A Case of Chronic A&E Pain: Part 5

Saturday, October 10, 2015

Dr_Bob_ThumbnailDr Bob runs a Clinic for Sick Systems and is sharing the Case of St Elsewhere’s® Hospital which is suffering from chronic pain in their A&E department.

The story so far: The history and examination of St.Elsewhere’s® Emergency Flow System have revealed the footprint of a Horned Gaussian in their raw A&E data. This characteristic sign suggests that the underlying disease includes carveoutosis.  StE has signed up for treatment and has started by installing learning loops. This is the one week follow up appointment.


<Dr Bob> Hi there. How are things? What has changed this week?

<StE> Lots! We shared the eureka moment we had when you described the symptoms, signs and pathogenesis of carvoutosis temporalis using the Friday Afternoon Snail Mail story.  That resonated strongly with lots of people. And as a result that symptom has almost gone – as if by magic!  We are now keeping on top of our emails by doing a few each day and we are seeing decisions and actions happening much more quickly.

<Dr Bob> Excellent. Many find it surprising to see such a large beneficial impact from such an apparently small change. And how are you feeling overall? How is the other pain?

<StE> Still there unfortunately. Our A&E performance has not really improved but we do feel a new sense of purpose, determination and almost optimism.  It is hard to put a finger on it.

<Dr Bob> Does it feel like a paradoxical combination of “feels subjectively better but looks objectively the same”?

<StE> Yes, that’s exactly it. And it is really confusing. Are we just fire-fighting more quickly but still not putting out the fire?

<Dr Bob> Possibly. It depends on your decisions and actions … you may be unwittingly both fighting and fanning the fire at the same time.  It may be that you are suffering from carveoutosis multiforme.

<StE> Is that bad?

<Dr Bob> No. Just trickier to diagnose and treat. It implies that there is more than one type of carveoutosis active at the same time and they tend to amplify each other. The other common type is called carveoutosis spatialis. Shall we explore that hypothesis?

<StE> Um, OK. Does it require more painful poking?

<Dr Bob> A bit. Do you want to proceed? I cannot do so without your consent.

<StE> I suppose so.

<Dr Bob> OK. Can you describe for me what happens to emergency patients after they are admitted. Where do they go to?

<StE> That’s easy.  The medical emergencies go to the medical wards and the others go to the surgical wards. Or rather they should. Very often there is spillover from one to the other because the specialty wards are full. That generates a lot of grumbling from everyone … doctors, nurses and patients. We call them outliers.

<Dr Bob> And when a patient gets to a ward where do they go? Into any available empty bed?

<StE> No.  We have to keep males and females separate, to maintain privacy and dignity.  We get really badly beaten up if we mix them.  Our wards are split up into six-bedded bays and a few single side-rooms, and we are constantly juggling bays and swapping them from male to female and back. Often moving patients around in the process, and often late at night. The patients do not like it and it creates lots of extra work for the nurses.

<Dr Bob> And when did these specialty and gender segregation policies come into force?

<StE> The specialty split goes back decades, the gender split was introduced after StE was built. We were told that it wouldn’t make any difference because we are still admitting the same proportion of males and females so it would average out, but it causes us a lot of headaches!  Maybe we are now having to admit more patients than the hospital was designed to hold!

<Dr Bob> That is possible, but even if you were admitting the same number for the same length of time the symptoms of carveoutosis spatialis are quite predictable. When there is any form of variation in demand, casemix, or gender then if you split your space-capacity into ‘ring-fenced’ areas you will always need more total space-capacity to achieve the same waiting time performance. Always. It is mandated by the Laws of Physics. It is not negotiable. And it does not average out.

<StE> What! So we were mis-informed?  The chaos we are seeing was predictable?

<Dr Bob> The effect of carveoutosis spatialis is predictable. But knowing that does not prove it is the sole cause of the chaos you are experiencing. It may well be a contributory factor though.

<StE> So how big an effect are we talking about here? A few percent?

<Dr Bob> I can estimate it for you.  What are your average number of emergency admissions per day, the split between medical and surgical, the split between gender, and the average length of stay in each group?

<StE> We have an average of sixty emergency admissions per day, the split between medicine and surgery is 50:50 on average;  the gender split is 50:50 on average and the average LoS in each of those 4 groups is 8 days.  We worked out using these number that we should need 480 beds but even now we have about 540 and even that doesn’t seem to be enough!

<Dr Bob> OK, let me work this out … with those parameters and assuming that the LoS does not change then the Laws of Flow Physics predict that you would need about 25% more beds than 480 – nearer six hundred – to be confident that there will always be a free bed for the next emergency admission in all four categories of  patient.

<StE> What! Our Director of Finance has just fallen off his chair! That can’t be correct!

[pause]

But that is exactly what we are seeing.

[pause]

If we we were able to treated this carvoutosis spatialis … if, just for the sake of argument, we could put any patient into any available bed … what effect would that have?  Would we then only need 480 beds?

<Dr Bob> You would if there was absolutely zero variation of any sort … but that is impossible. If nothing else changed the Laws of Physics predict that you would need about 520 beds.

<StE> What! But we have 540 beds now. Are you saying our whole A&E headache would evaporate just by doing that … and we would still have beds to spare?

<Dr Bob> That would be my prognosis, assuming there are no other factors at play that we have not explored yet.

<StE> Now the Head of Governance has just exploded! This is getting messy! We cannot just abandon the privacy and dignity policy.  But there isn’t much privacy or dignity lying on a trolley in the A&E corridor for hours!  We’re really sorry Dr Bob but we cannot believe you. We need proof.

<Dr Bob> And so would I were I in your position. Would you like to prove it to yourselves?  I have a game you can play that will demonstrate this unavoidable consequence of the Laws of Physics. Would you like to play it?

<StE> We would indeed!

<Dr Bob> OK. Here are the instructions for the game. This is your homework for this week.  See you next week.


St.Elsewhere’s® is a registered trademark of Kate Silvester Ltd,  and to read more real cases of 4-hour A&E pain download Kate’s: The Christmas Crisis


Part 1 is here. Part 2 is here. Part 3 is here. Part 4 is here.