Posted by: medicblog999 | October 17, 2010

The Clash of the Assessments!

This post may come out a little rambling, but that is only because I am trying to structure a balanced discussion inside of my head instead of an all out ranting post!

In the UK over the last few years, we have seen hundreds of NHS Walk in Centres (WIC) sprout up around the country. These are primarily Nurse led units that are placed strategically in various towns and cities to provide care for those residents who are suffering from either minor injury or illness. They most definitely have a place in the wider primary health care environment, but ask any Medic what they think of them, and most will tell stories of picking up patients from the Walk In Centre to take up to the Accident and Emergency department who clearly do not have any specific life threatening or emergent need, and who, in the paramedics opinion should have been treat and discharged from the Walk in Centre.

There is the other side of the argument as well though.

My service has direct referral pathways to the Walk in Centres. If I have a patient who I think fits the fairly strict criteria for assessment and treatment at a WIC, then I can contact one of the nurse partitioners on the phone and discuss my patient so that they know what I am bringing in and more importantly that they know they are suitable for their level of care and will not need to be shipped out to the A&E department at a later time.

Fair enough right?

This system SHOULD work, but there are a number of crucial factors that keep rearing their heads which result in a certain level of disillusionment from the Ambulance crews and frustration from the WIC nurses.

Now, instead of just going off on one about how you have to virtually fight tooth and nail to get a minor injury or illness patient through the door of a WIC, I will try to look at it from both sides.

There are good paramedics, there are average paramedics and there are bad paramedics (hopefully working down in frequency too!)

There are good nurses, there are average nurses and there are bad nurses also (again hopefully more of the good than the others!)

The reason why our referral pathways keep on coming up short to this particular care provider is that a small minority of practitioners on both sides, cause trouble which affects the way the whole service is perceived.

I have numerous stories of nurses refusing to see patients which I know are completely suitable for assessment in a walk in centre.

I have numerous stories of patients we have transferred to A&E from a WIC who are quickly assessed and discharged home within a very short time of arriving in the department.

I am positive that the nurses have numerous stories of the paramedics who brought them patients who very quickly needed transporting up to A&E because they were far more unwell than what was made out in the handover. I am sure that there are also many stories of patients who have arrived by ambulance who have not had a thorough and full clinical assessment before the medic has decided that there is nothing much wrong with them and they can go to the WIC.

All it takes is a run of these before the paramedics decide that its not worth even trying to take someone to a WIC, or the nurses become so suspicious of incomplete assessments or a lack of trust in the paramedics, that they knock patients back who are more than suitable for there level of care.

There needs to be a rebuilding of trust between the two professions, and it needs to start sooner rather than later.

If I contact a nurse at a Walk in Centre to discuss the care of a patient, then I have already completed a full and thorough assessment, have made my provisional diagnosis and have decided on the most appropriate course of action. I will provide a professional and full telephone handover and answer all of the questions that are asked of me and about my patient. I am a professional care provider in the pre-hospital environment and I would give anything for the minority of these nurses to trust in my judgement. The majority of these do know me and know that when I ring, my patient will be suitable; but sometimes, even I get to the point when I think that there is no point in even trying any more.

Paramedics also need to realise the limitations that these nurse practitioners have too. They work to guidelines just like us, and even though we may think it is appropriate, the patient presentation may fall outside of their scope of practice (even if it is a minor problem). If that happens, then do we really expect them to just do their own thing and go against their guidelines? Would we?

There is a reason why A&E is the default option when no other referral pathways can be made available. They don’t close, they don’t say no, and the always see whatever comes through the door.

That doesn’t make it right that they should be the dumping ground for the minor injury and minor illness patients.

There is a lack of understanding and a lack of respect from both sides. If we get this right, we could have a valuable resource to the community. Its just going to take some time and some real effort.

Im willing to put the effort in. I hope everyone else is too……

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Responses

  1. You must have been trying to work in the area that I do. We have a local WIC, and for about the last 3-4 years have had a protocol in place that has allowed us to take certain categories of illnesses and injuries there for treatment. It all started off beautifully. We were enthusiastic about the change, although the WIC less so.
    It did beg the question, however, of why we were conveying these patients in the first place. Surely a patient who is in the category of those who can be treated at a WIC, is not in the category of needing an ambulance to get there. But that’s maybe for another discussion, possibly the new model being trialled in London very soon… (Quick plug for the Ambulance Matters podcast)
    One of the other problems was that they started throwing patients out at least an hour before their scheduled closing time. Sometimes this would involve dialling 999 and asking for an ambulance for a patient who was clearly not in need of one.
    They also tried their damndest not to accept any patient coming by ambulance, and would insist on triaging them whilst still in the back of the ambulance, and either not relying on what we would hand over or refusing outright to accept them on some made up rule/regulation/whim.
    Now, I just don’t bother. We’ve tried to speak to them, both directly and through management, but it would seem that they’re just not willing to accept either the extra workload, or the training/skills/knowledge/word of a paramedic…
    Shame

  2. This is why, at least in a reasonably sized town or city, GP Out of Hours and Walk in Centres should be housed on the hospital site, adjacent to A&E, and sharing facilities.

    Integration is the key. I would like to see the Ambulance Service taking over all urgent/emergency care. I firmly believe that if call centres were expanded, and the algorithms changed, the most appropriate resource could be assigned to the patient, whether this is a DMA, a paramedic on a car, an ECP, a rapid responder and a DMA, OOH GP, or the patient told to self-present to a WIC, OOH GP surgery, or A&E department, based on what facilities are available where.

    If the WIC/GP/A&E were located on one site, porters could then be used to transfer patients between locations should they fall through the net and end up at the wrong place.

    Encourage members of staff to discuss whether admissions were appropriate or not after the fact, and for the ultimate diagnoses to be passed back along the chain from wards to A&E to pre-hospital staff, and we have a system which helps the patient get to the right place, and which helps the practitioner to learn from the decisions they have made, by hearing the outcomes and having feedback on the decisions.

  3. We have those too- except ours are staffed by MDs and “mid-level providers,” such as NPs (Nurse Practitioners) and PAs (Physician Assistants).

    They frequently send patients to the ED via EMS (mostly by private services in my area, keeping the 911 services available), but my sense is that the vast majority of these patient do actually require some higher level of assessment or care- you wouldn’t believe how many STEMIs they catch!

    That said, I have little doubt that our experience would be much the same as yours is these walk-in “urgent care” centers were staffed solely by nurses.

  4. […] “The Clash of the Assessments” – 999medic.com […]


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