Under pressure: Safely managing increased demand in emergency departments
The ever increasing demand on healthcare resources is a topic that never strays too far from media headlines. The combination of an ageing population with the growing prevalence of complex and chronic diseases, places further pressure on emergency care departments year after year.
How they handle this increasing pressure varies, and the CQC’s recent findings state that the overall picture remains “precarious”. The report aims to contribute to the discussion about how those working in health and social care can encourage effective planning for periods of peak demand, such as the winter months. As there is no reason to assume that demand will decrease over the coming years, the CQC emphasises that a ‘whole system’ approach’ should be implemented.
Annual attendance at Type 1 emergency departments (consultant led 24 hour services) has increased by 9.1% between 2011/12 and 2017/18. Operational pressures have found emergency services being rated as inadequate, and some system leaders describing the scale and frequency of pressures as if it were ‘always winter’.
A previous CQC report identified eight areas requiring improvement:
- Ambulance arrivals – delays in patient handovers to hospitals
- First clinical assessment – delays in the early assessment of patients upon arrival
- Deterioration – identifying those at risk of deterioration
- Escalation – strategies for managing surges in demand
- Specialist referrals – delays in referrals and the working relationships between the emergency department and specialist teams
- Use of inappropriate physical spaces – such as corridors for treating patients
- Staffing – the wellbeing of staff and staff shortages
- Patient outcomes – monitoring the outcome of a patient’s treatment
The CQC identified, in conjunction with clinical leads and matrons from 24 hospitals nationwide, 27 suggestions to improve the current emergency care situation. Some of these suggestions have been reproduced below:
How to reduce demand on services
- Extended access to community services during the week and at weekends to reduce unscheduled attendance at emergency departments.
- Processes and pathways out of hospital for frequent attenders to emergency department need to be in place, for example community falls teams and mental health services.
- Early follow up clinics following discharge after medical or surgical procedures to make sure that patients are receiving appropriate follow up care.
How to improve capacity in the transition of patients through emergency care
- Effective streaming on arrival, triage or clinical assessment to identify critically ill patients and those at risk of deterioration. E.g. use of the Queue Nurse Model, where the emergency department supports the first three patients in the queue, after which the ward staff are called upon to support patients.
- Reviews by specialty teams should take place within 30 minutes of referral, and an incident reporting system put in place to record any lapses against this standard.
- The specific trust must manage crowding in the emergency department as a high risk. There needs to be a trust wide assessment of where the safest place to care for any patient is, and patients should not be cared for in unsuitable spaces such as emergency department corridors.
How to improve patient output from hospital
- Closer multi-specialty team working e.g. the use of validated risk stratification tools to inform clinical decisions about hospital admissions for patients with medical emergencies.
- Improved bed management/inpatient capacity. Ensure that patients are not placed in any bed, but are given an appropriate bed for their needs and that they are available when patients need them.
- Earlier discharge of patients during the day, not late in the afternoon. This requires a proactive approach to discharge, and regular ward rounds by the consultants.
It is recognised in this report that the problems we are seeing in emergence care services is symptomatic of a much wider problem of capacity in the health and social care system. The suggestions offered for managing the increased demand are dependent on increased communication between the various healthcare bodies and structured and effective planning to ensure patient safety, from before admission to after discharge.
Critically, the picture painted by the CQC findings is of a system under considerable pressure. It is under these circumstances that professionals and providers may find themselves requiring prompt and reliable legal advice. We are recognised leaders in the field of healthcare law and practice, we have extensive knowledge in CQC and Healthcare regulatory proceedings.
This briefing is for guidance purposes only. RadcliffesLeBrasseur accepts no responsibility or liability whatsoever for any action taken or not taken in relation to this note and recommends that appropriate legal advice be taken having regard to a client's own particular circumstances.