Portal de Periódicos da CAPES

We hate Mondays! Tuesdays are not usually that crash hot for emergency physicians either….!

1998; Wiley; Volume: 10; Issue: 2 Linguagem: Inglês

10.1111/j.1442-2026.1998.tb00665.x

1035-6851

Gordian Fulde,

Emergency and Acute Care Studies

Recently, while I was visiting another very busy emergency department which had just been renovated, I was discussing mutual problems with a colleague. Among other issues we considered how to cope with the ever increasing patient loads and how to deal with exit block and the lack of hospital beds. We discovered an immediate bond as the result of the fact that we both routinely work Monday evenings, the most difficult day of the week. Why are emergency departments and hospitals ‘clogged up’ on Monday's? EDIS computer readouts consistently demonstrate that Monday is the busiest day of the emergency department week. The reason for this must be multifactorial. Patients perhaps do not ‘bother’ their general practitioner for two days over the weekend and therefore are referred in larger numbers for emergency assessment on Monday. Some perhaps have ‘more important’ (or interesting) things to do at the weekend and wait to seek medical attention until the beginning of the working week. These factors cannot be changed, but what we can and must change is the bed management practices within our hospitals. An administrator at our hospital who attended a major seminar on bed management reported that the observation had been made that in general, bed management practices for medical patients were very wanting. It has been relatively straight forward over the years to ‘adjust’ surgical admissions and hound surgeons, but it must be remembered that surgical patients are responsible for only about 30% of emergency department admissions and only a very small proportion of the longer hospital admissions. By contrast, medical admissions, by far the majority, have been largely ignored and left to drift on. It has been obvious to us in the emergency department that inpatient medical services focus most of their time and effort on the sicker patients, often neglecting those who are ‘nearly ready’ to go home. There is no imperative for active early decision making about disposition. Discharge decisions often wait for a late afternoon consultant round by which time it is too late to book that nursing home or organise transport! A simple illustration - an elderly medical patient is admitted Friday late afternoon (or even Thursday if Friday is the once a month hospital wide low activity day). The patient is seen by the duty medical registrar. In most hospitals, due to restrictions on overtime, there are no routine ward rounds on weekends, and if there are any it is to quickly sort out the sicker patients. On Monday, the inpatient medical team battles to catch up on their ‘new’ admissions and the very sick. So it is often not until Tuesday, or even Wednesday, allowing for physician training sessions and outpatients, that thought can be given to discharge/disposition of our elderly patients. Meantime, on Saturday, Sunday and Monday, the inflow of emergency patients never ceased—but our patient and others like her are occupying beds they maybe do not need—the result: tensions, hassles and exit block! Hospital beds and resources will continue to decrease. The load of older and more complicated patients will increase. We have a part to play in the solution. We have to teach the hospital system some emergency medicine decision making skills. They are desperate, and willing to learn solutions. We must push for physicians to take charge of bed management of the patients and for the imperatives of disposition to be emphasised. We must champion attitude engineering at all levels (medical students, RMOs, Registrars, Consultants and Administrators) towards the ordering of only those tests which will alter management. Anyone thoughtlessly ordering batteries of tests and ‘awaiting results’ needs urgent re-education! Charging the unit ordering the tests would be a good start. If we can achieve these things, we will increase the numbers of beds available to all patients, emergency and elective. It may make Mondays in the emergency department better too!