SO FAR, SO BAD E.B.S. 1959-63

824

time consultant status might be through service as a staff physician in a rejuvenated National Health Service. Many of the suggestions in these two papers are made in principle in the report of the Standing Medical Advisory Committee’s Subcommittee on General Practice (the Gillie Committee). It has been our purpose to develop one interpretation of these principles in a practical sense, as a stimulus to discussion and a possible basis for their implementation.

Special SO

Articles

FAR, SO BAD E.B.S. 1959-63

G. F. ABERCROMBIE M.A., M.D. Cantab. CHAIRMAN, EMERGENCY KING "

To

EDWARD’S

BED SERVICE

Other responsible people have described the situation to " me as frightening ". Sir George Godber3 says : COMMITTEE,

HOSPITAL FUND FOR LONDON

the things which need doing and to with determination to get them done."-Attributed to the Minister of Health.’

identify with certainty

proceed

MATERNITY

figures have gone from bad to worse (see accompanying table). Four years ago, when requests for maternity admissions reached the unprecedented total of THE

QUARTERLY

APPLICATIONS FOR URGENT ADMISSION TO MATERNITY BEDS: AGE-GROUP

be able to protect the hospital from the Emergency Bed Service, or, at least, from your medical referee. We have 66 beds and on thirteen occasions at night, in March, we had more than that number of adults in the hospital, on one night 72. Our junior staff have been instructed always to accept a case from the Emergency Bed Service if they have a bed, but on occasion refereeing has occurred when the hospital is full and this occurred again last night. My House Surgeon accepted a refereed case in the middle of the night, although he was over his number, and he acted against his instructions. This morning we had another refereed case and, although we refused it, the case was sent on by ambulance. " I am concerned about the deterioration of our standards... the medical responsibility for conduct of the hospital is quietly slipping out of the hands of the medical staff." not seem to

15-44.

"

In the London area, although four out of five now have their babies in hospital, there is a last-minute scramble for beds which leads to between two and three thousand normal patients each year going into labour without even knowing in what hospital they are to be delivered ..." This is today something of an understatement, though it would have been true enough four and five years ago. In not a few cases there is a last-minute scramble for trolleys, and although, as Sir George says, any normal confinement

is safe in a good home, the trouble is we do not know that it is normal until afterwards. I see no reason to suppose that the upward trend to institutional confinement will halt at 80%, and it is to be hoped that " they "* are planning for at least 95%. Women are being taught that it is safer to have the baby in hospital, or in a general-practitioner unit attached thereto. Better selection of cases is a myth, unfair and unworkable. 3. *

Lancet, 1963, i, 1061. Nominative of themz that great unknown amorphous body composed apparently of anyone remotely connected with officialdom."-H. C. Miller, The Ageing Countryman, 1963.

than 800 in a single quarter, I wrote that " the mounting obstetric demand calls for immediate action ".2 Since then, all previous records have been broken; in the latest quarter-April to June, 1963-E.B.S. has been asked to find beds for 1272 women in labour, and for a short period in 1962 the annual total exceeded 4000. It seems more than likely that this will be exceeded this year, for it is above that number now. Plotting the figures in the table as a graph, and adding for comparison the number of abortions and of acute surgical conditions in the same female age-group (15-44) brings out very well the huge relative increase in maternity (fig. 1). Surgical cases over these last nine years are remarkably steady; abortions have increased by 40%; maternity cases by about 400%. It has become increasingly difficult to find beds for all these patients. As always, a few requests are cancelled voluntarily for one reason or another, but in a single month -March 1963-E.B.S. was twice defeated. Of 504 applicants, 489 were admitted, although for 103 of these the medical referee (hereinafter M.R.) procedure had to be invoked. For 2 patients every effort failed: it proved impossible to find a bed, and they had to be delivered at home. One day this may be very serious. Let us look at the problem from another angle. On May 8, 1962, Mr. Donald Fraser, chairman of the medical staff of the City of London Maternity Hospital, wrote to me officially, and I have his permission to quote: more

"

and I are concerned at the chronic state of the Citv of London Maternity Hosnital, and we do 1. Brit. med. J. 1962, i, 1354. 2. Abercrombie, G. F. Lancet, 1959, ii, 398.

My colleagues

overwork

at

Fig. l.-Maternity cases, cases of abortion, and acute surgical cases, in females aged 15-44, submitted to E.B.S. in 1954-63.

825

These things are managed better in Aberdeen, where " we are fortunate enough to be able to admit not only those women for whom hospital confinement is desirable but also those who prefer to be confined in hospital. We can therefore avoid distasteful selection of cases and the unhappiness caused by it."4 RECENT WINTERS

In the ordinary way, E.B.S. has no difficulty in finding beds for general practitioners’ acute cases until applications exceed 1500 a week. In 1959-60, this number was not even approached (fig. 2), but it is to be noted that, for the quarter ended March 31, 1960, 11.4% of admissions were made through M.R. 4.

Baird, Sir Dugald, Lancet, 1960, ii,

609.

was a sharp rise immedireached 1739 applications in ately after Christmas which the week ended Jan. 3. When this rise had subsided, another quickly followed culminating in 1826 applications in the week ending Feb. 8-not an unduly hard winter, but showing an M.R. rate of 15-2% from January to March. In the nine days preceding Jan. 4, 1962, weekly applications mounted from 1280 to 1995. Fortunately there was no second peak in this winter, but the hospitals were still so full during March that, though applications never reached the 1500 mark, the M.R. procedure had to be invoked for 18-8% of admissions in that month, and the percentage for the quarter works out at 16.2-the highest yet recorded. All this, however, cannot stand comparison with the winter of 1962-63, which was one of the most difficult in our experience. On Dec. 3, almost ten years to the day after the great fog of 1952, dense fog with a high degree of atmospheric pollution again settled upon London; by Dec. 11, weekly applications had reached 1730. On Dec. 5, 394 requests for general acute beds were received. Only once had this figure been surpassed when, on Dec. 9, 1952, 492 requests were received in the twenty-four hours.5 Happily this more recent crisis was brief, and by Christmas time the weekly figure had fallen to 1020. Then followed an exceptionally hard winter. By Jan. 15, weekly applications had reached 1500, and they remained above that level for two months. The peak was 2058 for the week ending January 29. The proportion of admissions, 4309 of 20,181, in which it was necessary to use M.R., rose to 21-3% for this January to March quarter, 1963. M.R. procedure has been described and discussed at length 6; but such a high percentage, even in such a winter as this, is far from satisfactory. We shall study this

In

1960-61, however, there

problem again. YELLOW AND RED WARNINGS

In 1961

warnings

in force thus:

were

The effect of these warnings appeared to have been much smaller in this year than on previous occasions. At the beginning of 1962 the following warnings were in force:

Such

the

it, that the red warning Jan. 1 was issued without a preliminary yellow and it proved most effective. On Dec. 31 the M.R. rate had been 215%; on Jan. 1 it was 14-6%, and for the whole period Jan. 1 to 9 it averaged 14-1%. When the red was replaced by yellow warning, the M.R. rate rose a little; when the yellow was cancelled, weekly applications were 1409, and the M.R. rate 15-8%. At the end of 1962 a brief red warning (Dec. 5 to 9) was brought about by fog and by a very rapid rise in applications. At the start of 1963 warnings were issued as follows: was

situation,

as we saw

on

The first

does

have been fully increase. The red warning, at 1850 a week, was in general reasonably effective, at first holding the M.R. rate steady despite the continuing rise in applications, and after a few days

yellow warning

effective, for the

Fig. 2.-Acute 1962-63.

cases

submitted to

E.B.S.

in

winters- from 1959-60

to

5. 6.

M.R. rate

not seem to

continued

Abercrombie, G. Abercrombie, G.

to

F. ibid. 1953, i, 234. F. ibid. 1956, ii, 1039.

826

apparently causing the M.R. rate to fall from 26% to 17%. Hereabouts it stayed for the remainder of the red warning period, with applications at 1800 to 2000 or so. On Feb. 21, we felt that the red warning, then nearly a month old, must come off; but the M.R. rate at once increased, so that in the early days of March it had to be used for &mid ot;

almost

one case

by hospitals

in three. It

on a

seems

yellow warning

is

clear that action taken

inadequate.

ACTION THIS DAY

Last July we invited a number of hospital representatives to discuss the warning system with us. They all agreed that very little action was now taken when a yellow warning was received, and they were unanimous that, since it was ineffective, it should be abolished, leaving only the red warning to be used at times of crisis. The E.B.S. committee has considered this and believes that a yellow warning following a red is in the nature of an anticlimax and should not be used in future. Cancellation of the red warning will, we hope, mean " all clear ". On the other hand, a yellow warning preceding a red may still be of value and should be retained, particularly if hospitals can be induced to take more effective action to implement it. As always, the red warning will announce that E.B.S. is handling to the best of its ability a grave crisis-almost certainly of respiratory disease 7-and calls for all possible cooperation from hospitals. greatly indebted to the staff of the Emergency Bed Service fol help with the preparation of this paper, and particularly to Mrs. B Williams who draws the diagrams. I

am

AN EASILY STERILISED DISPOSABLE SUBSTITUTE FOR MACKINTOSH SHEETING R. E. M. THOMPSON M.B. Lond. READER IN BACTERIOLOGY, MIDDLESEX HOSPITAL MEDICAL SCHOOL,

LONDON, W.1

F. W. O’GRADY M.D. Lond. READER

ST.

BARTHOLOMEW’S

IN

BACTERIOLOGY, COLLEGE, LONDON, E.C.1

HOSPITAL MEDICAL

MARGARET

J. PARKER

S.R.N.

SISTER-IN-CHARGE,

CENTRAL STERILE SUPPLY

MIDDLESEX

DEPARTMENT,

HOSPITAL, LONDON, W.1

THE mackintosh sheeting used in operating-theatres has presented a sterilisation hazard for many years. The material is generally some type of rubber-often rubberbacked cotton (’ Jaconet ’) or red rubber sheeting-which is destroyed by dry heat and is impermeable to steam. For sterilisation in the autoclave, it must be packed in such a way that steam has free access to every part of the surface. This implies either packing the material very loosely (unfolded) or interleaving it with linen towelling to provide steam channels between the folds. A number of substitutes for mackintosh sheeting have been tried with varying success-for example, siliconised cotton, cotton towelling (untreated), and varieties of plastic sheeting. For various reasons none of these materials is entirely satisfactory. We describe a type of waterproof paper which has become available recently, and which we consider to be the most suitable substitute for mackintosh sheeting which has yet appeared. It may also have a number of other uses for the packaging of sterile materials. 7.

Abercrombie, G. F. ibid. 1951, ii, 1175.

Fig. 1-Diagram of the apparatus used for measuring waterproofness and wet strength quantitatively. MATERIALS AND METHODS

The ideal substitute for mackintosh should be waterproof, of high tensile strength when wet, steam permeable or otherwise easily sterilised, unaltered in properties by sterilisation, easily disposable, and cheap. The following materials were examined as possible substitutes for rubber sheeting: a group of water-repellent papers, including ’Sterifield’ D.c.26 and D.c.21 (E. S. & A. Robinson & Co. Ltd., Bristol); siliconised cotton; and jaconet; polyethylene laminate paper (KimberlyClark Ltd., Maidstone, Kent). The laminated paper consists of two layers of paper tissue separated by a layer of polyethylene (0-006 in. thick), bonded together during the manufacturing process. Tests

of Waterproofing Wet-pressure test.-In the operating-theatre the biggest strain on a waterproof material is exerted by placing on it a heavy wet instrument or tray of instruments. To simulate this in the laboratory, an enamel tray of 10 x8 x 2 in. was dipped into cold tap water and transferred to a sheet of the test material under which was a sheet of filterpaper of the saine size. The tray was weighted with a 1 lb. weight, and it was allowed to stand for 1 minute. After this period the tray was removed and the filterpaper was examined for wet patches. This was useful as a rapid assessment of the waterproof efficiency of materials, but it gave no lasting record for comparison. Blueing test.-The material was tested by spraying one side with ferrous-sulphate solution and the other side with potassium-ferricyanide solution. Any flaw in the polyethylene layer allowed the two solutions to come into contact, with the formation of a stain of Turnbull’s blue at the site of the flaw. In the case of the polyethylene laminate, this test was sensitive enough to pick up minute penetrations of the polyethylene layer caused by single fibres of the paper-flaws so small that they produced no change in the quantitative waterproof test described below. The blueing test was valuable for assessing and comparing large sheets of the material, but it was so sensitive that only large blue flaws (1 cm. diameter or more) represented defects of practical importance. Quantitative tests.-The waterproof property and wet