Providing compassionate care to patients waiting on Emergency Department Trolleys: can we do more?

摘要

Long waiting times for patients and relatives in the Emergency Department (ED) have become an almost accepted feature of modern hospital health care. Owing to demands for, and at times the public's misuse of ED services, many patients are inappropriately forced to remain on trolleys for prolonged periods, a concern that has attracted media attention (Sheehy 2013). Trolleys are typically used to transfer patients, but within an ED they are designed for short stay activities such as to perform clinical assessments or for undertaking minor treatments and procedures. They are not intended as an alternative to beds and consequently their misuse places individuals at risk of developing pressure ulcers which could contribute to or exacerbate chronic illness (Lewis et al., 2003). It is also possible that that the distress and isolation that these situations may cause could serve to worsen patients' pain (Papathanassoglou, 2014). There is also some evidence to suggest that high occupancy rates in ED's in general are associated with an increase in mortality rate (Bernstein et al., 2009; Jo et al., 2014). As high occupancy often precipitates excessive trolley waits, these facts are important. In the UK, in excess of £820 million has been invested since 2007 with the aim of reducing waiting times, improving quality of care and improving patient outcomes in the emergency setting (Department of Health, 2001; Mason et al., 2012). In addition, a recent review of the NHS ED system in England provides a more far reaching approach to reducing the demands on ED by measures such as refocusing care into the community; increasing scope of practice of ambulance personnel and increased telephone support for patients in need (NHS England, 2013). A key feature of these initiatives has been to reduce the over crowdedness of the ED with a target for all patients to be either admitted (to hospital) or discharged from the ED within 4 h of arrival. However, within this debate lies the patient (Department of Health, 2001; Mason et al., 2012). While metrics such as waiting times and mortality rate are important quality considerations, it is all too easy to miss the human experience of delay. Even though the delay may be within acceptable limits, consideration needs to be given to the patients' experience of this. Furthermore, despite the investment and the measures undertaken, evidence suggests that little positive impact on these delays has been demonstrated (Jones and Schimanski, 2010; Crawford et al., 2013). In both the UK and Ireland, families are still experiencing considerable distress at having long delays in ED (Letham and Gray, 2012). However, notwithstanding the comprehensive vision for future ED care provision (NHS England, 2013) there remains considerable public interest in ED overcrowding issues. This is evidenced by the very public apology to an 86-year-old pensioner, who spent 8 h on a trolley while experiencing chest pain (STV News, 2013). Dubbed the ‘corridors of shame’ (Hurry, 2013), there are harrowing stories of older people being forced to rest on trolleys for up to 98 h. While efforts have been made to reduce delays, recent figures indicate that patients' perceive waiting times to have increased (Quality Care Commission, 2014). Fourteen percent of respondents said that from the time they arrived at the hospital, it ‘definitely’ felt as though they had to wait a long time to be admitted to a ward bed (up from 12% in 2011) and 21% said ‘yes, to some extent’ (up from 20% in 2011), although no specifics of waiting on trolleys was provided (Quality Care Commission, 2014). Clearly, there are systemic reasons why delays in ED occur such as excessive demand on the system, inappropriate use of the ED, insufficient capacity within the GP/community services, reduced hospital bed capacity, insufficient social care services to permit prompt safe discharge from hospital or major accidents/emergencies that divert intensive resources (NHS England, 2013).