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Emergency care: the challenges of COVID’s second wave, winter pressures and outdated targets

Emergency departments are facing their greatest challenges of the pandemic with overcrowding and respiratory-based presentations

Emergency departments are facing their greatest challenges of the pandemic with overcrowding and respiratory-based presentations

This winter sees new challenges land atop historic ones as a second peak of COVID-19 attendances pushes many emergency departments (EDs) to their limits.

For many trusts, the focus of trying to achieve the four-hour national waiting target standard in EDs has been long-forgotten as they concentrate on maximising patient safety in crowded and under-resourced departments.

Last month only 83.8% of patients were

Emergency departments are facing their greatest challenges of the pandemic with overcrowding and respiratory-based presentations

Emergency departments are facing their greatest challenges of the COVID-19 pandemic
Picture: iStock

This winter sees new challenges land atop historic ones as a second peak of COVID-19 attendances pushes many emergency departments (EDs) to their limits.

For many trusts, the focus of trying to achieve the four-hour national waiting target standard in EDs has been long-forgotten as they concentrate on maximising patient safety in crowded and under-resourced departments.

Last month only 83.8% of patients were seen within four hours in all EDs in England and the 95% standard was last met in July 2015.

Perhaps it is the time to replace this antiquated standard with new standards to ensure the sickest – and most in need – gain access to an inpatient ward within one hour of a bed being requested.

ED challenges include maintaining a back-to-normal service while segregating increasing numbers of suspected COVID-19 patients; minimising the risk of cross-contamination; and providing high dependency care to patients requiring respiratory support.

There is real potential for some EDs to be overwhelmed with patients, and some nursing staff must be asking themselves: ‘Where are the Nightingale hospitals when they are so clearly needed?’

Patient FIRST support tool introduced to support emergency admissions and their delivery

Nursing workforces up and down the country are feeling the strain as some members of their team are either hospitalised with COVID-19, have to self-isolate or are unable to work for other reasons.

Our workforce is our greatest asset and it is crucial that nurse leaders are visibly supporting their teams at this time. The well-being of our front-line staff is paramount.

The Care Quality Commission recently published the Patient FIRST support tool, which is based on establishing five key principles to support emergency admission and its delivery. Designed by clinicians for clinicians, the Patient FIRST tool includes practical solutions that all senior hospital management teams must consider to support good, efficient and safe patient care.

What is the Patient FIRST support tool?

The Care Quality Commission’s Patient FIRST support tool sets out five principles to support emergency admission and its delivery.

FIRST stands for :

  • Flow
  • Infection control, including social distancing
  • Reduced patients in emergency departments (EDs)
  • Staffing
  • Treatment

The five key principles are:

  1. Patients must come first and safety cannot be compromised
  2. EDs must focus on rapid assessment and stabilisation of critically ill and injured patients
  3. ED staff must have the authority to move people from the department after their initial assessment to a more appropriate pathway of care outside the ED
  4. Patients must have access to other services outside the hospital to help ensure EDs are not the default pathway
  5. Delivering good quality urgent and emergency care must have the support of all services inside and outside hospitals

Source: Care Quality Commission (2020)

Nursing absence levels on inpatient wards have a negative knock-on effect on patient admissions and on EDs, as these become crowded with patients waiting for beds.

‘There is real potential for some emergency departments to be overwhelmed with patients, and some nursing staff must be asking themselves: “Where are the Nightingale hospitals when they are so clearly needed?”’

This bottleneck has the potential to result in many acutely unwell patients unable to be placed in ED cubicles and receive critical treatments within the expected timeframes.

Ambulances experience handover delays due to departments being full during the COVID-19 pandemic
Picture: iStock

We know the dangers associated with overcrowded environments and the effect on the wider community as ambulances experience handover delays due to departments being full.

Evidence also informs us that insufficient nurse-to-patient ratios results in avoidable harm to patients, so the national situation is serious.

Feedback from senior colleagues around the country tells the same story: 2020 will be the hardest year in recent memory.

Many ED staff are working additional shifts to support their teams and ensure patient safety

The added pressure of managing so many patients receiving aerosol generating procedures requires additional well-trained nurses – and some members of our team are having to undertake this role every day.

It’s hard work – especially when you’re wearing personal protective equipment – and so many staff members are working additional shifts every week to support their teams, as well as ensure patient safety.

‘Historically, February brings the peak of the winter period, with a surge in respiratory-based presentations, and could present the greatest challenge for nursing staff’

I've seen so many great examples of our team regularly going the extra mile. I’m proud to work alongside them and to know I played a role in ensuring they have the right skills and knowledge to deal with such a national emergency.

Our respiratory team has also provided fantastic support.

The ED workforce has become increasingly diverse over recent years. It’s great to have roles, such as advanced and emergency practitioners, physicians associates, nursing associates, associate practitioners and nursing students in addition to traditional roles, all having an impact.

Some hospitals are seeing more patients now than during pandemic’s first peak

In my geographic area of England, we have seen some of the highest national prevalence rates over recent weeks and having this workforce in place has been vital.

The national picture and the stress that EDs and staff are feeling differ greatly.

Some hospitals only have around 6% COVID-19-related admission rates, others are managing rates as high as 50% and are now seeing far more patients than during the first peak, making the need for region-wide approaches essential.

Historically, February brings the peak of the winter period, with a surge in respiratory-based presentations, and could present the greatest challenge for nursing staff.

If the increasing trend of level 2 high dependency patients continues, then maintaining hospital oxygen supplies could again become an issue.

These patients require more oxygen to drive therapies, such as continuous positive airway pressure, as opposed to the traditional ventilated patient receiving oxygen through closed circuits.

Hopefully, the COVID-19 vaccines will bring light to the end of the tunnel.

View our COVID-19 resource centre

Find out more

Care Quality Commission (2020) Project Reset in Emergency Medicine: Patient First

Royal College of Emergency Medicine (2020) Performance and Statistics


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