- Capacity and demand – Excluding the anomalies of attendance during the first lockdown of 2020, the attendances to the Emergency Departments (EDs) in England have steadily increased. The number of general and acute beds has fallen, and bed occupancy regularly exceeds what many consider to be a safe level, leading to exit block and crowding. Staffing shortages, in particular at nursing and middle-grade medical level, compound the issue.
- Complexity – By any measure, the ED is a complex environment. As a result, we often observe (from audits, QIPs, complaints, incidents, targets) that we fall below the standard of care we aspire to or are expected to deliver. In response to this, we often add further checks or prompts in the system to try and ensure improvement. This is not always the most appropriate response.
- Crowding has become the norm in most EDs. Crowding can result in suboptimal care being delivered to patients, poor infection control, longer waiting times and delays in diagnosis and treatment. This in turn can lead to increased length of admission, increased mortality and increased incidence of serious incidents, such as missed deterioration. The elderly and those with time critical conditions are at greatest risk. It is estimated that over 4 500 patients died in England in the year 2020-21 due to crowding (see RCEM reports). Workforce challenges, including difficulty in recruiting and retaining the nursing and medical workforce, burnout and moral injury are also related to crowding.
What we are doing now
During 2020, the Emergency Department work was paused. As the third wave of the pandemic in our region wanes, we will re-invigorate this work, as part of the Managing Deterioration Safety Improvement Programme.
In the pre-pandemic era, we held several educational and network events for emergency department staff. As COVID restrictions have lifted, in association with the Yorkshire & Humber regional board of the Royal College of Emergency Medicine, we hosted an ED event in June 2022.
Our ED work was paused at the start of the pandemic. As restrictions are now lifted, please get in touch if there are any areas of work with which we can help.
The Emergency Department Safety Checklist:
This was developed in Bristol. It helps to standardise and improve the delivery of basic care in emergency departments. It has been shown to decrease the number of cases of missed deterioration and increase compliance with safe monitoring and care of patients within departments. Through the Patient Safety Collaborative, we are funded to spread the checklist throughout the Yorkshire & Humber Academic Health Sciences Network region.
Our experience in Yorkshire and Humber is that departments can not just pick up the ED safety checklist and implement it overnight. We therefore worked with a number of EDs on the barriers and facilitators to improved safety, focusing on:
- Teamwork and Safety Culture – measurement and improvement of culture, is an essential building block for improvement.
- Listening to patients – patients can tell us a lot about how safe the care they receive is. We have translated the PRASE (Patient Reporting for a Safe Environment) tool, which was developed to be used in the inpatient ward setting, to make it suitable for the ED environment. Several departments have used this to ensure that improvements are patient-centred. The narratives that patients give help engage the staff in the improvement work. We have also used the Yorkshire Patient Experience Toolkit in conjunction with PRASE, to gain further insight from patients in the ED.
- Achieving Behaviour Change (ABC) – we have used the Theoretical Domains Framework in the ABC for Patient Safety tool to improve pain scoring in one ED.
- Improving Initial Assessment – we are working with one team to improve the initial assessment process, as part of their patient safety checklist implementation work.
Achieving Reliable Care
The Improvement Academy is working with Emergency Departments in 2 trusts to improve reliability of care and improve patient flow. Using the ARCS tools, the departments have defined what safe care should look; measured what they were delivering, and tested changes.