Quality and Safety Programme Emergency departments Case for change

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1 Quality and Safety Programme Emergency departments Case for change February 2013

2 Table of contents Foreword... 4 Executive summary Introduction The scope of the review Defining an emergency department Emergency department quality indicators Emergency department workload Emergency departments Children and young people Quality and safety in emergency departments Workforce Staffing in emergency departments The role of the emergency medicine consultant Consultant-delivered care The role of the middle grade emergency medicine doctor The role of nurses Advanced nursing roles within the emergency department Teaching, training and research Managing patient flow in an emergency department Patient flow Crowding Clinical decision units Access to key diagnostics Supporting specialities Ambulance turn-around times Reception, administration and information technology support Patient experience

3 5. Conclusion Glossary of terms Appendix 1: Membership of the emergency department clinical expert panel and the adult emergency services patient panel Appendix 2: Provider codes

4 Foreword There are over three million attendances to emergency departments in London each year. Londoners often have little choice in where they present in an emergency and they expect that emergency departments across the capital will provide them with a consistently high quality service not dependent on location, time of day or day of the week. I believe this expectation should underpin the way that all emergency department services are commissioned and delivered across London. This is why I took on the challenge of leading a clinical expert panel for the review of emergency departments in London. The College of Emergency Medicine cites proper staffing as the single most important factor in providing a high quality, timely and clinically effective service to patients. Evidence from recent reports from the College of Emergency Medicine has demonstrated the importance of the emergency medicine consultant providing senior clinical leadership to the emergency department. Unfortunately nationally, and in London there is too often a dependency on doctors in training to provide services; they may be exposed to circumstances beyond their capability; and the necessary senior clinical leadership and experience is absent at times when it is most needed and could be most effective. It is clear that consultant-delivered care brings benefits for patients receiving emergency care, it was disappointing to find such inequitable hours of consultant presence between London s emergency departments. Additionally, although evidence has shown that an emergency department requires a designated nursing base in order to function effectively; data shows a significant variation in nursing management. Furthermore, the College of Emergency Medicine proposed that the safe delivery of care in an emergency department depends on timely access to diagnostics and investigations, yet this review found variation in access to key diagnostics across emergency departments in London. Emergency departments across London are not functioning as well as they could, or should be. Allowing such inconsistency in service provision to continue is not an option. This review explored the extent to which emergency departments across London were providing high-quality and safe care throughout twenty-four hours a day, seven days a week by considering the availability of key staff, as well as access to the necessary diagnostic support systems. Unacceptable variability in practice emerged; suggesting that the quality of care a patient receives is impacted by the day of the week or the hospital at which a patient happens to present at. I would like to thank the many individuals that helped to develop this case for change which presents clear opportunities for improvement across the capital s emergency departments. Dr Andrew Hobart Consultant in Emergency Medicine, South London Healthcare NHS Trust and Chair of the Quality and Safety Programme emergency departments clinical expert panel 4

5 Executive summary The case for change sets out the context of the emergency departments review and summarises the key issues affecting the quality and safety of London s emergency departments. Variation between and within hospitals has been found. This case for change will be used as the evidence base for setting these standards. It outlines: Emergency department workload Current variation and challenges in workforce Difficulties in managing patient flow in an emergency department Despite changes in the provision of emergency care in the primary care setting, over the last eight years London emergency departments have seen a 60 per cent increase in the number of attendances. The rise in attendances coincides with difficulty in staffing emergency departments across the country. Establishing the right balance of skills and competencies of the workforce within an emergency department, as recommended by the College of Emergency Medicine, is essential to deliver a high quality, timely and clinically effective service for all patients 1. The College of Emergency Medicine has highlighted that emergency medicine consultants provide senior clinical leadership and consultant-delivered care improves outcomes for patients. Furthermore, the senior review of patients has a positive impact on patient outcomes and involvement and input of experienced and competent emergency medicine doctors twenty-four hours a day, seven days a week is recommended. Appropriate staffing mix both doctors and nurses is an integral component of an effective emergency department and the delivery of high quality emergency medicine. On average, patients attending London s emergency departments typically spend a greater length of time in an emergency department than the England average; length of stay is generally greater during the evenings. This is unacceptable and can be associated with a reduction in supporting services and specialties out-of-hours when there is also a reduced senior staff presence in the emergency department. Key messages Despite changes in the provision of emergency care in the primary care setting, attendance numbers across London over the past eight years have increased by sixty per cent. An emergency department s workload is unbounded and there is a call for consultant presence when the service is busy with sick patients and larger volumes, along with the need for an experienced doctor in the department at all times, and access to other staff. The triage process is essential to effectively manage risk in an emergency department; yet it is often withdrawn when staffing levels are low. Appropriate staffing is integral to an effective emergency department however there is increasing difficulty in staffing emergency departments across the country. Consultant-delivered care brings benefits for patients receiving emergency care however just three emergency departments in London meet the recommended 1 The College of Emergency Medicine, The Way Ahead, ,

6 consultant presence across all seven days of the week. Furthermore there is significant variation in the number of hours that consultants are present between weekdays and weekends. An emergency department requires a designated nursing base in order to function effectively. In London, there is significant variation in nursing management and skill base across emergency departments, coupled with high vacancy rates. The involvement of experienced, senior doctors twenty-four hours a day and consultant presence at times of peak activity to midnight seven days a week is required to ensure timely patient care and flow. This practice is uncommon in the capital and few London emergency departments have the recommended number of emergency medicine consultants to support such a rota. Crowding in an emergency department is an emerging threat to patient safety and can have a significant impact on the critically ill. Timely access is required from supporting specialties to enable appropriate admission and transfer of patients to improve patient flow within the emergency department. Emergency departments rely on timely access to diagnostics and investigations to deliver safe care. Variation in access to key diagnostics exists across London s hospitals. National recommendations state that as a minimum, an emergency department must have support 24 hours a day, seven days a week from the seven key specialities : critical care, acute medicine, imaging, laboratory services (including blood bank), paediatrics, orthopaedics and general surgery, to ensure timely appropriate referral to inpatient teams. 6

7 1. Introduction Improving the quality and safety of acute emergency and maternity services has been identified as one of the NHS in London s key priorities to deliver in 2012/13. Working with clinical experts, NHS London and London Health Programmes have recently undertaken a review of acute medicine and emergency general surgery pathways for adult services that included all patients that were admitted to hospital on an emergency basis with an acute medical or emergency general surgical condition. The review demonstrated that patients admitted as an emergency at the weekend have a significantly increased risk of dying compared to those admitted on a weekday 2. Data suggests that a minimum of 500 lives could be saved every year in London. Variation in working practices throughout the week such as reduced service provision, including fewer consultants working at weekends, is associated with this higher mortality rate. Clinical quality standards have been developed to address these issues. Compliance with these standards will ensure that the assessment and subsequent treatment and care of patients admitted to these services as an emergency will be consultant-delivered (that is, care delivered by consultants 3 ) seven days a week and consistent across all providers of these services. The clinical quality standards to address the issues raised in the adult emergency services (AES) case for change were fully endorsed by the London Delivery Group 4 in August 2011 and the Clinical Senate 5 in September All providers of acute medicine and emergency general surgery services within London were expected to comply with the standards from April Similarly a review of paediatric emergency services began in September 2011 with the aim of developing clinical standards to ensure children and young people also access high quality and safe care. The development of clinical quality standards has been expanded to all adult acute emergency and maternity services to ensure that they are consultant-delivered, seven days a week and consistent across all providers of these services. This will ensure that they are of consistently high quality and safe across all providers. This document identifies the evidence as to why services need to change in order to offer patients attending an emergency department a high-quality service. Commissioning standards which address how this should be achieved by changing the way emergency department services are delivered will follow the case for change London Health Programmes, Acute medicine and emergency surgery: Case for change, 2011 Academy of Royal Colleges, The benefits of consultant-delivered care, 2012 The London Delivery Group aims to develop the strategic direction for the NHS in London and co-ordinate 3-5 year strategy planning across London The London Clinical Senate has been set up to make sure clinicians in the capital are more involved in potential changes and developments in healthcare services 7

8 1.1 The scope of the review The overall scope of the Quality and Safety Programme focuses on addressing the variation that currently exists in patient outcomes between and within hospitals, and between weekdays and weekends. The scope of the review of emergency departments is the quality and safety of a patient s care from their arrival at an emergency department to be seen and treated until they are admitted to an inpatient ward, safely transferred to an alternative facility or discharged from the department. 1.2 Defining an emergency department Emergency departments, formerly known as accident and emergency departments and prior to that as casualty, are the hub of the emergency secondary care system. Patients are guaranteed access to an emergency department 24 hours a day, seven days a week. The work of an emergency department is unbounded as it provides care for emergency conditions illness and injury of all severities of all types and for patients of all ages, twenty-four hours a day, seven days a week. 1.3 Emergency department quality indicators A new set of clinical quality indicators 6 developed by the Department of Health in collaboration with the College of Emergency Medicine and Royal College of Nursing were introduced for use from April The indicators cover the following domains: outcomes; clinical effectiveness; safety and service experience; and timeliness. The directive from the Department of Health was to promote a focus on higher quality of care. Emergency departments are required to publish data on their performance against each indicator and benchmark their performance against similar hospitals. 6 A&E Clinical Quality Indicators Implementation Guidance, Department of Health, April

9 Monday Tuesday Wednesday Thurs day Friday Sa turday Sunday Percentage of total attendances 2. Emergency department workload London s emergency departments cover the capital s resident population of 7.9 million, as well as an additional 1.3 million people working and commuting through the capital on a daily basis. Emergency departments see a large volume of cases of varying complexities; there were over three million attendances to emergency departments in London in 2009/10. Twenty-two per cent of these attendances were children and young people (aged 0 to 16 years) and nine per cent were patients aged over 75 years old. 2.1 Emergency departments With an estimated one in four of the national population visiting an emergency department in any one year, emergency departments are the hub of the secondary emergency care system 7. Figure 1 shows emergency department attendances by day of the week of presentations to the emergency department. Figure 1: Emergency department attendances, England and London by day of the week, 2009/ % 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% England London Source: Hospital Episode Statistics 2009/10 Day of week As shown in figure 1, attendances are highest on a Monday which may be associated with the lack of primary care access over the weekend. Despite changes in the provision of emergency care in the primary care setting, including the establishment of urgent care and walk-in centres, attendance numbers across London s emergency departments have risen by 60 per cent over the past eight years. This is outlined in figure 2 and has resulted in an increased workload for London s emergency departments in terms of numbers and acuity. 7 The College of Emergency Medicine, The Way Ahead ,

10 Figure 2: Total emergency department attendances in London, 2002/ /11 Source: Department of Health QMAE data Furthermore, numerous initiatives have been introduced to improve the provision of urgent and emergency care to ensure that patients attend the most appropriate care setting for their needs, and level of acuity. However, it is clear from the rising attendance rates that the public still consider the emergency department as the bedrock for emergency care. Key message Despite changes in the provision of emergency care in the primary care setting, attendance numbers across London over the past eight years have increased by sixty per cent. Attendance patterns and occupancy levels show a fairly consistent pattern across the seven days of the week. Emergency department attendances and occupancy levels are highest on Mondays although the higher occupancy cannot solely be explained by the increased attendances at the front end of a hospital. Figure 3 shows the occupancy levels of London s emergency departments by day of the week and hour of the day showing a similar pattern for weekdays and weekends. In turn, this demonstrates the need for consistency in working patterns by experienced emergency medicine doctors across all seven days of the week. 10

11 Total ED attendances and LAS conveyances Number of patients in London EDs Figure 3: London emergency department occupancy by day of the week and hour of the day, 2009/10 2,500 Monday Tuesday Wednesday Thursday Friday Saturday Sunday 2,000 1,500 1, Hour of day Source: Department of Health QMAE data As demonstrated, in figure 4, the majority of total attendances are during the day and into the evening. Total ambulance conveyances show relatively less variation over the 24 hour period. Figure 4: Total attendances to emergency departments and ambulance pre-alert calls by hour, London 2010/11 250,000 Total ED attendances LAS ambulance conveyances 200, , ,000 50, Sources: Hospital Episode Statistics and London Ambulance Service 2010/11 However, ambulance pre-alert calls to emergency departments may be considered as a proxy marker for sicker patients. The variation in such calls over the 24 hour period is not as great as the variation in total attendances but there is a two to three fold variation between the peak in such calls at and the trough between midnight and as shown in figure 5. 11

12 Total ED attendances and LAS conveyances LAS pre-alerts Figure 5: Total ambulance pre-alert calls by hour, London 2010/11 250,000 Total ED attendances LAS pre-alerts 3, ,000 2, ,000 2,000 1, ,000 1,000 50, Sources: Hospital Episode Statistics and London Ambulance Service 2010/11 This data supports the need for an experienced and competent emergency medicine doctor in the department at all times with targeting of consultant hours to the times with the greatest demand for their skills. In order to ensure that an emergency department is able to meet these demands, the College of Emergency Medicine calls for consultant presence at least into the late evening and at weekends when the service is busy with sick patients and larger volumes 8. Key message An emergency department s workload is unbounded and there is a call for consultant presence when the service is busy with sick patients and larger volumes, along with the need for an experienced doctor in the department at all times, coupled with access to other staff. 2.2 Children and young people The recent review of London s paediatric emergency services highlighted the issues in working practices and current arrangements across London s emergency departments in the care and treatment of children and young people. The Paediatric Emergency Services Case for Change highlights that due to the unplanned nature of patient attendance; emergency departments must be able to provide initial treatment for a broad spectrum of illnesses and should have the required staffing and skills to treat paediatric emergencies. Emergency departments can have a paediatric emergency department which is staffed separately, however across many emergency departments there is a mix of both general and paediatric trained professionals seeing and assessing children. Skilled assessment by an experienced and trained professional, sometimes with a short period of observation, may be useful to differentiate a minor condition from a life-threatening condition 9. However, the review of London s paediatric emergency services found that many children are seen and assessed by doctors and nurses who have not undergone formal, postgraduate paediatric training. Furthermore, the CEMACH pilot study Why Children Die 8 9 College of Emergency Medicine, Operational Handbooks Highlights, The Way Ahead, 2012 Ibid. 12

13 outlined that errors were repeated and compounded by the fact that the principal assessment of a child was being performed by a junior doctor with no postgraduate training in paediatrics, in settings where there was no supervision by an experienced specialist/ paediatrician 10. [www.londonhp.nhs.uk] Evidence suggests that an increased presence of emergency consultant staff has a positive impact and leads to better outcomes in emergency departments. An Australian study conducted between 2000 and 2004 showed that the provision of additional consultant medical staff in a paediatric emergency department coincided with a decreased in the percentage of children admitted, complaints to the department and average waiting times 11. The 2007 Services for Children in Emergency Departments document and the London paediatric emergency services standards recommend that a consultant with subspeciality training in paediatric emergency medicine be appointed for each emergency department with greater than 16,000 annual paediatric visits Quality and safety in emergency departments The emergency department is accepted as a high risk specialty 13. One study conducted over four years found that 953 diagnostic errors were noted in 934 patients and that the majority of these errors were made by junior doctors. Twenty-two diagnostic errors resulted in complaints and legal actions, and three patients died 14. Triage Triage has been defined as a complex decision-making process designed to manage clinical risk 15 by making a rapid assessment to identify or rule out life or limb threatening conditions and begin appropriate investigations and management including pain relief. A recent report 16 found that triage was frequently withdrawn when staffing levels in the main department were low, leaving patients without any clinical supervision or prioritisation in the waiting area. All patients entering an emergency department site should have an assessment undertaken within 15 minutes of arrival by a registered healthcare practitioner experienced in emergency/urgent care and who has received specific training and is able to demonstrate competency in this role. The triage process should be audited and support national standards, such as pain assessments and early identification of time dependent clinical conditions such as cardiac chest pains, and sepsis 17. Key message The triage process is essential to effectively manage risk in an emergency department, yet it is often withdrawn when staffing levels are low Confidential Enquiry into Maternal and Child Health (2008) Why Children Die: A pilot study 2006 Geelhoed, G. and Geelhoed, E. Positive impact of increased number of emergency departments, Arch Dis Child (2008) 93:62-64 Royal College of Paediatric and Child Health. The role of the consultant paediatrician with sub-speciality training in paediatric emergency medicine. London: RCPCH, August 2008 Guly, H.R. Diagnostic errors in an accident and emergency department Emergency Medicine Journal, 2001;18: Ibid. The College of Emergency Medicine, Emergency Nurse Consultants Association and Royal College of Nursing, April 2011: Triage Position statement. Independent Enquiry into the care provided by Mid Staffordshire NHS Foundation Trust, Jan 2005-March The College of Emergency Medicine, Emergency Nurse Consultants Association and Royal College of Nursing, April 2011: Triage Position statement 13

14 Pain management and vital signs recording Pain assessment and pain management is regularly audited nationally and although there have been progressive improvements in this area, pain remains poorly managed in many emergency departments. The College of Emergency Medicine recommends 18 that senior medical and nursing staff consider specific initiatives to improve pain management in ED. One such initiative would be to enable experienced nurses to administer a range of analgesia either as independent prescribers or under PGD (Patients Group Direction). Vital Signs standards were developed through a partnership between the College of Emergency Medicine, the Royal College of Nursing, the Faculty of Emergency Nursing and the Emergency Nurse Consultants Association. The first national audit found that in 50 to 60 per cent of departments patients within the majors area, had vital signs recorded within 20 minutes of arrival but re-recording within 20 minutes were achieved in less than 25 per cent of departments Workforce 3.1 Staffing in emergency departments The College of Emergency Medicine states that proper staffing is the single most important factor in providing a high quality, timely and clinically effective service to patients 20. There is a need to ensure a balanced workforce within an emergency department in order to provide a safe service. The UK s historical model of staffing within emergency departments which resulted in the majority of care being delivered by inexperienced junior doctors, is inappropriate 21. More recent studies of the performance of junior doctors highlight that they are seeing fewer patients than their predecessors 22 and feel less confident in their clinical skills 23. Appropriate staffing mix utilising the appropriate skills of doctors, nurses and support workers is an integral component of an effective emergency department. The provision of care in an emergency department is a team effort and the appropriate numbers of staff from each staffing group are required to facilitate this. The public inquiry into the high number of deaths at Mid Staffordshire NHS Foundation Trust is expected to recommend that minimum staffing ratios be set for total numbers and the skills mix of doctors and nurses in emergency departments in England to ensure the safety of care for patients attending an emergency department 24. There is increasing difficulty in staffing emergency departments across the country. At consultant level the vacancy rate is disguised by the reluctance of many trusts to advertise unless they are confident of applications. Excluding the four major trauma centres, the average number of emergency medicine consultants in post in London s emergency The College of Emergency Medicine, 2010/11 Audits: Renal Colic The College of Emergency Medicine, 2010/11 Audits: Vital Signs in Majors. The College of Emergency Medicine, The Way Ahead , 2008 The College of Emergency Medicine Emergency Medicine Operational Handbook, 2011 Armstrong, PAR. et al Senior house officer and foundation year doctors in emergency medicine: do they perform equally? Emergency Medicine Journal 2008;25:725-7 Croft, S.J., Mason, S. Are emergency department junior doctors becoming less experienced in performing common practical procedures? Emergency Medicine Journal 2007;24:657-8 Torjesen, I. Minimum safe staffing levels may be set for emergency departments and elderly care wards British Medical Journal 2012;344:d

15 departments is 5.5 whole time equivalents per emergency department. Middle grade doctors (Specialty Registrars, Specialty Doctors and Trust Grades) provide the vital safety net of experienced medical care and supervision round the clock. Vacancy rates at this grade are high both for the training grade registrars and the other grades. Key message Appropriate staffing is integral to an effective emergency department however there is increasing difficulty in staffing emergency departments across the country. 3.2 The role of the emergency medicine consultant The role of the emergency medicine consultant is to provide senior clinical leadership to the emergency department. This will consist of providing direct clinical care to individual patients, the supervision and support of doctors in training in emergency medicine and other specialties as well as a close working relationship with departmental and Trust management teams to ensure safe systems and processes are in place for all patients attending with emergency conditions. A significant proportion of this work will require the consultant to be present within normal working hours, to enable engagement with other specialties and Trust management 25. The College of Emergency Medicine states that emergency departments should have an emergency medicine consultant on-call at all times. An on-call emergency medicine consultant may return to the department to provide direct senior clinical input into selected, serious cases as well as providing telephone advice on clinical, medico-legal and ethical issues. It is also expected that the consultant should be kept informed of any significant departmental events that may represent clinical risk to individual or multiple patients, including excessive attendance numbers, unusual case mix or staffing issues. The on-call emergency medicine consultant will also provide the required clinical leadership in the event of a major incident. 3.3 Consultant-delivered care The 2010 Temple report concluded that consultant-delivered, as opposed to consultant-led or consultant-based, care was the only viable model for the future of medical care in the UK. This is believed to be because consultants make better decisions more quickly and are critical to reducing the costs of patient care while maintaining quality 26. The Temple report defines consultant-delivered care as 24 hour presence, or ready availability. There is evidence to suggest that consultant-delivered care in an emergency department, improves outcomes for some patient groups. For example, the introduction of Major Trauma Networks with consultant-led resuscitation and assessment of severely injured patients saved 58 lives in London in the first year of operation 27. Comparing emergency medicine consultant staffing in England with similar models in Australasia and North America, the current consultant numbers in emergency medicine in England are less than half those that would be provided in similar departments in these regions 28. The College of Emergency Medicine recommends a minimum provision of College of Emergency Medicine Temple J. Time for training, 2010 The London Trauma Office The College of Emergency Medicine Emergency Medicine Consultants Workforce Recommendations, April

16 WTE consultants in each emergency department, adjusted where appropriate for larger departments and those providing emergency care for a larger number of patients 29. This would allow for the move towards senior sign-off and early senior involvement in patient care. The potential benefits of consultant-delivered care in emergency departments include: Enhanced and more timely clinical decision making, in particular leading the resuscitation of the critically ill or injured; Increased supervision of more junior members of the emergency department medical team; Reduced numbers of serious untoward incidents; Less unplanned returns; and Fewer misinterpreted x-rays that result in missed diagnoses. Recent studies 30, 31 found that consultant-delivered care in emergency departments contributed to cost savings and increased service efficiency including: Reduction in admissions >20%; Reduction in waiting time; and Cost saving of 3 million to one hospital/ trust. A 2008 study of emergency care in a Scottish hospital over a six month period found that senior doctor care provided in an emergency department as opposed to emergency care provided by junior doctors changed the primary outcome plan in 155 (28 per cent) patients. Improved outcomes included accuracy of decisions, a reduction in the number of re-admissions and prevention of inappropriate discharge 32. Also, a recent study highlighted that a consultant based service offers many advantages that cannot be matched by either junior or middle grades. This would be in addition to a consultant s supervisory role in the emergency department and therefore consultant expansion is required 33. The College of Emergency Medicine argues for urgent expansion to establish sufficient emergency medicine consultant numbers in order to provide consultant presence in the emergency department for at least fourteen hours a day, seven days a week as a minimum in all emergency departments. As shown in figure 6, currently, only two hospitals in London (excluding the four major trauma centres) meet this recommendation across all seven days of the week The College of Emergency Medicine Emergency Medicine Consultants Workforce Recommendations, April 2010 Positive impact of increased number of emergency consultants. Geelhoed GC, Geelhoed EA Arch Dis Child2008;93:62-64 White AL, Armstrong PAR, and Thakore S. The impact of senior clinical review on patient disposition from the emergency department Emergency Medicine Journal, 2010;27: Academy of Royal Colleges The Benefits of Consultant-delivered care, 2012 Sen, A. et al. The impact of consultant delivered service in emergency medicine: the Wrexham Model Emergency Medicine Journal 2012;29:

17 ICH-HH BHT-NUH NWL-CMH UHL ESH-EH BCFH-CF C&W WMUH EH BCFH-BH NMUH WH THH GSTT-ST ESH-ST SLH-PRUH ICH-CXH RFL UCLH CUH HUH BHT-WXH BHRT-QH NWL-NPH BHRT-KG KH SLH-QEH The College of Emergency Medicine recommends a minimum of ten emergency medicine consultants to provide at least 14 hours a day of consultant on site cover. The attendance and occupancy profile of London emergency departments would suggest that 16 hours (for example 8am to midnight) of cover would better match patients needs. This is likely to require a minimum of 12 emergency medicine consultants per department. Although the aspiration would be for consultant presence 24 hours a day, seven days a week, it is recognised that this is currently not viable. Figure 6: Consultant presence in London s emergency departments, 2012* 18 Monday - Friday Saturday - Sunday Weekday median Weekend median Source: London Quality and Safety Programme Audit 2012 * Excluding London s four major trauma centres Significant variation exists in the number of hours that consultants are present between London s emergency departments. Marked variation also exists in working practices during weekdays and weekends across the capital s emergency departments. Weekday consultant presence ranges from eight to sixteen hours, whilst weekend consultant presence ranges from zero to fourteen hours. Data shows that emergency department attendances peak in the evening hours but many of London s emergency departments are unable to provide consultant presence during this time. Key message Consultant-delivered care brings benefits for patients receiving emergency care; however just three emergency departments in London meet the recommended consultant presence across all seven days of the week. Furthermore there is significant variation in the number of hours that consultants are present between weekdays and weekends. 17

18 3.4 The role of the middle grade emergency medicine doctor To ensure the delivery of high quality emergency medicine, the involvement and input of experienced and competent emergency medicine doctors twenty-four hours a day is required, as recommended by the College of Emergency Medicine 34. It is suggested that 10 whole time equivalents would be required to staff such a rota. The senior review of patients has a positive impact on patient outcomes. A study undertaken to assess the influence and effect of real-time senior clinician supervision on patient disposition in a UK emergency department found that senior review of 556 patients reduced inpatient admissions (by 11.9 per cent) and reduced admissions to the acute medical unit specifically (by 21.2 per cent). Furthermore, inappropriate discharge was prevented in 9.4 per cent of cases, improving patient safety, and the appropriate use of outpatient facilities resulted in a rise of 34.6 per cent in outpatient appointments The role of nurses Emergency departments incorporate a variety of nursing and health care support worker roles dependent on specific local needs. These range from unqualified staff, newly qualified nurses, through to those working in advanced practice roles and nurse consultants. The emergency department requires designated staffing based on minimum levels to meet service requirements. Several reports 36, 37 have highlighted high rates of nursing vacancies and inadequate skill mix within the emergency department, which can lead to poorer outcomes for patients 38, 39. However, currently there is not a national tool for determining the balance between levels of qualified and unqualified staff (skill mix) in emergency nursing. The optimum skill mix is achieved when the correct numbers of nursing staff are using their professional skills to deliver quality care as cost-effectively as possible. There are several reports 40,41 highlighting that where care has been found to be poor, the majority of care was delivered by unregistered staff with insufficient nurses to supervise them. It has been demonstrated 42 that as the percentage of healthcare assistants rises, combined with increased bed occupancy, mortality rates can rise. Further work on the development and validation of an emergency specific skill mix tool is underway across emergency nursing organisations, in conjunction with College of Emergency Medicine, and evidence so far suggests that a skill mix ratio of qualified nurses to unregistered health professionals should be a minimum of 80: The College of Emergency Medicine, The Way Ahead , 2008 White AL, Armstrong PAR, and Thakore S. The impact of senior clinical review on patient disposition from the emergency department Emergency Medicine Journal, 2010;27: Independent Enquiry into the care provided by Mid Staffordshire NHS Foundation Trust, Jan 2005-March Care Quality Commission, October 2011: Investigation report: Barking, Havering and Redbridge University Hospital NHS Foundation Trust Kane R, et al (2007) The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis, Medical Care 45(12). Pp Twigg, D et al (2012) Impact of skill mix variations on patient outcomes following implementation of nursing hours per patient day staffing: a retrospective study, Journal of Advanced Nursing [Available at: The Patient Association (2010) Listen to patients, speak up for change. Tinyurl.com/listen-patients Care Quality Commissioning (2011) Dignity and Nutrition Inspection Programme. National Overview. Newcastle Upon Tyne. CQC.tinyurl.com/dignity-overview Jarman,B, et al(1999) Exlaining differences in English hospital death rates using routinely collected data. BMJ,318, Lipley, N (2011) How to make the numbers add up: staff to receive guide on skill mix. Emergency Nurse, vol.,19(8):9 18

19 There is significant variation in nursing management across emergency departments. The role of the shift co-ordinator as a constant presence in providing clinical leadership in the emergency department has been highlighted to provide day-to-day management of effective nursing care, and should be undertaken by an experienced emergency department nurse at band 7 or above 44. Key message An emergency department requires a designated nursing base in order to function effectively. In London, there is significant variation in nursing management and skill mix across emergency departments coupled with high vacancy rates. 3.6 Advanced nursing roles within the emergency department Over the past 10 years there has been a plethora of new nursing roles within emergency and urgent care, which have been introduced to meet local needs with little or no formal critical evaluation 45. Emergency nurse practitioners The role of nurse led services for the care of minor injuries either in the form of minor injury units or through the establishment of enhanced nursing roles (Clinical nurse specialist, Nurse practitioner), can improve the efficiency of the emergency department 46. Nurse practitioners are a well established part of emergency departments, minor injury units and urgent care centres workforce, but the role remains significantly disparate between various settings. Evidence suggests that when general nursing numbers on a shift is low, emergency nurse practitioners (ENPs) are pulled from their role to undertake traditional nursing roles, reducing ENPs clinical exposure and confidence in maintaining skills and knowledge, which can limit their confidence in their ability to treat a wider range of clinical presentations 47. There are no national requirements in terms of educational qualifications, role preparation or competencies for emergency nurse practitioners. The Nursing and Midwifery Council recognises this and supports the principle of having a separate register for advanced level practitioners 48. However, to date, there has been no formal agreement on the basic competencies of this nursing group. Assurance is required to ensure that equitable service provision exists across London for clinical care provided by nurse practitioners, regardless of which emergency department a patient attends. Advanced nurse practitioners Within the emergency department setting, advanced nurse practitioners work across the full patient s dependency range, including majors and resuscitation. This role is less developed within London 49, but has been developed at other hospitals in the country in The College of Emergency Medicine, The Way Ahead , 2008 NHS Evidence, August 2010: Management Briefing: new roles in emergency care Enhanced Nursing Practice in Emergency Departments, National Council for the professional development of nursing and midwifery, April 2008 (Ireland) Care Quality Commission, October 2011: Investigation report: Barking, Havering and Redbridge University Hospital NHS Foundation Trust. Nursing and Midwifery Council: Regulation of Advanced Practice, 2010 Royal College of Nursing Advanced Nurse Practitioners-an RCN guide to the advanced nurse practitioner role, competences and programme accreditation,

20 conjunction with local universities to the point where almost half of all emergency attendances are seen, assessed and treated exclusively by advanced practitioners 50. Nurse consultants A recent enquiry has highlighted the lack of clinical leadership and supervision for nursing staff 51. Traditionally, nursing career pathways in emergency departments have been into management, with the loss of highly experienced practitioners from direct patient care. However, some emergency departments have moved towards the role of the nurse consultant, which was introduced in 2000 with the aim of improving quality of care and services, whilst simultaneously provide a career progression for nurses wishing to stay in clinical practice rather than management. There are approximately 40 nurse consultants nationally working within emergency care settings, with approximately eight of these based in London. Nurse consultants typically clinically manage and lead groups of ENPs/ANPs and provide clinical leadership to matrons and clinical educators 52 often working across traditional organisational and professional boundaries. 3.7 Teaching, training and research The emergency department is the one hospital environment where doctors, nurses and allied health professionals from all specialties learn the immediate care of ill and injured patients, and half of all medical graduates will spend time training in this department 53. Additionally, emergency medicine is one of the leading specialities in life support training. Emergency medicine has also been leading the way in research and evidence for patient treatment and policy development. It is therefore vital that high-quality and safe care is provided in the department to ensure a supportive teaching, training and research environment. The role of the emergency medicine consultant plays a vital role in teaching and training, a role most pertinent during periods of peak activity NHS Evidence, August 2010: Management Briefing: New roles in emergency care Independent Enquiry into the care provided by Mid Staffordshire NHS Foundation Trust, Jan 2005-March 2009 CEM: The Emergency Medicine Operational Handbook (The Way Ahead) Ahead%202011/: page 46 The College of Emergency Medicine, The Way Ahead ,

21 4. Managing patient flow in an emergency department 4.1 Patient flow Ensuring patient flow through the emergency department is a vital element of providing a high-quality and safe service. On average, patients attending London s emergency departments typically spend a greater length of time in an emergency department than the England average; length of stay is generally greater during evenings (figure 7). This can be associated with a reduction in supporting services such as diagnostics and specialities out-of-hours when there is also a reduced senior staff presence in the emergency department. Figure 7: Emergency department attendances and mean length of stay (minutes), 2009/10 Source: Hospital Episode Statistics 2009/10 To ensure the delivery of high quality emergency medicine and ensure timely patient flow, ideally, the involvement and input of experienced, senior doctors twenty-four hours a day and consultant presence late into the evening, seven days a week is required, as recommended by the College of Emergency Medicine 54. This practice is uncommon in the United Kingdom. The involvement of senior clinicians in initial patient assessment in the emergency department has been found to be highly effective and can result in a dramatic overall reduction in the number of patients waiting to be seen and many patients can be effectively treated and discharged after the initial consultation The College of Emergency Medicine, The Way Ahead , 2008 Terris et al Making an IMPACT on emergency department flow: improving patient processing assisted by consultant at triage Emergency Medicine Journal 21:

22 One study in an emergency department found that senior doctor provision of emergency care prevented inappropriate discharge, and outpatient appointments were judged to be more appropriately managed; which benefitting patient flow of the emergency department and improved patient safety 56. Key message The involvement of experienced, senior doctors twenty-four hours a day and consultant presence during peak activity to midnight seven days a week is required to improve the quality and safety of the department and ensure timely patients flow. This practice is uncommon in the capital and few London emergency departments have the recommended consultants to support such a rota. 4.2 Crowding There is a need for emergency departments to ensure that there is adequate space for all members of the emergency department team, patients and their carers; and provide safety, confidentiality, privacy and dignity. Separate areas within the emergency department for children, both whilst waiting and during treatment are required. Poor patient flow associated with a lack of support from inpatient specialties, wards and services can result in emergency department overcrowding 57. If overcrowding is not addressed through triggering additional support services, a threat to patient safety can emerge which could have a significant impact on the critically ill. Crowding can result in a dysfunctional emergency department and is associated with: Longer waiting times; Increased delays in admission to hospital; and Transmission of infectious diseases 58. Crowding in emergency departments is normally subject to seasonal variance, whereby high risk patient groups present with increased levels of acuity. Emergency department crowding is associated with significant negative outcomes, including unnecessary death. 59 There is evidence 60 to suggest that the mortality rates for patients who present to emergency departments during periods of crowding when the emergency department has reached capacity, are higher than those patients who present during off peak times. Key message Crowding in an emergency department is an emerging threat to patient safety and can have a significant impact on the critically ill. Timely access is required from supporting specialties to enable appropriate admission and transfer of patients to improve patient flow within the emergency department White AL, Armstrong PAR, and Thakore S. The impact of senior clinical review on patient disposition from the emergency department Emergency Medicine Journal, 2010;27: Higginson, I. Emergency department crowding, Journal of Emergency Medicine 2012, Vol. 29, Number :437e443 Increase in patient mortality at 10 days associated with emergency department overcrowding, MJA, Vol. 184 Number 5, 6 March 2006 Slote Morris et al (2011) Emergency department crowding: towards an agenda for evidence based intervention for evidence-based intervention Ibid. 22

23 4.3 Clinical decision/ observation areas Many emergency departments run clinical decision/ observation areas as part of the drive to improve patient care and view these facilities as an integral part of emergency medicine. Clinical decision/ observation areas maximise the use of available resources and are viewed as a better alternative for patients than a inpatient admission as they provide a period of observation or treatment, typically four to twelve hours, for those patients with an expected recovery time or a short, defined period of active treatment for specific diagnoses. These units also allow time to investigate and to safely rule out serious diagnoses preventing both unsafe discharges and inpatient admissions. Overall, clinical decision/ observation areas can provide patients with cost effective shorter lengths of stay. These are most effective when they are ring-fenced areas exclusively managed by emergency medicine doctors and nurses with clear operational policies. However, not all emergency departments in London have access to such a facility and there is considerable variation in the way in which they function. 4.4 Access to key diagnostics The safe delivery of care in an emergency department depends on timely access to diagnostics and investigations 61 as clinical diagnosis alone cannot be relied on to make safe diagnoses in many cases. Early access to diagnostics can also prevent unnecessary admission to hospital 62, therefore providing better outcomes for patients. Emergency departments should have access to appropriate imaging (CT, ultrasound and plain radiography) to allow immediate investigation of potentially life threatening conditions. As demonstrated by the recent London Adult Emergency Services Review for emergency admissions, access to key diagnostics is required twenty-four hours a day, seven days a week, although variation exists. Immediate, hot reporting is ideal but as a minimum, all reports should be available for review within 48 hours 63 and all radiographs must be reviewed by a radiologist/radiographer. Key message Emergency departments rely on timely access to diagnostics and investigations to deliver safe care. Variation in access to key diagnostics exists across London s hospitals. 4.5 Supporting specialities To ensure a high-quality and safe emergency department is provided, access to inpatient beds, speciality clinical opinion and support from other specialities in the hospital is required. Additionally, there is a need for clear referral and transfer guidelines for patients requiring care and treatment at other hospitals. Patients waiting in the emergency department (often on hospital trolleys) due to a lack of inpatient beds is sub-optimal and evidence suggests that patients with prolonged trolley times have longer lengths of stay The College of Emergency Medicine, The Way Ahead , 2008 Ibid. The College of Emergency Medicine, The Way Ahead ,

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