Counting on A&E

The closest I have got to experiencing the demands on Accident and Emergency (A&E) of a hospital is watching the TV series MASH, but recently I was right in the middle of it!

Waiting for attention I was interested in the way that the staff were managing the wide range of medical problems that were rolling through the door. There were: people holding limbs in great pain, a head covered in sticking plasters, two to three people bright red and coughing, a queue of wheel chairs with a legs in plaster, and somebody hobbling around in too much pain to sit down. In the background Ambulances were rushing in and trollies were rattling along corridors. All of this activity is, in a management sense, ‘unplanned’ e.g. people could arrive at A&E anytime of the day or night with a wide range of problems. I started to wonder how a typical A&E is organised and operates to manage the situation and to meet the 4 hour waiting target.

A few days later I was waiting in another queue this time in my local coffee shop. As I slowly moved along I did a quick sum1 to work out how long I would have to wait and came up with the following calculation:

(4 customers) x (1 min/customer) = 4 minutes.

If the queue had been longer then I would have waited longer. Or if there had been more staff serving then the quicker the service and the shorter the waiting time. To apply the same approach to A&E I took some statistics from the data published monthly on A&E performance where the average number of people attending A&E per hour is approximately 12 / hour ( on average there are 8,500 people attending A&E for each hospital in NHS England per month ). I also assumed that a typical A&E department can manage 10 cases per hour then the using the same approach as a the coffee shop I calculated:

(12 A&E attendees ) x ( 6 minutes per attendees ) = 72 minutes or approximately 1 hour

which was close to my experience in A&E. The calculation confirms what we would expect: if the A&E department’s capacity was increased by adding more doctors and nurses then the waiting time would reduce. Similarly if the number of people attending A&E was reduced then the waiting time reduces.

Of course the calculation is too simplistic to be applied to the complex operation of an A&E Department because it assumes average quantities. But trying to answer the question: Why can it not be applied ? - highlights some of the underlying factors that are adding to the complexity of its operation.

Starting with the average arrival rate of A&E attendees, A&E statistics show that there is a wide variability during a typical week. For example Monday is the busiest day at A&E with attendance 13% above the daily average and also 13% above the next - busiest day, Sunday. Also, in 2013/14, 24% of A&E attendances arrived by ambulance or helicopter who require immediate attention. All of this starts to show the variability in the arrival rate of people requiring medical attention.

Similarly the wide range of patient’s medical problems will affect an A&E department’s capacity to manage their diagnosis and subsequent treatment. For example if there was a major emergency situation, say a train crash or a flu epidemic, then the capacity of A&E would be overloaded. Another area is diagnosing the medical condition. For example 3% of patients attending A&E have severe life threatening conditions and must be seen immediately. Also, if about 40% of attendees are not seen within an an hour of arrival at A&E their condition could deteriorate to life threatening.

There are many more factors affecting the performance of A&E for example the well publicised bed blocking and transfer to social care which can increase the time seen by the doctors and nurses. Other factors are not so obvious for example the impact of weather - when average daily temperatures hit 20°C compared with 5°C, trips to A&E rise by nearly 20%. However, very cold weather does also cause longer waits.

Although the assumption of using average quantities to describe the operation of A&E is over simplistic, asking the question “why do the assumptions break down ?” can gives a better understanding of the underlying factors that contribute to its performance. Based on my experience, the way that the staff manage the range of the medical problems that come through the doors of A&E is much more impressive than the TV characters Hawkeye and Trapper John!

1. More formally the calculation is an example of Little's Law which states that the long-term average number of customers in a stable system L is equal to the long-term average effective arrival rate, λ, multiplied by the average time a customer spends in the system, W. For a different and more detailed discussion on the application of Little's Law to staffing levels in A&E see: Little’s Law: The Science Behind Proper Staffing

Being Creative With A Bear And Honey

Over the years I have been involved in group sessions to develop solutions to business problems but when I heard about a session using a bear I had to find out more.

Many years ago the Pacific Power and Light (PP&L), now Pacific Power, had a problem with ice building up on the power cables which supplied their customers in the Cascade Mountains. During the autumn and spring the build up of ice on the cables could over stress the lines causing them to break. The normal solution was for a linesman to climb the towers and shake the power line. It was a very dangerous job with a high chance of the linesman falling off the towers.

There had been many attempts to come up with a solution but the company was struggling, so they turned to a professional facilitator who suggested that a diverse group be assembled to look at the problem. A group was assembled that included the linesmen, supervisors, accountants and people from the mail room.

Over a coffee break one of the linesmen recounted the story of how he come across a black bear who was not happy that he was trespassing on his territory and ended up chasing him for over a mile. To try and stimulate the group, the facilitator retold the story. One person suggested that training the bears to climb the poles to shake the ice off the lines. Ideas followed about how they could be tempted with pots of honey placed on top of the poles. Elaine Camper picks up the story: “.. one of the more senior, more sarcastic linemen said, ‘You know all those fancy helicopters those fat cats in the front office fly around in all the time? Why don’t we grab one of those and fly from pole to pole placing the honey pots on top just after an ice storm. That way the honey will be there when we need it, and, besides, it will do those fat executives some good to walk for a change.’

Still another period of laughter followed. Then one of the secretaries spoke for the first time. ‘I was a nurse’s aide in Vietnam. I saw many injured soldiers arrive at the field hospital by helicopter. The down wash from the helicopter blades was amazing. Dust would fly everywhere. It was almost blinding. I wonder if we just flew the helicopter over the power lines at low altitude, would the down wash from those blades be sufficient to shake the lines and knock the ice off?’

This time there was no laughter - just silence. She had come up with an answer. By valuing diversity and by encouraging divergent thinking, the resource had enabled the group to come up with a possible solution to a problem all wanted solved.”

There are a number of lessons from this story that can be applied to any group session for developing solutions to business problems. The fist step is to design the group session with an aim in mind. In the case of PP&L the aim was to find a way to knock ice off the power lines without using linesmen and at a tolerable cost. Next step is pull together enough people with different backgrounds, either professionally or it could include people with non-business experience. With a diverse group it will produce many different perspectives of the problem and could result in a radically different solution. The final part of the design must include enough time for people to relax and have fun which will let the ideas flow.

The problem to be solved must be described in simples terms, so that it is easily understood by a diverse group of people, therefore it needs to be devoid of any technical terms. The importance of the problem needs to be emphasised. In the case of the ice forming on the power lines apart from the linesman going out into bad weather, with the potential of falling off the power transmission towers, meeting up with a bear in a bad mood adds to the health problems!

Now the tricky bit. Managing different groups of people in a meeting is very difficult. For example people with a technical background will immediately start work on designing a solution, which will leave the rest of the group behind. For the session to be successful many voices need to be heard therefore those on the periphery must always be brought into the discussion. It is important that the facilitator works around the groups of people that huddle around the coffee machine during the breaks to pick up on little stories and feed them back into the meeting. All participants need to be encouraged to throw off their inhibitions and be creative in their contributions to the session.

After the session a criteria must be developed to assess all of the ideas, even if there is one that is head and shoulders above the rest. The criteria can be used to rank the ideas so that if the obvious solution doesn’t work then there are other solutions to investigate. A good record of the session must be kept so that every solution is captured just in case they need to be returned too, for example if there is a change in technology that makes one of the ideas more viable. It is important to follow up with the participants of the session, thanking them for their contribution, and letting them know how the solution is progressing towards implementation.

The group session was a success and PP&L used a helicopter to blow the ice off the power cables. It is a solution that many other companies around the world have adopted and improved. But if they hadn’t found a bear during a coffee break then they may never have found the helicopter.

See the attached video for a helicopter blowing snow and ice off a power line using a steam hose:

Fly Fishing On Prescription

Watching the line whispering through the morning light and softly landing on the lake, balancing between hope and tension. Fly fishing is an art that creates its own poetry but what does it do for my health ?

Fly fishing is trying to trick a fish, normally trout or salmon, into taking something that is made to look like a fly. The skill is to place an artificial fly in front of a trout at the point where it is hungry enough to wrap its mouth around it. Sounds simple but after many years of trying to outwit one of the wildest animals on the planet they are still ahead on cunning.

After a days fishing I feel much better both physically and mentally. This feeling is supported by studies which have shown the benefits from standing in the fresh air are: a reduction in exposure to pollution, boosting the immune system, increase in energy and is a source of Vitamin D which increases the protection from bone problems, heart disease, diabetics etc. Also, because the trout usually are aware of what I am up to they quickly move away and I have to follow. All this walking has been shown to help fight dementia, cut the risk of dying from cancer, and helps improve heart muscles. Another benefit is from walking on rough and slippery surface on the edge of a lake where it has been shown that it aids balance and coordination . Then there is the cast and re-cast which is the balletic movement of the arm, rod and flick of the line out across the water which apart from keeping muscles strong gets the heart beating. And finally the wrestle with the fish when it pulls and tugs on the line after it has taken the fly, although it isn’t High Intensity Training my heart is usually beating hard against my ribs.

Apart from the physical benefits there are mental health benefits from fly fishing. Watching for movement of the fly, or just trying to spot a trout, requires lots of concentration, and although there are no studies about the effect of concentration on benefits for mental health, most fisherman that I chat to report that their worries are shut out by watching for the twitch of the fly. Another aspect is the reduction in stress. In a 2009 study by a team of researchers from the University of Southern Maine, the University of Utah, and the VA in Salt Lake City they found that combat veterans had significant reductions in stress and post-traumatic stress disorder symptoms and improvements in sleep quality after participating in fly fishing.

I would add to the list of benefits from fly fishing is the activity of learning. And there is lots to learn: understanding how fish live, the impact of weather on their feeding, casting technique, tying flies, etc. which is an ongoing process. Studies have shown that learning new skills can improves mental wellbeing in particular learning can boost self-confidence and self-esteem, build a sense of purpose, and help connect with other people.

On the surface there may appear to be many barriers to fly fishing. For example, the world of fly fishing may look like a totally male-dominated activity, however there is a long legacy of female anglers. Women have been involved in angling in one way or another for many centuries. Dame Juliana Verna wrote a book called Treatise on the Angle published in 1497. In recent times Joan Wulff who pioneered casting techniques is still fishing at 89. There are many more women revolutionising fly fishing as well as increasing numbers of women’s clubs for example Angling Clubs, fly fishing women, and a successful health initiative Casting for Recovery whose mission “is to enhance the quality of women with breast cancer through a unique retreat program that combines breast cancer education and peer support with the therapeutic sport of fly fishing.” Age is no barrier either, with initiatives such as Fishing for schools and The Prince Albert Angling Society Junior Section and at the other end of the age spectrum there are courses run my Age UK.

For many people contemplating fly fishing a big question looms - what do I do when I catch the fish ? do I have to kill it ? No. The vast majority of fish are returned to the water, and because of their experience of being caught, are even more aware of strange looking flies and more difficult to catch. Unhooking a fish must be one of the great experiences as you hold a wild animal for a few seconds before letting it go back into its own world.

Of course weather is an issue. On a bright spring morning standing on a lakeside it could be something straight out of a Constable painting. But it can be wet and windy. However with the proper clothing you can carry on fishing which makes the end of the day cup of tea and piece of cake even more delicious. Or you can do what I do which is shelter in below a tree and wait for the rain clouds to pass over; spending the time thinking about my next tactic to catch that trout!

Cost can be an issue but for a few hundred pound a rod, line and a box of flies can get you started. It is important to add to the list some form of glasses to protect your eyes from an erratic fly during casting and some head gear to protect from the sun, or in my case, a fly sticking in my head. However, there is one thing that is a must and that is proper training for casting. A few hours with an accredited trainer can make sure that bad habits are not adopted.

In summary there are lots of health benefits from fly fishing. Therefore my call to the medical professionals is that instead of reaching for a programme of drugs, or activities with strange sounding names, why not prescribe some fly fishing for long term health benefits?

The Day Mathematics Became Real

Holding my breath I knocked on the door. Waited. I knocked again. This time a softly spoken “yes” came back; I gripped the door handle and I went in.

The head of the Mathematics Department, the Prof, looked up and carefully put his Parker pen down. He was the first real mathematician that I had met. His room was lined with large glass fronted bookcases that bulged with mathematics journals. The only window in the room and it let the autumn light shine onto his desk. I was in awe. He sat upright in his neatly tailored light tweed jacket that he filled. As he started to tidy away the papers from the top of his desk and he looked up. I had never been this close to the Prof, he was usually several rows away in a lecture theatre, and the neatness of his black hair and the strong cheek bones made him look younger than he probably was. His intense eyes passed through his dark rimmed glasses and held me under scrutiny.

After completing an Engineering degree and a “year out” to earn some money I had decided that I really wanted to study Applied Mathematics. I enjoyed thinking engineering problems and then using mathematics to develop practical solutions. The course at Cranfield Institute of Technology ( now called Cranfield University ) was a two year conversion course that was developing me to Masters level in Applied Mathematics. But I was now in the orbit of real mathematicians and struggling.

The Prof had was an expert in partial differential equations which he had studied at Cambridge. These equations cover a wide range of applications but his speciality was in working out how molten steel flowed in castings. The technique of casting is used to shape components used in the everyday objects that we use from printers to aeroplanes.

I was good at applying formulae to solve mathematical problems but was hitting a brick wall with his homework. I started to take the Prof through my attempts at solving the problems, explaining the different formulae that I had tried to apply. Suddenly he sat back in his chair and in a frustrated voice said “Your not an Engineer now, you’re a Mathematician!” His outburst came as a shock after all I felt I was a mathematician wasn’t I on the course! We started going through the first problem and he pushed me to think harder about the properties of the problem: what were the equations telling me ?, could they be rearranged to see a better solution ?, could they be simplified to get a start on the solution ?, had I solved similar problems in the past ?, could I solve one small part of the problem and then build my way back to solving the original problem ? We moved through each problem and with his encouragement I started to learn that it was more important to understand the problem and play with ideas about solutions rather than simply apply formulae. Closing his door behind me I felt that I had been shown the first steps in becoming a mathematician and that the real work was ahead.

I still keep up with the latest developments in applied mathematics and when I start to think about an engineering related problem a sense of excitement begins as I let my imagination play with the equations. At the back of my mind is the Prof’s words steering me away from beaching on the shores of applying formulae.

Career Advice From A Philosopher

Recently the paper shredder has been working overtime. It has been chewing its way through bills, bank statements and a few drawers worth of career documents: CVs, pay slips, bonus letters and redundancy notices. Stopping frequently to let it cool down, a thought emerged about my career and the path it had taken - had it been worth it ? Then I remembered the advice the philosopher Wittgenstein gave to Maurice Drury, one of his ex-students.

Wittgenstein met Maurice Drury in 1929 during his period as a philosophy lecturer at Cambridge University. He actively encouraged his students not to become professional philosophers, and in Drury’s case after graduating he became a psychiatrist. They met as often as circumstances allowed until Wittgenstein’s death in 1951.

During one visit they went for an evening walk when Drury, who was a newly trained doctor, doubted his career path, because of his “ignorance and clumsiness.” At the time Wittgenstein brushed off the conversation as Drury’s lack of experience. Later that evening he wrote him a letter giving advice about his choice of career. After a section where he admonished Drury for “thinking about himself” when he should be “thinking about others e.g. your patients”, he wrote:

“But not because being a doctor you may not go the wrong way, or go to the dogs, but because if you do, this has nothing to do with your choice of profession being a mistake. For what human being can say what would have been the right thing if this is the wrong one? You didn’t make a mistake because there was nothing at the time you knew or ought to have known that you overlooked.”

Wittgenstein’s approach to solving philosophical problems was to untangle the misuse of words. In particular, it is using words where they have lost their meaning that leads to philosophical problems for example: is truth the highest good?, are computers conscious? and can he can feel my pain? Wittgenstein’s solution was to show that the use of words such as “truth”, “good”, and “conscience” were being misused and once shown then the problems disappear.

In their conversation Wittgenstein picked up on Drury’s use of the word “mistake” and questioned if he had used it correctly. The word mistake is used in the context of knowing the action that should be taken. For example when I take a route to visit a friend and arrive late because I took a wrong turn I may say “Sorry I am late, but I made a mistake and turned left instead of right at the traffic lights”. I am using the word mistake correctly because I am describing where I went wrong. Therefore within the context of visiting my friend the word mistake is being correctly used and its meaning is clear to both of us. However, in the case of a career to use the word mistake correctly would mean that I would have known what the correct career route was, and nobody knows that because we can’t read into the future. Drury made the best decisions he could within the circumstances at that time.

Wittgenstein’s advice to Drury is not the standard career guidance that floods the book shops and web with ‘Ten Steps To Success’ type headings. Instead, he untangles the misuse of a word that leads to Drury’s frustration about his career choice. As the shredder grinds through the last staff appraisal, Wittgenstein’s career advice has questioned whether I was asking the right question!

To read the full letter, click here.