Meet one of the fastest improving emergency department services in the UK
At a time when emergency departments are under increasing pressure, one department has been commended for its progress
At a time when emergency departments are under increasing pressure, one trust's department has been commended for improving its performance
- Recent Care Quality Commission report states that urgent and emergency services are the poorest performing in the acute hospital sector
- East Lancashire Hospitals NHS Trust has been praised for its improvements and introduction of a home support service team
- Healthcare professionals can work together to identify people at risk of an emergency department visit and offer support at home instead
East Lancashire Hospitals NHS Trust has one of the fastest improving emergency department (ED) services in the country.
Historically, it was among the worst performing trusts for ED waiting times and in 2013 was placed in special measures.
Now the trust is rated ‘good’ with its approach to supporting patients at risk of an emergency admission praised by the Care Quality Commission in its 2018-19 State of Care report.
The trust's urgent and emergency services are split between two sites – Burnley General Hospital and Royal Blackburn, with support from a minor injury unit in Accrington.
Waiting times are still below the national target, but performance is on the up compared to other trusts, and turnaround times improved by 30% in 2018-19.
How has East Lancashire Hospitals NHS Trust improved the performance of its ED?
Action has been taken, including streaming people away from the ED and creating a joint NHS and social care unit – the intermediate care allocation team – to act as a single point of access to health and care services.
But the trust, which delivers acute and community services, has taken its innovation a step further by setting up a rapid response intensive home support service to reduce demand on the emergency system further.
The team was established in 2015 when the trust was in the early stages of its improvement.
It works with GPs, district nurses, social care, local hospitals and the ambulance service to identify people at risk of an ED visit and subsequent emergency admission.
Its remit is to take referrals that require short bouts of intensive support which can be delivered outside the hospital.
Patients can be accepted seven days a week, 365 days a year between 8.30am and 10pm.
The team commonly sees more than 400 patients a month, the majority of whom would have otherwise gone to the ED or been an emergency admission.
Patients who can be cared for outside hospital are supported to do so
East Lancashire head of nursing for urgent and emergency care Jonathan Smith says the team's effect on urgent and emergency services at the trust has been invaluable.
‘Patients who do not need to be in hospital and can be cared for in a different environment are supported to do so,’ Mr Smith says.
Common referrals include patients who have respiratory problems, have had falls, are in pain, have urinary tract infections, confusion, chronic heart failure or dehydration.
Intensive home support service advanced clinical practitioner Fran Bamford says: ‘It is important to identify someone quickly before they are admitted, carry out a detailed assessment and get a care plan in place. We go into their home at least once a day, with the idea of providing seven days of intensive support.’
This can involve anything from monitoring antibiotics to helping them with nebulisers alongside general care and support. The team can also prescribe medicines and order scans.
The National Early Warning Score screening tool is used to monitor a patient’s condition and help determine the frequency of support and if hospital care is needed.
Ms Bamford adds: ‘If after seven days patients need longer-term support or rehabilitation we can work with social care or the reablement team and transfer them. However, it is not a strict seven day cut-off – if we think a couple more days will make a difference they can stay.’
Expanding the work of the home support service team
The team has grown from 15 members to 40, and includes advanced clinical practitioners, community matrons, staff nurses, a mental health nurse and physiotherapists.
The service has a ‘front door’ team that works in the ED and medical assessment unit and helps to identify patients that could benefit from the service.
‘Patients who do not need to be in hospital and can be cared for in a different environment are supported to do so’
Jonathan Smith, head of nursing for urgent and emergency care, East Lancashire Hospitals NHS Trust
Ms Bamford says: ‘With EDs so busy it is helpful to have someone there to help staff spot the patients who do not need to be there.
‘We tend to use a band 6 nurse who is there Monday to Friday from 8am to mid-afternoon.’
The approach provides a vital source of referrals. In September 2019, one quarter of the patients the service worked with were deflected from the ED and medical assessment unit.
The success of the work has also convinced the trust to expand the work of the intensive home support service.
It has started accepting referrals from paramedics – 30 people were referred by the ambulance service in September 2019, avoiding the need for transfers to hospital.
Meanwhile, a pilot involving two nursing homes is under way.
Ms Bamford says the new developments will present a challenge, but it is one she and her colleagues are pleased to take on.
‘It’s great to be working and having an effect in this way. It’s good for patients and good for the trust and urgent and emergency system.’
What the State of Care report said about emergency care
The Care Quality Commission’s (CQC) State of Care 2018-19 report is an annual stocktake of how services are doing.
Urgent and emergency services were the poorest performing in the acute hospital sector.
In total, 44% were rated as ‘requires improvement’ and 8% were ‘inadequate’. This represents a decline on the previous year and means the proportion of substandard emergency departments (EDs) is twice that of maternity, outpatient or critical care departments.
But the CQC's chief inspector of hospitals Ted Baker says these figures should not be taken as a sign that there is something inherently wrong with the urgent and emergency care system.
A lack of services in the community
Instead, Professor Baker believes EDs are overloaded because not enough services exist in the community.
‘There needs to be system-wide change. People should get the care they need in the community. For many, an ED is not the best place to go. But it is the only part of the system that has ever-open doors that people can access most easily.’
RCN director of England Patricia Marquis says this is having a negative impact on nurses, warning they are reaching breaking point in trying to do the best for patients.
‘In EDs nursing staff have been left to pick up the pieces of a health and social care system that is failing to meet needs.’
What are other trusts doing?
Alongside East Lancashire Hospital NHS Trust’s intensive home support service, the Care Quality Commission highlighted other examples of good practice.
- A collaboration between five GP practices in the Surrey town of Farnham, where a team of community nurses, mental health practitioners, voluntary sector organisations, GPs and social workers provide step-up care for those at risk of being admitted to hospital and step-down care for those who are being discharged
- The introduction of an experienced social care practitioner in the emergency department at St Mary’s Hospital on the Isle of Wight, to assess people with multiple chronic conditions to see if a care package could avoid a hospital admission. Of the 120 people the practitioner worked with in the first four months of 2019, 81 avoided hospital admission
Nick Evans is a freelance health writer