Tweets from the emergency department

In the second week of December several NHS services in England joined a national “tweetathon” to “provide anonymised, real time accounts of the range of conditions and reasons people visit the hospital’s A+E [accident and emergency department].” Why? “Because thousands of local people use urgent and emergency NHS services for all types of illnesses and injury, even if it is not the most suitable place to treat their needs.” The tweets were identified on Twitter by the hashtag #tweetwell.

The clinical director of Leeds Teaching Hospitals NHS Trust, Steve Bush, said that this was the first time that a “national social media approach has been used to educate local people about using the Emergency Department appropriately. It is really important that people use alternatives so that we can ensure we use our resources to support those that are seriously ill or injured.”1

Many NHS hospitals decided to send live tweets about events in emergency and urgent care venues. But some supposedly preventive advice tweets approached parody, such as, “Avoid colds this winter by wrapping up warm,” and, “Left your Xmas preparations to the last minute? Don’t panic! Slips, trips and falls are more likely to happen when you rush!”

Several NHS trusts also tweeted, “One out of every four people who go to A+E could have been treated elsewhere in the community, or could have self treated.” So, who are these people? Here, Twitter becomes hazardous. To explain appropriate use of the service, one trust tweeted, “Staff very busy now with 16 majors. Patients with chest pains and internal bleeding. These are real emergencies.” Another trust described “four majors . . . seizures, gastric bleeding, abdominal pain.” Given the trust’s geographical information and the live nature of the information feed, it became possible for patients to identify themselves or others.

Other tweets seemed to judge the appropriateness of visits. “Patient complaining of headaches assessed by A+E team nothing serious advised if symptoms continue to visit GP.” A later tweet from another trust read, “A headache is not usually an emergency. Save the Emergency Dept for real emergencies!” Another complained, “People still walking into A+E with flu-like symptoms/vomiting bugs despite campaigns urging us to stay at home to stop the spread.” One trust told its followers that 12 people were waiting to be seen but “5 of them should be seeing their GP—not URGENT or life threatening!” Another stated, “Someone in A+E after swallowing a coin—not necessary unless difficulty breathing or chest pain—it will pass through!” Giving such details is contrary to the advice given by NHS Direct and others.2

Educating people in the 140 characters of Twitter presents several hazards, as brevity trumps detail. Trade unions, royal colleges, and medical regulatory bodies have published or drafted various guidelines on use of social media by doctors and nurses.3 4 5 6 Last month’s tweetathon, however, involved members of NHS trusts’ public relations or media teams, and the Department of Health told me that no official guidance had been produced specifically for them.

Crucially, the “experiment” assumed only benefits of live tweeting and was not run on an investigative basis to assess possible harms. As well as giving examples of unusual, past, but very identifiable cases handled by a named nurse, one trust tweeted, “Lots of ladies coming in for emergency contraception—you should get this from your pharmacy.”

Jules Hillier, executive director of communications for the sexual health charity Brook, was unhappy about some of the tweets. “We have a great deal of insight into young people and their need to have trust in a service (which includes trust that they will not be judged and that their visit will be confidential). People must trust their healthcare provider, whatever the setting, to take them seriously, listen to their concerns, and maintain their confidentiality.” She didn’t think that there was maliciousness in such tweets, but “sometimes enthusiasm and a desire to make an organisation appear more engaging is in danger of breaching that trust.” Although social media have a useful role in spreading information about services, she thinks that there is no need to discuss individual cases or to “belittle people.” So, she said, the tweet about emergency contraception could just as easily have been “EC is most effective the sooner you take it—it will be much quicker for you to go to your pharmacy or clinic than come to A&E, and here’s a link to find your local service.”

The trust responsible for the tweet about contraception said in a statement that some patients had “given permission to share details of their trip to the emergency department” but that this applied to the few individual cases its tweets had mentioned, not to more general comments on attendances.

Nor is it clear how attitudes about health might be changed through social media. One mental health trust’s tweet, “We find that just as many people admitted present a danger to themselves as much as a danger to others,” was inaccurate and potentially alarmist: people with mental illness are far less likely to be a danger to others than to themselves.7 When the trust continued, “A patient has been admitted . . . next step to search for contraband such as sharp objects, alcohol and drugs,” the live nature of the tweet exposed a possibly distressing process, occurring in a small named ward, to the world. The trust in this instance said that no consent from individual patients was taken as the tweets were “generic.” Yet patients could have thought that they were being described. What was the point? Who benefits, the patient or the trust, by raising its profile?

Replying to my concerns, another trust said, “We take our responsibility to protect patient confidentiality extremely seriously and do not believe this was breached at any time during the tweetathon. Feedback from the event was entirely positive.” Yet unless efforts are made to identify the harms of such innovations, they will go ignored. It was the Medical Defence Union that pointed out to doctors in a tweet, “Don’t forget confidentiality applies online too. Even seemingly superficial details could break confidentiality.” If only they had addressed that tweet to each tweeting press office as well.