efficiently outside normal working hours because the house surgeons inexperience meant assessment and treatment times were longer and tests were used more often than when the A amp E officer was present

Many senior medical staff in the urban A amp E departments were concerned at the lack of supervision for house surgeons outside normal working hours and so would have Ii ked more senior A amp E staff Several of the house surgeons were also concerned although others enjoyed the autonomy they had and were not concerned about working without supervision

I am not happy with house surgeons managing the A amp E department on their own They only have a three month shift in the department and often most of this time is spent learning how to do A amp E wor k The house surgeons can have problems deciding when to call a registrar to treat a patient and there can be delays in obtaining a registrar The A amp E department needs full-time trained medical staff on duty 24 hours a day to give proper supervision to the house surgeons and to run an efficient department

A amp E officer

On night shift I can feel rather alone if something goes wrong

House surgeon

I enjoy the variety of work and the independence I have to treat most patients as I see fit

House surgeon

41 _A

Arraflgements for consultative backup and support when senior A amp E staff were not on duty varied from hospital to hospital according to hospital size n urban hospitals the house surgeons would usually call on the appropriate registrar and the acute admitting or specialist teams for emergencymiddot cases In some places the house surgeons could calIon the consultant if a registrar was unavailable but this was usually seen as a last resort call In the provincial and rural hospitals the house surgeons would call on the appropriate senior doctor who was available This was usually one of the cQnsultants or a registrar if any were employed by the hospital The A amp E Qfficer might occasionally be called and in hospitals without an A~amp E oHicer th~ medical superintendent would also provid~ backup

Generally house surgeons were happy with the support they received A physically compact hospital was mentioned several times as facilitating ~ ~ fast back-up Howeve( in some hospitals there could be considerable delays in 9etting surgical and orthopaedic registrars to the A amp E department usually because they were in theatre Also at two hospitals backup in the minor specialties was considered inadequate bull

Use of first year house surgeons

Urban and suburban hospitals had a policy of using second year house surgeons as much as possible in the A amp E department and of using first year house surgeons only in their second six months This policy was generally butmiddot not always carried out For example the on-call arrangements of some urban A amp E departments resulted in inexperienced first year house surgeons working in the department In the smaller hospitals also the limited pool of house surgeons available tended to result in more first year house surgeons working in the department

The hospital could not provide cover for the A amp E department without using first year house surgeons However there are always senior staff and the medical registrar readily available as backup

Medical superintendent

When direct supervision was limited first year house surgeons did find A amp E work difficult

Training

The training received by the house surgeons in the A amp E departments varied greatly Two hospitals ran half-day or one-day orientation courses before -house surgeons started in the department Three A amp E departments ran weekly or fortnightly training sessions on specific conditions while another department ran sessions on an irregular basis However house surgeons often missed training sessions because they were treating pat~entsln more than half tmiddothe A amp E departments no formal training was giVen and house surgeons were taught on-the-job when senior A amp E staff were available This teaching placed a considerable load on senior staff

The three-monthly changeover of house surgeons is frustrating and the first month with new house surgeons is very demanding because they have little confidence or competence

A amp E officer

ACKNOWLEDGMENTS

Many people have helped with this study In particular we would like to thank

o John Mills who visited the hospitals drafted the physical characteristics chapter and gave freely of his time and expertise

o the staff of the hospitals visited for sharing their time and thoughts with us

o Desmond Keenan Shelagh McRae and Denis Snelgar for allowing us to use the information they had collected

o Clare Salmond Mike Moore and Sylvia Nichol for their assistance with computer analysis

o readers ofmiddot drafts of this report who offered helpful criticism and suggestion

o the typists and publication staff of the Department of Health

We also acknowledge the Director-General of Health for permission to publish

DISCLAIMER

The views expressed in this report are those of the authors and do not necessarily represent the views of the Department of Health

COPYRIGHT

Provided the source is acknowledged information contained in this report may be freely used by any person

CONTENTS

Page

ACKNOWIEDGEMENTS LIST OF TABLES LIST OF FIGURES

1 INTRODUCTION I

Background Thewider questions of emergency medical services The overseas situation An historical perspective in New Zealand

Interview studies on the utilisation of A amp E departments Record studies on the utili satjon of A amp E departments Studies of the organisation of A amp E departments

Overview of this study Aims Sources of information

References

2 DEFINITIONS 11

The Accident and Emergency department Attendance The hospitals Recording systems References

3 PROCEDURES IN THE ACCIDENT AND EMERGENCY DEPARTMENT 15

Entry Sorting 1 reatmen t Disposal Follow-upcare Admissions Discussion References

4 PHYSICAL CHARACTERISTICS OF ACCIDENT AND EMERGENCY DEPARTMENTS 23

PrinCiples Size Location

Entrances Access to other hospital facilities

Layout Waiting area Examination and treatment area Resuscitation area Operating theatre Plaster room Interview room Reception and records office Staff offices Holding ward

Discussion References

5

6

7

8

STAFFING OF ACCIDENT AND EMERGENCY DEPARTMENTS 35

Medical staffing Senior medical staffing Junior medical staffing Accident and emergency work as a career

Nurse staffing Other staff involved with the A amp E department

Reception and clerical staff Orderlies Social workers Ambulance personnel

Discussion References

PATIENT ATTENDANCE CHARACTERISTICS 55

Overall attendance and trends Age and sex Conditions

Injury conditions Sickness conditions

Recall attendance GP-load

Non-urgent sickness Discussion References

PATIENT ATTI~UDES TO THE ACCIDENT AND EMERGENCY DEPARTMENT AND STAFF ATTITUDES TO THE PATIENTS 75

Reasons for visiting the A amp E department Overseas studies New Zealand studies

Effect of health centres and deputising services on A amp E utilisation A amp E staff views of patients

Overseas studies The New Zealand situation

Discussion References

UTILISATION OF ACCIDENT AND EMERGENCY DEPARTMENTS 91

Comparison of A amp E utilisation among hospital catchment areas Results Effect of general practitioner availability

Factors explaining catchment area variations in A amp E utilisation Method Results of the mUltivariate analyses

Comparison of A amp E use and general practitioner use Discussion References

9 CONCLUSIONS 107

The A amp E department as a hospital department The A amp E department as an emergency service The A amp E department as a primary care service Where from here

APPENDICES

APPENDIX A QUestion sheets 116

APPENDIX B Accident and emergency department records 120

APPENDIX C Statistical analyses of accident and 123 emergency department attendance rates by neighbourhoods

APPENDIX D Childrens use of general practitioners 128 and accident and emergency departments in Wellington

TABLES

Table

1 Proportion of first attendance patients discharged recalled referred or admitted

2 Areas of A amp E department~

3 Area to attendance ratios for adjusted total areas and waiting areas of A amp E departments by first attendance and total attendance

4 Numbers of examination and treatment cubicles or rooms and recommended numbers based on first attendance and total attendance

Medical staffing of A amp E departments

6 Total medical staffing (full-time equivalents) and medical staffing to attendance ratios for first attendance and total attendance

7 Nurse staffing of A amp E departments excluding student nurses and hospital aids

Nurse staffing (full-time equivalents) and nurse staffing to attendance ratios for first attendance and total attendance

Average attendance at A amp E departments 1978-1981

10 Trends in attendance at A amp E departments 1978-1981

11 Proportion of A amp E attendance that was recall attendance

12 Proportion of A amp E attendance that was for sickness

13 Proportion of total A amp E attendance that was for Sickness by policy and age groups

14 Use of general practitioners by first attenders at A amp E departments

15 Reasons for A amp E first attendance from three New Zealand studiesmiddot

Itgt Attendance (mean age-adjusted rates per 1000 per quarter) within each A amp E department catchment area

Page

18

24

25

29

37

39

45

46

56

57

66middot

70

71

77

78

92

(continued)

Table Page

17 Hospital admissionsfor accidental injury (mean 93 age-adjusted rates per 1000 per year) and death due to accidental injury (mean age-adjusted rates per 1000 per year) within each A amp E department catchment area

IB Attendance (mean age-adjusted and neighbourhoodshy 99 adjusted rates per 1000 per quarter) and populationshyto-general practitioner ratio within each A amp E department catchment area

19 Comparison of first attendances for injury at A amp E 101 departments and general practitioners

FIGURES

Figure Page

1 Percentage of total attendance at 58 A amp E departments by age and sex

2 Percentage of total attendance at 59 A amp E departments for sickness and injury conditions by age and sex

3 Injury first attendances by type of injury 6U all ages

4 Injury first attendances by type of injury 61 by age groups

5 Sickness attendances by type of sickness 62 all ages

6 Sickness attendances by type of sickness 63 by age groups

7 Comparison of medical staff availability and 67 level of recall attendance

Comparison of nursing staff availability and 67 level of attendance

9 Location at which accidents happened by those 79 attending the A amp E department or the general practitioner for accidental injury

Use of general practitioners and A amp E departments 131 by Wellington children 1978 (rates per 1000 children per quarter)

1

CHAPTER 1

Introduction

BACKGROUND

This report arises f rom concerns expressed by several groups about the availability especially out of hours of emergency car~ and its provision by Accident and Emergency (A amp E) departments in New Zealand

In _SQe mid 1970 s the people of Porirua were worried that local general -pr-actitioners were not available at nights and weekends and by the delays

involved in travelling to Wellington and Hutt A amp E departments [IJ At the same time the people of North Shore were campaigning to keep their local A amp E department open More recently community groups in Upper Hutt have been pressing for the addition of an A amp E service to a local health centre Overall people are concerned that appropriate care (including facilities such as x-rays) is readily available in emergency situations

General practitioners are another group who have been concerned about A amp E departments in particular about inappropriate uses of A amp E departments A long-standing complaint bas been that patients are using A amp E departments for care which wou~d be better given by a general practitioner and that the A amp E departments retain patients instead of referr ing them back to their general practitioner for follow-up care [2 3J In 1981 the research group of the Wellington Faculty of the Royal NZ College of General Practitioners sponsored a study of children presenting at A amp E departments because they were worried that unnecessary admissions of children to hospital occurred because their parents had bypassed the general practitioners and gone straight to hospital [4J

Also A amp E staff and hospital administrators have been concerned that caring for patients who could have been treated by general practitioners has limited their ability to deal with emergency cases [567]

THE WIDER QUESTIONS OF EMERGENCY MEDICAL SERVICES

Emergency care requires not only the provision of hospital services (the A amp E department with back-up from other hospital facilities) but also the organisation of services outside the hospital and co-ordination between both sets of services Emergency medical services outside the hospital include alarm and communication systems transport systems and first aid services There are important questions for New Zealand within this framework For example what should be the role of general practitioners in on-site emergency care What level of training is appropriate for ambulance officers Should voluntary personnel staff ambulances To what extent is double manning of ambulances required [8910]

In order to limit the study to manageable proportions this report focusses only on the hospital services namely the A amp E department Emergency medical services provided outside hospitals are mentioned only where they impinge noticeably on the A ampE department It is hoped that due attention will be given to the wider questions of emergency medical services in the future (see Chapter 9)

2

THE OVERSEAS SITUATION

Concern with emergencymiddot care facilities especially their increasing use has been apparent in other countries for the past thirty years While some articles report on the situation in Canada Australia Sweden France and the USSR most of the literature is about the United States and Britain This section briefly outlines the major themes of the literature and their relevance to New Zealand More specific aspects are covered in the appropriate chapters

Many United States researchers have studied the operations of different emergency rooms exploring patients reasons for using the emergency room their demographic characteristics and their use of the family doctor Often the studies have tried to explain an increasing use of emergency rooms and some have reported on the effectiVeness of measures introduced to reduce thei r use These studies provided models for some of the analyses carried out in this study However the debate in the United States over appropriate methods of funding and staffing for emergency rooms is seldom relevant to New Zealand because of the differences both in philosophy and organisation of medical care in the two countries

The Platt [11] committee on A amp E services in Britain in 1962 was concerned about casual attenders ie patients not in need of urgent attention but wishing to avoid the trouble of attending their general practitioners surgery They also criticised the unsuitable accommodation and the insufficient numbers of senior medical staff supervising Casualty Departments The report recommended changing the name Casualty Service to Accident and Emergency Service (to discourage casual attendance) and rationalising the service by clOSing smaller A amp E units and centralising facilities These recommendations have been partially carried out

However there has been continuing research in Br i tain into the reasons given by patients particularly self-referred patients for their use of A amp E departments and the trade-off between general practitioner and A amp E services There has also been continuing debate over the medical staffing of A amp E departments

The British studies are of some relevance to the New Zealand situation since the organisation of medical care here is similar but no overseas experience can provide a blueprint for New Zealand For example the direct cost to the patient of general practice care in New Zealand raises the possibility of patients attending the A amp E department because it is free whereas the British system of general practitioner funding provides no such incentive

AN HISTORICAL PERSPECTIVE IN NEW ZEALAND

Little is known about the historical development of A amp E services in New Zealand Presumably they followed the British tradition described in the Platt report [11 p23-24)

The word casualty in its proper meaning of a serious injury has a long history It occurs in Shakespeare and Dickens writing in 1837 used casualty ward to describe the ward in a hospital in which accidents were treated Unfortunately the meaning alt~red in the second half of the last century The Nuffield Report (1960) Casualty Services and their Setting

3

gives an interesting quotation from a survey made by the Lancet in 1869 The out-patients at St Bartholomews Hospital are it says divided into two categories They are the middotcasualtymiddot which comprises those who are supposed to require temporary treatment for diseases or injuries of a trifling character and the middotout-patientsmiddot properly so called who after receiving a regular letter of admission are entitled to the advice of the assistant surgeons and physicians for a period of 12 months It is in the casualty division that the increase of numbers has been most marked bullbullbull It is estimated that not less than a thousand patients frequently attend on a Monday or Tuesday morning

Certainly by 1872 vlellingtons private medical practitioners were incensed at the hospitals provision of free treatment for their patients Five hundred outpatients were treated in Wellington that year [12] Separate casualty departments were operating at Wellington Hospital by 1924 [12] at Auckland Hospital by the 1940s [13] and Christchurch Hospital by 1952 [14]

The 1960 Board of Health report [15] on outpatient servicesmiddot expressed concern over the duplication of services by outpatient departments which were also available from general practitioners However it recommended that general hospitals continue to provide a casualty service available at all times

Since the late 1960s a series of New Zealand studies have considered the use of A amp E departments either by interviewing patients or by analysing data drawn from A amp E record systems and the organisation of A amp E departments

Interview studies on the utilisation of A amp E departments

The first interview study was an investigation of first attenders at the Dunedin A amp E department in 1968 by Dixon et al [2] Their results have not been contradicted by any of the later studies

They found that the principal attenders were males aged 15 to 24 who recorded first attendance rates of over 100 per 1000 each year The young men were also the most likely to report having no general practitioner Dixon found that the age and sex pattern of those attending at the A amp E department was nearly converse to the pattern of those attending a general practitioner

Dixon pointed out that the conditions treated at the A amp E department were rarely disease-related rather they were predominantly lacerations and open wounds bruising sprains and strains effects of foreign bodies and fractures The major reason given for attending the department was that it was seen as appropriate

Dixon concluded that the A amp E service was complementary and not competitive to general practice that the public were realistic in regarding it as the only practical and effective primary medical care for accident and emergency injuries and that payment for service did not appear to figure in the decision to attend the department

o

4

TwO interview studies of first attenders at Auckland Hospital A amp E department have been carried out by Hunton in 1972 and Richards in 1975 [16] Both studies included an assessment by the student interviewers and A amp E staff as to the suitability of the patients condition for general practice care 42-43 per cent were considered suitable Richards concluded that public education programmes encouraging people to use their general practitioner prior to attending the A amp E department should be instituted

In 1978 Keenan interviewed patients who had attended Christchurch A amp E department collecting detailed information on the accident or sickness leading to the attendance (unpublished see Chapter 6 and 7) He found the same set of reasons for using A amp E departments as Dixon found the A amp E department was seen as appropriate and accessible

Kljakovic found similar results when interviewing the parents of children attending A amp E departments in the Wellington region in 1978 [4] He also found that in choosing between the general practitioner and the A amp E department parents were more likely to use the service which was closer to the family home Children f rom lower socio-economic status families were more likely than other children to see thei r general practitioner before gOing to the A amp E department

Records studies on the utilisation of A amp E departments

Several studies have gathered data from A amp E records to investigate A amp E utilisation In 1979 Snelgar described the characteristics of people attending Northland Base Hospital A amp E department [17] He found similar results to Dixon apart from a higher proportion of injuries In the same year McRae reviewed all attendances at Waikato Hospital A amp E department and found a similar picture [lB]

Three records studies have looked at the relationship between A amp E use and general practitioner use Maynard looked at Mosgiel residents use of Dunedin A amp E facilities for three years before and three years after the opening of a local health centre [19] No difference was found ~asap

investigated assertions that people from one part of the Wellington Hospital catchment area had suddenly begun to use the A amp E department heavily for conditions that should have been seen by a general practitioner [20] In fact that part of the catchment area had much lower rates of A amp E use than other areas Reinken tested whether the doubling of general practitioner cover in one part of the Wellington region affected A amp E presentation rates differently than in other areas nearby [21] There was no clear evidence that the increased cover had any effect

Studies on the organisation of A amp E departments

As part of a thesis looking at young doctors Salmond examined the work of house surgeons in A amp E departments using a postal questionnaire [22J He concluded that working in an A amp E department was good experience for a house surgeon only if second year house surgeons were deployed in the department the house surgeon was well-supervised by senior medical staff there was a good working relationship with the A amp E chargemiddot nurse and the house surgeon was not over-tired He also suggested that good senior staffing was closely related to effective administration and better service in the A amp E department

5

The Hospital Design and EValuation Unit of the Department of Health prepared a report documenting the planning requirements of New Zealand A amp E departments [23] The report outlined several principles of A amp E design and made detailed recommendations on the facilities rooms and equipment necessary

OVERVIEW OF THIS STUDY

Aims

The aim of this study is to describe A amp E departments in New Zealand Because the material presented in the previous section was collected by different researchers at different times and from different A amp E

departments detailed comparisons across the studies have been difficult To get a more comprehensive picture of A amp E use in New Zealand a systematic investigation was necessary

The specific aims of this report are

o to describe the organisation of A amp E departments by looking at their procedures physical characteristics and staffing patterns

o to describe attendance at A amp E departments including the patients profile and pattern of attendance and the load placed on the departments by patients who would be more appropriately treated by a general practitioner

o to describe the use of A amp E departments by consumers by analysing patients reasons for attending the departments and analysing demographic factors inrelation to A amp E attendance

Sources of information

Information was gathered from three sources

The site visits

Fourteen A amp E departments were visited between May and September 1981 by a Department of Health study team consisting of a medical officer from the Division of Hospitals and a res~arch officer from the Management Services and Research Unit

At each hospital the team examined the facilities and spoke with staff involved with the A amp E department including

o the medical superintendent (and in some hospitals the principal nurse)

o the A amp E officer or medical officer in charge of the A amp E department (where such a position existed and was filled)

o the nurse supervisor andor charge nurse of the A amp E department

o at least one house surgeon working in the A amp E department

6

In some hospitals the team also spoke with other staff members including experienced A amp E staff nurses and hospital social workers

Question sheets were used during interviews so that a comparable body of information was collected at each hospital Interviews were open-ended to allow discussion of local procedures or problems (See Appendix A for question sheets)

Hospitals were carefully selected so that the A amp E departments in the study would represent a cross-section of New Zealand A amp E departments Those selected served a range of communities in both the North and South Islands

o major urban Dunedin)

areas (Auckland Wellington Christchurch and

o provincial centres (Rotorua Taranaki and Timaru)

o predominantly rural areas (Whakatane and Grey)

In centres with more than one A amp E department all were visited so that a complete picture of the services and use could be developed This involved visiting Auckland Green Lane Middlemore and North Shore hospitals in Auckland and Wellington Hutt and Kenepuru hospitals in Wellington

The information gathered in the site visits has been used in describing the organisation of A amp E departments (Chapters 3 4 arid 5)

The A amp E records data collection

On each site visit a sample of 1981 attendances was drawn from the A amp E record system and the following information was recorded for each person age sex presenting condition (sickness or injury) time of presentation residential address and whether the visit was a first attendance for the condition or a recall visit

Exceptions were Christchurch and the three Wellington Hospital Board A amp E departments Comparable data collected by Keenan in Ch ristchurch in 1978 and Allan in Wellington during 1980 were used instead

This information has been used to describe the attendance at A amp E departments (Chapter 6) and for the analysis of demographic factors in relation to attendance (Chapter 8)

The consumer studies

In 1978 Keenan carried out interviews with patients attending Christchurch A amp E department working from a one in eight sample drawn from the A amp E log over a four-week period and gaining a 99 response rate Results from this study have been analysed and compared with the results of the published New Zealand interview studies [2416] Anecdotal material from Kljakovic s study of children attending Wellington A amp E departments has also been included to illustrate the results of the numerical analysis

We realise that in studying only a selection of A amp E departments some local variations may have been missed but we are confident that the broad pattern and major issues in the organisation of A amp E care have been

7

covered Also as the A amp E departments studied serve two-thirds of the population of New Zealand the utilisation patterns discussed in the report are likely to prevail throughout New Zealand We hope that the mater ial presented the conclusions drawn and the questions raised in this report will encourage discussion about the current operation and future developmiant of A amp E departments in NewmiddotZealand

a

8

REFERENCES

1 de LACEY A REINKEN J and SALMOND C E - Community attitudes to sickness and health stimulus and response v 3 Community attitudes - Wellington Management Services and Research Unit Dept of Health 1980 p 103-105 (Special report series no 56)

2 DIXON C W Emery G M and SPEARS G F S - Casualty department utilisation survey in NZ Med J - v 71 (1970) p 272-279

3 [Editorial] in G P Journal of the General Practitioner Society no 42 (1981) P 1-2

4 KLJAKOVIC M ALLAN BC and REINKEN J - Why skip the general practitioner and go to the accident and emergency department in NZ Med J - v 93 (1981) P 49-52

5 SKUDDER Paul A McCARROLL James R and WADE Preston A - Hospital emergency facilities and services a survey in Emergency medical services behavioural and planning perspectives edited by John H Noble Jr et ale - New York Behavioural Publications 1973 p 17-35

6 MAYNARD Edward J - The application of epidemiological methods to the evaluation of primary medical care in a health centre environment shyUniversity of Otago 1980 Ph D Thesis Social and Preventive Medicine

7 Hospital misuse brings protest in Taranaki Daily News (1 Sept 1980) bull

8 FAHEY Morgan - The role of the family doctor in disaster and emergency medicine in NZ Family Physician - v 5 no 1 (1978) p 42-44

9 Proceedings of the emergency care seminar Auckland 19-23 March 1979 in NZ Med J - (1980) P 194-196

10 Double manning of ambulances [editorial] in NZ Hosp - v 32 no 3 (1980) p 1

11 Gt Brit Central Health Services Council - Standing Medicine Advisory Committee Accident and emergency services report of the subcommittee - London HMSO 1962 Chaired by Sir Harry Platt

12 BARBER Laurie H and TOWERS Roy J - Wellington Hospital 1847-1976 Wellington Wellington Hospital Board 1976

13 The story of Auckland Hospital 1847-1977 edited by David Scott -Auckland Medical Historical Library Committee of the Royal Australasian College of Physicians in New Zealand 1977 p 35-36

14 BENNETT FO - Hospital on the Avon the story of the Christchurch Hospital 1862-1962 Christchurch North Canterbury Hospital

o Board 1962

9

15 Outpatient services in public hospitals in New Zealand - Wellington Government Printer 196U (Report series Board of Health no 2)

16 RICHARDS J G and WHITE G R - Accident and emergency services at Auckland Hospital in NZ Med J - v 85 (1977) P 272-274

17 SNELGAR Denis - Accident and emergency utilisation study Paper prepared for the Primary Health Care Shadow Service Development Group Northland 1981 (Unpublished)

18 McRAE Shelagh and TOPPING Mark - Casualty attendances one years experience at Waikato Hospital in NZ Med J - v 95 (1982) P 12-14

19 MAYNARD Edward J and DODGE Jeffrey S - Introducing a community health centre at Mosgiel New Zealand effects on use of the hospital accident and emergency department in Med Care - v 21 no 4 (1983) p 379-388

20 KASAP D - Personal communication 1975

21 REINKEN J - Effect of changes in general practitioner cover on accident and emergency utilisation in the Porirua Basin Wellington Management Services and Research Unit Dept of Health 1979 (Unpublished)

22 SALMOND G C - Young doctors an exercise in social research methodology - University of Otago 1970 Ph D Thesis Social and Preventive Medicine p 179-214

23 Accident and emergency departments a study of planning requirements prepared by the Hospital Design and Evaluation Unit - Wellington Department of Health 1973

11

CHAPTER 2

Definitions

lhis chapter provides the definitions of terms used in our study In general our terminology is consistent with the literature However in some areas such as the classification of presenting conditions as sickness or injury or the description of GP-load there is no general consistency and we have developed our own definitions

THE ACCIDENT AND EMERGENCY DEPARTMENT

This name is the one commonly used in New Zealand We have used it in preference to the older description Casualty Depariment [1] and the American description of Emergency Department It is one hospital department which patients can approach without prior notification

Emergencies can be any condition that - in the opinion of the patient their family or whoever assumes the responsibility of bringing the patient to the hospital - requires immediate medical attention

However using such a definition means every case is an emergency In New Zealand A amp E departments patients tend to be classified in a similar way to the description given by the American Hospital Association [2]

o emergencies where delay is harmful and the condition potentially threatens life or function

a urgent cases which require attention within a few hours

o non-urgent cases where the condition is minor or non-acute and does not require the resources of the emergency service

An accident is an unexpected event Accidents which have resulted in attendance at an A amp E department are ones that have caused some trauma whether through shock or other injury The Platt report [1] decided on the term A amp E department in recognition that the real emergencies were a trickle while the accidents were a mighty flood

In general the A amp E department is regarded as part of the hospitals outpatient services and like these in day to day running it provides specific clinics generally for the treatment of traumatic injury x-ray burns dressings plasters and so forth

An accident and emergency patient is a person who is entered in the A amp E log book This can involve a certain amount of error however as some outpatients or discharged patients may return for follow-up care through the A amp E department Also the A amp E department often handles the acute admissions to the hospital

12

ATrENDANCE

A first visit (or first attendance) is the first visit a patient makes for one particular condition

A recall visit is any visit made for one particular condition which is not the first visit for the condition Some recall visits are patient initiated (eg due to pain bleeding infection or an accident to the dressing or plaster) but for the most part revisits are scheduled return visits suggested by A amp E staff

Total attendance is the sum of first visits and recall visits

Inj ury attendances are defined to include the results of trauma (cuts burns fractures sprains strains bruises head injuries multiple injur ies and so forth) as well as foreign bodies in the eye or other orifices and toxic effects whether from accidental or self-poisoning events Late effects of minor injury (pain bleeding abscesses or such) are not included as injury but as sickness

Sickness attendances include collapse (whether stroke coma heart attack or other) shortness of breath abdominal pain general sickness (fever vomiting diarrhoea unwell) mental distress and minor conditions

Non-urgent sicknesses are defined as the minor conditions abdominal pain and general sickness except for preschool children and adults over 65 where the general sickness and abdominal pain conditions can be urgent A amp E staff defined non-urgent sickness less specifically they tended to define it as longstanding or minor sickness

GP-load describes the patients whom A amp E staff feel should have seen a general practitioner It includes patients with longstanding or minor sickness conditions and patients with minor traumatic injury (eg cuts bumps and bruises)

In hours attendance refers to all attendances in the normal working hours of 0800 to 1800 Monday to Friday excluding holidays

Out of hours attendance refers to all other attendances outside the defined normal working hours

In an average week 50 hours fall in the in hours category and 118 hours in the out of hours category If we assume that an average person sleeps eight hours a night then that person is awake for 62 hours in the out of hours category (and all the in hours of course) Thus the out of hours category is 70 per cent of the total time in a week and 55 per cent of the waking time in a week

Minor conditions included abscesses backaches infected wounds or wound pain headache pain (unspecified) earaches eye problems toothaches nosebleeds limb pains We have called it the skin pain or bleeding category in Chapter 6

13

Attendance rates measure the use of A amp E departments for a defined population They express the number of cases from an area over a defined period per 1000 population in that area Rates were obtained by age and sex for sickness and injury and in and out of hours for each census area unit or neighbourhood served by each hospital

THE- HOSPITALS

We grouped hospitals into four types

o urban hospitals (where average annual first attendances at A amp E departments are over 25000 patients)

o provincial hospitals (serving 6000 to 12000 new A amp E patients each year)

o rural hospitals (serving fewer than 6000 new A amp E patients each year)

o suburban hospitals where A amp E departments are not open 24 hours per day North Shore Hospital was open 7 days a week 830 am shy530 pm and Kenepuru Hospital was open 5 days a week 830 am shy430 pm

Most of the A amp E departments visited had a senior position variously called the A amp E officer the A amp E director the senior medical officer or the medical officer in charge For convenience we call this position the A amp E officer

RECORDING SYSTEMS

The log is the record kept at the A amp E department which records some information on every patient who presents It will often give no more than the patients name the date and time of visit

The A amp E record is usually a card and it records basic patient information and case notes It may be held for several years in the A amp E department and may therefore contain information on a series of separate events for anyone patient

14

REFERENCES

1 GtBrit Central Health Services Council - Standing Medical Advisory Committee Accident and emergency services report of the sUbcommittee - London HMSO 1962 Chaired by Sir Harry Platt

2 Emergency services the hospital emergency department in an emergency care system Chicago American Hospital Association 1972 p vii-viii

15

D

CHAPTER 3

Procedures in the accident and emergency department

In this chapter we begin describing the organisation of A amp E departments by looking at the way they operate We follow the course of a patients care entry to the A amp E department sorting into priority order for care (triage) treatment and follow-up care

ENTRY

Most people presenting at the A amp E department were ambulant (the walking wounded as they are colloquially known) They came through the A amp E departments main entrance to the reception desk where they were first seen by a receptionist or nurse (Exceptions to this occurred in the smaller hospitals where patients presenting at night were first seen by the telephonist who called the nursing staff) Nurses did reception duties at

all the provincial and rural A amp E departments and at two of the urban A amp E departments when receptionists were not on duty (eg lunchtimes nights) bull At times nurses found that having to cover the reception desk interfered with their care of patients

When the receptionists are off duty the nurses do the reception work This can be a nuisance because it interferes with patient care and sometimes patients ring the bell at the reception desk and the staff working in the resuscitation room dont hear it

A amp E nurse

Unless their condition required immediate care the ambulant patients then spent several minutes at the reception desk while their details (eg name address general practitioner complaint) were noted on the A ampE records (See Appendix B for more information on A amp E records) Then they waited in the waiting room until they were called for treatment

A small proportion of patients arrived by ambulance andmiddot at almost all hospitals entered the A amp E department through a separate ambulance entrance In the larger hospitals some nursing staff were stationed in or near the ambulance entrance to care for these patients In other hospitals the staff had often been warned of incoming urgent cases and were standing by when the ambulance arrived As the condition of ambulance patients tended to be urgent they were usually taken straight to a resuscitation or treatment area patients condition permitted or friends or the ambulance driver

Record with the

keeping assist

was ance

carried of thei r

out r

when elativ

the es

SORTING

All A amp E departments operated some triage system to sort the ambulant patients by the urgency of their need for care (Themiddot only exception was Grey A amp E department where there was seldom more than one patient in the department at a time) At most A amp E departments the patients were sorted

16

into urgent and non-urgent categories with urgent cases being seen immediately and non-urgent cases being seen in the order they presented At some of the urban A amp E departments a more complex sorting was done For example

Priority is given in the following order

urgent need very young and very old patients those with general practitioner notes those without general practitioner notes

A lie E nurse

Usually ambulance cases were not triaged since they tended to arrive on their own and required urgent care However several A lie E departments had triage arrangements planned for the arrival of many ambulance cases at once as in a disaster

Sorting was largely a responsibility of the nurses although some A amp E doctors would occasionally check the condition of patients- in the waiting room too The receptionists often played a role in triage as well alerting the nursing staff to urgent cases This happened more in A amp E departments where the physical layout made it difficult for nurses to watch the entrance and the waiting room

The receptionists do tQe basic sorting They have guidelines to follow distressed patients severe cuts or bleeding go straight to the nurses open wounds or eye injuries go directly to a cubicle and are assessed by the nurses patients with abdominal pain or chest pain go on to trolleys and wait in the recovery room This system usually works well although occasionally a fracture patient will not be recognised and will sit in the waiting room

A lie E nurse

In several A lie E departments doctors and nurses stressed the value of an experienced receptionist in recognising and reacting quickly to acutely ill or injured patients

TREATMENT

Almost all the A amp Edepartments visited had a policy that all patients presenting had to be seen by a doctor The doctor did not necessarily have to treat the patient he or she could advise the patient to see a general practitioner Some A amp E doctors commented that by the time they saw the patients it was as easy to treat them as to send them away_ At a few departments the nurses (and occasionally the receptionist) could advise the patient that the department was not an appropriate place for their condition and that they should see a general practitioner This was usually done in consultation with the A E doctor but at times the nurses acted on their own initiative In these places a triage system similar to that reported by Weinerman et al [1] where patients were assigned to the appropriate service inside or outsidemiddot the hospital appeared to be operating

7

The assessment of patients the ordering of tests andmiddot the supervision of treatment were usually seen ~s medical functions The nurses would prepare patients for treatment (removing dressings) and carry out urgent first aid measures (stem bleeding start gastric lavage or cardio-pulmonary resuscitation) Generally however a nurse would only initiate treatment if the patients condition was urgent and a doctor was not available or was already busy with another emergency Exceptions to this situation occurred in some hospitals with A amp E nurse training programmes and in some smaller hospitals where the doctor is on call rather than working in the A amp E department In these departments experienced nurses could order tests such as x-rays and initiate treatments such as suturing and removing foreign bodies from eyes

In most A amp E departments nurses would perform some treatments under a doctors supervision However the range of treatments nurses were allowed to perform varied considerably among hospitals At some hospitals nurses sutured after training but at others they never sutured

The nurses do not suture although they would like to There are four reasons for this there is no full-time A amp E officer so good standards of sutur ing could not be maintained there could be medico-legal problems if a nurse sutured a cut which was more complicated than it looked eg with tendon involvement the nurses have enough to do at present and if they start suturing they will be expected to do it always and the young doctors need to learn suturing as part of their training

Principal nurse

Electrocardiograms were taken by nurses in some A amp E departments by technicians at others Taking blood samples was a doctors job in some departments but was done by nurses in others Similarly gastric lavage using a def ibrillator and plaster work were done by nurses in some departments Most A amp E nurses would maintain intra-venous drips but only nurses with special training WOUld insert them

Some nurses expressed frustration at restrictions on the treatments they were allowed to perform However several sen~or nurses stressed that they had to select carefully the nurses they allowed to perform more difficult treatments

We are very selective about choosing the nurses to do triage suturing and the more complicated procedures This seems to have been successful weve had no problems with nurses undertaking treatment theyre not competent to provide

A amp E senior nurse

I make sure the nurses understand they can be dangerous people If theyre not aware of their limitations theyre not suitable for A amp E work

A amp E senior nurse o

Also one department which had comparatively few nurses discouraged them from increasing the range of treatments they performed so that their workload did not become overwhelming

18

For diagnosis the A amp E departments made heavy use of the x-ray departments (The Design and Evaluation Unit study [21 estimated that 30 per cent of A amp E attenders had an x-ray during their visit) Some A amp E departments found their arrangements with the x-ray department very convenient with an x-ray machine aVailable 24 hours a day in or close to the A amp E department and with patients and x-ray films or reports returning within an hour At other hospitals arrangements Were less convenient in some places reporting bac k of x-rays took two or three hours delaying patients considerably while in others the x-ray departmentmiddot was located on a different floor from the A amp E ~epartment causing difficulties in transporting and accompanying patients there

Little use was made of the laboratory services other than for blood and urine tests and arrangements were generally satisfactory However in many hospitals x-ray and laboratory staff had to be called in to perform tests out of hours and because of the expense involved these out of hours tests were discouraged Some house surgeons found this a difficult situation

I I m caught between contradictory pressures the orthopaedic surgeons say that x-rays are necessary for proper diagnosis and the hospital board is trying to limit out of hours x-rays to save money

House surgeon

DISPOSAL

After treating the patient the A amp E doctor decides on the appropriate disposal discharging from care arranging follow-up treatment by referring to another source of care or recalling to the A amp E department or admitting the patient Information on disposal was only readily available from three A amp E departments The most common disposal pattern was in fact discharging from care with 40 to 55 per cent of patients making a first Visit being discharged

TABLE I PROPORTION OF FIRST ATTENDANCE PATIENrs DISCHARGED RECALLED REFERRED OR ADMITTED

Discharged Recalled Referred to Admitted Other First to A amp E GP Specialist attendance

Clinic tallied

Waikato l 393 132 222 99 134 19 25 707 Green Lane2 550 220 110 40 80 Unknown Taranaki 41 5 268 73 103 116 24 164

1 From McRaes study of Waikato A amp E departmen~ in 1979 2 From a study carried out by Green Lane A amp E department

19

FOLLOW-UP CARE

The decision to be made on follow-up care was usually between re~alling to the A amp E department or referring back to the patient I s general practitioner Some A amp E departments also referred patients (especially children) to district nurses or patients with work 1n]uries to an occupational health nurse or clinic Many departments referred fracture patients to orthopaedic clinics held in the hospital outpatients department and one A amp E department which was very short of space referred patients needing redressings to the outpatients department

There were large differences in referral practices (see Table 1) Between 13 and 27 per cent of first attenders were recalled to the A amp E department for follow-up care while 15 to 30 per cent were referred elsewhere either to a general practitioner or to a specialist clinic Also recall attendances expressed as a proportion of total attendances varied considerably among the A amp E departments from 10 per cent to 50 per cent (see Chapter 6 Table 11) and clearly reflected different follow-up practices

All of the urban and two of the provincial A amp E departments had a policy of referring most patients requiring follow-up care to a general practitioner and of keeping recall visits as low as possible This was similar to general policy in both Britain and the United States which appears to discourage re-at tendance at A amp E departments [34] However in the suburban rural and other provincial A amp E departments the decision on follow-up care was left to the judgement of the A amp E doctor

In practice however the choice to refer or to recall was reiated to several factors First the decision related to characteristics of the patients If the patients had serious wounds or burns or injuries which could develop complications they were usually recalled They were also recalled if the A amp E staff thought they would not receive appropriate care at home or they would not see a general practitioner for follow-up care Patients living a long way from the hospital were usually referred to their general practitioner At some A amp E departments patients were given the choice of referral or recall according to A amp E staff comments most chose to return to theA amp E department

The patients prefer to come back to the hospital Money is not a factor in this because the ACC pays for accident treatment at the general practitioner

A amp E nurse

Second there were general practitioner factors If the local general practitioners were unhappy about the A amp E department recalling patients or if a general practitioner had referred the patient to the department originally the A amp E doctors would refemiddotr rather than recall However if the A amp E doctors thought that the general practitioner did not have the facilities and in some cases the ability to provide follow-up care (eg for serious woundS eye injuries) they would recall the patient

Some GPs dont like following up care initiated by the A amp E department or dont have the necessary facilities so I tend not to send patients back to them

A amp E officer

20

Im more likely to refer a patient back to a GP who is reliable

House surgeon

Third many of the house surgeons said they would recall patients if they were interested in the condition or if they were worried about their diagnosis and treatment and wanted to see the outcome Several medical superintendents noted that recalling under these circumstances was acceptable because it comprised part of the house surgeons training

Fourth the workload of the A amp E department sometimes affected the follow-up decision with very busy departments actively discouraging recalls And finally there was the philosophy of A amp E medicine held by the A amp E doctor In one department where the A amp E officer considered it an ethical duty to see any treatment initiated through to a successful conclusion almost all patients who needed follow-up care were recalled At two other departments the A amp E officers stressed the importance of being able to deal efficiently with any emergencies presenting they kept recalls low so that the department was not clogged with extra patients Other A amp E doctors thought that the general practitioner could provide better continuity of care than the A amp E department so they referred as many patients as possible

When referring patients to the general practitionermiddot most of the A amp E doctors made a verbal recommendation to the patient and then relied on the patient to attend the general practitioner They would only write a formal referral letter if the patients condition was serious In several A amp E departments however greater efforts were made to inform the patient t s general practitioner Three departments gave referred patients cyclostyled forms with details of diagnosis and treatment to be passed to their general practitioner while the Whakatane department sent a copy of the A amp E record form to each patients general practitioner

ADMISSIONS

Table I suggests that between a and 14 per cent of all first attendances were admitted to the hospitals Admissions could well be higher for children Kljakovic [5] found that 20 per cent of the children presenting at the Wellington Hospital Board A amp E departments were admitted

The A amp E departments were involved in several different pathways for the admission of acutely ill or injured patients (Scheduled admissions did not involve the A amp E department at any of the hospitals visited) Self-referred patients could be admitted directly from the A amp E department to the wards or could be cared for in a holding (or acute admitting) ward before going to the wards

There was considerable variation among the hospitals as to which members of the medical staff were able to admit patients At some of the urban hospitals only the registrars could admit while at others the A amp E doctor could admit if the registrar was delayed and unable to assess the patient quickly At some of the provincial and one of the urban hospitals the A amp E doctor could admit in consultation with the admitting officer or appropriate registrar while at-another urban hospital and the rural A amp E departments the A amp E doctors regularly admitted patients

21

Hospitals with lower levels of bed occupancy were more likely to allow A amp E doctors to admit Senior A amp E doctors were more likely to play a role in admissions (actually admitting patients or advising the registrar) than house surgeons

Some patients referred by a general practitioner for acute admission also passed through the A amp E department At one hospital the general practitioners rang the A amp E officer to arrange for all acute admissions and all such GP-referred patients were seen first in the A amp E department However more usually the general practitioners rang the appropriate registrar to make arrangements and the registrar decided whether to admit the patient directly to the wards or through the A amp E department The involvement of A amp E staff with patients requiring admission ranged from almost none (where the patient went directly from the A amp E department to the ward or specialist unit) to a full initial assessment including tests (often undertaken at the request of the registrar responsible for the patient) bull

Generally the A amp E doctors were satisfied with the admission procedures However at one hospital where the A amp E doctors could not admit patients waiting for admission tended to clog the department The doctorselt that if they had admission rights the situation would be remedied

DISCUSSION

There were few differences among the A amp E departments in the reception and sorting of patients However there were differences in some aspects of treatment follow-up care and admission procedures

lhe role of the A amp E nurses in treatment varied considerably with some departments allowing nurses to initiate and perform many treatments and other departments allowing little autonomy Careful training and selection were essential before nurses increased their responsibility for treatment bull

Policies on follow-up care differed among the departments with the urban and provincial departments generally referring patients to general practitioners and the rural and suburban departments leaving the referral decision to the A amp E doctor In practice however the differences were less clear-cut with several factors other than the patient I s condition affecting the follow-up care decisions These factors included the A amp E staffs communicat ion with local general practitioners the inexperience and training needs of house surgeons the workload of the department and the senior A amp E doctors philosophy with regard to A amp E medicine

The A amp E departments also differed considerably in thei r procedures for acute admissions At some hospitals the A amp E doctor could admit an A amp E patient while at others the patient had to be held in the department until admitted by a registrar Also at some hospitals patients referred by general practitioners for acute admission were seen in the A amp E department before going to a ward While having to hold patients sometimes caused

clogging in the department A amp E staff were generally satisfied with the procedures

22

REfERENCES

1 WEINERMAN E Richard RUfZEN S Robert and PEARSON David shyEffects of medical -triage- in hospital emergency service in Public health reports - v 80 no 5 (May 1965) p 389-399

2 Accident and emergency departments a study of planning requirements prepared by the Hospital Design and Evaluation Unit - Wellington Department of Health 1973

3 Accident and emergency services - Gt Brit National Health Service memorandum HM (68)83

4 Emergency department organisation and management edited by AL Jenkins - St Louis Hosby 1975

5 KLJAKOVIC M ALLAN B C and REINKEN J - Why skip the general practitioner and go to the accident and emergency department in NZ Med J - v 93 (1981) P 49-52

23

CHAPTER 4

Phy~i~~1 c~~raft~rhtics of accident and emergency departments

This chapter describes the physical characteristics of A amp E departments their overall size location and layout as well as specific areas within the departments It discusses the effects of the physical characteristlcs on the organisation and functioning of the A amp E departments Our investigation worked from the detailed base established in bullAccident and emergency departments a studY of planning r~quirements a report prepared by the Hospital Design and Evaluation gnit Departmellt of HeCilth [1]

PRINCIPLES

The 1973 Hospital Design and Evaluation Unit (DEU) report [l] outlined the following principles to be applied in designing A amp E departments

o the A amp E department must be patients seeking emergency care

ready to receive and deal with

o the A amp E department mus~ be able load within a reasonable period

to cope with an average i

busy

o the A amp E department must be capable of adaptation to exceptional situations arising from major accidents ltgtrqther disasters

o the layout should be simple easily unqerstood and compact

o the layout and procedures should facilitate easy flow of patients through the department

o spaces should be multipurpose to give greatest versatility

o p~tient ~ovew~n~ should be minimised )

priv~cy for patientsshould be provided as far as is practicable andconsistent with the need for supervisi0rt

SIZE

There was considerable variation in the total sizes of the A amp E -a~1-ftment~ vi~ited witll floor areas ranging from 250 sql1a~e metres to 2115 ~guare m~ties (see Table 2) Eight of the 14 departments visited had i

hhid1pgw~fd~oracUte admitting ward However even wt)en ~he area of th~ f~ ~ bull ~middotc1~A~- _ ~ - bull bull ~

AampE department WCiS adjusted for the presence of a holding ward this I~1-getv~-rH~tion in irea reniained

24

TABLE 2 AREAS OF A amp E DEPARTMENTS

Total area Holding ward Adjusted total Waiting room area areal area

sqm sqm sqm sqm

Full-time departments

Urban Auckland 2 115 225 1 890 55 Middlemore 1 045 140 905 50 Green Lane 960 240 720 70 Wellington 575 190 385 75 Hutt 270 270 30 Christchurch 470 470 40 Dunedin 635 90 545 20

Provincial Rotorua 515 20 495 90 Taranaki Base 720 90 630 40 Timaru 605 70 535 80

Rural Whakatane 430 430 20 Grey 310 310 15

Part-time departments

Suburban North Shore 255 255 30 Kenepuru 540 540 30

1 Adjusted total area = total area minus holding ward area Considerable sharing with outpatients department

The area of the A amp E department was not closely related to the attendance (see Table 3) Obviously there is a certain minimum size for an A amp E department since certain facilities are essential regardless of the attendance served Thus as would be expected the rural and to a lesser extent the provincial A amp E departments had high area to attendance ratios However even within the group of urban A amp E departments there was a fourfold difference in the total area to attendance ratio

The design at Auckland~ laid out along several corridors with many separate consulting and treatment rooms possibly contributed to its high ratio At Wellington Hutt and Christchurch hospitals staff commented on their difficulties working in cramped conditions The lack of space often forced staff to work under extreme pressure to move patients through the departments very quickly

25

TABLE 3 AREA TO ATTENDANCE RATIOS FOR ADJUSTED TOTAL AREAS 1 AND WAITING AREAS OF A amp E DEPARTMENTS BY FIRST ATTENDANCE2 AND TOTAL ATTENDANCE 2

Adjusted total area to attendance ratio Waiting area to to attendance ratio

Sqm per 1000 Sqm per 1000 Sqm per 1000 first attendance total attendance total attendance pa p a p a

Full-time departments ~

Urban Auckland 323 291 08 Middlemore 232 157 09 Green Lane 3 230 168 16 Wellington 80 69 13 Hutt 82 63 07 Christchurch 76 64 05 Dunedin 200 143 05

Provincial Rotorua 404 293 53 Taranaki Base 609 399 25 Timaru 466 266 403

Rural Whakatane 718 490 23 Grey 805 61 2 30

Part-time departments

Suburban I INorth Shore 272 148 17

Kenepuru 924 597 33

1 Adjusted total area = total area minus holding ward area

2 See Table 9 for attendance figures used in calculations

3 Considerable sharing with outpatients department

Spearman rank correlations [2] of adjusted total area with

( a) first attendance r = 0310 p gt 010 Not significant ( b) total attendance r = 0297 pgt 010 Not significant

26

LOCATION

There is broad agreement that the A amp E department should be located on the ground floor well signposted and easily accessible to ambulatory patients and ambulances The ambulance entrance should be able to handle several ambulances at once and should have adequate turning space It should be projected from the weather and screened from the view of the other A amp E department patients

The A amp E department should also be located as closely as possible to radiology facilities (either the x-ray department itself or a branch) The A amp E department and the outpatients department can share some facilities and provide additional staff and accommodation in an emergen~y

situation if they are sited together Acute patient care areas (operating theatres intensive care unitsmiddot and cardiac care units) and laboratory services should also be readily accessible from the A amp E department [134]

Entrances

Almost all of the A amp E departments visited were on the ground floor of the hospital and were well signposted Generally access for ambulatory patients was good apart from two hospitals where they had to walk up steps to enter the building o

Few departments had ambulance access which could cope with a shuttle of ambulances bringing mass casualties from a disaster There w~s little relation between the size of the department or the population served and the ease of ambulance flow Indeed those departments with a relatively low probability of being involved in a mass casualty situation had good ambulance flow (eg Whakatane) while those with a greater possibility had relatively poor ambulance access (eg Wellington) Several departments had particularly poor a~bulance flow with only a one-lane access Three departments had good drive-straight-through access while at the rest ambulances had to reverse However there were advantages to some of the bull reversing I situations in that the bays into which the ambulances had to reverse were more likely to give the patient protection from the weather All the A amp E departments visited had separate ambulance entrances which in all but three cases guaranteed screening of ambulance patients from public view

Access to other hospital facilities

In many of the hospitals the A amp E department was adjacent to the outpatients department or to the orthopaedic outpatients section When this occurred the plaster room and x-ray facilities were usually shared and waiting areas and the records office were sometimes shared In the smaller hospitals both departments often shared the nursing staff

The access to the x-ray department ranged from excellent in places which had x-ray facilities immediately adjacent to the A amp E department to very poor where the patient had to be transported hundreds of metres and to a different floor The time taken for the A amp E doctor to get the result of the x-ray varied from five minutes to over two hours though the physical separation of the two departments was only one of the factors which affected this

27

Access to acute care facilities was similarly variable In Christchurch the intensive care unit was adjacent to the A amp E department while in Rotorua it was at the other end of the hospital In many cases additions or alterations to the hospital buildings and changes of function of certain areas have meant that the A amp E department no longer bears the same physical relationship to other hospital departments as was originally the case

LAYOUT

Several studies have concluded that the A amp Edepartment should be designed so that there is an orderly progression of patients from registration to examination to investigations if necessary to treatment and to referral admission or discharge Staff time and effort is best conserved by a compact plan with waiting areas and treatment areas easily accessible and supervised However the need for easy supervision has to be balanced by consideration of the patients privacy Two basic A amp E plans have evolved

o a radial plan where the waiting examination and treatment rooms are arranged on the perimeter of the departmentmiddot with the nurses station doctors room and records office in the centre

o a linear plan where the examination and treatment rooms are arranged down each side of a corridor with the waiting area records office and staff offices at one end [145]

Many of the A amp E departments visited had a linear layout with the largest Auckland being arranged along several corridors In these departments staff often commented that their overall view of the patients was not good and a considerable amount of walking was needed to supervise them Middlemore A amp E department and the treatment areas of several other departments had radial layouts which staff found very satisfactory Generally the A amp E staff prefer red open plan layouts using curtained cubicles rather than enclosed rooms Staff (especially nursing staff) often commented that their department would be better if certain walls or partitions were removed to give easier surveillance of the department as a whole However staff also commented on the relative lack of privacy for patients being examined or treated and noted that some private rooms were needed for instance for obstetric or paediatric patients

Waiting area

There is general agreement that the waiting area should be adjacent to the reception desk easily visible to the receptionist and if possible overlooked by the nurses office or station It should be a cheerful comfortable area with toys provided for children and a range of magazines and books Public toiletspublic telephones and arrangements for refreshments are also needed [146]

The size of the waiting area varied considerably among the A amp E departments visited (refer back tomiddot Table 2) Again this variation bore little relationship to the workload of the department (see Table 3) Some waiting areas were clearly too small and this put pressure on the staff to deal with patients quickly in order to clear the waiting room

28

Staff comments suggested that not only the size of the waiting area but also its design affected its crowding Basically square rooms with seats around the edges had fewer problems than corridor-style rooms with only one row of seats

In all the A amp E departments visited the waiting areas were adjacent to the reception area Sometimes they were visible from the nurses office or work area but where this was not possible the nurses relied on the receptionists to alert them to urgent cases or checked the wai Hng area often themselves

Facilities in waiting areas varied from nothing but seats to areas in which there were hot and cold drink dispensing machines a childrens play area with toys and health-related poster and pamphlet displays Some had a TV set or a tropical fish tank Most staff were agreed that a pleasant atmosphere in the waiting room was important and adVerse comments about the waiting area were made by staff in departments which lacked this In some departments staff commented that vandalism made it difficult to retain facilities and a pleasant atmosphere

Examination and treatment area

The examination and treatment area provides for the needs of all A amp E patients other than those with serious conditions requiring the resuscitation room or those needing special facilities such as plastering Because special purpose areas are frequently under-utilised flexibility is a key requi rement Hence multipurpose cubicles with standardised equipment are usually recommended The cubicles must be big enough to give easy access for patients (not necessarily walking) to accommodate eqUipment and to give staff enough room to work Curtained cubicles are generally sufficient but at least one enclosed cubicle is required for patients needing extra privacy or for light control in eye examinations A cubicle especially set up for children (with appropriately-sized equipment toys and posters) is also desirable [1346]

Most of themiddot A ~ E departments visited had curtained cubicles in the examination and treatment area with perhaps one or two enclosed cubicles or rooms as well Four A amp E departments only had separate rooms for treatment Curtained cubicles made for ease of access while separate rooms did present some difficulties in manoeuvering patient trolleys and wheelchairs In one case it was impossible to get a patient trolley into the room at all and the room was consequently little used

Curtained cubicles did afford greater flexibility in use and did provide more room to work but had the disadvantage of being considerably less private than rooms Surveillance was easier in departments with curtains than those withmiddot walls and doors In the Auckland A amp E department treatment rooms doors had been removed in the interests of improved surveillance Staff in this department commented that its rigid design could lead to difficulties in accommodating a large number of patients in a disaster

The DEU report [1] recommended that the number of cubicles required by an A amp E department was NIlS where N is the anticipated average number of new patients per day It noted that in A amp E departments with few new patients per day a minimum of two cubicles should be provided It also recommended that the flow of recalled patients should be regulated so that they did not greatly affect the need for cubicles

29

As can be seen from Table 4 most departments had enough cubicles to cope with their first attendance workload Even applying the DEU recommendation of N18 to their total attendance most of the departments had an adequate number of cubicles The exceptions were Hutt Christchurch and Dunedin

TABLE 4 NUMBERS OF EXAMINATION AND TREATMENT CUBICLES OR ROOMS AND RECOMMENDED NUMBERS l BASED ON FIRST ATTENDANCE 2 AND TOTAL ATTENDANCE 2

Actual number of DEU recommended numbers (minimum of 2) cubiclesrooms based on

first attendance total attendance pa pa

Full-time departments

Urban Auckland 13 89 99 Middlemore 9 59 88

Green Lane 7 40 65 Wellington 10 73 85 Hutt 4 51 66 Christchurch 7 94 11 2 Dunedin 3 41 58

Provincial Rotorua 4 2 26 Taranaki Base 4 2 24 Timaru 6 2 31

Rural Whakatane 3 2 2 Grey 3 2 2

Part-time departments

Suburban North Shore3 8 22 37 Kenepuru3 6 22 30

1 Based on DEU report [l which recommended NIS cubicles where N average number of new patients per day ie N6750 where N = average first attendance pa

2 See Table 9 for attendance figures used in calculations

3 Recommended numbers increased to adjust for North Shore and Kenepuru treating their attendance numbers in part-time rather than full-time hours

30

Resuscitation area

The resusciation area is used for the immediate life--saving treatment of seriously injured or sick patients It is the acute treatment area in contrast to the examination and treatment area which is used for relatively minor procedures In making its recommendations about the resuscitation area the DEU report [I] balanced the probability of the A amp E department having to treat multiple accident victims with the comparative rarity of use of resuscitation rooms It recommended that a resuscitation room of suff icient size to deal with two patients concurrently be provided in all A amp E departments It also noted that the ambulance entrance and resuscitation area should be located as close together as possible

Most of the departments visited had purpose-built resuscitation rooms of varying size and with varying degrees of sophistication in equipment Some had x-ray facilities in the resuscitat ion area and in those that did not its absence was regarded as a serious impediment to the efficient care of severe trauma

In four of the seven urban A amp E departments the resuscitation rooms were regarded by the staff as being too small The comment was made in one urban department that because of the small size of the resuscitation area patients sometimes had to be moved out of the area before it was felt clinically desirable to do so in order to accommodate incoming patients In the rural and prOVincial A amp E departments the resuscitation rooms wereshyadequate for the demands placed on them

Most resuscitation rooms were sited close to the ambulance entrance and afforded good access to stretcher patients However in three A amp E departments patients had to be moved some distance and in another department up one floor by lift

Operating theatre

In discussing provision of operating theatres in the A amp E departments the DEU report [1] noted that

o most surgery done is minor requires only local anaesthesia and could be done within adequately designed cubicles

o the A amp E department is not a proper place for general anaesthesia

o using A amp Etheatres for day surgery tends to block other A amp E facilities and staff causin~ delay in treating A amp E patients

The report concluded that special facilities appear to be justified only if there is a clear intention of widening the scope of accident surgery in the departments

bullMinor ops theatres of varying sizes and equipped to varying standards were available in many departments Very variable use was made of such theatres - never in some departments to daily in others It was used less in departments with very heavy workloads and where the medical staff were not satisfied that sufficiently sterile conditions could be maintained In one department the theatre was only used for day surgery cases

31

Plaster room

In the plaster room casts are applied and removed and fractures and dislocations can be manipulated The DEU report [1] noted that the plaster room could be an integral part of the A amp E department or shared with the orthopaedic department or belonging entirely to the latter It recommended that the plaster room be close to the A amp E department and the x-ray department

Most departments had a separate plaster room available In many cases this was shared with an adjacent orthopaedic outpatients or fracture clinic Th~ staff generally found the plaste~-rooms satisfactory although two particularly narrow rooms were difficult to work in

Interview room

The DEU report [l] recommended that A amp E departments in medium-sized and larger hospitals should have a small interview room where a patient IS

relatives could talk with A amp E staff the police or others

No A amp E department had a room specifically designated as an interview room for bereaved or distressed relatives although one A amp E department shared such a room with another department In most departments one of the staff off ices was generally used for this purpose In departments where staff offices were small or crowded the lack of an interview room was seen as a serious flaw in departmental layout

Reception and records office

The reception desk should be immediately visible to ambulant patients arriving at the A amp E department and it is desirable for the receptionist to be aware of what is happening at the ambulance entrance as well The current A amp E records should be held at the reception desk or nearby [1]

In the A ampE departments visited the reception desk was usually well-placed for dealing with ambulant patients but in only four cases did it overlook the ambulance entrance In two departments the reception desk was some distance from the treatment area (separated by a waiting room or outpatients room) and the nursing staff found it difficult to oversee incoming patients Current A amp E records were held at the reception desk in all but one of the departments visited The amount of space available in relation to the throughput of patients was a major factor in determining the length of time records could be kept within the department This in turn affected the ease and therefore speed of record retrieval

Staff offices

These ranged from non existent to very cramped spaces serving many other functions to pleasant specifically designated and relatively quiet areas The latter offices are conducive to good staff morale and being a place for exchange of views and experiences could be expected to contribute quite markedly to the overall effectiveness and eff iciency of the department

32

Holding ward

The DEU report [1] said that holding beds should be used primarily for A amp E patients requiring a period of observation prior to a decision about admission or for those who could be expected to go home after a rest period The report noted that using holding beds as recovery beds for day patients for arranged admissions or for pre-admission clinics was not desirable

Most of the urban and provincial A amp E departments visited had holding or acute admitting wards These holding wards were used mainly for assessing patients requiring acute admission but in some hospitals were also used for observing patients (eg with suspected concussion) and for holding night admissions till the morning to save disturbing the wards Neither of the rural A amp E departments had a holding ward although one had an I A amp E admission procedure where a patient could be admitted for up to 24 hours for observation without the need for full admission procedures In the A amp E departments with holding wards a patient staying for more than four hours was formally admitted

Our study showed that the A amp E departments had some problems using holding wards properly In two A amp E departments holding wards were little used at night because nursing levels were too low to staff them safely In another department the beds were used for patients recovering from day surgery and even for some pre-ar ranged admissions At times general practitioner-referred admissions could also clog the holding wards

DISCUSSION

Most of the A amp E departments were generally adequate in size location and layout The exceptions were Christchurch and Butt where conditions were very cramped with particularly limited examination and treatment areas and poor layout We understand that improvements are planned at Hutt and that recent extensions have improved the Christchurch department considerably but at the time of our visits staff in both these departments were working under extreme pressure because of the physical conditions

Despite the general adequacy of the departments almost all had some flaw which affected their operation and inconvenienced staff and patients Major flaws found in several A amp E departments included

o ambulance access unsuitable for a shuttle of ambulances in a disaster

o difficult access to the x-ray department

o resuscitation room too small for easy treatment of more than one patient at a time

o no interview room for relatives of patients

33

REFERENCES

1 Accident and emergency departments a study of planning requirements prepared by the Hospital Design and Evaluation Unit - Wellington Department of Health 1973

2 SIEGEL Sydney - Nonparametric statistics for the behavioural sciences - Tokyo McGraw-Hill Kogakusha 1956 p 202-213

3 Emergency services the hospital emergency department in an emergency care system Chicago American Hospital Association 1972 p 44-49

4 Emer~ency department organisation and management edited by A L Jenkins - St Louis Mosby 1975 p 8-16

5 Design of departments in Br Med J - v 2 (1979) p 1204-7

6 McKINLAY Robin - The care of children in New Zealand hospitals -Aucklandmiddot National Childrens Health Research Foundation 1982 p 79-80

35

CHAPTER 5

Staffing of accident and emergency departments

This chapter describes the staffing both medical and nursing looking at their numbers and experience their previous training and the training they receive in the A amp E department and their satisfaction with their work and conditions We also describe the clerical and reception staff and briefly the involvement of other workers (orderlies social workers and ambulance personnel) in the departments

MEDICAL STAFFING

Senior medical staffing

Organising appropriate medical staffing for hospital emergency services is a prQblem in many countries [1] The variety of staffing arrangements in A amp E departments within many countries suggests that none have established a generally satisfactory pattern of medical staffing

The Platt report [2] found that in Br itish A amp E departments the great majority of patients were seen by junior staff only and that supervision of the A amp E departments by conSUltants was often little more than nominal The committee recommended that

o the junior medical staff should be adequately supervised by consultants

o a consultant orthopaedic surgeon should normally be in charge of theA amp E unit

o an accident and emergency unit should have at least three consultant surgeons each giving a substantial part of their time to this work

o the primary task of general practitioners in emergency services is to deal with minor accidents and emergencies at any time of the day or night (by organising a rota to answer emergency calls within their practice by working sessions in A amp E departments or by attending cottage hospitals at short notice for emergency calls) bull

Since then some progress has been made but standards continue to lag behind those recommended [34] There has been considerable debate over the appropriate staffing arrangements for A amp E departments Some hospitals have implemented the Platt report recommendations others have appointed a full-time A amp E specialist others have employed a full-time non-specialist doctor and some have employed general practitioners

Despite the various systems there is a consensus in both the United States and Britain that experienced medical staffmiddot are essential in the A amp E department They are necessary for prompt effective treatment of emergency conditions for efficient running of the departments and for adequate supervision of the junior doctors employed [23567 p 17-23]

36

Similar concerns have been expressed in New Zealand since the Board of Health report on outpatient services in 1960 [8] This report recommended that general hospitals continue to provide a casualty service available at all times and staffed by experiencedmedical officers

Salmond [9] found that when a senior A amp E officer directed the department A amp E work was handled more efficiently and house surgeons were more closely supervised and supported He suggested that one senior member of the hospital staff (ideally a full-time A amp E officer) should accept full responsibility for the overall supervision of A amp E services

Most of the A amp E departments that we visited had an A amp E officer The position was vacant at both Wellington and Hutt hospitals at the time of our visit while at North Shore Hospital responsibility for the A amp E department was shared by two senior doctors The A amp E departments of the rural hospitals had no senior medical staff

In A amp E departments with heavy workloads additional experienced doctors were often employed as deputy A amp E officers usually medical officer special scale or as Medical Reserve Scheme registrars (see Table 5) There was no general practitioner staffing of any of the Aamp E departments visited although general practitioners had been part-time staff of some of themiddot smaller A amp E departments in previous years One medical superintendent commented that since very few general practitioners could be classified as specialists they could only be paid as medical officers special scale This low level of payment acted as a disincentive to general practitioner recruitment

The A amp E officers usually worked normal office hours (830 am - 430 pm or 9 am - 5 pm weekdays) apart from two who worked part-time covering morning periods If additional experienced doctors were employed they usually covered evening periods (eg 5 pm - 10 pm) and weekend day shifts

There was a wide range of experience among the A amp E officers Half of the senior A amp E doctors had a general practice background and these doctors often had specific surgical medical pharmacological or Armed Forces medical experience as well Several A amp E officers had primarily a surgical background while others had a considerable range of hospital experience In hospitals where the A amp E officers had a general practice background the Medical Superintendent or the A amp E officer often stressed the suitability of this background for A amp E work

An extensive general practitioner background is useful in dealing with the multitude of problems seen in an Accident and Emergency department An orthopaedic or surgical background is not as necessary because of the good backup from the specialties And staff who have only had hospital experience particularly junior staff can lack skills in general assessment and triage

A amp E officer

In other hospitals staff stressed that an orthopaedic and surgical background was very valuable as was experience in dealing with specific types of injury such as soft tissue wounds

37

TABLE 5 MEDICAL STAFFING OF A amp E DEPARTMENTS

Full-time departments

Urban Auckland Middlemore Green Lane Wellington2

Hutt2

Christchurch Dunedin

Provincial Rotorua Taranaki Base Timaru

Rural Whakatane Grey

Part-time departments

Suburban North Shore Kenepuru

Senior medical staffing

Number of full-time equivalents

A amp E officer ( including deputies) 25 15 I 16

I 2

I 03 I

2 05

Registrar

06

1 1

House surgeons

Number on Number A amp E runs covering

some shifts in A amp E deptl

6 2-3 6 2 5 I 5 4 2-3 5 2 2

All on rotating basis 1 3 1 2

5 on rotating basis 4 on rotating basis

None in A amp E dept 4 on rotating basis

1 On general relieving duties 2 Senior A amp E position vacant at time of visit

Junior medical staffing

The issues

Junior medical staffing of A amp E departments has concerned many commentators in the United States Britain and New Zealand The Platt report [2] noted that recently qualified staff when serving in the casualty department undertake responsibility which they would not have in the wards or outpatient clinics

38

In 1960 the New Zealand Board of Health report [8] on out-patient services deplored the staffing of casualty departments by I relatively inexperienced men [sic] and suggested that these staff I should be regarded more as assistants under supervision and training than responsible officers in the outpatients departments The undesirability of staffing A amp E departments with first year house surgeons (or pre-registration doctors) has been reiterated since Junior doctors are often unsure when to ask for advice or help and are sometimes unwilling to admit that they are over-tired and unable to cope [91011)

The report on the working conditions of New Zealand resident medical officers [12] noted the heavy load carried by house surgeons working long shifts in A amp E departments It also commented that when house surgeons are required to look after the A amp E department while carrying out ward duties inadequate cover of the A amp E department could result

The New Zealand situation

The urban A amp E departments had between two and six house surgeons working on three month A amp E runs and in several of these hospitals another one to three house surgeons on general relieving duties covered some A amp E shifts There were more house surgeons in A amp E departments with heavier workloads or with fewer senior medical staff The provincial and rural departments did not usually have house surgeons working on specific A amp E runs rather the A amp E department was covered by all (or most) of the house surgeons in the hospital on a rotatng basis Of the two suburban A amp E departments Kenepuru was covered by the house surgeons on a rotating basis while North Shore did not have any house surgeons because there was no inpatient or consultative backup available (see Table 5)

The total medical staffing of the departments (senior A amp E doctors and house surgeons together) ranged from 10 to 100 full-time equivalents and was closely related to the attendance at the departments (see Table 6) The provincial and rural A amp E departments had higher medical staff to attendance ratios because they had to provide a 24-hour service regardless of the size of the attendance

Each A amp E department visited rostered its house surgeons differently depending on the availability of senior medical staff the workload of the department and the house surgeons other duties In the urban departments house surgeons worked between 45 and 60 hours a week on shifts usually 8 to 12 hours long Many of the house surgeons working in these departments complained about long shifts and suggested that more staff were needed to reduce the shift lengths Split shifts were also unpopular

The most worrying aspect of the staff ing arrangements in bhe Accident and Emergency department is the long hours We need another house surgeon to reduce the hours on some shifts and to proviae another pair of hands in busy periods (eg Friday and Saturday night Sunday afternoon)

House surgeon

39

TABLE 6 TOTAL MEDICAL STAFFING (FULL-TIME EQUIVALENTS) AND MEDICAL STAFFING TO ATTENDANCE RATIOS FOR FIRST ATTENDANCE I AND TOTAL ATTENDANCE 1

Total medical Total medical staffing to staffing attendance ratio

FTE per FTE per 10000 first 10000 total

Full-time attendance attendance equivalents p a pa

Full-time departments

Urban

Auckland2 100 17 15 Middlemore2 91 23 16 Green Lane2 65 25 15 Wellington 66 14 12 Hutt2 55 17 13 Christchurch 70 11 10 Dunedin2 60 22 16

Provincial Rotorua 42 34 25 Taranaki Base2 28 27 18 Timaru 22 19 11

Rural Whakatane3 15 25 17 Grey 10 26 20

Part-time departments

Suburban North Shore 20 21 12 Kenepuru3 20 34 22

1 See Table 9 for attendance figures used in calculations 2 FTE estimated since A amp E department partially covered by house

surgeons on general relieving duties 3 FTE estimated since A amp E department covered by house surgeons on

rotating basis

Spearman rank correlations [131 of total medical staffing with

(a) first attendance r = 0953 p lt 001 (b) total attendance r = 0933 p 001

In the provincial and rural hospitals house surgeons were often on call for long shifts over nights and weekends They were usually covering a ward or the whole hospital at the same time and simultaneous demands from the wards and the A amp E department sometimes caused problems However

40

these house surgeons generally found their rostering satisfactory despite the long hours on call perhaps because the actual work required in the A amp E department was comparatively light

An ordinary week night is usually quiet after midnight thered be three to five calls and Id have to get up once on average Weekend nights are busier but I usually get at least two or three hours sleep

House surgeon

Several house surgeons were irritated that while they worked more intensively on A amp E runs than on ward runs they spent fewer hours on-call and consequently they were paid less

Supervision by senior medical staff

In the larger A amp F departments house surgeons worked with the senior medical staff on most day and some evening shifts only on night shifts (and some evening shifts) were house surgeons the sole medical staff in a department By contrast in the smaller and part-time departments house surgeons covered the department alone seldom working with any senior A amp E medical staff

Several nurses commented that the A amp E department ran less efficiently outside normal working hours because the house surgeons inexperience meant assessment and treatment times were longer and tests were used more often than when the A amp E officer was present

Many senior medical staff in the urban A amp E departments were concerned at the lack of supervision for house surgeons outside normal working hours and so would have Ii ked more senior A amp E staff Several of the house surgeons were also concerned although others enjoyed the autonomy they had and were not concerned about working without supervision

I am not happy with house surgeons managing the A amp E department on their own They only have a three month shift in the department and often most of this time is spent learning how to do A amp E wor k The house surgeons can have problems deciding when to call a registrar to treat a patient and there can be delays in obtaining a registrar The A amp E department needs full-time trained medical staff on duty 24 hours a day to give proper supervision to the house surgeons and to run an efficient department

A amp E officer

On night shift I can feel rather alone if something goes wrong

House surgeon

I enjoy the variety of work and the independence I have to treat most patients as I see fit

House surgeon

41 _A

Arraflgements for consultative backup and support when senior A amp E staff were not on duty varied from hospital to hospital according to hospital size n urban hospitals the house surgeons would usually call on the appropriate registrar and the acute admitting or specialist teams for emergencymiddot cases In some places the house surgeons could calIon the consultant if a registrar was unavailable but this was usually seen as a last resort call In the provincial and rural hospitals the house surgeons would call on the appropriate senior doctor who was available This was usually one of the cQnsultants or a registrar if any were employed by the hospital The A amp E Qfficer might occasionally be called and in hospitals without an A~amp E oHicer th~ medical superintendent would also provid~ backup

Generally house surgeons were happy with the support they received A physically compact hospital was mentioned several times as facilitating ~ ~ fast back-up Howeve( in some hospitals there could be considerable delays in 9etting surgical and orthopaedic registrars to the A amp E department usually because they were in theatre Also at two hospitals backup in the minor specialties was considered inadequate bull

Use of first year house surgeons

Urban and suburban hospitals had a policy of using second year house surgeons as much as possible in the A amp E department and of using first year house surgeons only in their second six months This policy was generally butmiddot not always carried out For example the on-call arrangements of some urban A amp E departments resulted in inexperienced first year house surgeons working in the department In the smaller hospitals also the limited pool of house surgeons available tended to result in more first year house surgeons working in the department

The hospital could not provide cover for the A amp E department without using first year house surgeons However there are always senior staff and the medical registrar readily available as backup

Medical superintendent

When direct supervision was limited first year house surgeons did find A amp E work difficult

Training

The training received by the house surgeons in the A amp E departments varied greatly Two hospitals ran half-day or one-day orientation courses before -house surgeons started in the department Three A amp E departments ran weekly or fortnightly training sessions on specific conditions while another department ran sessions on an irregular basis However house surgeons often missed training sessions because they were treating pat~entsln more than half tmiddothe A amp E departments no formal training was giVen and house surgeons were taught on-the-job when senior A amp E staff were available This teaching placed a considerable load on senior staff

The three-monthly changeover of house surgeons is frustrating and the first month with new house surgeons is very demanding because they have little confidence or competence

A amp E officer

DISCLAIMER

The views expressed in this report are those of the authors and do not necessarily represent the views of the Department of Health

COPYRIGHT

Provided the source is acknowledged information contained in this report may be freely used by any person

CONTENTS

Page

ACKNOWIEDGEMENTS LIST OF TABLES LIST OF FIGURES

1 INTRODUCTION I

Background Thewider questions of emergency medical services The overseas situation An historical perspective in New Zealand

Interview studies on the utilisation of A amp E departments Record studies on the utili satjon of A amp E departments Studies of the organisation of A amp E departments

Overview of this study Aims Sources of information

References

2 DEFINITIONS 11

The Accident and Emergency department Attendance The hospitals Recording systems References

3 PROCEDURES IN THE ACCIDENT AND EMERGENCY DEPARTMENT 15

Entry Sorting 1 reatmen t Disposal Follow-upcare Admissions Discussion References

4 PHYSICAL CHARACTERISTICS OF ACCIDENT AND EMERGENCY DEPARTMENTS 23

PrinCiples Size Location

Entrances Access to other hospital facilities

Layout Waiting area Examination and treatment area Resuscitation area Operating theatre Plaster room Interview room Reception and records office Staff offices Holding ward

Discussion References

5

6

7

8

STAFFING OF ACCIDENT AND EMERGENCY DEPARTMENTS 35

Medical staffing Senior medical staffing Junior medical staffing Accident and emergency work as a career

Nurse staffing Other staff involved with the A amp E department

Reception and clerical staff Orderlies Social workers Ambulance personnel

Discussion References

PATIENT ATTENDANCE CHARACTERISTICS 55

Overall attendance and trends Age and sex Conditions

Injury conditions Sickness conditions

Recall attendance GP-load

Non-urgent sickness Discussion References

PATIENT ATTI~UDES TO THE ACCIDENT AND EMERGENCY DEPARTMENT AND STAFF ATTITUDES TO THE PATIENTS 75

Reasons for visiting the A amp E department Overseas studies New Zealand studies

Effect of health centres and deputising services on A amp E utilisation A amp E staff views of patients

Overseas studies The New Zealand situation

Discussion References

UTILISATION OF ACCIDENT AND EMERGENCY DEPARTMENTS 91

Comparison of A amp E utilisation among hospital catchment areas Results Effect of general practitioner availability

Factors explaining catchment area variations in A amp E utilisation Method Results of the mUltivariate analyses

Comparison of A amp E use and general practitioner use Discussion References

9 CONCLUSIONS 107

The A amp E department as a hospital department The A amp E department as an emergency service The A amp E department as a primary care service Where from here

APPENDICES

APPENDIX A QUestion sheets 116

APPENDIX B Accident and emergency department records 120

APPENDIX C Statistical analyses of accident and 123 emergency department attendance rates by neighbourhoods

APPENDIX D Childrens use of general practitioners 128 and accident and emergency departments in Wellington

TABLES

Table

1 Proportion of first attendance patients discharged recalled referred or admitted

2 Areas of A amp E department~

3 Area to attendance ratios for adjusted total areas and waiting areas of A amp E departments by first attendance and total attendance

4 Numbers of examination and treatment cubicles or rooms and recommended numbers based on first attendance and total attendance

Medical staffing of A amp E departments

6 Total medical staffing (full-time equivalents) and medical staffing to attendance ratios for first attendance and total attendance

7 Nurse staffing of A amp E departments excluding student nurses and hospital aids

Nurse staffing (full-time equivalents) and nurse staffing to attendance ratios for first attendance and total attendance

Average attendance at A amp E departments 1978-1981

10 Trends in attendance at A amp E departments 1978-1981

11 Proportion of A amp E attendance that was recall attendance

12 Proportion of A amp E attendance that was for sickness

13 Proportion of total A amp E attendance that was for Sickness by policy and age groups

14 Use of general practitioners by first attenders at A amp E departments

15 Reasons for A amp E first attendance from three New Zealand studiesmiddot

Itgt Attendance (mean age-adjusted rates per 1000 per quarter) within each A amp E department catchment area

Page

18

24

25

29

37

39

45

46

56

57

66middot

70

71

77

78

92

(continued)

Table Page

17 Hospital admissionsfor accidental injury (mean 93 age-adjusted rates per 1000 per year) and death due to accidental injury (mean age-adjusted rates per 1000 per year) within each A amp E department catchment area

IB Attendance (mean age-adjusted and neighbourhoodshy 99 adjusted rates per 1000 per quarter) and populationshyto-general practitioner ratio within each A amp E department catchment area

19 Comparison of first attendances for injury at A amp E 101 departments and general practitioners

FIGURES

Figure Page

1 Percentage of total attendance at 58 A amp E departments by age and sex

2 Percentage of total attendance at 59 A amp E departments for sickness and injury conditions by age and sex

3 Injury first attendances by type of injury 6U all ages

4 Injury first attendances by type of injury 61 by age groups

5 Sickness attendances by type of sickness 62 all ages

6 Sickness attendances by type of sickness 63 by age groups

7 Comparison of medical staff availability and 67 level of recall attendance

Comparison of nursing staff availability and 67 level of attendance

9 Location at which accidents happened by those 79 attending the A amp E department or the general practitioner for accidental injury

Use of general practitioners and A amp E departments 131 by Wellington children 1978 (rates per 1000 children per quarter)

1

CHAPTER 1

Introduction

BACKGROUND

This report arises f rom concerns expressed by several groups about the availability especially out of hours of emergency car~ and its provision by Accident and Emergency (A amp E) departments in New Zealand

In _SQe mid 1970 s the people of Porirua were worried that local general -pr-actitioners were not available at nights and weekends and by the delays

involved in travelling to Wellington and Hutt A amp E departments [IJ At the same time the people of North Shore were campaigning to keep their local A amp E department open More recently community groups in Upper Hutt have been pressing for the addition of an A amp E service to a local health centre Overall people are concerned that appropriate care (including facilities such as x-rays) is readily available in emergency situations

General practitioners are another group who have been concerned about A amp E departments in particular about inappropriate uses of A amp E departments A long-standing complaint bas been that patients are using A amp E departments for care which wou~d be better given by a general practitioner and that the A amp E departments retain patients instead of referr ing them back to their general practitioner for follow-up care [2 3J In 1981 the research group of the Wellington Faculty of the Royal NZ College of General Practitioners sponsored a study of children presenting at A amp E departments because they were worried that unnecessary admissions of children to hospital occurred because their parents had bypassed the general practitioners and gone straight to hospital [4J

Also A amp E staff and hospital administrators have been concerned that caring for patients who could have been treated by general practitioners has limited their ability to deal with emergency cases [567]

THE WIDER QUESTIONS OF EMERGENCY MEDICAL SERVICES

Emergency care requires not only the provision of hospital services (the A amp E department with back-up from other hospital facilities) but also the organisation of services outside the hospital and co-ordination between both sets of services Emergency medical services outside the hospital include alarm and communication systems transport systems and first aid services There are important questions for New Zealand within this framework For example what should be the role of general practitioners in on-site emergency care What level of training is appropriate for ambulance officers Should voluntary personnel staff ambulances To what extent is double manning of ambulances required [8910]

In order to limit the study to manageable proportions this report focusses only on the hospital services namely the A amp E department Emergency medical services provided outside hospitals are mentioned only where they impinge noticeably on the A ampE department It is hoped that due attention will be given to the wider questions of emergency medical services in the future (see Chapter 9)

2

THE OVERSEAS SITUATION

Concern with emergencymiddot care facilities especially their increasing use has been apparent in other countries for the past thirty years While some articles report on the situation in Canada Australia Sweden France and the USSR most of the literature is about the United States and Britain This section briefly outlines the major themes of the literature and their relevance to New Zealand More specific aspects are covered in the appropriate chapters

Many United States researchers have studied the operations of different emergency rooms exploring patients reasons for using the emergency room their demographic characteristics and their use of the family doctor Often the studies have tried to explain an increasing use of emergency rooms and some have reported on the effectiVeness of measures introduced to reduce thei r use These studies provided models for some of the analyses carried out in this study However the debate in the United States over appropriate methods of funding and staffing for emergency rooms is seldom relevant to New Zealand because of the differences both in philosophy and organisation of medical care in the two countries

The Platt [11] committee on A amp E services in Britain in 1962 was concerned about casual attenders ie patients not in need of urgent attention but wishing to avoid the trouble of attending their general practitioners surgery They also criticised the unsuitable accommodation and the insufficient numbers of senior medical staff supervising Casualty Departments The report recommended changing the name Casualty Service to Accident and Emergency Service (to discourage casual attendance) and rationalising the service by clOSing smaller A amp E units and centralising facilities These recommendations have been partially carried out

However there has been continuing research in Br i tain into the reasons given by patients particularly self-referred patients for their use of A amp E departments and the trade-off between general practitioner and A amp E services There has also been continuing debate over the medical staffing of A amp E departments

The British studies are of some relevance to the New Zealand situation since the organisation of medical care here is similar but no overseas experience can provide a blueprint for New Zealand For example the direct cost to the patient of general practice care in New Zealand raises the possibility of patients attending the A amp E department because it is free whereas the British system of general practitioner funding provides no such incentive

AN HISTORICAL PERSPECTIVE IN NEW ZEALAND

Little is known about the historical development of A amp E services in New Zealand Presumably they followed the British tradition described in the Platt report [11 p23-24)

The word casualty in its proper meaning of a serious injury has a long history It occurs in Shakespeare and Dickens writing in 1837 used casualty ward to describe the ward in a hospital in which accidents were treated Unfortunately the meaning alt~red in the second half of the last century The Nuffield Report (1960) Casualty Services and their Setting

3

gives an interesting quotation from a survey made by the Lancet in 1869 The out-patients at St Bartholomews Hospital are it says divided into two categories They are the middotcasualtymiddot which comprises those who are supposed to require temporary treatment for diseases or injuries of a trifling character and the middotout-patientsmiddot properly so called who after receiving a regular letter of admission are entitled to the advice of the assistant surgeons and physicians for a period of 12 months It is in the casualty division that the increase of numbers has been most marked bullbullbull It is estimated that not less than a thousand patients frequently attend on a Monday or Tuesday morning

Certainly by 1872 vlellingtons private medical practitioners were incensed at the hospitals provision of free treatment for their patients Five hundred outpatients were treated in Wellington that year [12] Separate casualty departments were operating at Wellington Hospital by 1924 [12] at Auckland Hospital by the 1940s [13] and Christchurch Hospital by 1952 [14]

The 1960 Board of Health report [15] on outpatient servicesmiddot expressed concern over the duplication of services by outpatient departments which were also available from general practitioners However it recommended that general hospitals continue to provide a casualty service available at all times

Since the late 1960s a series of New Zealand studies have considered the use of A amp E departments either by interviewing patients or by analysing data drawn from A amp E record systems and the organisation of A amp E departments

Interview studies on the utilisation of A amp E departments

The first interview study was an investigation of first attenders at the Dunedin A amp E department in 1968 by Dixon et al [2] Their results have not been contradicted by any of the later studies

They found that the principal attenders were males aged 15 to 24 who recorded first attendance rates of over 100 per 1000 each year The young men were also the most likely to report having no general practitioner Dixon found that the age and sex pattern of those attending at the A amp E department was nearly converse to the pattern of those attending a general practitioner

Dixon pointed out that the conditions treated at the A amp E department were rarely disease-related rather they were predominantly lacerations and open wounds bruising sprains and strains effects of foreign bodies and fractures The major reason given for attending the department was that it was seen as appropriate

Dixon concluded that the A amp E service was complementary and not competitive to general practice that the public were realistic in regarding it as the only practical and effective primary medical care for accident and emergency injuries and that payment for service did not appear to figure in the decision to attend the department

o

4

TwO interview studies of first attenders at Auckland Hospital A amp E department have been carried out by Hunton in 1972 and Richards in 1975 [16] Both studies included an assessment by the student interviewers and A amp E staff as to the suitability of the patients condition for general practice care 42-43 per cent were considered suitable Richards concluded that public education programmes encouraging people to use their general practitioner prior to attending the A amp E department should be instituted

In 1978 Keenan interviewed patients who had attended Christchurch A amp E department collecting detailed information on the accident or sickness leading to the attendance (unpublished see Chapter 6 and 7) He found the same set of reasons for using A amp E departments as Dixon found the A amp E department was seen as appropriate and accessible

Kljakovic found similar results when interviewing the parents of children attending A amp E departments in the Wellington region in 1978 [4] He also found that in choosing between the general practitioner and the A amp E department parents were more likely to use the service which was closer to the family home Children f rom lower socio-economic status families were more likely than other children to see thei r general practitioner before gOing to the A amp E department

Records studies on the utilisation of A amp E departments

Several studies have gathered data from A amp E records to investigate A amp E utilisation In 1979 Snelgar described the characteristics of people attending Northland Base Hospital A amp E department [17] He found similar results to Dixon apart from a higher proportion of injuries In the same year McRae reviewed all attendances at Waikato Hospital A amp E department and found a similar picture [lB]

Three records studies have looked at the relationship between A amp E use and general practitioner use Maynard looked at Mosgiel residents use of Dunedin A amp E facilities for three years before and three years after the opening of a local health centre [19] No difference was found ~asap

investigated assertions that people from one part of the Wellington Hospital catchment area had suddenly begun to use the A amp E department heavily for conditions that should have been seen by a general practitioner [20] In fact that part of the catchment area had much lower rates of A amp E use than other areas Reinken tested whether the doubling of general practitioner cover in one part of the Wellington region affected A amp E presentation rates differently than in other areas nearby [21] There was no clear evidence that the increased cover had any effect

Studies on the organisation of A amp E departments

As part of a thesis looking at young doctors Salmond examined the work of house surgeons in A amp E departments using a postal questionnaire [22J He concluded that working in an A amp E department was good experience for a house surgeon only if second year house surgeons were deployed in the department the house surgeon was well-supervised by senior medical staff there was a good working relationship with the A amp E chargemiddot nurse and the house surgeon was not over-tired He also suggested that good senior staffing was closely related to effective administration and better service in the A amp E department

5

The Hospital Design and EValuation Unit of the Department of Health prepared a report documenting the planning requirements of New Zealand A amp E departments [23] The report outlined several principles of A amp E design and made detailed recommendations on the facilities rooms and equipment necessary

OVERVIEW OF THIS STUDY

Aims

The aim of this study is to describe A amp E departments in New Zealand Because the material presented in the previous section was collected by different researchers at different times and from different A amp E

departments detailed comparisons across the studies have been difficult To get a more comprehensive picture of A amp E use in New Zealand a systematic investigation was necessary

The specific aims of this report are

o to describe the organisation of A amp E departments by looking at their procedures physical characteristics and staffing patterns

o to describe attendance at A amp E departments including the patients profile and pattern of attendance and the load placed on the departments by patients who would be more appropriately treated by a general practitioner

o to describe the use of A amp E departments by consumers by analysing patients reasons for attending the departments and analysing demographic factors inrelation to A amp E attendance

Sources of information

Information was gathered from three sources

The site visits

Fourteen A amp E departments were visited between May and September 1981 by a Department of Health study team consisting of a medical officer from the Division of Hospitals and a res~arch officer from the Management Services and Research Unit

At each hospital the team examined the facilities and spoke with staff involved with the A amp E department including

o the medical superintendent (and in some hospitals the principal nurse)

o the A amp E officer or medical officer in charge of the A amp E department (where such a position existed and was filled)

o the nurse supervisor andor charge nurse of the A amp E department

o at least one house surgeon working in the A amp E department

6

In some hospitals the team also spoke with other staff members including experienced A amp E staff nurses and hospital social workers

Question sheets were used during interviews so that a comparable body of information was collected at each hospital Interviews were open-ended to allow discussion of local procedures or problems (See Appendix A for question sheets)

Hospitals were carefully selected so that the A amp E departments in the study would represent a cross-section of New Zealand A amp E departments Those selected served a range of communities in both the North and South Islands

o major urban Dunedin)

areas (Auckland Wellington Christchurch and

o provincial centres (Rotorua Taranaki and Timaru)

o predominantly rural areas (Whakatane and Grey)

In centres with more than one A amp E department all were visited so that a complete picture of the services and use could be developed This involved visiting Auckland Green Lane Middlemore and North Shore hospitals in Auckland and Wellington Hutt and Kenepuru hospitals in Wellington

The information gathered in the site visits has been used in describing the organisation of A amp E departments (Chapters 3 4 arid 5)

The A amp E records data collection

On each site visit a sample of 1981 attendances was drawn from the A amp E record system and the following information was recorded for each person age sex presenting condition (sickness or injury) time of presentation residential address and whether the visit was a first attendance for the condition or a recall visit

Exceptions were Christchurch and the three Wellington Hospital Board A amp E departments Comparable data collected by Keenan in Ch ristchurch in 1978 and Allan in Wellington during 1980 were used instead

This information has been used to describe the attendance at A amp E departments (Chapter 6) and for the analysis of demographic factors in relation to attendance (Chapter 8)

The consumer studies

In 1978 Keenan carried out interviews with patients attending Christchurch A amp E department working from a one in eight sample drawn from the A amp E log over a four-week period and gaining a 99 response rate Results from this study have been analysed and compared with the results of the published New Zealand interview studies [2416] Anecdotal material from Kljakovic s study of children attending Wellington A amp E departments has also been included to illustrate the results of the numerical analysis

We realise that in studying only a selection of A amp E departments some local variations may have been missed but we are confident that the broad pattern and major issues in the organisation of A amp E care have been

7

covered Also as the A amp E departments studied serve two-thirds of the population of New Zealand the utilisation patterns discussed in the report are likely to prevail throughout New Zealand We hope that the mater ial presented the conclusions drawn and the questions raised in this report will encourage discussion about the current operation and future developmiant of A amp E departments in NewmiddotZealand

a

8

REFERENCES

1 de LACEY A REINKEN J and SALMOND C E - Community attitudes to sickness and health stimulus and response v 3 Community attitudes - Wellington Management Services and Research Unit Dept of Health 1980 p 103-105 (Special report series no 56)

2 DIXON C W Emery G M and SPEARS G F S - Casualty department utilisation survey in NZ Med J - v 71 (1970) p 272-279

3 [Editorial] in G P Journal of the General Practitioner Society no 42 (1981) P 1-2

4 KLJAKOVIC M ALLAN BC and REINKEN J - Why skip the general practitioner and go to the accident and emergency department in NZ Med J - v 93 (1981) P 49-52

5 SKUDDER Paul A McCARROLL James R and WADE Preston A - Hospital emergency facilities and services a survey in Emergency medical services behavioural and planning perspectives edited by John H Noble Jr et ale - New York Behavioural Publications 1973 p 17-35

6 MAYNARD Edward J - The application of epidemiological methods to the evaluation of primary medical care in a health centre environment shyUniversity of Otago 1980 Ph D Thesis Social and Preventive Medicine

7 Hospital misuse brings protest in Taranaki Daily News (1 Sept 1980) bull

8 FAHEY Morgan - The role of the family doctor in disaster and emergency medicine in NZ Family Physician - v 5 no 1 (1978) p 42-44

9 Proceedings of the emergency care seminar Auckland 19-23 March 1979 in NZ Med J - (1980) P 194-196

10 Double manning of ambulances [editorial] in NZ Hosp - v 32 no 3 (1980) p 1

11 Gt Brit Central Health Services Council - Standing Medicine Advisory Committee Accident and emergency services report of the subcommittee - London HMSO 1962 Chaired by Sir Harry Platt

12 BARBER Laurie H and TOWERS Roy J - Wellington Hospital 1847-1976 Wellington Wellington Hospital Board 1976

13 The story of Auckland Hospital 1847-1977 edited by David Scott -Auckland Medical Historical Library Committee of the Royal Australasian College of Physicians in New Zealand 1977 p 35-36

14 BENNETT FO - Hospital on the Avon the story of the Christchurch Hospital 1862-1962 Christchurch North Canterbury Hospital

o Board 1962

9

15 Outpatient services in public hospitals in New Zealand - Wellington Government Printer 196U (Report series Board of Health no 2)

16 RICHARDS J G and WHITE G R - Accident and emergency services at Auckland Hospital in NZ Med J - v 85 (1977) P 272-274

17 SNELGAR Denis - Accident and emergency utilisation study Paper prepared for the Primary Health Care Shadow Service Development Group Northland 1981 (Unpublished)

18 McRAE Shelagh and TOPPING Mark - Casualty attendances one years experience at Waikato Hospital in NZ Med J - v 95 (1982) P 12-14

19 MAYNARD Edward J and DODGE Jeffrey S - Introducing a community health centre at Mosgiel New Zealand effects on use of the hospital accident and emergency department in Med Care - v 21 no 4 (1983) p 379-388

20 KASAP D - Personal communication 1975

21 REINKEN J - Effect of changes in general practitioner cover on accident and emergency utilisation in the Porirua Basin Wellington Management Services and Research Unit Dept of Health 1979 (Unpublished)

22 SALMOND G C - Young doctors an exercise in social research methodology - University of Otago 1970 Ph D Thesis Social and Preventive Medicine p 179-214

23 Accident and emergency departments a study of planning requirements prepared by the Hospital Design and Evaluation Unit - Wellington Department of Health 1973

11

CHAPTER 2

Definitions

lhis chapter provides the definitions of terms used in our study In general our terminology is consistent with the literature However in some areas such as the classification of presenting conditions as sickness or injury or the description of GP-load there is no general consistency and we have developed our own definitions

THE ACCIDENT AND EMERGENCY DEPARTMENT

This name is the one commonly used in New Zealand We have used it in preference to the older description Casualty Depariment [1] and the American description of Emergency Department It is one hospital department which patients can approach without prior notification

Emergencies can be any condition that - in the opinion of the patient their family or whoever assumes the responsibility of bringing the patient to the hospital - requires immediate medical attention

However using such a definition means every case is an emergency In New Zealand A amp E departments patients tend to be classified in a similar way to the description given by the American Hospital Association [2]

o emergencies where delay is harmful and the condition potentially threatens life or function

a urgent cases which require attention within a few hours

o non-urgent cases where the condition is minor or non-acute and does not require the resources of the emergency service

An accident is an unexpected event Accidents which have resulted in attendance at an A amp E department are ones that have caused some trauma whether through shock or other injury The Platt report [1] decided on the term A amp E department in recognition that the real emergencies were a trickle while the accidents were a mighty flood

In general the A amp E department is regarded as part of the hospitals outpatient services and like these in day to day running it provides specific clinics generally for the treatment of traumatic injury x-ray burns dressings plasters and so forth

An accident and emergency patient is a person who is entered in the A amp E log book This can involve a certain amount of error however as some outpatients or discharged patients may return for follow-up care through the A amp E department Also the A amp E department often handles the acute admissions to the hospital

12

ATrENDANCE

A first visit (or first attendance) is the first visit a patient makes for one particular condition

A recall visit is any visit made for one particular condition which is not the first visit for the condition Some recall visits are patient initiated (eg due to pain bleeding infection or an accident to the dressing or plaster) but for the most part revisits are scheduled return visits suggested by A amp E staff

Total attendance is the sum of first visits and recall visits

Inj ury attendances are defined to include the results of trauma (cuts burns fractures sprains strains bruises head injuries multiple injur ies and so forth) as well as foreign bodies in the eye or other orifices and toxic effects whether from accidental or self-poisoning events Late effects of minor injury (pain bleeding abscesses or such) are not included as injury but as sickness

Sickness attendances include collapse (whether stroke coma heart attack or other) shortness of breath abdominal pain general sickness (fever vomiting diarrhoea unwell) mental distress and minor conditions

Non-urgent sicknesses are defined as the minor conditions abdominal pain and general sickness except for preschool children and adults over 65 where the general sickness and abdominal pain conditions can be urgent A amp E staff defined non-urgent sickness less specifically they tended to define it as longstanding or minor sickness

GP-load describes the patients whom A amp E staff feel should have seen a general practitioner It includes patients with longstanding or minor sickness conditions and patients with minor traumatic injury (eg cuts bumps and bruises)

In hours attendance refers to all attendances in the normal working hours of 0800 to 1800 Monday to Friday excluding holidays

Out of hours attendance refers to all other attendances outside the defined normal working hours

In an average week 50 hours fall in the in hours category and 118 hours in the out of hours category If we assume that an average person sleeps eight hours a night then that person is awake for 62 hours in the out of hours category (and all the in hours of course) Thus the out of hours category is 70 per cent of the total time in a week and 55 per cent of the waking time in a week

Minor conditions included abscesses backaches infected wounds or wound pain headache pain (unspecified) earaches eye problems toothaches nosebleeds limb pains We have called it the skin pain or bleeding category in Chapter 6

13

Attendance rates measure the use of A amp E departments for a defined population They express the number of cases from an area over a defined period per 1000 population in that area Rates were obtained by age and sex for sickness and injury and in and out of hours for each census area unit or neighbourhood served by each hospital

THE- HOSPITALS

We grouped hospitals into four types

o urban hospitals (where average annual first attendances at A amp E departments are over 25000 patients)

o provincial hospitals (serving 6000 to 12000 new A amp E patients each year)

o rural hospitals (serving fewer than 6000 new A amp E patients each year)

o suburban hospitals where A amp E departments are not open 24 hours per day North Shore Hospital was open 7 days a week 830 am shy530 pm and Kenepuru Hospital was open 5 days a week 830 am shy430 pm

Most of the A amp E departments visited had a senior position variously called the A amp E officer the A amp E director the senior medical officer or the medical officer in charge For convenience we call this position the A amp E officer

RECORDING SYSTEMS

The log is the record kept at the A amp E department which records some information on every patient who presents It will often give no more than the patients name the date and time of visit

The A amp E record is usually a card and it records basic patient information and case notes It may be held for several years in the A amp E department and may therefore contain information on a series of separate events for anyone patient

14

REFERENCES

1 GtBrit Central Health Services Council - Standing Medical Advisory Committee Accident and emergency services report of the sUbcommittee - London HMSO 1962 Chaired by Sir Harry Platt

2 Emergency services the hospital emergency department in an emergency care system Chicago American Hospital Association 1972 p vii-viii

15

D

CHAPTER 3

Procedures in the accident and emergency department

In this chapter we begin describing the organisation of A amp E departments by looking at the way they operate We follow the course of a patients care entry to the A amp E department sorting into priority order for care (triage) treatment and follow-up care

ENTRY

Most people presenting at the A amp E department were ambulant (the walking wounded as they are colloquially known) They came through the A amp E departments main entrance to the reception desk where they were first seen by a receptionist or nurse (Exceptions to this occurred in the smaller hospitals where patients presenting at night were first seen by the telephonist who called the nursing staff) Nurses did reception duties at

all the provincial and rural A amp E departments and at two of the urban A amp E departments when receptionists were not on duty (eg lunchtimes nights) bull At times nurses found that having to cover the reception desk interfered with their care of patients

When the receptionists are off duty the nurses do the reception work This can be a nuisance because it interferes with patient care and sometimes patients ring the bell at the reception desk and the staff working in the resuscitation room dont hear it

A amp E nurse

Unless their condition required immediate care the ambulant patients then spent several minutes at the reception desk while their details (eg name address general practitioner complaint) were noted on the A ampE records (See Appendix B for more information on A amp E records) Then they waited in the waiting room until they were called for treatment

A small proportion of patients arrived by ambulance andmiddot at almost all hospitals entered the A amp E department through a separate ambulance entrance In the larger hospitals some nursing staff were stationed in or near the ambulance entrance to care for these patients In other hospitals the staff had often been warned of incoming urgent cases and were standing by when the ambulance arrived As the condition of ambulance patients tended to be urgent they were usually taken straight to a resuscitation or treatment area patients condition permitted or friends or the ambulance driver

Record with the

keeping assist

was ance

carried of thei r

out r

when elativ

the es

SORTING

All A amp E departments operated some triage system to sort the ambulant patients by the urgency of their need for care (Themiddot only exception was Grey A amp E department where there was seldom more than one patient in the department at a time) At most A amp E departments the patients were sorted

16

into urgent and non-urgent categories with urgent cases being seen immediately and non-urgent cases being seen in the order they presented At some of the urban A amp E departments a more complex sorting was done For example

Priority is given in the following order

urgent need very young and very old patients those with general practitioner notes those without general practitioner notes

A lie E nurse

Usually ambulance cases were not triaged since they tended to arrive on their own and required urgent care However several A lie E departments had triage arrangements planned for the arrival of many ambulance cases at once as in a disaster

Sorting was largely a responsibility of the nurses although some A amp E doctors would occasionally check the condition of patients- in the waiting room too The receptionists often played a role in triage as well alerting the nursing staff to urgent cases This happened more in A amp E departments where the physical layout made it difficult for nurses to watch the entrance and the waiting room

The receptionists do tQe basic sorting They have guidelines to follow distressed patients severe cuts or bleeding go straight to the nurses open wounds or eye injuries go directly to a cubicle and are assessed by the nurses patients with abdominal pain or chest pain go on to trolleys and wait in the recovery room This system usually works well although occasionally a fracture patient will not be recognised and will sit in the waiting room

A lie E nurse

In several A lie E departments doctors and nurses stressed the value of an experienced receptionist in recognising and reacting quickly to acutely ill or injured patients

TREATMENT

Almost all the A amp Edepartments visited had a policy that all patients presenting had to be seen by a doctor The doctor did not necessarily have to treat the patient he or she could advise the patient to see a general practitioner Some A amp E doctors commented that by the time they saw the patients it was as easy to treat them as to send them away_ At a few departments the nurses (and occasionally the receptionist) could advise the patient that the department was not an appropriate place for their condition and that they should see a general practitioner This was usually done in consultation with the A E doctor but at times the nurses acted on their own initiative In these places a triage system similar to that reported by Weinerman et al [1] where patients were assigned to the appropriate service inside or outsidemiddot the hospital appeared to be operating

7

The assessment of patients the ordering of tests andmiddot the supervision of treatment were usually seen ~s medical functions The nurses would prepare patients for treatment (removing dressings) and carry out urgent first aid measures (stem bleeding start gastric lavage or cardio-pulmonary resuscitation) Generally however a nurse would only initiate treatment if the patients condition was urgent and a doctor was not available or was already busy with another emergency Exceptions to this situation occurred in some hospitals with A amp E nurse training programmes and in some smaller hospitals where the doctor is on call rather than working in the A amp E department In these departments experienced nurses could order tests such as x-rays and initiate treatments such as suturing and removing foreign bodies from eyes

In most A amp E departments nurses would perform some treatments under a doctors supervision However the range of treatments nurses were allowed to perform varied considerably among hospitals At some hospitals nurses sutured after training but at others they never sutured

The nurses do not suture although they would like to There are four reasons for this there is no full-time A amp E officer so good standards of sutur ing could not be maintained there could be medico-legal problems if a nurse sutured a cut which was more complicated than it looked eg with tendon involvement the nurses have enough to do at present and if they start suturing they will be expected to do it always and the young doctors need to learn suturing as part of their training

Principal nurse

Electrocardiograms were taken by nurses in some A amp E departments by technicians at others Taking blood samples was a doctors job in some departments but was done by nurses in others Similarly gastric lavage using a def ibrillator and plaster work were done by nurses in some departments Most A amp E nurses would maintain intra-venous drips but only nurses with special training WOUld insert them

Some nurses expressed frustration at restrictions on the treatments they were allowed to perform However several sen~or nurses stressed that they had to select carefully the nurses they allowed to perform more difficult treatments

We are very selective about choosing the nurses to do triage suturing and the more complicated procedures This seems to have been successful weve had no problems with nurses undertaking treatment theyre not competent to provide

A amp E senior nurse

I make sure the nurses understand they can be dangerous people If theyre not aware of their limitations theyre not suitable for A amp E work

A amp E senior nurse o

Also one department which had comparatively few nurses discouraged them from increasing the range of treatments they performed so that their workload did not become overwhelming

18

For diagnosis the A amp E departments made heavy use of the x-ray departments (The Design and Evaluation Unit study [21 estimated that 30 per cent of A amp E attenders had an x-ray during their visit) Some A amp E departments found their arrangements with the x-ray department very convenient with an x-ray machine aVailable 24 hours a day in or close to the A amp E department and with patients and x-ray films or reports returning within an hour At other hospitals arrangements Were less convenient in some places reporting bac k of x-rays took two or three hours delaying patients considerably while in others the x-ray departmentmiddot was located on a different floor from the A amp E ~epartment causing difficulties in transporting and accompanying patients there

Little use was made of the laboratory services other than for blood and urine tests and arrangements were generally satisfactory However in many hospitals x-ray and laboratory staff had to be called in to perform tests out of hours and because of the expense involved these out of hours tests were discouraged Some house surgeons found this a difficult situation

I I m caught between contradictory pressures the orthopaedic surgeons say that x-rays are necessary for proper diagnosis and the hospital board is trying to limit out of hours x-rays to save money

House surgeon

DISPOSAL

After treating the patient the A amp E doctor decides on the appropriate disposal discharging from care arranging follow-up treatment by referring to another source of care or recalling to the A amp E department or admitting the patient Information on disposal was only readily available from three A amp E departments The most common disposal pattern was in fact discharging from care with 40 to 55 per cent of patients making a first Visit being discharged

TABLE I PROPORTION OF FIRST ATTENDANCE PATIENrs DISCHARGED RECALLED REFERRED OR ADMITTED

Discharged Recalled Referred to Admitted Other First to A amp E GP Specialist attendance

Clinic tallied

Waikato l 393 132 222 99 134 19 25 707 Green Lane2 550 220 110 40 80 Unknown Taranaki 41 5 268 73 103 116 24 164

1 From McRaes study of Waikato A amp E departmen~ in 1979 2 From a study carried out by Green Lane A amp E department

19

FOLLOW-UP CARE

The decision to be made on follow-up care was usually between re~alling to the A amp E department or referring back to the patient I s general practitioner Some A amp E departments also referred patients (especially children) to district nurses or patients with work 1n]uries to an occupational health nurse or clinic Many departments referred fracture patients to orthopaedic clinics held in the hospital outpatients department and one A amp E department which was very short of space referred patients needing redressings to the outpatients department

There were large differences in referral practices (see Table 1) Between 13 and 27 per cent of first attenders were recalled to the A amp E department for follow-up care while 15 to 30 per cent were referred elsewhere either to a general practitioner or to a specialist clinic Also recall attendances expressed as a proportion of total attendances varied considerably among the A amp E departments from 10 per cent to 50 per cent (see Chapter 6 Table 11) and clearly reflected different follow-up practices

All of the urban and two of the provincial A amp E departments had a policy of referring most patients requiring follow-up care to a general practitioner and of keeping recall visits as low as possible This was similar to general policy in both Britain and the United States which appears to discourage re-at tendance at A amp E departments [34] However in the suburban rural and other provincial A amp E departments the decision on follow-up care was left to the judgement of the A amp E doctor

In practice however the choice to refer or to recall was reiated to several factors First the decision related to characteristics of the patients If the patients had serious wounds or burns or injuries which could develop complications they were usually recalled They were also recalled if the A amp E staff thought they would not receive appropriate care at home or they would not see a general practitioner for follow-up care Patients living a long way from the hospital were usually referred to their general practitioner At some A amp E departments patients were given the choice of referral or recall according to A amp E staff comments most chose to return to theA amp E department

The patients prefer to come back to the hospital Money is not a factor in this because the ACC pays for accident treatment at the general practitioner

A amp E nurse

Second there were general practitioner factors If the local general practitioners were unhappy about the A amp E department recalling patients or if a general practitioner had referred the patient to the department originally the A amp E doctors would refemiddotr rather than recall However if the A amp E doctors thought that the general practitioner did not have the facilities and in some cases the ability to provide follow-up care (eg for serious woundS eye injuries) they would recall the patient

Some GPs dont like following up care initiated by the A amp E department or dont have the necessary facilities so I tend not to send patients back to them

A amp E officer

20

Im more likely to refer a patient back to a GP who is reliable

House surgeon

Third many of the house surgeons said they would recall patients if they were interested in the condition or if they were worried about their diagnosis and treatment and wanted to see the outcome Several medical superintendents noted that recalling under these circumstances was acceptable because it comprised part of the house surgeons training

Fourth the workload of the A amp E department sometimes affected the follow-up decision with very busy departments actively discouraging recalls And finally there was the philosophy of A amp E medicine held by the A amp E doctor In one department where the A amp E officer considered it an ethical duty to see any treatment initiated through to a successful conclusion almost all patients who needed follow-up care were recalled At two other departments the A amp E officers stressed the importance of being able to deal efficiently with any emergencies presenting they kept recalls low so that the department was not clogged with extra patients Other A amp E doctors thought that the general practitioner could provide better continuity of care than the A amp E department so they referred as many patients as possible

When referring patients to the general practitionermiddot most of the A amp E doctors made a verbal recommendation to the patient and then relied on the patient to attend the general practitioner They would only write a formal referral letter if the patients condition was serious In several A amp E departments however greater efforts were made to inform the patient t s general practitioner Three departments gave referred patients cyclostyled forms with details of diagnosis and treatment to be passed to their general practitioner while the Whakatane department sent a copy of the A amp E record form to each patients general practitioner

ADMISSIONS

Table I suggests that between a and 14 per cent of all first attendances were admitted to the hospitals Admissions could well be higher for children Kljakovic [5] found that 20 per cent of the children presenting at the Wellington Hospital Board A amp E departments were admitted

The A amp E departments were involved in several different pathways for the admission of acutely ill or injured patients (Scheduled admissions did not involve the A amp E department at any of the hospitals visited) Self-referred patients could be admitted directly from the A amp E department to the wards or could be cared for in a holding (or acute admitting) ward before going to the wards

There was considerable variation among the hospitals as to which members of the medical staff were able to admit patients At some of the urban hospitals only the registrars could admit while at others the A amp E doctor could admit if the registrar was delayed and unable to assess the patient quickly At some of the provincial and one of the urban hospitals the A amp E doctor could admit in consultation with the admitting officer or appropriate registrar while at-another urban hospital and the rural A amp E departments the A amp E doctors regularly admitted patients

21

Hospitals with lower levels of bed occupancy were more likely to allow A amp E doctors to admit Senior A amp E doctors were more likely to play a role in admissions (actually admitting patients or advising the registrar) than house surgeons

Some patients referred by a general practitioner for acute admission also passed through the A amp E department At one hospital the general practitioners rang the A amp E officer to arrange for all acute admissions and all such GP-referred patients were seen first in the A amp E department However more usually the general practitioners rang the appropriate registrar to make arrangements and the registrar decided whether to admit the patient directly to the wards or through the A amp E department The involvement of A amp E staff with patients requiring admission ranged from almost none (where the patient went directly from the A amp E department to the ward or specialist unit) to a full initial assessment including tests (often undertaken at the request of the registrar responsible for the patient) bull

Generally the A amp E doctors were satisfied with the admission procedures However at one hospital where the A amp E doctors could not admit patients waiting for admission tended to clog the department The doctorselt that if they had admission rights the situation would be remedied

DISCUSSION

There were few differences among the A amp E departments in the reception and sorting of patients However there were differences in some aspects of treatment follow-up care and admission procedures

lhe role of the A amp E nurses in treatment varied considerably with some departments allowing nurses to initiate and perform many treatments and other departments allowing little autonomy Careful training and selection were essential before nurses increased their responsibility for treatment bull

Policies on follow-up care differed among the departments with the urban and provincial departments generally referring patients to general practitioners and the rural and suburban departments leaving the referral decision to the A amp E doctor In practice however the differences were less clear-cut with several factors other than the patient I s condition affecting the follow-up care decisions These factors included the A amp E staffs communicat ion with local general practitioners the inexperience and training needs of house surgeons the workload of the department and the senior A amp E doctors philosophy with regard to A amp E medicine

The A amp E departments also differed considerably in thei r procedures for acute admissions At some hospitals the A amp E doctor could admit an A amp E patient while at others the patient had to be held in the department until admitted by a registrar Also at some hospitals patients referred by general practitioners for acute admission were seen in the A amp E department before going to a ward While having to hold patients sometimes caused

clogging in the department A amp E staff were generally satisfied with the procedures

22

REfERENCES

1 WEINERMAN E Richard RUfZEN S Robert and PEARSON David shyEffects of medical -triage- in hospital emergency service in Public health reports - v 80 no 5 (May 1965) p 389-399

2 Accident and emergency departments a study of planning requirements prepared by the Hospital Design and Evaluation Unit - Wellington Department of Health 1973

3 Accident and emergency services - Gt Brit National Health Service memorandum HM (68)83

4 Emergency department organisation and management edited by AL Jenkins - St Louis Hosby 1975

5 KLJAKOVIC M ALLAN B C and REINKEN J - Why skip the general practitioner and go to the accident and emergency department in NZ Med J - v 93 (1981) P 49-52

23

CHAPTER 4

Phy~i~~1 c~~raft~rhtics of accident and emergency departments

This chapter describes the physical characteristics of A amp E departments their overall size location and layout as well as specific areas within the departments It discusses the effects of the physical characteristlcs on the organisation and functioning of the A amp E departments Our investigation worked from the detailed base established in bullAccident and emergency departments a studY of planning r~quirements a report prepared by the Hospital Design and Evaluation gnit Departmellt of HeCilth [1]

PRINCIPLES

The 1973 Hospital Design and Evaluation Unit (DEU) report [l] outlined the following principles to be applied in designing A amp E departments

o the A amp E department must be patients seeking emergency care

ready to receive and deal with

o the A amp E department mus~ be able load within a reasonable period

to cope with an average i

busy

o the A amp E department must be capable of adaptation to exceptional situations arising from major accidents ltgtrqther disasters

o the layout should be simple easily unqerstood and compact

o the layout and procedures should facilitate easy flow of patients through the department

o spaces should be multipurpose to give greatest versatility

o p~tient ~ovew~n~ should be minimised )

priv~cy for patientsshould be provided as far as is practicable andconsistent with the need for supervisi0rt

SIZE

There was considerable variation in the total sizes of the A amp E -a~1-ftment~ vi~ited witll floor areas ranging from 250 sql1a~e metres to 2115 ~guare m~ties (see Table 2) Eight of the 14 departments visited had i

hhid1pgw~fd~oracUte admitting ward However even wt)en ~he area of th~ f~ ~ bull ~middotc1~A~- _ ~ - bull bull ~

AampE department WCiS adjusted for the presence of a holding ward this I~1-getv~-rH~tion in irea reniained

24

TABLE 2 AREAS OF A amp E DEPARTMENTS

Total area Holding ward Adjusted total Waiting room area areal area

sqm sqm sqm sqm

Full-time departments

Urban Auckland 2 115 225 1 890 55 Middlemore 1 045 140 905 50 Green Lane 960 240 720 70 Wellington 575 190 385 75 Hutt 270 270 30 Christchurch 470 470 40 Dunedin 635 90 545 20

Provincial Rotorua 515 20 495 90 Taranaki Base 720 90 630 40 Timaru 605 70 535 80

Rural Whakatane 430 430 20 Grey 310 310 15

Part-time departments

Suburban North Shore 255 255 30 Kenepuru 540 540 30

1 Adjusted total area = total area minus holding ward area Considerable sharing with outpatients department

The area of the A amp E department was not closely related to the attendance (see Table 3) Obviously there is a certain minimum size for an A amp E department since certain facilities are essential regardless of the attendance served Thus as would be expected the rural and to a lesser extent the provincial A amp E departments had high area to attendance ratios However even within the group of urban A amp E departments there was a fourfold difference in the total area to attendance ratio

The design at Auckland~ laid out along several corridors with many separate consulting and treatment rooms possibly contributed to its high ratio At Wellington Hutt and Christchurch hospitals staff commented on their difficulties working in cramped conditions The lack of space often forced staff to work under extreme pressure to move patients through the departments very quickly

25

TABLE 3 AREA TO ATTENDANCE RATIOS FOR ADJUSTED TOTAL AREAS 1 AND WAITING AREAS OF A amp E DEPARTMENTS BY FIRST ATTENDANCE2 AND TOTAL ATTENDANCE 2

Adjusted total area to attendance ratio Waiting area to to attendance ratio

Sqm per 1000 Sqm per 1000 Sqm per 1000 first attendance total attendance total attendance pa p a p a

Full-time departments ~

Urban Auckland 323 291 08 Middlemore 232 157 09 Green Lane 3 230 168 16 Wellington 80 69 13 Hutt 82 63 07 Christchurch 76 64 05 Dunedin 200 143 05

Provincial Rotorua 404 293 53 Taranaki Base 609 399 25 Timaru 466 266 403

Rural Whakatane 718 490 23 Grey 805 61 2 30

Part-time departments

Suburban I INorth Shore 272 148 17

Kenepuru 924 597 33

1 Adjusted total area = total area minus holding ward area

2 See Table 9 for attendance figures used in calculations

3 Considerable sharing with outpatients department

Spearman rank correlations [2] of adjusted total area with

( a) first attendance r = 0310 p gt 010 Not significant ( b) total attendance r = 0297 pgt 010 Not significant

26

LOCATION

There is broad agreement that the A amp E department should be located on the ground floor well signposted and easily accessible to ambulatory patients and ambulances The ambulance entrance should be able to handle several ambulances at once and should have adequate turning space It should be projected from the weather and screened from the view of the other A amp E department patients

The A amp E department should also be located as closely as possible to radiology facilities (either the x-ray department itself or a branch) The A amp E department and the outpatients department can share some facilities and provide additional staff and accommodation in an emergen~y

situation if they are sited together Acute patient care areas (operating theatres intensive care unitsmiddot and cardiac care units) and laboratory services should also be readily accessible from the A amp E department [134]

Entrances

Almost all of the A amp E departments visited were on the ground floor of the hospital and were well signposted Generally access for ambulatory patients was good apart from two hospitals where they had to walk up steps to enter the building o

Few departments had ambulance access which could cope with a shuttle of ambulances bringing mass casualties from a disaster There w~s little relation between the size of the department or the population served and the ease of ambulance flow Indeed those departments with a relatively low probability of being involved in a mass casualty situation had good ambulance flow (eg Whakatane) while those with a greater possibility had relatively poor ambulance access (eg Wellington) Several departments had particularly poor a~bulance flow with only a one-lane access Three departments had good drive-straight-through access while at the rest ambulances had to reverse However there were advantages to some of the bull reversing I situations in that the bays into which the ambulances had to reverse were more likely to give the patient protection from the weather All the A amp E departments visited had separate ambulance entrances which in all but three cases guaranteed screening of ambulance patients from public view

Access to other hospital facilities

In many of the hospitals the A amp E department was adjacent to the outpatients department or to the orthopaedic outpatients section When this occurred the plaster room and x-ray facilities were usually shared and waiting areas and the records office were sometimes shared In the smaller hospitals both departments often shared the nursing staff

The access to the x-ray department ranged from excellent in places which had x-ray facilities immediately adjacent to the A amp E department to very poor where the patient had to be transported hundreds of metres and to a different floor The time taken for the A amp E doctor to get the result of the x-ray varied from five minutes to over two hours though the physical separation of the two departments was only one of the factors which affected this

27

Access to acute care facilities was similarly variable In Christchurch the intensive care unit was adjacent to the A amp E department while in Rotorua it was at the other end of the hospital In many cases additions or alterations to the hospital buildings and changes of function of certain areas have meant that the A amp E department no longer bears the same physical relationship to other hospital departments as was originally the case

LAYOUT

Several studies have concluded that the A amp Edepartment should be designed so that there is an orderly progression of patients from registration to examination to investigations if necessary to treatment and to referral admission or discharge Staff time and effort is best conserved by a compact plan with waiting areas and treatment areas easily accessible and supervised However the need for easy supervision has to be balanced by consideration of the patients privacy Two basic A amp E plans have evolved

o a radial plan where the waiting examination and treatment rooms are arranged on the perimeter of the departmentmiddot with the nurses station doctors room and records office in the centre

o a linear plan where the examination and treatment rooms are arranged down each side of a corridor with the waiting area records office and staff offices at one end [145]

Many of the A amp E departments visited had a linear layout with the largest Auckland being arranged along several corridors In these departments staff often commented that their overall view of the patients was not good and a considerable amount of walking was needed to supervise them Middlemore A amp E department and the treatment areas of several other departments had radial layouts which staff found very satisfactory Generally the A amp E staff prefer red open plan layouts using curtained cubicles rather than enclosed rooms Staff (especially nursing staff) often commented that their department would be better if certain walls or partitions were removed to give easier surveillance of the department as a whole However staff also commented on the relative lack of privacy for patients being examined or treated and noted that some private rooms were needed for instance for obstetric or paediatric patients

Waiting area

There is general agreement that the waiting area should be adjacent to the reception desk easily visible to the receptionist and if possible overlooked by the nurses office or station It should be a cheerful comfortable area with toys provided for children and a range of magazines and books Public toiletspublic telephones and arrangements for refreshments are also needed [146]

The size of the waiting area varied considerably among the A amp E departments visited (refer back tomiddot Table 2) Again this variation bore little relationship to the workload of the department (see Table 3) Some waiting areas were clearly too small and this put pressure on the staff to deal with patients quickly in order to clear the waiting room

28

Staff comments suggested that not only the size of the waiting area but also its design affected its crowding Basically square rooms with seats around the edges had fewer problems than corridor-style rooms with only one row of seats

In all the A amp E departments visited the waiting areas were adjacent to the reception area Sometimes they were visible from the nurses office or work area but where this was not possible the nurses relied on the receptionists to alert them to urgent cases or checked the wai Hng area often themselves

Facilities in waiting areas varied from nothing but seats to areas in which there were hot and cold drink dispensing machines a childrens play area with toys and health-related poster and pamphlet displays Some had a TV set or a tropical fish tank Most staff were agreed that a pleasant atmosphere in the waiting room was important and adVerse comments about the waiting area were made by staff in departments which lacked this In some departments staff commented that vandalism made it difficult to retain facilities and a pleasant atmosphere

Examination and treatment area

The examination and treatment area provides for the needs of all A amp E patients other than those with serious conditions requiring the resuscitation room or those needing special facilities such as plastering Because special purpose areas are frequently under-utilised flexibility is a key requi rement Hence multipurpose cubicles with standardised equipment are usually recommended The cubicles must be big enough to give easy access for patients (not necessarily walking) to accommodate eqUipment and to give staff enough room to work Curtained cubicles are generally sufficient but at least one enclosed cubicle is required for patients needing extra privacy or for light control in eye examinations A cubicle especially set up for children (with appropriately-sized equipment toys and posters) is also desirable [1346]

Most of themiddot A ~ E departments visited had curtained cubicles in the examination and treatment area with perhaps one or two enclosed cubicles or rooms as well Four A amp E departments only had separate rooms for treatment Curtained cubicles made for ease of access while separate rooms did present some difficulties in manoeuvering patient trolleys and wheelchairs In one case it was impossible to get a patient trolley into the room at all and the room was consequently little used

Curtained cubicles did afford greater flexibility in use and did provide more room to work but had the disadvantage of being considerably less private than rooms Surveillance was easier in departments with curtains than those withmiddot walls and doors In the Auckland A amp E department treatment rooms doors had been removed in the interests of improved surveillance Staff in this department commented that its rigid design could lead to difficulties in accommodating a large number of patients in a disaster

The DEU report [1] recommended that the number of cubicles required by an A amp E department was NIlS where N is the anticipated average number of new patients per day It noted that in A amp E departments with few new patients per day a minimum of two cubicles should be provided It also recommended that the flow of recalled patients should be regulated so that they did not greatly affect the need for cubicles

29

As can be seen from Table 4 most departments had enough cubicles to cope with their first attendance workload Even applying the DEU recommendation of N18 to their total attendance most of the departments had an adequate number of cubicles The exceptions were Hutt Christchurch and Dunedin

TABLE 4 NUMBERS OF EXAMINATION AND TREATMENT CUBICLES OR ROOMS AND RECOMMENDED NUMBERS l BASED ON FIRST ATTENDANCE 2 AND TOTAL ATTENDANCE 2

Actual number of DEU recommended numbers (minimum of 2) cubiclesrooms based on

first attendance total attendance pa pa

Full-time departments

Urban Auckland 13 89 99 Middlemore 9 59 88

Green Lane 7 40 65 Wellington 10 73 85 Hutt 4 51 66 Christchurch 7 94 11 2 Dunedin 3 41 58

Provincial Rotorua 4 2 26 Taranaki Base 4 2 24 Timaru 6 2 31

Rural Whakatane 3 2 2 Grey 3 2 2

Part-time departments

Suburban North Shore3 8 22 37 Kenepuru3 6 22 30

1 Based on DEU report [l which recommended NIS cubicles where N average number of new patients per day ie N6750 where N = average first attendance pa

2 See Table 9 for attendance figures used in calculations

3 Recommended numbers increased to adjust for North Shore and Kenepuru treating their attendance numbers in part-time rather than full-time hours

30

Resuscitation area

The resusciation area is used for the immediate life--saving treatment of seriously injured or sick patients It is the acute treatment area in contrast to the examination and treatment area which is used for relatively minor procedures In making its recommendations about the resuscitation area the DEU report [I] balanced the probability of the A amp E department having to treat multiple accident victims with the comparative rarity of use of resuscitation rooms It recommended that a resuscitation room of suff icient size to deal with two patients concurrently be provided in all A amp E departments It also noted that the ambulance entrance and resuscitation area should be located as close together as possible

Most of the departments visited had purpose-built resuscitation rooms of varying size and with varying degrees of sophistication in equipment Some had x-ray facilities in the resuscitat ion area and in those that did not its absence was regarded as a serious impediment to the efficient care of severe trauma

In four of the seven urban A amp E departments the resuscitation rooms were regarded by the staff as being too small The comment was made in one urban department that because of the small size of the resuscitation area patients sometimes had to be moved out of the area before it was felt clinically desirable to do so in order to accommodate incoming patients In the rural and prOVincial A amp E departments the resuscitation rooms wereshyadequate for the demands placed on them

Most resuscitation rooms were sited close to the ambulance entrance and afforded good access to stretcher patients However in three A amp E departments patients had to be moved some distance and in another department up one floor by lift

Operating theatre

In discussing provision of operating theatres in the A amp E departments the DEU report [1] noted that

o most surgery done is minor requires only local anaesthesia and could be done within adequately designed cubicles

o the A amp E department is not a proper place for general anaesthesia

o using A amp Etheatres for day surgery tends to block other A amp E facilities and staff causin~ delay in treating A amp E patients

The report concluded that special facilities appear to be justified only if there is a clear intention of widening the scope of accident surgery in the departments

bullMinor ops theatres of varying sizes and equipped to varying standards were available in many departments Very variable use was made of such theatres - never in some departments to daily in others It was used less in departments with very heavy workloads and where the medical staff were not satisfied that sufficiently sterile conditions could be maintained In one department the theatre was only used for day surgery cases

31

Plaster room

In the plaster room casts are applied and removed and fractures and dislocations can be manipulated The DEU report [1] noted that the plaster room could be an integral part of the A amp E department or shared with the orthopaedic department or belonging entirely to the latter It recommended that the plaster room be close to the A amp E department and the x-ray department

Most departments had a separate plaster room available In many cases this was shared with an adjacent orthopaedic outpatients or fracture clinic Th~ staff generally found the plaste~-rooms satisfactory although two particularly narrow rooms were difficult to work in

Interview room

The DEU report [l] recommended that A amp E departments in medium-sized and larger hospitals should have a small interview room where a patient IS

relatives could talk with A amp E staff the police or others

No A amp E department had a room specifically designated as an interview room for bereaved or distressed relatives although one A amp E department shared such a room with another department In most departments one of the staff off ices was generally used for this purpose In departments where staff offices were small or crowded the lack of an interview room was seen as a serious flaw in departmental layout

Reception and records office

The reception desk should be immediately visible to ambulant patients arriving at the A amp E department and it is desirable for the receptionist to be aware of what is happening at the ambulance entrance as well The current A amp E records should be held at the reception desk or nearby [1]

In the A ampE departments visited the reception desk was usually well-placed for dealing with ambulant patients but in only four cases did it overlook the ambulance entrance In two departments the reception desk was some distance from the treatment area (separated by a waiting room or outpatients room) and the nursing staff found it difficult to oversee incoming patients Current A amp E records were held at the reception desk in all but one of the departments visited The amount of space available in relation to the throughput of patients was a major factor in determining the length of time records could be kept within the department This in turn affected the ease and therefore speed of record retrieval

Staff offices

These ranged from non existent to very cramped spaces serving many other functions to pleasant specifically designated and relatively quiet areas The latter offices are conducive to good staff morale and being a place for exchange of views and experiences could be expected to contribute quite markedly to the overall effectiveness and eff iciency of the department

32

Holding ward

The DEU report [1] said that holding beds should be used primarily for A amp E patients requiring a period of observation prior to a decision about admission or for those who could be expected to go home after a rest period The report noted that using holding beds as recovery beds for day patients for arranged admissions or for pre-admission clinics was not desirable

Most of the urban and provincial A amp E departments visited had holding or acute admitting wards These holding wards were used mainly for assessing patients requiring acute admission but in some hospitals were also used for observing patients (eg with suspected concussion) and for holding night admissions till the morning to save disturbing the wards Neither of the rural A amp E departments had a holding ward although one had an I A amp E admission procedure where a patient could be admitted for up to 24 hours for observation without the need for full admission procedures In the A amp E departments with holding wards a patient staying for more than four hours was formally admitted

Our study showed that the A amp E departments had some problems using holding wards properly In two A amp E departments holding wards were little used at night because nursing levels were too low to staff them safely In another department the beds were used for patients recovering from day surgery and even for some pre-ar ranged admissions At times general practitioner-referred admissions could also clog the holding wards

DISCUSSION

Most of the A amp E departments were generally adequate in size location and layout The exceptions were Christchurch and Butt where conditions were very cramped with particularly limited examination and treatment areas and poor layout We understand that improvements are planned at Hutt and that recent extensions have improved the Christchurch department considerably but at the time of our visits staff in both these departments were working under extreme pressure because of the physical conditions

Despite the general adequacy of the departments almost all had some flaw which affected their operation and inconvenienced staff and patients Major flaws found in several A amp E departments included

o ambulance access unsuitable for a shuttle of ambulances in a disaster

o difficult access to the x-ray department

o resuscitation room too small for easy treatment of more than one patient at a time

o no interview room for relatives of patients

33

REFERENCES

1 Accident and emergency departments a study of planning requirements prepared by the Hospital Design and Evaluation Unit - Wellington Department of Health 1973

2 SIEGEL Sydney - Nonparametric statistics for the behavioural sciences - Tokyo McGraw-Hill Kogakusha 1956 p 202-213

3 Emergency services the hospital emergency department in an emergency care system Chicago American Hospital Association 1972 p 44-49

4 Emer~ency department organisation and management edited by A L Jenkins - St Louis Mosby 1975 p 8-16

5 Design of departments in Br Med J - v 2 (1979) p 1204-7

6 McKINLAY Robin - The care of children in New Zealand hospitals -Aucklandmiddot National Childrens Health Research Foundation 1982 p 79-80

35

CHAPTER 5

Staffing of accident and emergency departments

This chapter describes the staffing both medical and nursing looking at their numbers and experience their previous training and the training they receive in the A amp E department and their satisfaction with their work and conditions We also describe the clerical and reception staff and briefly the involvement of other workers (orderlies social workers and ambulance personnel) in the departments

MEDICAL STAFFING

Senior medical staffing

Organising appropriate medical staffing for hospital emergency services is a prQblem in many countries [1] The variety of staffing arrangements in A amp E departments within many countries suggests that none have established a generally satisfactory pattern of medical staffing

The Platt report [2] found that in Br itish A amp E departments the great majority of patients were seen by junior staff only and that supervision of the A amp E departments by conSUltants was often little more than nominal The committee recommended that

o the junior medical staff should be adequately supervised by consultants

o a consultant orthopaedic surgeon should normally be in charge of theA amp E unit

o an accident and emergency unit should have at least three consultant surgeons each giving a substantial part of their time to this work

o the primary task of general practitioners in emergency services is to deal with minor accidents and emergencies at any time of the day or night (by organising a rota to answer emergency calls within their practice by working sessions in A amp E departments or by attending cottage hospitals at short notice for emergency calls) bull

Since then some progress has been made but standards continue to lag behind those recommended [34] There has been considerable debate over the appropriate staffing arrangements for A amp E departments Some hospitals have implemented the Platt report recommendations others have appointed a full-time A amp E specialist others have employed a full-time non-specialist doctor and some have employed general practitioners

Despite the various systems there is a consensus in both the United States and Britain that experienced medical staffmiddot are essential in the A amp E department They are necessary for prompt effective treatment of emergency conditions for efficient running of the departments and for adequate supervision of the junior doctors employed [23567 p 17-23]

36

Similar concerns have been expressed in New Zealand since the Board of Health report on outpatient services in 1960 [8] This report recommended that general hospitals continue to provide a casualty service available at all times and staffed by experiencedmedical officers

Salmond [9] found that when a senior A amp E officer directed the department A amp E work was handled more efficiently and house surgeons were more closely supervised and supported He suggested that one senior member of the hospital staff (ideally a full-time A amp E officer) should accept full responsibility for the overall supervision of A amp E services

Most of the A amp E departments that we visited had an A amp E officer The position was vacant at both Wellington and Hutt hospitals at the time of our visit while at North Shore Hospital responsibility for the A amp E department was shared by two senior doctors The A amp E departments of the rural hospitals had no senior medical staff

In A amp E departments with heavy workloads additional experienced doctors were often employed as deputy A amp E officers usually medical officer special scale or as Medical Reserve Scheme registrars (see Table 5) There was no general practitioner staffing of any of the Aamp E departments visited although general practitioners had been part-time staff of some of themiddot smaller A amp E departments in previous years One medical superintendent commented that since very few general practitioners could be classified as specialists they could only be paid as medical officers special scale This low level of payment acted as a disincentive to general practitioner recruitment

The A amp E officers usually worked normal office hours (830 am - 430 pm or 9 am - 5 pm weekdays) apart from two who worked part-time covering morning periods If additional experienced doctors were employed they usually covered evening periods (eg 5 pm - 10 pm) and weekend day shifts

There was a wide range of experience among the A amp E officers Half of the senior A amp E doctors had a general practice background and these doctors often had specific surgical medical pharmacological or Armed Forces medical experience as well Several A amp E officers had primarily a surgical background while others had a considerable range of hospital experience In hospitals where the A amp E officers had a general practice background the Medical Superintendent or the A amp E officer often stressed the suitability of this background for A amp E work

An extensive general practitioner background is useful in dealing with the multitude of problems seen in an Accident and Emergency department An orthopaedic or surgical background is not as necessary because of the good backup from the specialties And staff who have only had hospital experience particularly junior staff can lack skills in general assessment and triage

A amp E officer

In other hospitals staff stressed that an orthopaedic and surgical background was very valuable as was experience in dealing with specific types of injury such as soft tissue wounds

37

TABLE 5 MEDICAL STAFFING OF A amp E DEPARTMENTS

Full-time departments

Urban Auckland Middlemore Green Lane Wellington2

Hutt2

Christchurch Dunedin

Provincial Rotorua Taranaki Base Timaru

Rural Whakatane Grey

Part-time departments

Suburban North Shore Kenepuru

Senior medical staffing

Number of full-time equivalents

A amp E officer ( including deputies) 25 15 I 16

I 2

I 03 I

2 05

Registrar

06

1 1

House surgeons

Number on Number A amp E runs covering

some shifts in A amp E deptl

6 2-3 6 2 5 I 5 4 2-3 5 2 2

All on rotating basis 1 3 1 2

5 on rotating basis 4 on rotating basis

None in A amp E dept 4 on rotating basis

1 On general relieving duties 2 Senior A amp E position vacant at time of visit

Junior medical staffing

The issues

Junior medical staffing of A amp E departments has concerned many commentators in the United States Britain and New Zealand The Platt report [2] noted that recently qualified staff when serving in the casualty department undertake responsibility which they would not have in the wards or outpatient clinics

38

In 1960 the New Zealand Board of Health report [8] on out-patient services deplored the staffing of casualty departments by I relatively inexperienced men [sic] and suggested that these staff I should be regarded more as assistants under supervision and training than responsible officers in the outpatients departments The undesirability of staffing A amp E departments with first year house surgeons (or pre-registration doctors) has been reiterated since Junior doctors are often unsure when to ask for advice or help and are sometimes unwilling to admit that they are over-tired and unable to cope [91011)

The report on the working conditions of New Zealand resident medical officers [12] noted the heavy load carried by house surgeons working long shifts in A amp E departments It also commented that when house surgeons are required to look after the A amp E department while carrying out ward duties inadequate cover of the A amp E department could result

The New Zealand situation

The urban A amp E departments had between two and six house surgeons working on three month A amp E runs and in several of these hospitals another one to three house surgeons on general relieving duties covered some A amp E shifts There were more house surgeons in A amp E departments with heavier workloads or with fewer senior medical staff The provincial and rural departments did not usually have house surgeons working on specific A amp E runs rather the A amp E department was covered by all (or most) of the house surgeons in the hospital on a rotatng basis Of the two suburban A amp E departments Kenepuru was covered by the house surgeons on a rotating basis while North Shore did not have any house surgeons because there was no inpatient or consultative backup available (see Table 5)

The total medical staffing of the departments (senior A amp E doctors and house surgeons together) ranged from 10 to 100 full-time equivalents and was closely related to the attendance at the departments (see Table 6) The provincial and rural A amp E departments had higher medical staff to attendance ratios because they had to provide a 24-hour service regardless of the size of the attendance

Each A amp E department visited rostered its house surgeons differently depending on the availability of senior medical staff the workload of the department and the house surgeons other duties In the urban departments house surgeons worked between 45 and 60 hours a week on shifts usually 8 to 12 hours long Many of the house surgeons working in these departments complained about long shifts and suggested that more staff were needed to reduce the shift lengths Split shifts were also unpopular

The most worrying aspect of the staff ing arrangements in bhe Accident and Emergency department is the long hours We need another house surgeon to reduce the hours on some shifts and to proviae another pair of hands in busy periods (eg Friday and Saturday night Sunday afternoon)

House surgeon

39

TABLE 6 TOTAL MEDICAL STAFFING (FULL-TIME EQUIVALENTS) AND MEDICAL STAFFING TO ATTENDANCE RATIOS FOR FIRST ATTENDANCE I AND TOTAL ATTENDANCE 1

Total medical Total medical staffing to staffing attendance ratio

FTE per FTE per 10000 first 10000 total

Full-time attendance attendance equivalents p a pa

Full-time departments

Urban

Auckland2 100 17 15 Middlemore2 91 23 16 Green Lane2 65 25 15 Wellington 66 14 12 Hutt2 55 17 13 Christchurch 70 11 10 Dunedin2 60 22 16

Provincial Rotorua 42 34 25 Taranaki Base2 28 27 18 Timaru 22 19 11

Rural Whakatane3 15 25 17 Grey 10 26 20

Part-time departments

Suburban North Shore 20 21 12 Kenepuru3 20 34 22

1 See Table 9 for attendance figures used in calculations 2 FTE estimated since A amp E department partially covered by house

surgeons on general relieving duties 3 FTE estimated since A amp E department covered by house surgeons on

rotating basis

Spearman rank correlations [131 of total medical staffing with

(a) first attendance r = 0953 p lt 001 (b) total attendance r = 0933 p 001

In the provincial and rural hospitals house surgeons were often on call for long shifts over nights and weekends They were usually covering a ward or the whole hospital at the same time and simultaneous demands from the wards and the A amp E department sometimes caused problems However

40

these house surgeons generally found their rostering satisfactory despite the long hours on call perhaps because the actual work required in the A amp E department was comparatively light

An ordinary week night is usually quiet after midnight thered be three to five calls and Id have to get up once on average Weekend nights are busier but I usually get at least two or three hours sleep

House surgeon

Several house surgeons were irritated that while they worked more intensively on A amp E runs than on ward runs they spent fewer hours on-call and consequently they were paid less

Supervision by senior medical staff

In the larger A amp F departments house surgeons worked with the senior medical staff on most day and some evening shifts only on night shifts (and some evening shifts) were house surgeons the sole medical staff in a department By contrast in the smaller and part-time departments house surgeons covered the department alone seldom working with any senior A amp E medical staff

Several nurses commented that the A amp E department ran less efficiently outside normal working hours because the house surgeons inexperience meant assessment and treatment times were longer and tests were used more often than when the A amp E officer was present

Many senior medical staff in the urban A amp E departments were concerned at the lack of supervision for house surgeons outside normal working hours and so would have Ii ked more senior A amp E staff Several of the house surgeons were also concerned although others enjoyed the autonomy they had and were not concerned about working without supervision

I am not happy with house surgeons managing the A amp E department on their own They only have a three month shift in the department and often most of this time is spent learning how to do A amp E wor k The house surgeons can have problems deciding when to call a registrar to treat a patient and there can be delays in obtaining a registrar The A amp E department needs full-time trained medical staff on duty 24 hours a day to give proper supervision to the house surgeons and to run an efficient department

A amp E officer

On night shift I can feel rather alone if something goes wrong

House surgeon

I enjoy the variety of work and the independence I have to treat most patients as I see fit

House surgeon

41 _A

Arraflgements for consultative backup and support when senior A amp E staff were not on duty varied from hospital to hospital according to hospital size n urban hospitals the house surgeons would usually call on the appropriate registrar and the acute admitting or specialist teams for emergencymiddot cases In some places the house surgeons could calIon the consultant if a registrar was unavailable but this was usually seen as a last resort call In the provincial and rural hospitals the house surgeons would call on the appropriate senior doctor who was available This was usually one of the cQnsultants or a registrar if any were employed by the hospital The A amp E Qfficer might occasionally be called and in hospitals without an A~amp E oHicer th~ medical superintendent would also provid~ backup

Generally house surgeons were happy with the support they received A physically compact hospital was mentioned several times as facilitating ~ ~ fast back-up Howeve( in some hospitals there could be considerable delays in 9etting surgical and orthopaedic registrars to the A amp E department usually because they were in theatre Also at two hospitals backup in the minor specialties was considered inadequate bull

Use of first year house surgeons

Urban and suburban hospitals had a policy of using second year house surgeons as much as possible in the A amp E department and of using first year house surgeons only in their second six months This policy was generally butmiddot not always carried out For example the on-call arrangements of some urban A amp E departments resulted in inexperienced first year house surgeons working in the department In the smaller hospitals also the limited pool of house surgeons available tended to result in more first year house surgeons working in the department

The hospital could not provide cover for the A amp E department without using first year house surgeons However there are always senior staff and the medical registrar readily available as backup

Medical superintendent

When direct supervision was limited first year house surgeons did find A amp E work difficult

Training

The training received by the house surgeons in the A amp E departments varied greatly Two hospitals ran half-day or one-day orientation courses before -house surgeons started in the department Three A amp E departments ran weekly or fortnightly training sessions on specific conditions while another department ran sessions on an irregular basis However house surgeons often missed training sessions because they were treating pat~entsln more than half tmiddothe A amp E departments no formal training was giVen and house surgeons were taught on-the-job when senior A amp E staff were available This teaching placed a considerable load on senior staff

The three-monthly changeover of house surgeons is frustrating and the first month with new house surgeons is very demanding because they have little confidence or competence

A amp E officer

CONTENTS

Page

ACKNOWIEDGEMENTS LIST OF TABLES LIST OF FIGURES

1 INTRODUCTION I

Background Thewider questions of emergency medical services The overseas situation An historical perspective in New Zealand

Interview studies on the utilisation of A amp E departments Record studies on the utili satjon of A amp E departments Studies of the organisation of A amp E departments

Overview of this study Aims Sources of information

References

2 DEFINITIONS 11

The Accident and Emergency department Attendance The hospitals Recording systems References

3 PROCEDURES IN THE ACCIDENT AND EMERGENCY DEPARTMENT 15

Entry Sorting 1 reatmen t Disposal Follow-upcare Admissions Discussion References

4 PHYSICAL CHARACTERISTICS OF ACCIDENT AND EMERGENCY DEPARTMENTS 23

PrinCiples Size Location

Entrances Access to other hospital facilities

Layout Waiting area Examination and treatment area Resuscitation area Operating theatre Plaster room Interview room Reception and records office Staff offices Holding ward

Discussion References

5

6

7

8

STAFFING OF ACCIDENT AND EMERGENCY DEPARTMENTS 35

Medical staffing Senior medical staffing Junior medical staffing Accident and emergency work as a career

Nurse staffing Other staff involved with the A amp E department

Reception and clerical staff Orderlies Social workers Ambulance personnel

Discussion References

PATIENT ATTENDANCE CHARACTERISTICS 55

Overall attendance and trends Age and sex Conditions

Injury conditions Sickness conditions

Recall attendance GP-load

Non-urgent sickness Discussion References

PATIENT ATTI~UDES TO THE ACCIDENT AND EMERGENCY DEPARTMENT AND STAFF ATTITUDES TO THE PATIENTS 75

Reasons for visiting the A amp E department Overseas studies New Zealand studies

Effect of health centres and deputising services on A amp E utilisation A amp E staff views of patients

Overseas studies The New Zealand situation

Discussion References

UTILISATION OF ACCIDENT AND EMERGENCY DEPARTMENTS 91

Comparison of A amp E utilisation among hospital catchment areas Results Effect of general practitioner availability

Factors explaining catchment area variations in A amp E utilisation Method Results of the mUltivariate analyses

Comparison of A amp E use and general practitioner use Discussion References

9 CONCLUSIONS 107

The A amp E department as a hospital department The A amp E department as an emergency service The A amp E department as a primary care service Where from here

APPENDICES

APPENDIX A QUestion sheets 116

APPENDIX B Accident and emergency department records 120

APPENDIX C Statistical analyses of accident and 123 emergency department attendance rates by neighbourhoods

APPENDIX D Childrens use of general practitioners 128 and accident and emergency departments in Wellington

TABLES

Table

1 Proportion of first attendance patients discharged recalled referred or admitted

2 Areas of A amp E department~

3 Area to attendance ratios for adjusted total areas and waiting areas of A amp E departments by first attendance and total attendance

4 Numbers of examination and treatment cubicles or rooms and recommended numbers based on first attendance and total attendance

Medical staffing of A amp E departments

6 Total medical staffing (full-time equivalents) and medical staffing to attendance ratios for first attendance and total attendance

7 Nurse staffing of A amp E departments excluding student nurses and hospital aids

Nurse staffing (full-time equivalents) and nurse staffing to attendance ratios for first attendance and total attendance

Average attendance at A amp E departments 1978-1981

10 Trends in attendance at A amp E departments 1978-1981

11 Proportion of A amp E attendance that was recall attendance

12 Proportion of A amp E attendance that was for sickness

13 Proportion of total A amp E attendance that was for Sickness by policy and age groups

14 Use of general practitioners by first attenders at A amp E departments

15 Reasons for A amp E first attendance from three New Zealand studiesmiddot

Itgt Attendance (mean age-adjusted rates per 1000 per quarter) within each A amp E department catchment area

Page

18

24

25

29

37

39

45

46

56

57

66middot

70

71

77

78

92

(continued)

Table Page

17 Hospital admissionsfor accidental injury (mean 93 age-adjusted rates per 1000 per year) and death due to accidental injury (mean age-adjusted rates per 1000 per year) within each A amp E department catchment area

IB Attendance (mean age-adjusted and neighbourhoodshy 99 adjusted rates per 1000 per quarter) and populationshyto-general practitioner ratio within each A amp E department catchment area

19 Comparison of first attendances for injury at A amp E 101 departments and general practitioners

FIGURES

Figure Page

1 Percentage of total attendance at 58 A amp E departments by age and sex

2 Percentage of total attendance at 59 A amp E departments for sickness and injury conditions by age and sex

3 Injury first attendances by type of injury 6U all ages

4 Injury first attendances by type of injury 61 by age groups

5 Sickness attendances by type of sickness 62 all ages

6 Sickness attendances by type of sickness 63 by age groups

7 Comparison of medical staff availability and 67 level of recall attendance

Comparison of nursing staff availability and 67 level of attendance

9 Location at which accidents happened by those 79 attending the A amp E department or the general practitioner for accidental injury

Use of general practitioners and A amp E departments 131 by Wellington children 1978 (rates per 1000 children per quarter)

1

CHAPTER 1

Introduction

BACKGROUND

This report arises f rom concerns expressed by several groups about the availability especially out of hours of emergency car~ and its provision by Accident and Emergency (A amp E) departments in New Zealand

In _SQe mid 1970 s the people of Porirua were worried that local general -pr-actitioners were not available at nights and weekends and by the delays

involved in travelling to Wellington and Hutt A amp E departments [IJ At the same time the people of North Shore were campaigning to keep their local A amp E department open More recently community groups in Upper Hutt have been pressing for the addition of an A amp E service to a local health centre Overall people are concerned that appropriate care (including facilities such as x-rays) is readily available in emergency situations

General practitioners are another group who have been concerned about A amp E departments in particular about inappropriate uses of A amp E departments A long-standing complaint bas been that patients are using A amp E departments for care which wou~d be better given by a general practitioner and that the A amp E departments retain patients instead of referr ing them back to their general practitioner for follow-up care [2 3J In 1981 the research group of the Wellington Faculty of the Royal NZ College of General Practitioners sponsored a study of children presenting at A amp E departments because they were worried that unnecessary admissions of children to hospital occurred because their parents had bypassed the general practitioners and gone straight to hospital [4J

Also A amp E staff and hospital administrators have been concerned that caring for patients who could have been treated by general practitioners has limited their ability to deal with emergency cases [567]

THE WIDER QUESTIONS OF EMERGENCY MEDICAL SERVICES

Emergency care requires not only the provision of hospital services (the A amp E department with back-up from other hospital facilities) but also the organisation of services outside the hospital and co-ordination between both sets of services Emergency medical services outside the hospital include alarm and communication systems transport systems and first aid services There are important questions for New Zealand within this framework For example what should be the role of general practitioners in on-site emergency care What level of training is appropriate for ambulance officers Should voluntary personnel staff ambulances To what extent is double manning of ambulances required [8910]

In order to limit the study to manageable proportions this report focusses only on the hospital services namely the A amp E department Emergency medical services provided outside hospitals are mentioned only where they impinge noticeably on the A ampE department It is hoped that due attention will be given to the wider questions of emergency medical services in the future (see Chapter 9)

2

THE OVERSEAS SITUATION

Concern with emergencymiddot care facilities especially their increasing use has been apparent in other countries for the past thirty years While some articles report on the situation in Canada Australia Sweden France and the USSR most of the literature is about the United States and Britain This section briefly outlines the major themes of the literature and their relevance to New Zealand More specific aspects are covered in the appropriate chapters

Many United States researchers have studied the operations of different emergency rooms exploring patients reasons for using the emergency room their demographic characteristics and their use of the family doctor Often the studies have tried to explain an increasing use of emergency rooms and some have reported on the effectiVeness of measures introduced to reduce thei r use These studies provided models for some of the analyses carried out in this study However the debate in the United States over appropriate methods of funding and staffing for emergency rooms is seldom relevant to New Zealand because of the differences both in philosophy and organisation of medical care in the two countries

The Platt [11] committee on A amp E services in Britain in 1962 was concerned about casual attenders ie patients not in need of urgent attention but wishing to avoid the trouble of attending their general practitioners surgery They also criticised the unsuitable accommodation and the insufficient numbers of senior medical staff supervising Casualty Departments The report recommended changing the name Casualty Service to Accident and Emergency Service (to discourage casual attendance) and rationalising the service by clOSing smaller A amp E units and centralising facilities These recommendations have been partially carried out

However there has been continuing research in Br i tain into the reasons given by patients particularly self-referred patients for their use of A amp E departments and the trade-off between general practitioner and A amp E services There has also been continuing debate over the medical staffing of A amp E departments

The British studies are of some relevance to the New Zealand situation since the organisation of medical care here is similar but no overseas experience can provide a blueprint for New Zealand For example the direct cost to the patient of general practice care in New Zealand raises the possibility of patients attending the A amp E department because it is free whereas the British system of general practitioner funding provides no such incentive

AN HISTORICAL PERSPECTIVE IN NEW ZEALAND

Little is known about the historical development of A amp E services in New Zealand Presumably they followed the British tradition described in the Platt report [11 p23-24)

The word casualty in its proper meaning of a serious injury has a long history It occurs in Shakespeare and Dickens writing in 1837 used casualty ward to describe the ward in a hospital in which accidents were treated Unfortunately the meaning alt~red in the second half of the last century The Nuffield Report (1960) Casualty Services and their Setting

3

gives an interesting quotation from a survey made by the Lancet in 1869 The out-patients at St Bartholomews Hospital are it says divided into two categories They are the middotcasualtymiddot which comprises those who are supposed to require temporary treatment for diseases or injuries of a trifling character and the middotout-patientsmiddot properly so called who after receiving a regular letter of admission are entitled to the advice of the assistant surgeons and physicians for a period of 12 months It is in the casualty division that the increase of numbers has been most marked bullbullbull It is estimated that not less than a thousand patients frequently attend on a Monday or Tuesday morning

Certainly by 1872 vlellingtons private medical practitioners were incensed at the hospitals provision of free treatment for their patients Five hundred outpatients were treated in Wellington that year [12] Separate casualty departments were operating at Wellington Hospital by 1924 [12] at Auckland Hospital by the 1940s [13] and Christchurch Hospital by 1952 [14]

The 1960 Board of Health report [15] on outpatient servicesmiddot expressed concern over the duplication of services by outpatient departments which were also available from general practitioners However it recommended that general hospitals continue to provide a casualty service available at all times

Since the late 1960s a series of New Zealand studies have considered the use of A amp E departments either by interviewing patients or by analysing data drawn from A amp E record systems and the organisation of A amp E departments

Interview studies on the utilisation of A amp E departments

The first interview study was an investigation of first attenders at the Dunedin A amp E department in 1968 by Dixon et al [2] Their results have not been contradicted by any of the later studies

They found that the principal attenders were males aged 15 to 24 who recorded first attendance rates of over 100 per 1000 each year The young men were also the most likely to report having no general practitioner Dixon found that the age and sex pattern of those attending at the A amp E department was nearly converse to the pattern of those attending a general practitioner

Dixon pointed out that the conditions treated at the A amp E department were rarely disease-related rather they were predominantly lacerations and open wounds bruising sprains and strains effects of foreign bodies and fractures The major reason given for attending the department was that it was seen as appropriate

Dixon concluded that the A amp E service was complementary and not competitive to general practice that the public were realistic in regarding it as the only practical and effective primary medical care for accident and emergency injuries and that payment for service did not appear to figure in the decision to attend the department

o

4

TwO interview studies of first attenders at Auckland Hospital A amp E department have been carried out by Hunton in 1972 and Richards in 1975 [16] Both studies included an assessment by the student interviewers and A amp E staff as to the suitability of the patients condition for general practice care 42-43 per cent were considered suitable Richards concluded that public education programmes encouraging people to use their general practitioner prior to attending the A amp E department should be instituted

In 1978 Keenan interviewed patients who had attended Christchurch A amp E department collecting detailed information on the accident or sickness leading to the attendance (unpublished see Chapter 6 and 7) He found the same set of reasons for using A amp E departments as Dixon found the A amp E department was seen as appropriate and accessible

Kljakovic found similar results when interviewing the parents of children attending A amp E departments in the Wellington region in 1978 [4] He also found that in choosing between the general practitioner and the A amp E department parents were more likely to use the service which was closer to the family home Children f rom lower socio-economic status families were more likely than other children to see thei r general practitioner before gOing to the A amp E department

Records studies on the utilisation of A amp E departments

Several studies have gathered data from A amp E records to investigate A amp E utilisation In 1979 Snelgar described the characteristics of people attending Northland Base Hospital A amp E department [17] He found similar results to Dixon apart from a higher proportion of injuries In the same year McRae reviewed all attendances at Waikato Hospital A amp E department and found a similar picture [lB]

Three records studies have looked at the relationship between A amp E use and general practitioner use Maynard looked at Mosgiel residents use of Dunedin A amp E facilities for three years before and three years after the opening of a local health centre [19] No difference was found ~asap

investigated assertions that people from one part of the Wellington Hospital catchment area had suddenly begun to use the A amp E department heavily for conditions that should have been seen by a general practitioner [20] In fact that part of the catchment area had much lower rates of A amp E use than other areas Reinken tested whether the doubling of general practitioner cover in one part of the Wellington region affected A amp E presentation rates differently than in other areas nearby [21] There was no clear evidence that the increased cover had any effect

Studies on the organisation of A amp E departments

As part of a thesis looking at young doctors Salmond examined the work of house surgeons in A amp E departments using a postal questionnaire [22J He concluded that working in an A amp E department was good experience for a house surgeon only if second year house surgeons were deployed in the department the house surgeon was well-supervised by senior medical staff there was a good working relationship with the A amp E chargemiddot nurse and the house surgeon was not over-tired He also suggested that good senior staffing was closely related to effective administration and better service in the A amp E department

5

The Hospital Design and EValuation Unit of the Department of Health prepared a report documenting the planning requirements of New Zealand A amp E departments [23] The report outlined several principles of A amp E design and made detailed recommendations on the facilities rooms and equipment necessary

OVERVIEW OF THIS STUDY

Aims

The aim of this study is to describe A amp E departments in New Zealand Because the material presented in the previous section was collected by different researchers at different times and from different A amp E

departments detailed comparisons across the studies have been difficult To get a more comprehensive picture of A amp E use in New Zealand a systematic investigation was necessary

The specific aims of this report are

o to describe the organisation of A amp E departments by looking at their procedures physical characteristics and staffing patterns

o to describe attendance at A amp E departments including the patients profile and pattern of attendance and the load placed on the departments by patients who would be more appropriately treated by a general practitioner

o to describe the use of A amp E departments by consumers by analysing patients reasons for attending the departments and analysing demographic factors inrelation to A amp E attendance

Sources of information

Information was gathered from three sources

The site visits

Fourteen A amp E departments were visited between May and September 1981 by a Department of Health study team consisting of a medical officer from the Division of Hospitals and a res~arch officer from the Management Services and Research Unit

At each hospital the team examined the facilities and spoke with staff involved with the A amp E department including

o the medical superintendent (and in some hospitals the principal nurse)

o the A amp E officer or medical officer in charge of the A amp E department (where such a position existed and was filled)

o the nurse supervisor andor charge nurse of the A amp E department

o at least one house surgeon working in the A amp E department

6

In some hospitals the team also spoke with other staff members including experienced A amp E staff nurses and hospital social workers

Question sheets were used during interviews so that a comparable body of information was collected at each hospital Interviews were open-ended to allow discussion of local procedures or problems (See Appendix A for question sheets)

Hospitals were carefully selected so that the A amp E departments in the study would represent a cross-section of New Zealand A amp E departments Those selected served a range of communities in both the North and South Islands

o major urban Dunedin)

areas (Auckland Wellington Christchurch and

o provincial centres (Rotorua Taranaki and Timaru)

o predominantly rural areas (Whakatane and Grey)

In centres with more than one A amp E department all were visited so that a complete picture of the services and use could be developed This involved visiting Auckland Green Lane Middlemore and North Shore hospitals in Auckland and Wellington Hutt and Kenepuru hospitals in Wellington

The information gathered in the site visits has been used in describing the organisation of A amp E departments (Chapters 3 4 arid 5)

The A amp E records data collection

On each site visit a sample of 1981 attendances was drawn from the A amp E record system and the following information was recorded for each person age sex presenting condition (sickness or injury) time of presentation residential address and whether the visit was a first attendance for the condition or a recall visit

Exceptions were Christchurch and the three Wellington Hospital Board A amp E departments Comparable data collected by Keenan in Ch ristchurch in 1978 and Allan in Wellington during 1980 were used instead

This information has been used to describe the attendance at A amp E departments (Chapter 6) and for the analysis of demographic factors in relation to attendance (Chapter 8)

The consumer studies

In 1978 Keenan carried out interviews with patients attending Christchurch A amp E department working from a one in eight sample drawn from the A amp E log over a four-week period and gaining a 99 response rate Results from this study have been analysed and compared with the results of the published New Zealand interview studies [2416] Anecdotal material from Kljakovic s study of children attending Wellington A amp E departments has also been included to illustrate the results of the numerical analysis

We realise that in studying only a selection of A amp E departments some local variations may have been missed but we are confident that the broad pattern and major issues in the organisation of A amp E care have been

7

covered Also as the A amp E departments studied serve two-thirds of the population of New Zealand the utilisation patterns discussed in the report are likely to prevail throughout New Zealand We hope that the mater ial presented the conclusions drawn and the questions raised in this report will encourage discussion about the current operation and future developmiant of A amp E departments in NewmiddotZealand

a

8

REFERENCES

1 de LACEY A REINKEN J and SALMOND C E - Community attitudes to sickness and health stimulus and response v 3 Community attitudes - Wellington Management Services and Research Unit Dept of Health 1980 p 103-105 (Special report series no 56)

2 DIXON C W Emery G M and SPEARS G F S - Casualty department utilisation survey in NZ Med J - v 71 (1970) p 272-279

3 [Editorial] in G P Journal of the General Practitioner Society no 42 (1981) P 1-2

4 KLJAKOVIC M ALLAN BC and REINKEN J - Why skip the general practitioner and go to the accident and emergency department in NZ Med J - v 93 (1981) P 49-52

5 SKUDDER Paul A McCARROLL James R and WADE Preston A - Hospital emergency facilities and services a survey in Emergency medical services behavioural and planning perspectives edited by John H Noble Jr et ale - New York Behavioural Publications 1973 p 17-35

6 MAYNARD Edward J - The application of epidemiological methods to the evaluation of primary medical care in a health centre environment shyUniversity of Otago 1980 Ph D Thesis Social and Preventive Medicine

7 Hospital misuse brings protest in Taranaki Daily News (1 Sept 1980) bull

8 FAHEY Morgan - The role of the family doctor in disaster and emergency medicine in NZ Family Physician - v 5 no 1 (1978) p 42-44

9 Proceedings of the emergency care seminar Auckland 19-23 March 1979 in NZ Med J - (1980) P 194-196

10 Double manning of ambulances [editorial] in NZ Hosp - v 32 no 3 (1980) p 1

11 Gt Brit Central Health Services Council - Standing Medicine Advisory Committee Accident and emergency services report of the subcommittee - London HMSO 1962 Chaired by Sir Harry Platt

12 BARBER Laurie H and TOWERS Roy J - Wellington Hospital 1847-1976 Wellington Wellington Hospital Board 1976

13 The story of Auckland Hospital 1847-1977 edited by David Scott -Auckland Medical Historical Library Committee of the Royal Australasian College of Physicians in New Zealand 1977 p 35-36

14 BENNETT FO - Hospital on the Avon the story of the Christchurch Hospital 1862-1962 Christchurch North Canterbury Hospital

o Board 1962

9

15 Outpatient services in public hospitals in New Zealand - Wellington Government Printer 196U (Report series Board of Health no 2)

16 RICHARDS J G and WHITE G R - Accident and emergency services at Auckland Hospital in NZ Med J - v 85 (1977) P 272-274

17 SNELGAR Denis - Accident and emergency utilisation study Paper prepared for the Primary Health Care Shadow Service Development Group Northland 1981 (Unpublished)

18 McRAE Shelagh and TOPPING Mark - Casualty attendances one years experience at Waikato Hospital in NZ Med J - v 95 (1982) P 12-14

19 MAYNARD Edward J and DODGE Jeffrey S - Introducing a community health centre at Mosgiel New Zealand effects on use of the hospital accident and emergency department in Med Care - v 21 no 4 (1983) p 379-388

20 KASAP D - Personal communication 1975

21 REINKEN J - Effect of changes in general practitioner cover on accident and emergency utilisation in the Porirua Basin Wellington Management Services and Research Unit Dept of Health 1979 (Unpublished)

22 SALMOND G C - Young doctors an exercise in social research methodology - University of Otago 1970 Ph D Thesis Social and Preventive Medicine p 179-214

23 Accident and emergency departments a study of planning requirements prepared by the Hospital Design and Evaluation Unit - Wellington Department of Health 1973

11

CHAPTER 2

Definitions

lhis chapter provides the definitions of terms used in our study In general our terminology is consistent with the literature However in some areas such as the classification of presenting conditions as sickness or injury or the description of GP-load there is no general consistency and we have developed our own definitions

THE ACCIDENT AND EMERGENCY DEPARTMENT

This name is the one commonly used in New Zealand We have used it in preference to the older description Casualty Depariment [1] and the American description of Emergency Department It is one hospital department which patients can approach without prior notification

Emergencies can be any condition that - in the opinion of the patient their family or whoever assumes the responsibility of bringing the patient to the hospital - requires immediate medical attention

However using such a definition means every case is an emergency In New Zealand A amp E departments patients tend to be classified in a similar way to the description given by the American Hospital Association [2]

o emergencies where delay is harmful and the condition potentially threatens life or function

a urgent cases which require attention within a few hours

o non-urgent cases where the condition is minor or non-acute and does not require the resources of the emergency service

An accident is an unexpected event Accidents which have resulted in attendance at an A amp E department are ones that have caused some trauma whether through shock or other injury The Platt report [1] decided on the term A amp E department in recognition that the real emergencies were a trickle while the accidents were a mighty flood

In general the A amp E department is regarded as part of the hospitals outpatient services and like these in day to day running it provides specific clinics generally for the treatment of traumatic injury x-ray burns dressings plasters and so forth

An accident and emergency patient is a person who is entered in the A amp E log book This can involve a certain amount of error however as some outpatients or discharged patients may return for follow-up care through the A amp E department Also the A amp E department often handles the acute admissions to the hospital

12

ATrENDANCE

A first visit (or first attendance) is the first visit a patient makes for one particular condition

A recall visit is any visit made for one particular condition which is not the first visit for the condition Some recall visits are patient initiated (eg due to pain bleeding infection or an accident to the dressing or plaster) but for the most part revisits are scheduled return visits suggested by A amp E staff

Total attendance is the sum of first visits and recall visits

Inj ury attendances are defined to include the results of trauma (cuts burns fractures sprains strains bruises head injuries multiple injur ies and so forth) as well as foreign bodies in the eye or other orifices and toxic effects whether from accidental or self-poisoning events Late effects of minor injury (pain bleeding abscesses or such) are not included as injury but as sickness

Sickness attendances include collapse (whether stroke coma heart attack or other) shortness of breath abdominal pain general sickness (fever vomiting diarrhoea unwell) mental distress and minor conditions

Non-urgent sicknesses are defined as the minor conditions abdominal pain and general sickness except for preschool children and adults over 65 where the general sickness and abdominal pain conditions can be urgent A amp E staff defined non-urgent sickness less specifically they tended to define it as longstanding or minor sickness

GP-load describes the patients whom A amp E staff feel should have seen a general practitioner It includes patients with longstanding or minor sickness conditions and patients with minor traumatic injury (eg cuts bumps and bruises)

In hours attendance refers to all attendances in the normal working hours of 0800 to 1800 Monday to Friday excluding holidays

Out of hours attendance refers to all other attendances outside the defined normal working hours

In an average week 50 hours fall in the in hours category and 118 hours in the out of hours category If we assume that an average person sleeps eight hours a night then that person is awake for 62 hours in the out of hours category (and all the in hours of course) Thus the out of hours category is 70 per cent of the total time in a week and 55 per cent of the waking time in a week

Minor conditions included abscesses backaches infected wounds or wound pain headache pain (unspecified) earaches eye problems toothaches nosebleeds limb pains We have called it the skin pain or bleeding category in Chapter 6

13

Attendance rates measure the use of A amp E departments for a defined population They express the number of cases from an area over a defined period per 1000 population in that area Rates were obtained by age and sex for sickness and injury and in and out of hours for each census area unit or neighbourhood served by each hospital

THE- HOSPITALS

We grouped hospitals into four types

o urban hospitals (where average annual first attendances at A amp E departments are over 25000 patients)

o provincial hospitals (serving 6000 to 12000 new A amp E patients each year)

o rural hospitals (serving fewer than 6000 new A amp E patients each year)

o suburban hospitals where A amp E departments are not open 24 hours per day North Shore Hospital was open 7 days a week 830 am shy530 pm and Kenepuru Hospital was open 5 days a week 830 am shy430 pm

Most of the A amp E departments visited had a senior position variously called the A amp E officer the A amp E director the senior medical officer or the medical officer in charge For convenience we call this position the A amp E officer

RECORDING SYSTEMS

The log is the record kept at the A amp E department which records some information on every patient who presents It will often give no more than the patients name the date and time of visit

The A amp E record is usually a card and it records basic patient information and case notes It may be held for several years in the A amp E department and may therefore contain information on a series of separate events for anyone patient

14

REFERENCES

1 GtBrit Central Health Services Council - Standing Medical Advisory Committee Accident and emergency services report of the sUbcommittee - London HMSO 1962 Chaired by Sir Harry Platt

2 Emergency services the hospital emergency department in an emergency care system Chicago American Hospital Association 1972 p vii-viii

15

D

CHAPTER 3

Procedures in the accident and emergency department

In this chapter we begin describing the organisation of A amp E departments by looking at the way they operate We follow the course of a patients care entry to the A amp E department sorting into priority order for care (triage) treatment and follow-up care

ENTRY

Most people presenting at the A amp E department were ambulant (the walking wounded as they are colloquially known) They came through the A amp E departments main entrance to the reception desk where they were first seen by a receptionist or nurse (Exceptions to this occurred in the smaller hospitals where patients presenting at night were first seen by the telephonist who called the nursing staff) Nurses did reception duties at

all the provincial and rural A amp E departments and at two of the urban A amp E departments when receptionists were not on duty (eg lunchtimes nights) bull At times nurses found that having to cover the reception desk interfered with their care of patients

When the receptionists are off duty the nurses do the reception work This can be a nuisance because it interferes with patient care and sometimes patients ring the bell at the reception desk and the staff working in the resuscitation room dont hear it

A amp E nurse

Unless their condition required immediate care the ambulant patients then spent several minutes at the reception desk while their details (eg name address general practitioner complaint) were noted on the A ampE records (See Appendix B for more information on A amp E records) Then they waited in the waiting room until they were called for treatment

A small proportion of patients arrived by ambulance andmiddot at almost all hospitals entered the A amp E department through a separate ambulance entrance In the larger hospitals some nursing staff were stationed in or near the ambulance entrance to care for these patients In other hospitals the staff had often been warned of incoming urgent cases and were standing by when the ambulance arrived As the condition of ambulance patients tended to be urgent they were usually taken straight to a resuscitation or treatment area patients condition permitted or friends or the ambulance driver

Record with the

keeping assist

was ance

carried of thei r

out r

when elativ

the es

SORTING

All A amp E departments operated some triage system to sort the ambulant patients by the urgency of their need for care (Themiddot only exception was Grey A amp E department where there was seldom more than one patient in the department at a time) At most A amp E departments the patients were sorted

16

into urgent and non-urgent categories with urgent cases being seen immediately and non-urgent cases being seen in the order they presented At some of the urban A amp E departments a more complex sorting was done For example

Priority is given in the following order

urgent need very young and very old patients those with general practitioner notes those without general practitioner notes

A lie E nurse

Usually ambulance cases were not triaged since they tended to arrive on their own and required urgent care However several A lie E departments had triage arrangements planned for the arrival of many ambulance cases at once as in a disaster

Sorting was largely a responsibility of the nurses although some A amp E doctors would occasionally check the condition of patients- in the waiting room too The receptionists often played a role in triage as well alerting the nursing staff to urgent cases This happened more in A amp E departments where the physical layout made it difficult for nurses to watch the entrance and the waiting room

The receptionists do tQe basic sorting They have guidelines to follow distressed patients severe cuts or bleeding go straight to the nurses open wounds or eye injuries go directly to a cubicle and are assessed by the nurses patients with abdominal pain or chest pain go on to trolleys and wait in the recovery room This system usually works well although occasionally a fracture patient will not be recognised and will sit in the waiting room

A lie E nurse

In several A lie E departments doctors and nurses stressed the value of an experienced receptionist in recognising and reacting quickly to acutely ill or injured patients

TREATMENT

Almost all the A amp Edepartments visited had a policy that all patients presenting had to be seen by a doctor The doctor did not necessarily have to treat the patient he or she could advise the patient to see a general practitioner Some A amp E doctors commented that by the time they saw the patients it was as easy to treat them as to send them away_ At a few departments the nurses (and occasionally the receptionist) could advise the patient that the department was not an appropriate place for their condition and that they should see a general practitioner This was usually done in consultation with the A E doctor but at times the nurses acted on their own initiative In these places a triage system similar to that reported by Weinerman et al [1] where patients were assigned to the appropriate service inside or outsidemiddot the hospital appeared to be operating

7

The assessment of patients the ordering of tests andmiddot the supervision of treatment were usually seen ~s medical functions The nurses would prepare patients for treatment (removing dressings) and carry out urgent first aid measures (stem bleeding start gastric lavage or cardio-pulmonary resuscitation) Generally however a nurse would only initiate treatment if the patients condition was urgent and a doctor was not available or was already busy with another emergency Exceptions to this situation occurred in some hospitals with A amp E nurse training programmes and in some smaller hospitals where the doctor is on call rather than working in the A amp E department In these departments experienced nurses could order tests such as x-rays and initiate treatments such as suturing and removing foreign bodies from eyes

In most A amp E departments nurses would perform some treatments under a doctors supervision However the range of treatments nurses were allowed to perform varied considerably among hospitals At some hospitals nurses sutured after training but at others they never sutured

The nurses do not suture although they would like to There are four reasons for this there is no full-time A amp E officer so good standards of sutur ing could not be maintained there could be medico-legal problems if a nurse sutured a cut which was more complicated than it looked eg with tendon involvement the nurses have enough to do at present and if they start suturing they will be expected to do it always and the young doctors need to learn suturing as part of their training

Principal nurse

Electrocardiograms were taken by nurses in some A amp E departments by technicians at others Taking blood samples was a doctors job in some departments but was done by nurses in others Similarly gastric lavage using a def ibrillator and plaster work were done by nurses in some departments Most A amp E nurses would maintain intra-venous drips but only nurses with special training WOUld insert them

Some nurses expressed frustration at restrictions on the treatments they were allowed to perform However several sen~or nurses stressed that they had to select carefully the nurses they allowed to perform more difficult treatments

We are very selective about choosing the nurses to do triage suturing and the more complicated procedures This seems to have been successful weve had no problems with nurses undertaking treatment theyre not competent to provide

A amp E senior nurse

I make sure the nurses understand they can be dangerous people If theyre not aware of their limitations theyre not suitable for A amp E work

A amp E senior nurse o

Also one department which had comparatively few nurses discouraged them from increasing the range of treatments they performed so that their workload did not become overwhelming

18

For diagnosis the A amp E departments made heavy use of the x-ray departments (The Design and Evaluation Unit study [21 estimated that 30 per cent of A amp E attenders had an x-ray during their visit) Some A amp E departments found their arrangements with the x-ray department very convenient with an x-ray machine aVailable 24 hours a day in or close to the A amp E department and with patients and x-ray films or reports returning within an hour At other hospitals arrangements Were less convenient in some places reporting bac k of x-rays took two or three hours delaying patients considerably while in others the x-ray departmentmiddot was located on a different floor from the A amp E ~epartment causing difficulties in transporting and accompanying patients there

Little use was made of the laboratory services other than for blood and urine tests and arrangements were generally satisfactory However in many hospitals x-ray and laboratory staff had to be called in to perform tests out of hours and because of the expense involved these out of hours tests were discouraged Some house surgeons found this a difficult situation

I I m caught between contradictory pressures the orthopaedic surgeons say that x-rays are necessary for proper diagnosis and the hospital board is trying to limit out of hours x-rays to save money

House surgeon

DISPOSAL

After treating the patient the A amp E doctor decides on the appropriate disposal discharging from care arranging follow-up treatment by referring to another source of care or recalling to the A amp E department or admitting the patient Information on disposal was only readily available from three A amp E departments The most common disposal pattern was in fact discharging from care with 40 to 55 per cent of patients making a first Visit being discharged

TABLE I PROPORTION OF FIRST ATTENDANCE PATIENrs DISCHARGED RECALLED REFERRED OR ADMITTED

Discharged Recalled Referred to Admitted Other First to A amp E GP Specialist attendance

Clinic tallied

Waikato l 393 132 222 99 134 19 25 707 Green Lane2 550 220 110 40 80 Unknown Taranaki 41 5 268 73 103 116 24 164

1 From McRaes study of Waikato A amp E departmen~ in 1979 2 From a study carried out by Green Lane A amp E department

19

FOLLOW-UP CARE

The decision to be made on follow-up care was usually between re~alling to the A amp E department or referring back to the patient I s general practitioner Some A amp E departments also referred patients (especially children) to district nurses or patients with work 1n]uries to an occupational health nurse or clinic Many departments referred fracture patients to orthopaedic clinics held in the hospital outpatients department and one A amp E department which was very short of space referred patients needing redressings to the outpatients department

There were large differences in referral practices (see Table 1) Between 13 and 27 per cent of first attenders were recalled to the A amp E department for follow-up care while 15 to 30 per cent were referred elsewhere either to a general practitioner or to a specialist clinic Also recall attendances expressed as a proportion of total attendances varied considerably among the A amp E departments from 10 per cent to 50 per cent (see Chapter 6 Table 11) and clearly reflected different follow-up practices

All of the urban and two of the provincial A amp E departments had a policy of referring most patients requiring follow-up care to a general practitioner and of keeping recall visits as low as possible This was similar to general policy in both Britain and the United States which appears to discourage re-at tendance at A amp E departments [34] However in the suburban rural and other provincial A amp E departments the decision on follow-up care was left to the judgement of the A amp E doctor

In practice however the choice to refer or to recall was reiated to several factors First the decision related to characteristics of the patients If the patients had serious wounds or burns or injuries which could develop complications they were usually recalled They were also recalled if the A amp E staff thought they would not receive appropriate care at home or they would not see a general practitioner for follow-up care Patients living a long way from the hospital were usually referred to their general practitioner At some A amp E departments patients were given the choice of referral or recall according to A amp E staff comments most chose to return to theA amp E department

The patients prefer to come back to the hospital Money is not a factor in this because the ACC pays for accident treatment at the general practitioner

A amp E nurse

Second there were general practitioner factors If the local general practitioners were unhappy about the A amp E department recalling patients or if a general practitioner had referred the patient to the department originally the A amp E doctors would refemiddotr rather than recall However if the A amp E doctors thought that the general practitioner did not have the facilities and in some cases the ability to provide follow-up care (eg for serious woundS eye injuries) they would recall the patient

Some GPs dont like following up care initiated by the A amp E department or dont have the necessary facilities so I tend not to send patients back to them

A amp E officer

20

Im more likely to refer a patient back to a GP who is reliable

House surgeon

Third many of the house surgeons said they would recall patients if they were interested in the condition or if they were worried about their diagnosis and treatment and wanted to see the outcome Several medical superintendents noted that recalling under these circumstances was acceptable because it comprised part of the house surgeons training

Fourth the workload of the A amp E department sometimes affected the follow-up decision with very busy departments actively discouraging recalls And finally there was the philosophy of A amp E medicine held by the A amp E doctor In one department where the A amp E officer considered it an ethical duty to see any treatment initiated through to a successful conclusion almost all patients who needed follow-up care were recalled At two other departments the A amp E officers stressed the importance of being able to deal efficiently with any emergencies presenting they kept recalls low so that the department was not clogged with extra patients Other A amp E doctors thought that the general practitioner could provide better continuity of care than the A amp E department so they referred as many patients as possible

When referring patients to the general practitionermiddot most of the A amp E doctors made a verbal recommendation to the patient and then relied on the patient to attend the general practitioner They would only write a formal referral letter if the patients condition was serious In several A amp E departments however greater efforts were made to inform the patient t s general practitioner Three departments gave referred patients cyclostyled forms with details of diagnosis and treatment to be passed to their general practitioner while the Whakatane department sent a copy of the A amp E record form to each patients general practitioner

ADMISSIONS

Table I suggests that between a and 14 per cent of all first attendances were admitted to the hospitals Admissions could well be higher for children Kljakovic [5] found that 20 per cent of the children presenting at the Wellington Hospital Board A amp E departments were admitted

The A amp E departments were involved in several different pathways for the admission of acutely ill or injured patients (Scheduled admissions did not involve the A amp E department at any of the hospitals visited) Self-referred patients could be admitted directly from the A amp E department to the wards or could be cared for in a holding (or acute admitting) ward before going to the wards

There was considerable variation among the hospitals as to which members of the medical staff were able to admit patients At some of the urban hospitals only the registrars could admit while at others the A amp E doctor could admit if the registrar was delayed and unable to assess the patient quickly At some of the provincial and one of the urban hospitals the A amp E doctor could admit in consultation with the admitting officer or appropriate registrar while at-another urban hospital and the rural A amp E departments the A amp E doctors regularly admitted patients

21

Hospitals with lower levels of bed occupancy were more likely to allow A amp E doctors to admit Senior A amp E doctors were more likely to play a role in admissions (actually admitting patients or advising the registrar) than house surgeons

Some patients referred by a general practitioner for acute admission also passed through the A amp E department At one hospital the general practitioners rang the A amp E officer to arrange for all acute admissions and all such GP-referred patients were seen first in the A amp E department However more usually the general practitioners rang the appropriate registrar to make arrangements and the registrar decided whether to admit the patient directly to the wards or through the A amp E department The involvement of A amp E staff with patients requiring admission ranged from almost none (where the patient went directly from the A amp E department to the ward or specialist unit) to a full initial assessment including tests (often undertaken at the request of the registrar responsible for the patient) bull

Generally the A amp E doctors were satisfied with the admission procedures However at one hospital where the A amp E doctors could not admit patients waiting for admission tended to clog the department The doctorselt that if they had admission rights the situation would be remedied

DISCUSSION

There were few differences among the A amp E departments in the reception and sorting of patients However there were differences in some aspects of treatment follow-up care and admission procedures

lhe role of the A amp E nurses in treatment varied considerably with some departments allowing nurses to initiate and perform many treatments and other departments allowing little autonomy Careful training and selection were essential before nurses increased their responsibility for treatment bull

Policies on follow-up care differed among the departments with the urban and provincial departments generally referring patients to general practitioners and the rural and suburban departments leaving the referral decision to the A amp E doctor In practice however the differences were less clear-cut with several factors other than the patient I s condition affecting the follow-up care decisions These factors included the A amp E staffs communicat ion with local general practitioners the inexperience and training needs of house surgeons the workload of the department and the senior A amp E doctors philosophy with regard to A amp E medicine

The A amp E departments also differed considerably in thei r procedures for acute admissions At some hospitals the A amp E doctor could admit an A amp E patient while at others the patient had to be held in the department until admitted by a registrar Also at some hospitals patients referred by general practitioners for acute admission were seen in the A amp E department before going to a ward While having to hold patients sometimes caused

clogging in the department A amp E staff were generally satisfied with the procedures

22

REfERENCES

1 WEINERMAN E Richard RUfZEN S Robert and PEARSON David shyEffects of medical -triage- in hospital emergency service in Public health reports - v 80 no 5 (May 1965) p 389-399

2 Accident and emergency departments a study of planning requirements prepared by the Hospital Design and Evaluation Unit - Wellington Department of Health 1973

3 Accident and emergency services - Gt Brit National Health Service memorandum HM (68)83

4 Emergency department organisation and management edited by AL Jenkins - St Louis Hosby 1975

5 KLJAKOVIC M ALLAN B C and REINKEN J - Why skip the general practitioner and go to the accident and emergency department in NZ Med J - v 93 (1981) P 49-52

23

CHAPTER 4

Phy~i~~1 c~~raft~rhtics of accident and emergency departments

This chapter describes the physical characteristics of A amp E departments their overall size location and layout as well as specific areas within the departments It discusses the effects of the physical characteristlcs on the organisation and functioning of the A amp E departments Our investigation worked from the detailed base established in bullAccident and emergency departments a studY of planning r~quirements a report prepared by the Hospital Design and Evaluation gnit Departmellt of HeCilth [1]

PRINCIPLES

The 1973 Hospital Design and Evaluation Unit (DEU) report [l] outlined the following principles to be applied in designing A amp E departments

o the A amp E department must be patients seeking emergency care

ready to receive and deal with

o the A amp E department mus~ be able load within a reasonable period

to cope with an average i

busy

o the A amp E department must be capable of adaptation to exceptional situations arising from major accidents ltgtrqther disasters

o the layout should be simple easily unqerstood and compact

o the layout and procedures should facilitate easy flow of patients through the department

o spaces should be multipurpose to give greatest versatility

o p~tient ~ovew~n~ should be minimised )

priv~cy for patientsshould be provided as far as is practicable andconsistent with the need for supervisi0rt

SIZE

There was considerable variation in the total sizes of the A amp E -a~1-ftment~ vi~ited witll floor areas ranging from 250 sql1a~e metres to 2115 ~guare m~ties (see Table 2) Eight of the 14 departments visited had i

hhid1pgw~fd~oracUte admitting ward However even wt)en ~he area of th~ f~ ~ bull ~middotc1~A~- _ ~ - bull bull ~

AampE department WCiS adjusted for the presence of a holding ward this I~1-getv~-rH~tion in irea reniained

24

TABLE 2 AREAS OF A amp E DEPARTMENTS

Total area Holding ward Adjusted total Waiting room area areal area

sqm sqm sqm sqm

Full-time departments

Urban Auckland 2 115 225 1 890 55 Middlemore 1 045 140 905 50 Green Lane 960 240 720 70 Wellington 575 190 385 75 Hutt 270 270 30 Christchurch 470 470 40 Dunedin 635 90 545 20

Provincial Rotorua 515 20 495 90 Taranaki Base 720 90 630 40 Timaru 605 70 535 80

Rural Whakatane 430 430 20 Grey 310 310 15

Part-time departments

Suburban North Shore 255 255 30 Kenepuru 540 540 30

1 Adjusted total area = total area minus holding ward area Considerable sharing with outpatients department

The area of the A amp E department was not closely related to the attendance (see Table 3) Obviously there is a certain minimum size for an A amp E department since certain facilities are essential regardless of the attendance served Thus as would be expected the rural and to a lesser extent the provincial A amp E departments had high area to attendance ratios However even within the group of urban A amp E departments there was a fourfold difference in the total area to attendance ratio

The design at Auckland~ laid out along several corridors with many separate consulting and treatment rooms possibly contributed to its high ratio At Wellington Hutt and Christchurch hospitals staff commented on their difficulties working in cramped conditions The lack of space often forced staff to work under extreme pressure to move patients through the departments very quickly

25

TABLE 3 AREA TO ATTENDANCE RATIOS FOR ADJUSTED TOTAL AREAS 1 AND WAITING AREAS OF A amp E DEPARTMENTS BY FIRST ATTENDANCE2 AND TOTAL ATTENDANCE 2

Adjusted total area to attendance ratio Waiting area to to attendance ratio

Sqm per 1000 Sqm per 1000 Sqm per 1000 first attendance total attendance total attendance pa p a p a

Full-time departments ~

Urban Auckland 323 291 08 Middlemore 232 157 09 Green Lane 3 230 168 16 Wellington 80 69 13 Hutt 82 63 07 Christchurch 76 64 05 Dunedin 200 143 05

Provincial Rotorua 404 293 53 Taranaki Base 609 399 25 Timaru 466 266 403

Rural Whakatane 718 490 23 Grey 805 61 2 30

Part-time departments

Suburban I INorth Shore 272 148 17

Kenepuru 924 597 33

1 Adjusted total area = total area minus holding ward area

2 See Table 9 for attendance figures used in calculations

3 Considerable sharing with outpatients department

Spearman rank correlations [2] of adjusted total area with

( a) first attendance r = 0310 p gt 010 Not significant ( b) total attendance r = 0297 pgt 010 Not significant

26

LOCATION

There is broad agreement that the A amp E department should be located on the ground floor well signposted and easily accessible to ambulatory patients and ambulances The ambulance entrance should be able to handle several ambulances at once and should have adequate turning space It should be projected from the weather and screened from the view of the other A amp E department patients

The A amp E department should also be located as closely as possible to radiology facilities (either the x-ray department itself or a branch) The A amp E department and the outpatients department can share some facilities and provide additional staff and accommodation in an emergen~y

situation if they are sited together Acute patient care areas (operating theatres intensive care unitsmiddot and cardiac care units) and laboratory services should also be readily accessible from the A amp E department [134]

Entrances

Almost all of the A amp E departments visited were on the ground floor of the hospital and were well signposted Generally access for ambulatory patients was good apart from two hospitals where they had to walk up steps to enter the building o

Few departments had ambulance access which could cope with a shuttle of ambulances bringing mass casualties from a disaster There w~s little relation between the size of the department or the population served and the ease of ambulance flow Indeed those departments with a relatively low probability of being involved in a mass casualty situation had good ambulance flow (eg Whakatane) while those with a greater possibility had relatively poor ambulance access (eg Wellington) Several departments had particularly poor a~bulance flow with only a one-lane access Three departments had good drive-straight-through access while at the rest ambulances had to reverse However there were advantages to some of the bull reversing I situations in that the bays into which the ambulances had to reverse were more likely to give the patient protection from the weather All the A amp E departments visited had separate ambulance entrances which in all but three cases guaranteed screening of ambulance patients from public view

Access to other hospital facilities

In many of the hospitals the A amp E department was adjacent to the outpatients department or to the orthopaedic outpatients section When this occurred the plaster room and x-ray facilities were usually shared and waiting areas and the records office were sometimes shared In the smaller hospitals both departments often shared the nursing staff

The access to the x-ray department ranged from excellent in places which had x-ray facilities immediately adjacent to the A amp E department to very poor where the patient had to be transported hundreds of metres and to a different floor The time taken for the A amp E doctor to get the result of the x-ray varied from five minutes to over two hours though the physical separation of the two departments was only one of the factors which affected this

27

Access to acute care facilities was similarly variable In Christchurch the intensive care unit was adjacent to the A amp E department while in Rotorua it was at the other end of the hospital In many cases additions or alterations to the hospital buildings and changes of function of certain areas have meant that the A amp E department no longer bears the same physical relationship to other hospital departments as was originally the case

LAYOUT

Several studies have concluded that the A amp Edepartment should be designed so that there is an orderly progression of patients from registration to examination to investigations if necessary to treatment and to referral admission or discharge Staff time and effort is best conserved by a compact plan with waiting areas and treatment areas easily accessible and supervised However the need for easy supervision has to be balanced by consideration of the patients privacy Two basic A amp E plans have evolved

o a radial plan where the waiting examination and treatment rooms are arranged on the perimeter of the departmentmiddot with the nurses station doctors room and records office in the centre

o a linear plan where the examination and treatment rooms are arranged down each side of a corridor with the waiting area records office and staff offices at one end [145]

Many of the A amp E departments visited had a linear layout with the largest Auckland being arranged along several corridors In these departments staff often commented that their overall view of the patients was not good and a considerable amount of walking was needed to supervise them Middlemore A amp E department and the treatment areas of several other departments had radial layouts which staff found very satisfactory Generally the A amp E staff prefer red open plan layouts using curtained cubicles rather than enclosed rooms Staff (especially nursing staff) often commented that their department would be better if certain walls or partitions were removed to give easier surveillance of the department as a whole However staff also commented on the relative lack of privacy for patients being examined or treated and noted that some private rooms were needed for instance for obstetric or paediatric patients

Waiting area

There is general agreement that the waiting area should be adjacent to the reception desk easily visible to the receptionist and if possible overlooked by the nurses office or station It should be a cheerful comfortable area with toys provided for children and a range of magazines and books Public toiletspublic telephones and arrangements for refreshments are also needed [146]

The size of the waiting area varied considerably among the A amp E departments visited (refer back tomiddot Table 2) Again this variation bore little relationship to the workload of the department (see Table 3) Some waiting areas were clearly too small and this put pressure on the staff to deal with patients quickly in order to clear the waiting room

28

Staff comments suggested that not only the size of the waiting area but also its design affected its crowding Basically square rooms with seats around the edges had fewer problems than corridor-style rooms with only one row of seats

In all the A amp E departments visited the waiting areas were adjacent to the reception area Sometimes they were visible from the nurses office or work area but where this was not possible the nurses relied on the receptionists to alert them to urgent cases or checked the wai Hng area often themselves

Facilities in waiting areas varied from nothing but seats to areas in which there were hot and cold drink dispensing machines a childrens play area with toys and health-related poster and pamphlet displays Some had a TV set or a tropical fish tank Most staff were agreed that a pleasant atmosphere in the waiting room was important and adVerse comments about the waiting area were made by staff in departments which lacked this In some departments staff commented that vandalism made it difficult to retain facilities and a pleasant atmosphere

Examination and treatment area

The examination and treatment area provides for the needs of all A amp E patients other than those with serious conditions requiring the resuscitation room or those needing special facilities such as plastering Because special purpose areas are frequently under-utilised flexibility is a key requi rement Hence multipurpose cubicles with standardised equipment are usually recommended The cubicles must be big enough to give easy access for patients (not necessarily walking) to accommodate eqUipment and to give staff enough room to work Curtained cubicles are generally sufficient but at least one enclosed cubicle is required for patients needing extra privacy or for light control in eye examinations A cubicle especially set up for children (with appropriately-sized equipment toys and posters) is also desirable [1346]

Most of themiddot A ~ E departments visited had curtained cubicles in the examination and treatment area with perhaps one or two enclosed cubicles or rooms as well Four A amp E departments only had separate rooms for treatment Curtained cubicles made for ease of access while separate rooms did present some difficulties in manoeuvering patient trolleys and wheelchairs In one case it was impossible to get a patient trolley into the room at all and the room was consequently little used

Curtained cubicles did afford greater flexibility in use and did provide more room to work but had the disadvantage of being considerably less private than rooms Surveillance was easier in departments with curtains than those withmiddot walls and doors In the Auckland A amp E department treatment rooms doors had been removed in the interests of improved surveillance Staff in this department commented that its rigid design could lead to difficulties in accommodating a large number of patients in a disaster

The DEU report [1] recommended that the number of cubicles required by an A amp E department was NIlS where N is the anticipated average number of new patients per day It noted that in A amp E departments with few new patients per day a minimum of two cubicles should be provided It also recommended that the flow of recalled patients should be regulated so that they did not greatly affect the need for cubicles

29

As can be seen from Table 4 most departments had enough cubicles to cope with their first attendance workload Even applying the DEU recommendation of N18 to their total attendance most of the departments had an adequate number of cubicles The exceptions were Hutt Christchurch and Dunedin

TABLE 4 NUMBERS OF EXAMINATION AND TREATMENT CUBICLES OR ROOMS AND RECOMMENDED NUMBERS l BASED ON FIRST ATTENDANCE 2 AND TOTAL ATTENDANCE 2

Actual number of DEU recommended numbers (minimum of 2) cubiclesrooms based on

first attendance total attendance pa pa

Full-time departments

Urban Auckland 13 89 99 Middlemore 9 59 88

Green Lane 7 40 65 Wellington 10 73 85 Hutt 4 51 66 Christchurch 7 94 11 2 Dunedin 3 41 58

Provincial Rotorua 4 2 26 Taranaki Base 4 2 24 Timaru 6 2 31

Rural Whakatane 3 2 2 Grey 3 2 2

Part-time departments

Suburban North Shore3 8 22 37 Kenepuru3 6 22 30

1 Based on DEU report [l which recommended NIS cubicles where N average number of new patients per day ie N6750 where N = average first attendance pa

2 See Table 9 for attendance figures used in calculations

3 Recommended numbers increased to adjust for North Shore and Kenepuru treating their attendance numbers in part-time rather than full-time hours

30

Resuscitation area

The resusciation area is used for the immediate life--saving treatment of seriously injured or sick patients It is the acute treatment area in contrast to the examination and treatment area which is used for relatively minor procedures In making its recommendations about the resuscitation area the DEU report [I] balanced the probability of the A amp E department having to treat multiple accident victims with the comparative rarity of use of resuscitation rooms It recommended that a resuscitation room of suff icient size to deal with two patients concurrently be provided in all A amp E departments It also noted that the ambulance entrance and resuscitation area should be located as close together as possible

Most of the departments visited had purpose-built resuscitation rooms of varying size and with varying degrees of sophistication in equipment Some had x-ray facilities in the resuscitat ion area and in those that did not its absence was regarded as a serious impediment to the efficient care of severe trauma

In four of the seven urban A amp E departments the resuscitation rooms were regarded by the staff as being too small The comment was made in one urban department that because of the small size of the resuscitation area patients sometimes had to be moved out of the area before it was felt clinically desirable to do so in order to accommodate incoming patients In the rural and prOVincial A amp E departments the resuscitation rooms wereshyadequate for the demands placed on them

Most resuscitation rooms were sited close to the ambulance entrance and afforded good access to stretcher patients However in three A amp E departments patients had to be moved some distance and in another department up one floor by lift

Operating theatre

In discussing provision of operating theatres in the A amp E departments the DEU report [1] noted that

o most surgery done is minor requires only local anaesthesia and could be done within adequately designed cubicles

o the A amp E department is not a proper place for general anaesthesia

o using A amp Etheatres for day surgery tends to block other A amp E facilities and staff causin~ delay in treating A amp E patients

The report concluded that special facilities appear to be justified only if there is a clear intention of widening the scope of accident surgery in the departments

bullMinor ops theatres of varying sizes and equipped to varying standards were available in many departments Very variable use was made of such theatres - never in some departments to daily in others It was used less in departments with very heavy workloads and where the medical staff were not satisfied that sufficiently sterile conditions could be maintained In one department the theatre was only used for day surgery cases

31

Plaster room

In the plaster room casts are applied and removed and fractures and dislocations can be manipulated The DEU report [1] noted that the plaster room could be an integral part of the A amp E department or shared with the orthopaedic department or belonging entirely to the latter It recommended that the plaster room be close to the A amp E department and the x-ray department

Most departments had a separate plaster room available In many cases this was shared with an adjacent orthopaedic outpatients or fracture clinic Th~ staff generally found the plaste~-rooms satisfactory although two particularly narrow rooms were difficult to work in

Interview room

The DEU report [l] recommended that A amp E departments in medium-sized and larger hospitals should have a small interview room where a patient IS

relatives could talk with A amp E staff the police or others

No A amp E department had a room specifically designated as an interview room for bereaved or distressed relatives although one A amp E department shared such a room with another department In most departments one of the staff off ices was generally used for this purpose In departments where staff offices were small or crowded the lack of an interview room was seen as a serious flaw in departmental layout

Reception and records office

The reception desk should be immediately visible to ambulant patients arriving at the A amp E department and it is desirable for the receptionist to be aware of what is happening at the ambulance entrance as well The current A amp E records should be held at the reception desk or nearby [1]

In the A ampE departments visited the reception desk was usually well-placed for dealing with ambulant patients but in only four cases did it overlook the ambulance entrance In two departments the reception desk was some distance from the treatment area (separated by a waiting room or outpatients room) and the nursing staff found it difficult to oversee incoming patients Current A amp E records were held at the reception desk in all but one of the departments visited The amount of space available in relation to the throughput of patients was a major factor in determining the length of time records could be kept within the department This in turn affected the ease and therefore speed of record retrieval

Staff offices

These ranged from non existent to very cramped spaces serving many other functions to pleasant specifically designated and relatively quiet areas The latter offices are conducive to good staff morale and being a place for exchange of views and experiences could be expected to contribute quite markedly to the overall effectiveness and eff iciency of the department

32

Holding ward

The DEU report [1] said that holding beds should be used primarily for A amp E patients requiring a period of observation prior to a decision about admission or for those who could be expected to go home after a rest period The report noted that using holding beds as recovery beds for day patients for arranged admissions or for pre-admission clinics was not desirable

Most of the urban and provincial A amp E departments visited had holding or acute admitting wards These holding wards were used mainly for assessing patients requiring acute admission but in some hospitals were also used for observing patients (eg with suspected concussion) and for holding night admissions till the morning to save disturbing the wards Neither of the rural A amp E departments had a holding ward although one had an I A amp E admission procedure where a patient could be admitted for up to 24 hours for observation without the need for full admission procedures In the A amp E departments with holding wards a patient staying for more than four hours was formally admitted

Our study showed that the A amp E departments had some problems using holding wards properly In two A amp E departments holding wards were little used at night because nursing levels were too low to staff them safely In another department the beds were used for patients recovering from day surgery and even for some pre-ar ranged admissions At times general practitioner-referred admissions could also clog the holding wards

DISCUSSION

Most of the A amp E departments were generally adequate in size location and layout The exceptions were Christchurch and Butt where conditions were very cramped with particularly limited examination and treatment areas and poor layout We understand that improvements are planned at Hutt and that recent extensions have improved the Christchurch department considerably but at the time of our visits staff in both these departments were working under extreme pressure because of the physical conditions

Despite the general adequacy of the departments almost all had some flaw which affected their operation and inconvenienced staff and patients Major flaws found in several A amp E departments included

o ambulance access unsuitable for a shuttle of ambulances in a disaster

o difficult access to the x-ray department

o resuscitation room too small for easy treatment of more than one patient at a time

o no interview room for relatives of patients

33

REFERENCES

1 Accident and emergency departments a study of planning requirements prepared by the Hospital Design and Evaluation Unit - Wellington Department of Health 1973

2 SIEGEL Sydney - Nonparametric statistics for the behavioural sciences - Tokyo McGraw-Hill Kogakusha 1956 p 202-213

3 Emergency services the hospital emergency department in an emergency care system Chicago American Hospital Association 1972 p 44-49

4 Emer~ency department organisation and management edited by A L Jenkins - St Louis Mosby 1975 p 8-16

5 Design of departments in Br Med J - v 2 (1979) p 1204-7

6 McKINLAY Robin - The care of children in New Zealand hospitals -Aucklandmiddot National Childrens Health Research Foundation 1982 p 79-80

35

CHAPTER 5

Staffing of accident and emergency departments

This chapter describes the staffing both medical and nursing looking at their numbers and experience their previous training and the training they receive in the A amp E department and their satisfaction with their work and conditions We also describe the clerical and reception staff and briefly the involvement of other workers (orderlies social workers and ambulance personnel) in the departments

MEDICAL STAFFING

Senior medical staffing

Organising appropriate medical staffing for hospital emergency services is a prQblem in many countries [1] The variety of staffing arrangements in A amp E departments within many countries suggests that none have established a generally satisfactory pattern of medical staffing

The Platt report [2] found that in Br itish A amp E departments the great majority of patients were seen by junior staff only and that supervision of the A amp E departments by conSUltants was often little more than nominal The committee recommended that

o the junior medical staff should be adequately supervised by consultants

o a consultant orthopaedic surgeon should normally be in charge of theA amp E unit

o an accident and emergency unit should have at least three consultant surgeons each giving a substantial part of their time to this work

o the primary task of general practitioners in emergency services is to deal with minor accidents and emergencies at any time of the day or night (by organising a rota to answer emergency calls within their practice by working sessions in A amp E departments or by attending cottage hospitals at short notice for emergency calls) bull

Since then some progress has been made but standards continue to lag behind those recommended [34] There has been considerable debate over the appropriate staffing arrangements for A amp E departments Some hospitals have implemented the Platt report recommendations others have appointed a full-time A amp E specialist others have employed a full-time non-specialist doctor and some have employed general practitioners

Despite the various systems there is a consensus in both the United States and Britain that experienced medical staffmiddot are essential in the A amp E department They are necessary for prompt effective treatment of emergency conditions for efficient running of the departments and for adequate supervision of the junior doctors employed [23567 p 17-23]

36

Similar concerns have been expressed in New Zealand since the Board of Health report on outpatient services in 1960 [8] This report recommended that general hospitals continue to provide a casualty service available at all times and staffed by experiencedmedical officers

Salmond [9] found that when a senior A amp E officer directed the department A amp E work was handled more efficiently and house surgeons were more closely supervised and supported He suggested that one senior member of the hospital staff (ideally a full-time A amp E officer) should accept full responsibility for the overall supervision of A amp E services

Most of the A amp E departments that we visited had an A amp E officer The position was vacant at both Wellington and Hutt hospitals at the time of our visit while at North Shore Hospital responsibility for the A amp E department was shared by two senior doctors The A amp E departments of the rural hospitals had no senior medical staff

In A amp E departments with heavy workloads additional experienced doctors were often employed as deputy A amp E officers usually medical officer special scale or as Medical Reserve Scheme registrars (see Table 5) There was no general practitioner staffing of any of the Aamp E departments visited although general practitioners had been part-time staff of some of themiddot smaller A amp E departments in previous years One medical superintendent commented that since very few general practitioners could be classified as specialists they could only be paid as medical officers special scale This low level of payment acted as a disincentive to general practitioner recruitment

The A amp E officers usually worked normal office hours (830 am - 430 pm or 9 am - 5 pm weekdays) apart from two who worked part-time covering morning periods If additional experienced doctors were employed they usually covered evening periods (eg 5 pm - 10 pm) and weekend day shifts

There was a wide range of experience among the A amp E officers Half of the senior A amp E doctors had a general practice background and these doctors often had specific surgical medical pharmacological or Armed Forces medical experience as well Several A amp E officers had primarily a surgical background while others had a considerable range of hospital experience In hospitals where the A amp E officers had a general practice background the Medical Superintendent or the A amp E officer often stressed the suitability of this background for A amp E work

An extensive general practitioner background is useful in dealing with the multitude of problems seen in an Accident and Emergency department An orthopaedic or surgical background is not as necessary because of the good backup from the specialties And staff who have only had hospital experience particularly junior staff can lack skills in general assessment and triage

A amp E officer

In other hospitals staff stressed that an orthopaedic and surgical background was very valuable as was experience in dealing with specific types of injury such as soft tissue wounds

37

TABLE 5 MEDICAL STAFFING OF A amp E DEPARTMENTS

Full-time departments

Urban Auckland Middlemore Green Lane Wellington2

Hutt2

Christchurch Dunedin

Provincial Rotorua Taranaki Base Timaru

Rural Whakatane Grey

Part-time departments

Suburban North Shore Kenepuru

Senior medical staffing

Number of full-time equivalents

A amp E officer ( including deputies) 25 15 I 16

I 2

I 03 I

2 05

Registrar

06

1 1

House surgeons

Number on Number A amp E runs covering

some shifts in A amp E deptl

6 2-3 6 2 5 I 5 4 2-3 5 2 2

All on rotating basis 1 3 1 2

5 on rotating basis 4 on rotating basis

None in A amp E dept 4 on rotating basis

1 On general relieving duties 2 Senior A amp E position vacant at time of visit

Junior medical staffing

The issues

Junior medical staffing of A amp E departments has concerned many commentators in the United States Britain and New Zealand The Platt report [2] noted that recently qualified staff when serving in the casualty department undertake responsibility which they would not have in the wards or outpatient clinics

38

In 1960 the New Zealand Board of Health report [8] on out-patient services deplored the staffing of casualty departments by I relatively inexperienced men [sic] and suggested that these staff I should be regarded more as assistants under supervision and training than responsible officers in the outpatients departments The undesirability of staffing A amp E departments with first year house surgeons (or pre-registration doctors) has been reiterated since Junior doctors are often unsure when to ask for advice or help and are sometimes unwilling to admit that they are over-tired and unable to cope [91011)

The report on the working conditions of New Zealand resident medical officers [12] noted the heavy load carried by house surgeons working long shifts in A amp E departments It also commented that when house surgeons are required to look after the A amp E department while carrying out ward duties inadequate cover of the A amp E department could result

The New Zealand situation

The urban A amp E departments had between two and six house surgeons working on three month A amp E runs and in several of these hospitals another one to three house surgeons on general relieving duties covered some A amp E shifts There were more house surgeons in A amp E departments with heavier workloads or with fewer senior medical staff The provincial and rural departments did not usually have house surgeons working on specific A amp E runs rather the A amp E department was covered by all (or most) of the house surgeons in the hospital on a rotatng basis Of the two suburban A amp E departments Kenepuru was covered by the house surgeons on a rotating basis while North Shore did not have any house surgeons because there was no inpatient or consultative backup available (see Table 5)

The total medical staffing of the departments (senior A amp E doctors and house surgeons together) ranged from 10 to 100 full-time equivalents and was closely related to the attendance at the departments (see Table 6) The provincial and rural A amp E departments had higher medical staff to attendance ratios because they had to provide a 24-hour service regardless of the size of the attendance

Each A amp E department visited rostered its house surgeons differently depending on the availability of senior medical staff the workload of the department and the house surgeons other duties In the urban departments house surgeons worked between 45 and 60 hours a week on shifts usually 8 to 12 hours long Many of the house surgeons working in these departments complained about long shifts and suggested that more staff were needed to reduce the shift lengths Split shifts were also unpopular

The most worrying aspect of the staff ing arrangements in bhe Accident and Emergency department is the long hours We need another house surgeon to reduce the hours on some shifts and to proviae another pair of hands in busy periods (eg Friday and Saturday night Sunday afternoon)

House surgeon

39

TABLE 6 TOTAL MEDICAL STAFFING (FULL-TIME EQUIVALENTS) AND MEDICAL STAFFING TO ATTENDANCE RATIOS FOR FIRST ATTENDANCE I AND TOTAL ATTENDANCE 1

Total medical Total medical staffing to staffing attendance ratio

FTE per FTE per 10000 first 10000 total

Full-time attendance attendance equivalents p a pa

Full-time departments

Urban

Auckland2 100 17 15 Middlemore2 91 23 16 Green Lane2 65 25 15 Wellington 66 14 12 Hutt2 55 17 13 Christchurch 70 11 10 Dunedin2 60 22 16

Provincial Rotorua 42 34 25 Taranaki Base2 28 27 18 Timaru 22 19 11

Rural Whakatane3 15 25 17 Grey 10 26 20

Part-time departments

Suburban North Shore 20 21 12 Kenepuru3 20 34 22

1 See Table 9 for attendance figures used in calculations 2 FTE estimated since A amp E department partially covered by house

surgeons on general relieving duties 3 FTE estimated since A amp E department covered by house surgeons on

rotating basis

Spearman rank correlations [131 of total medical staffing with

(a) first attendance r = 0953 p lt 001 (b) total attendance r = 0933 p 001

In the provincial and rural hospitals house surgeons were often on call for long shifts over nights and weekends They were usually covering a ward or the whole hospital at the same time and simultaneous demands from the wards and the A amp E department sometimes caused problems However

40

these house surgeons generally found their rostering satisfactory despite the long hours on call perhaps because the actual work required in the A amp E department was comparatively light

An ordinary week night is usually quiet after midnight thered be three to five calls and Id have to get up once on average Weekend nights are busier but I usually get at least two or three hours sleep

House surgeon

Several house surgeons were irritated that while they worked more intensively on A amp E runs than on ward runs they spent fewer hours on-call and consequently they were paid less

Supervision by senior medical staff

In the larger A amp F departments house surgeons worked with the senior medical staff on most day and some evening shifts only on night shifts (and some evening shifts) were house surgeons the sole medical staff in a department By contrast in the smaller and part-time departments house surgeons covered the department alone seldom working with any senior A amp E medical staff

Several nurses commented that the A amp E department ran less efficiently outside normal working hours because the house surgeons inexperience meant assessment and treatment times were longer and tests were used more often than when the A amp E officer was present

Many senior medical staff in the urban A amp E departments were concerned at the lack of supervision for house surgeons outside normal working hours and so would have Ii ked more senior A amp E staff Several of the house surgeons were also concerned although others enjoyed the autonomy they had and were not concerned about working without supervision

I am not happy with house surgeons managing the A amp E department on their own They only have a three month shift in the department and often most of this time is spent learning how to do A amp E wor k The house surgeons can have problems deciding when to call a registrar to treat a patient and there can be delays in obtaining a registrar The A amp E department needs full-time trained medical staff on duty 24 hours a day to give proper supervision to the house surgeons and to run an efficient department

A amp E officer

On night shift I can feel rather alone if something goes wrong

House surgeon

I enjoy the variety of work and the independence I have to treat most patients as I see fit

House surgeon

41 _A

Arraflgements for consultative backup and support when senior A amp E staff were not on duty varied from hospital to hospital according to hospital size n urban hospitals the house surgeons would usually call on the appropriate registrar and the acute admitting or specialist teams for emergencymiddot cases In some places the house surgeons could calIon the consultant if a registrar was unavailable but this was usually seen as a last resort call In the provincial and rural hospitals the house surgeons would call on the appropriate senior doctor who was available This was usually one of the cQnsultants or a registrar if any were employed by the hospital The A amp E Qfficer might occasionally be called and in hospitals without an A~amp E oHicer th~ medical superintendent would also provid~ backup

Generally house surgeons were happy with the support they received A physically compact hospital was mentioned several times as facilitating ~ ~ fast back-up Howeve( in some hospitals there could be considerable delays in 9etting surgical and orthopaedic registrars to the A amp E department usually because they were in theatre Also at two hospitals backup in the minor specialties was considered inadequate bull

Use of first year house surgeons

Urban and suburban hospitals had a policy of using second year house surgeons as much as possible in the A amp E department and of using first year house surgeons only in their second six months This policy was generally butmiddot not always carried out For example the on-call arrangements of some urban A amp E departments resulted in inexperienced first year house surgeons working in the department In the smaller hospitals also the limited pool of house surgeons available tended to result in more first year house surgeons working in the department

The hospital could not provide cover for the A amp E department without using first year house surgeons However there are always senior staff and the medical registrar readily available as backup

Medical superintendent

When direct supervision was limited first year house surgeons did find A amp E work difficult

Training

The training received by the house surgeons in the A amp E departments varied greatly Two hospitals ran half-day or one-day orientation courses before -house surgeons started in the department Three A amp E departments ran weekly or fortnightly training sessions on specific conditions while another department ran sessions on an irregular basis However house surgeons often missed training sessions because they were treating pat~entsln more than half tmiddothe A amp E departments no formal training was giVen and house surgeons were taught on-the-job when senior A amp E staff were available This teaching placed a considerable load on senior staff

The three-monthly changeover of house surgeons is frustrating and the first month with new house surgeons is very demanding because they have little confidence or competence

A amp E officer