I’ve had a very “Herald”-orientated week. On Tuesday, I went to the Herald-sponsored Glasgow Cruciverbalists’ Club. We meet monthly in an upstairs room in Curlers on Byres Road and solve crosswords in a studious Bletchley Park atmosphere. It’s better fun than it sounds. The company’s good. Somebody asked me what compiler’s software I used and I gave a plug for ‘Sympathy’ and said I was thinking of upgrading to their latest version. “No doubt,” came the response, “to ‘Empathy’.” Next month I am providing the crossword to be solved. I was asked if my puzzle was fiendish. I borrowed an expression from the President-elect. More like Number One Tricky.
On Wednesday morning I opened my Herald to read about the latest Queen Elizabeth University Hospital statistics purporting to be a measure of the Emergency Department (ED) “performance”. Like every other ED in the NHS this one has a “four-hour rule”, and every month the Herald reports the extent to which the department has fallen short in its observation of the rule. Of course they are not alone in this. The BBC does the same. Every time I hear the report my blood pressure goes up and I am minded to fire off a disgruntled letter to the Herald. Sometimes they publish me; sometimes they don’t.
I should explain why I get so exercised about it. First up, the report is always written thus: “For the week ending 15th Inst only 87% of patients were seen in QEUH “A & E” (sic) within four hours. The target is 95%.”
Now, that is just not true. I would venture to say that virtually 100% of patients were seen within five minutes – that is, within five minutes of their arrival. They would have been seen virtually immediately by a triage nurse whose job is to assign a level of urgency to the patient’s clinical presentation, which stipulates how quickly the patient should be assessed by a doctor. Australia and New Zealand use the National Triage Scale which identifies 5 categories of acuity. Triage category 1 – the patient must be seen immediately; 2 – within 10 minutes; 3 – within 30 minutes; 4 – within 1 hour; 5 – within 2 hours. Most emergency departments in the English-speaking world use a system not dissimilar to this. The degree to which a department meets these targets is certainly worthy of study.
The four-hour rule measures something quite different. It measures the total time the patient spends in the ED between presentation and discharge. In the language of medical audit, the “criterion” is that patients should be discharged from the ED within four hours of arrival. The “standard” is that this should happen to 95% of patients. I’m always a little puzzled by medical audit standards. They seem to me to be arbitrary. After all, if something is worth doing, why not aim to do it all the time?
Now, each time the department fails to achieve the “standard” (and that is virtually all the time), this is deemed to be an index of, perhaps even a surrogate marker for, “poor performance”. This notion that an emergency department’s performance somehow relates to how quickly it disposes of the patient seems to me to be utterly absurd. Imagine a music critic berating an orchestra, not for being unmusical, but for taking too long. The Maestro at rehearsal might tear his hair out. “Ladies and Gentlemen, we simply must get Mahler 8 under 90 minutes!”
Anyway I wrote to the Herald in this regard on Wednesday. I didn’t think they’d publish me. Experience has told me that the best way to get published in the Letters column is to be polite, to make a single point worth making, and make it succinctly. My letter was more diffuse than this; it made several points. So I didn’t think it would go in, but at least it helped me get something off my chest.
Judge my surprise on Thursday when not only was I in, I was in poll position, complete with big headline. “Medical staff should ignore this arbitrary four-hour rule”. I was delighted with that. The other main point in my letter alluded to Westminster Health Secretary Jeremy Hunt suggesting that the public might have to be educated about the “appropriate” use of “A & E” (sic). I made the simple suggestion that the term “Accident & Emergency (A & E)” be dropped. After all, somebody who has an “accident”, say sprains an ankle, might say, shouldn’t I go to A & E? That, after all, is what it says on the tin. The emergency medicine community in Australia and New Zealand understood this thirty years ago, and dropped the word “accident”. I’ve written about this often, and make no apology for bringing it up again. We shouldn’t use archaic terminology. Never use the most archaic and the most dehumanising word of all, “Casualty”- either to allude to a department or to the person attending it. The department is the “emergency department” and the person is the “patient”. If you hear somebody using the A word or the C word, politely correct them. Will you join me in this?
On Friday I perused the Herald Letter pages again. I think it’s important to keep vigilant for the riposte. You know the sort of thing. “It’s time for Dr Campbell to wake up and smell the coffee!” There was nothing by way of adverse comment. Quite the opposite; the Letters editor had written a piece in praise of the paper’s correspondents and I was delighted to be mentioned in dispatches. Then on Saturday, Myops, resident cruciverbalist, used one of my clues. A chronicle of small beer, you say. Yet I admit I love to be in print. I’d have quite liked to have been a hack.