Top tips for maintaining a safe emergency department during times of high demand

After a difficult winter, the Care Quality Commission has published some recommendations for emergency departments on maintaining safe, high-quality care despite additional pressures

After a difficult winter, the Care Quality Commission has published some recommendations for emergency departments on maintaining safe, high-quality care despite additional pressures

Picture: iStock

Last winter was probably the toughest for a generation in emergency departments (EDs).

Waiting times reached their worst levels since the four-hour target was introduced in 2004 and reports emerged of patients being treated in corridors and ambulances queuing outside EDs.


Urgent and emergency services rated as inadequate or requires improvement 

Source: CQC

At the very top, there is an acceptance that things must change with prime minister Theresa May confirming a planned rise in funding for the NHS over the next few years.

But there are also practical steps hospitals can take, according to the Care Quality Commission (CQC).

The regulator has published a report, Under Pressure: Safely Managing Increased Demand in Emergency Departments, that sets out a number of measures that can be taken.

It is based on evidence presented to the regulator during its inspections and a workshop involving more than 70 front-line clinicians.

The solutions focus on action that can be taken to help keep people well and reduce attendance, steps to manage the flow of patients through the hospital and ways to help avoid unnecessary admissions and ensure early discharge.

Here are 12 of the recommendations:

1. Have a plan for frequent attenders

Work with community falls prevention teams, alcohol and drug misuse services and mental health services to establish a way to support those patients who continuously turn up at EDs.

2. Put in place special arrangements for frail older patients

Pathways that enable frail patients to bypass the ED can make a huge difference and it allows them to receive the care they need quickly and also supports a speedier discharge.

3. Extra specialist outpatient clinics

Arranging 'hot clinics' and rapid access and ambulatory care appointments can help prevent avoidable admission to EDs during crucial periods.

4. Create a clear route for GP referrals

Patients sent by family doctors should go straight to an appropriate assessment area for specialist review. They should not be channelled through EDs.

5. Keep an eye out for at-risk patients

Streaming, triaging and assessment on arrival should be used to identify critically ill patients and those at risk of deterioration.

1 in 20

Ambulances delayed for more than 60 minutes at EDs over Christmas

Source: CQC

6. Manage the ambulance queue

Clinicians need to be at the front door to make sure that the ED is aware of the status of all patients in the ambulance queue. The team should have the power to admit patients directly to inpatient wards if necessary.

7. Get staffing right

Planning for staff should take into account variation in demand and not be purely based on average demand. At the beginning of shifts, each clinical service should identify members of staff who can be deployed to the ED.

8. Speedy access to specialty teams

Reviews should take place within 30 minutes of referral with an incident reporting system that records lapses. The specialty team responsible for acute admissions should be free of elective and outpatient commitments.

9. Manage over-crowding

Hospitals need to make a trust-wide assessment of where the safest place to care for any patient is. They should not be cared for in unsuitable places, such as ED corridors or in ambulances on the forecourt.

10. Early discharge planning

This should start at the moment the decision to admit the patient is made, particularly for medical patients. The process should also aim to allow discharge earlier on in the day to help patient flow. That is likely to mean decisions are made the night before when possible.


Rise in type one ED attendances in the past six years

Source: CQC

11. Improve bed management

Appointing a bed coordinator and having an electronic board to display bed status can help. Bed management should make sure that patients are not just placed in any bed, but are given an appropriate bed for their needs.

12. Working with care homes

Improving clinical support to nursing homes and residential homes and, in particular, making sure there are care plans in place for people with long-term conditions can reduce unnecessary admissions to hospital. Review of medications and assessment of the risk of polypharmacy is an important part of this, as is ensuring patients approaching the end of life have end of life care plans in place.

Ted Baker

A system-wide response

CQC chief inspector of hospitals Ted Baker says the steps should not necessarily be seen as a silver bullet as the pressures in the ED will need a system-wide response.

But he says they provide ‘practical solutions that can be used to help maintain safe, high-quality care in the face of operational pressures’.

‘We cannot accept that each winter will be worse than the one before – we are already seeing the impact on both patients and staff.

‘It is clear that what used to work doesn’t work anymore. New ways of collaborating and planning for surges in demand need to happen now to ensure that next winter is different.’ 

Supporting frail older patients

Consultant nurse for older people
Claire Nelson

Frimley Park Hospital in Surrey has been developing the way it supports frail older patients in recent years.

This has included providing geriatrician in-reach support at its ED and opening a short-stay 22-bed unit.

Those developments have been followed by the creation of an integrated frailty liaison team, comprising of a consultant nurse, a specialist frailty nurse and occupational therapist, junior doctor and in-reach GPs, led by a consultant geriatrician.

The team provides support to the ED and wards that do not have a geriatrician.

The service is currently available Monday to Friday, but there are plans to expand it to seven days a week.

During the most recent month, the team provided assessments to 134 frail patients who came to the ED. An admission was avoided in two thirds of cases.

Consultant nurse for older people Claire Nelson says: ‘It’s had a really positive impact not just for older adults presenting with frailty and their families, but also for the teams in the ED who are under tremendous pressure. We are very proud of what has been achieved so far.’


Dealing with frequent attenders

Bristol Royal Infirmary set up a multidisciplinary group in 2015 to work with people who frequently attend EDs.

The High Impact User Group includes an ED matron, consultant, psychiatry liaison nurse, the homeless health team and a drug and alcohol nurse along with regular input from the police and ambulance service.

Johanna Lloyd-Rees

The team identified the 100 most regular users – some of whom were visiting the ED up to 70 times a year.

Support plans and behavioural contracts were drawn up for each, helping to engage them with services that can provide support to them.

When they do attend the ED, an alert is immediately flagged up on the system so staff know how to help them and allowing them to call on the group for help.

ED matron Johanna Lloyd-Rees says: ‘These are some of the most vulnerable patients we see. They kept coming for the same problems and that was tough on staff.  It was taking up a lot of time and was not good for the individuals. Now they are getting more help to keep them out of the ED and consistent care when they do come.’

After the introduction of the group, there was an 80% reduction in ED attendances and admissions.


Nick Evans is a freelance journalist

Find out more

Care Quality Commission (2018) Under Pressure: Safely Managing Increased Demand in Emergency Departments

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