I have a dream….

Bert arrives in the ED at 8 o’clock on a Tuesday morning by ambulance.  He’s a 77-year-old chap who had a bit of tummyache and diarrhoea yesterday which got much worse this morning.

He is seen on arrival jointly by the ED consultant running the RATS (rapid assessment and treatment system) and the triage nurse.  His observations are taken on the bedside monitor and automatically integrated into his EMR (electronic medical record), which flags to the clinicians his moderate tachycardia (110), tachypnoea (24) and hypothermia (35.9C).  Because the ambulance service EMR is fully compatible with the hospital and their record is assimilated as Bert is booked in, the clinicians can see that these obs are the same as at initial ambulance assessment and haven’t improved with the 500ml crystalloid bolus given by the ambulance crew.  Bloods are taken at triage, including a point of care venous gas.  Bert is transferred to resus, where the ED St6 continues assessing him.

Bert unfortunately has some memory issues so isn’t quite sure of the details of his medical history or medications.  This isn’t an issue as the ED staff are able to access his primary care record which has a summary of his ongoing and past diagnoses, his regular and recent meds (including their indications (warfarin for his AF)) and investigations (INR 1.6 last week).

He is also rather worried about his wife Betty who is effectively housebound with severe arthritis. The ED reg is reassured by the automated social care alerting system, which flags to the community care staff that an ambulance has attended an address where they provide care.  The ED is contacted by Bert and Betty’s senior care worker who confirms that she has increased Betty’s level of home care while Bert is in hospital, and also that Bert’s memory service worker (a familiar face) is on the way to help Bert negotiate his trip through the ED.

The venous gases, available in resus, show a marked metabolic acidosis with lactate of 4.3. This combined with Bert’s left iliac fossa tenderness leads the ED reg to think of intra-abdominal sepsis. The surgical reg, having no other commitments for her on-call week, is immediately able to attend and agrees; since they have all been involved in multidisciplinary training, the resus nursing staff have simultaneously activated the sepsis care bundle and contacted the research team for the PROMISE trial (the EMR provided a reminder for this with the care bundle).  Once “sepsis” is ticked on the EMR, all the appropriate sample labels are automatically printed and the default prescriptions for fluids and antibiotics suggested; the EMR combines the information about Bert’s penicillin allergy with the local antibiotic policy and suggests meropenem rather than tazocin.

A bedside ultrasound shows a small amount of intra-abdominal free fluid, so the surgical reg speaks to the duty radiology consultant who is based in the control room of the ED CT scanner and Bert’s CT is performed and reported (verbally and on the EMR) within 30 minutes – perforated diverticular disease. In the meantime, 1 of the anaesthetic consultants rostered to the emergency list has been to assess Bert and jointly counsel him with the consultant surgeon. Despite his memory problems Bert is able to understand and consent to the proposed surgery with the assistance of his memory service worker.

In the meantime Bert’s other bloods have been processed and an alarm message sent to the ED reg and resus nurse about his acute kidney injury (creatinine 300 against a baseline of 110); the ED reg acknowledges this electronically; in the event of her not doing this within 20 minutes an alarm message would be sent to the ED consultant.

Bert goes promptly to theatre, where his perforated diverticulum is resected.  Given his level of risk, he goes to the HDU jointly run by critical care and surgery for 2 days post-op. He is automatically reviewed by the surgicogeriatric team who institute early therapy and liaise with his and Betty’s home care team, so that he is able to go home at 8 days post-op with an enhanced care package until he is back to baseline.

Does it not happen like that? None of this is rocket science (or even brain surgery). So how do we get from where we are to here?

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