Recently, there was a discussion about patients waiting for 15 hours to get care at a hospital in Selangor. It started from the Emergency Department (ED).
This article will cause some discomfort to readers, but administrators may see it as “saying it point blank.” This is a two-part article. Part One just states the facts on pain points. Part Two states the facts for improvement.
Let’s address the proposed solution for the pain points. Remember, the core competency of all Emergency Physicians is to make the impossible possible by applying principles of alternate care pathways.
Solution to Pain Point 1: Ratio of Assistant Medical Officer to Supervisor is 1:1 for triage services.
This ratio can be successful by reducing the administrative tasks for Assistant Medical Officer (AMO) Supervisors. The Ministry of Health (MOH) must really sit down and sort out what administrative task requires clinical knowledge.
Back to the basics – “Triage Correctly Once and Always Repeatedly” – by having experienced personnel greeting patients in the Emergency Department.
This should not be a problem because there are centres that even have Emergency Physicians (EP) doing triage, which is a waste. The clinical practice capability of the AMO provided by regulations and policy in the MOH or hospital level is more than what they are practising now.
Solution to Pain Point 2: Reduce the number of Medical Officers in the Emergency Department. The ratio of Emergency Physician to Medical Officer per shift should be regulated.
Emergency Physicians will say this solution is ridiculous and impossible. Administrators will say it’s possible and that it may be the answer to bringing back the Emergency Department to its core zones of Red, Yellow, and Prehospital Care. Yes we have taken out the Green Zone and Observation Zone, which will be dealt with elsewhere.
The beauty of this solution – all patients will be greeted and seen by a functioning unit of one EP, one Medical Officer (MO), and maybe one House Officer (HO). The ED shall have no service MO, except those wanting to pursue Emergency Medicine as specialty training.
The caveat is – this solution is dangerous to be performed alone without the next solution (Solution to Pain Point 3).
Solution to Pain Point 3: The Emergency Department will be a Specialist-only area for all Specialties.
The stepladder review system for specialty is never about patient safety, but about health care culture. With fewer doctors in the service, we will now have more Specialists than MOs. When faced with this inverted pyramid, our culture must also change.
To reduce the waiting time of patients in the Emergency Department for either a bed or decision for admission, patients referred to Specialty will be seen by a Specialist or Registrar in the Emergency Department. In bed management; the push system can be started – the Specialist who has seen the patient can push admission into the ward, bypassing nursing bureaucracy.
In patient-centred care, the ward management care plan is now made by the expert from the ED and is ready to be implemented and learned by the Medical Officers managing the ward.
Ultimately, responsibility for clinical care patients waiting in the Emergency Department for a bed is shouldered by the Specialist or Consultant.
The caveat is – this solution is dangerous to be performed alone without the previous solution (Solution to Pain Point 2).
Solution to Pain Point 4: ED Observation Ward is a specialist zone and all patients shall be discharged with a discharge summary.
ED Observation Ward should now be declared as a zone for House Officers and Specialists only. It shall not be managed by the ED anymore, but by Hospital Clinical Administrators. This is easy if all the above solutions are implemented because patients have been seen by a Specialist.
The chain of responsibility is firm because patients will be discharged with a discharge summary that cannot be signed by a House Officer.
Solution 2 to 4 will burn the silo between administrators and clinicians because Bed Waiting Time in the Observations Wards is directly under the care of Hospital Clinical Administrators. It’s time for Matrons to have ward ownership.
Hospital Directors can now smile because this intervention will ultimately (1) reduce the risk of clinical misadventures in Emergency Department; (2) divert many Medical Officers away from Emergency Department to inpatient care; (3) reduce layers of on-call by “having the right patient seen by the right specialist the first time around.”
There will be no more patient football among Specialties because the ED System automatically becomes Specialist to Specialist Zone of Care.
Solution to Pain Point 5: Rebrand the Green Zone to Urgent Care Specialist Clinic.
There is no Emergency Medicine in the Green Zone any more. Patients in the Green Zone will be seen directly by major Specialty Services in the Hospital, such as Internal Medicine, General Surgery, Orthopedics, Pediatrics, Obstetrics and Gynecology.
If they need to wait for admission in the Observation Ward, please do refer to the respective Specialists for each Specialty there. This is a game-changer in a patient-centred care system.
To assist the Primary Health Care Service, there will be one Family Medicine Specialist in this area too. The Family Medicine Specialist will receive all referrals from Klinik Kesihatan (KK) that were referred to the ED for just blood test, imaging, and second opinion. “Unnecessary referrals” from KK will be managed in this way.
Summary
Hospital Medicine – the way our patients are being seen and managed needs to be changed. We cannot use yesterday’s system to solve today’s woes.
The evidence and needs to change the system is all around us. Waktu Bekerja Berlainan (WBB) was just one small component of the change needed.
It is interesting to read the new Health director-general’s Circular on New Grading System for Hospitals and Number of Doctors Doing Administrative Work. It is not what we need now.
We need solutions outside the box that everyone deems impossible but are really necessary. Health economists can start to calculate savings by bringing the right specialist and responsibility centre forward in the system.
I do know one thing. By having this change in the system, eventual change in work culture will ensue. We will then, as Specialists in the public service, be able to demand a higher salary scale from the savings of the reduced number of Medical Officers needed in managing patients in the Emergency Department.
The author is an emergency physician at a government hospital in the Klang Valley. CodeBlue is providing the author anonymity because civil servants are prohibited from writing to the press.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
