Waiting to be seen in accident and medical clinics
When injury or infection strikes outside the hours of normal general practice consultations, or holidaymakers and visitors find themselves in need of medical services, people are likely to seek help at the local accident and medical clinic. If the clinic is busy, some may spend several hours waiting for attention and — what seems worse — waiting while others who arrived after them are seen ahead of them. This may prompt the question: don’t these people have a system?
Accident and medical clinics, and many general practices, have a system for dealing with patients in need of medical attention who arrive without an appointment. The system should ensure that those most urgently in need of care are prioritised for attention, and that decisions taken regarding the urgency of care — or even whether care is provided at all — are made by staff trained to make appropriate and safe decisions.
Need for prioritising
Sorting out how quickly a patient should be seen when there is a waiting time, and by whom (doctor, nurse, or referred to a hospital emergency department), is a complex matter. A priority process has to take into account the patient’s need for treatment relative to others, as well as the resources available to provide that treatment. When there is no waiting time to see a doctor, the process is not needed, but when a clinic is very busy, staff have a responsibility to ensure that patients with most urgent need are seen ahead of those who can safely wait. How can appropriate prioritising be achieved?
Not all clinics have a formal system in place for prioritising urgent cases, and in fact many may not need one (see comment by HDC’s independent advisor Dr Steven Searle in case 03HDC16186 on www.hdc.org.nz). Having a formal process where all patients receive preliminary assessment could actually compromise patient care rather than improve it, if the time taken for a nurse to perform the assessments results in increased overall delay for all patients.
Recognising urgent conditions
In most clinics, patients first register with the receptionist, who may record details about the reason for the consultation. The information provided by a patient to the receptionist can be very helpful in assisting the receptionist to weigh up the relative urgency of a patient’s condition. If the patient has symptoms that may indicate the need for urgent treatment — such as shortness of breath or chest pain — or is very unwell, the receptionist can alert clinical staff. Training for all members of the practice team to enable them to recognise and respond appropriately to urgent medical conditions is identified as an essential standard for general practice, and in practices accredited under the College of General Practitioners quality improvement programme (Cornerstone), clinic staff, including receptionists, will have received this training (Aiming for Excellence — An Assessment Tool for General Practice 2002).
Return visits
It is well recognised that some conditions are difficult to diagnose in the early stages. For example, meningitis can resemble a viral flu-like illness (03HDC00575, 03HDC06973, 03HDC16186), while abdominal pain, vomiting and/or diarrhoea can lead to complications such as dehydration, or develop into appendicitis or perforated bowel (02HDC11786). Clinicians, who may be aware of a potential diagnosis but, at the time of the visit do not have the clinical evidence necessary to support it, will often advise patients to seek further attention if their condition deteriorates or does not improve. Patients returning for further assessment should advise the receptionist of this and outline the facts of the previous visit.
What to do
Whether or not a clinic has a process in place for sorting out who to see first when there is a wait for treatment, patients can enquire how consultations are prioritised when they register with the receptionist. If a patient believes the problem is urgent, or is very unwell, or is making a return visit because an ongoing condition is not improving, this should be brought to the receptionist’s attention.