Inadequate management in accident and emergency units
In 2007 the Norwegian Board of Health Supervision in the Counties carried out countrywide supervision of 28 of the 53 accident and emergency units within specialized health services in Norway, to see whether these services were provided in accordance with legislative requirements. We found that, in general, inadequate management and leadership affects the day-to-day running of these services. In our view, this sometimes results in provision of treatment that does not meet sound professional standards. When the units are busy and many patients arrive at the unit at the same time, patients often have to wait for a long time before the doctor examines them and makes a diagnosis. There is often a long waiting time before the patient comes to the department where medical treatment is provided. While waiting, patients may become dehydrated, or may not receive adequate pain relief. The result may be that the patient’s condition becomes worse, that the medical assessment is inadequate, or that the wrong treatment is given.
The leadership of the health trusts have responsibility for ensuring that daily tasks are planned, organized, carried out and improved in accordance with legislative requirements. Reception, prioritization, examination, diagnosis, monitoring and treatment of patients in accident and emergency units shall be in line with sound professional standards. The main aim of supervision of these services was to investigate whether health trusts fulfil their responsibilities, and how they do this. In order to investigate this, patients with undiagnosed conditions were chosen as an example. These are often elderly patients with multiple organ failure, and with a range of symptoms, such as back pain, stomach pain, confusion and nausea. In many ways, these patients present greater challenges for accident and emergency units, both medically and organizationally, than patients with complicated injuries, or patients with suspected heart attack, for whom there are standard routines, including transferral to the relevant hospital department.
“When it is most hectic, I am worried that serious conditions can go undetected...”
When there are many patients at the accident and emergency unit at the same time, this presents a challenge to register and give priority to patients in the correct order. The leadership has responsibility for ensuring that the unit has routines for standard practice when patients arrive at the unit, that patients are received, registered and assessed in an ordered queue, and that those who need the most urgent medical attention are given priority.
In more than half of the accident and emergency units that were included in the supervision, it was uncertain whether patients were examined and diagnosed in line with sound professional practice. In many units we found that, when the unit was very busy, patients with undiagnosed conditions had to wait several hours to be examined and for a diagnosis to be made. Long waiting times can increase the danger that the patient’s condition can become worse, that patients become dehydrated, that they do not receive adequate pain control, or that they become confused. It is important that patients are observed and followed up while they wait, that the personnel have relevant qualifications and skills, and that appropriate measures are implemented in time. We found that, in many cases, patients were not followed up adequately while they waited. If routines and practices are inadequate, serious conditions may go undetected, and treatment may not be given in time.
Sound routines for ensuring that adequate resources are available
Provision of adequate treatment in accident and emergency units depends on the availability of health care personnel with relevant qualifications and adequate skills to made complex medical decisions and assessments.
The results of supervision give cause for concern about whether the leaders of the units organize personnel resources in such a way as to ensure that patients receive adequate treatment during hectic periods. In most of the units, trainee doctors and junior doctors examined patients first. When newly appointed doctors, with variable qualifications and skills are the first doctors to see the patients, they must be given systematic training in tasks and routines. Routines must be flexible and robust, and there must be a low threshold for calling a more experienced doctor for help. This was not the case in several of the units where supervision was carried out.
Through routines and well-established practices, all the staff must know who shall call for help when personnel with higher or more specialized skills are needed, and who shall call for extra health care personnel in specially hectic periods or in times of crisis. Such situations can arise if many patients arrive at the same time, or if there are many patients waiting to be transferred to other hospital departments. In several of the units, the staff had different perceptions about situations that required extra help, and about who was responsible for calling extra help. Also, it seems that there is a high threshold in many of the units for calling in staff with more experience and qualifications. It does not seem to be usual practice to utilize the resources that are available in the health trust, when this is necessary to ensure that patients in accident and emergency units receive adequate examination and treatment. This gives cause for concern.
Good leadership and management – necessary in order to ensure that patients receive adequate treatment
The accident and emergency unit is the gateway to the hospital. This presents challenges for managing and running these services. Provision of adequate treatment must be ensured through teamwork between the unit and the other clinical departments in the hospital. For example, doctors who provide treatment in accident and emergency units are usually under the administration of the medical and surgical departments, and not the accident and emergency unit. This increases the need for clear lines of management and reporting. In 24 of the 28 health trusts that were included in the supervision, the leadership did not work in a systematic and goal-orientated manner to ensure that the unit was run in an adequate way, and that patients received treatment in accordance with statutory requirements. In our view, this is unacceptable.
In many of the health trusts, the leaders did not systematically collect information about what happens in the accident and emergency unit. For example, they did not use activity data to monitor the running of the unit, or to identify critical stages in the system. The leaders did not use systematic overviews of the flow of patients through the system and of waiting times, to assess whether diagnoses were made and treatment provided within reasonable time. Bottle-necks occur and the number of patients builds up in these units. Several of the health trusts lacked systematic overviews and assessments of the consequences. Generally, the leadership had an inadequate overview of the running of the unit, and did not manage to assess the risks in a systematic way in order to ensure adequate planning and management of health care personnel in the unit. Thus, the leadership lacked the basis for implementing goal-oriented measures to correct existing deficiencies, to reduce the danger of new deficiencies occurring, and to improve patient safety.
As a result of supervision, we also identified other deficiencies in the quality management system in the health trusts. For example, there is cause for concern that routines and procedures for central tasks and working processes are unfamiliar and thus not followed by the health care personnel in many of the units. Also, many of the units did not have a well-functioning system for dealing with nonconformities. Such a system should function in such a way that the staff have well-established routines and practice for reporting non-conformities related to activity and results in the unit, and that the leadership uses these report systematically to improve the service. It is not only serious injury to patients that should be reported, but also departures from daily routines and failure to meet activity goals. In order to learn from adverse events and ensure provision of adequate services, the leadership should give priority to dealing with non-conformities.
“The leadership of the health trusts have responsibility for ensuring that daily tasks are planned, organized, carried out and improved in accordance with legislative requirements.”
“There is cause for concern that routines and procedures for central tasks and working processes are unfamiliar and thus not followed by the health care personnel in many of the units.”
- Report from the Norwegian Board of Health Supervision 2/2008
- Guidelines for supervision.