04 / 12 / 2018
Improving Safety in the Emergency Department this winter
Royal College of Emergency Medicine, October 2018
In the run up to winter, the Royal College of Emergency Medicine have produced this report which is intended as a guide for Health service leaders and Boards.
The report highlights the scale of the challenge across the UK and finds that there is an increase in pressure all year round shown by the numbers of patients turning up at emergency departments which it says is equivalent to at least 13 new emergency departments in the UK, the increasing number of patients stranded in hospitals awaiting discharge and the substantial increases in the number of patients waiting more than 12 hours before admission into a hospital ward bed.
The report also demonstrates how the escalating demand is not just being felt in England , but also in Scotland, Wales and Northern Ireland. From quarter 1 2011-12 to quarter 4 2017-18, the number of people waiting more than 12 hours from decision to admit to admission increased by 11,831% across England. In Scotland it increased by 300% and Northern Ireland saw a 458% increase.
The RCEM has identified 3 key priorities which it believes should be at the forefront of managing the demands of winter pressures in hospital emergency departments. These are:
- Maintaining safety, time-critical care (based on clinical acuity) and dignity for all patients
- Supporting system performance (adequate staffing and acute bed capacity for system flow
- Ensuring training is always supported
To successfully improve safety, the RCEM says that Emergency departments need to offer high quality patient experience, have adequate staffing, participate in wider system engagement and excellent system leadership.
The report illustrates the different levels at which emergency departments might be operating at from green zone, which is regarded as exemplifying ‘good systems’, amber zone as ‘challenged systems’ and red zone, which is a system in which less than 85 per cent of patients are seen within 4 hours.
Good systems (green zone) are identified as having certain characteristics, including hospital wide ownership of the 4 hour emergency care system performance, including early capacity planning, better coordination of bed capacity, enhanced planning for holiday periods, joint ambulatory emergency care strategies, cost effective co-location of relevant services including primary care. Short and medium term ED workforce planning.
In a challenged system, emergency departments are encouraged to improve medical and nursing staffing on the emergency care pathway including medical wards to reduce the numbers waiting in ED corridors. Planning for seasonal cancellation of elective activity, seeking active community support, initiating a risk assessment and full capacity boarding option for acute wards.
In order that EDs stay safe when in the red zone, the report suggests that the hospital board should be made aware of the risk, so that they can act upon it, levels of medical and nursing staff should be enhanced, using locums and agency staff across the hospital and in ED. Solutions also need to be created for sharing the risk during sustained periods , these include better streaming, better engagement strategies for primary care, suing 111 and service in and out of hours.
The RCEM have produced a further quality checklist for hospital boards and executive teams to follow. The list asks them to consider how they maintain safety and dignity for patients in crowded EDs, what plans they have for safe staffing levels to cope with demand in EDs and for assessments and escalation areas, medical wards and outliers.
The Checklist also suggests that hospital boards and executives should ask how the hospital and system respond to demand in the evenings, at weekends and over holiday periods, whether or not wider system has been engaged in supporting the hospital to achieve the 4-hour target and to consider how the hospital will value staff and maintain morale during sustained pressure.