Strategies for reducing pressure in urgent and emergency care
Solutions to improve patient outcomes and patient journeys
- In November 2022, 37,837 patients waited more than 12 hours in A&E before being admitted – up 355% in a year.
- In December 2022, 24% of ambulance patients in England waited more than an hour to be handed over to A&E teams – the target is 0%.
- In one Trust a patient waited on a trolley in A&E for 99 hours while staff tried to find a bed.
Sources: NHS England / The Guardian
This article, based on debate during a recent Health Spaces thought-leadership webinar with Archus, considers strategies for reducing pressure in urgent and emergency care that could help to improve patient outcomes and patient journeys.
Models of Care are one possible solution, as well as innovation to ease ambulance handovers, tackling the elective backlog, best use of space, governance to reduce risk, taking care of staff and leveraging the capacity of the wider NHS and social care system , which can all play a crucial role to make a positive difference.
What does good emergency care look like?
Stark news headlines on New Year’s Day sounded a warning that 500 people could be dying each week because of delays to urgent and emergency care. This verdict from the president of the Royal College of Emergency Medicine, Dr Adrian Boyle, amid a severe flu outbreak and rising Covid cases, will have come as little surprise to NHS executives. “We need to actually get a grip of this,” Dr Boyle concluded, in a sentiment that will be shared by many.
How good emergency care can be provided is a complex topic, generating many points of view. The ideal could be translating national policy into a Model of Care that gives clinicians an opportunity to practice the level of care they would like to offer – such as the model detailed in our Emergency Care webinar and presented by Archus – which presents an optimum flow of patients depending on level of urgency, from “blue light” life-threating emergency cases to walk-in patients with minor injuries. It is underpinned by the principle of getting patients the best care in the right setting.
“It’s about how well we stream patients, whether they come by ambulance or walk in. You need the processes in place to be able to quickly identify that they should have come by blue light and then get them to rapid assessment treatment or majors as quickly as possible. It is in terms of how you do that at the front door and what that front door looks like.” – Paul Sheldon, specialist in healthcare facility planning at Archus.
Divyesh Gadhia, specialist in healthcare strategy, planning, reconfiguration and improvement at Archus, advises that ED flow is critical. There is wide agreement that patient safety must always be first and foremost, aligned to two more priorities: having a robust process on how patients are triaged and streamed; and having a rapid assessment process at the front door leading to the appropriate space for each patient.
There needs to be continuity of care, a clinical plan that is followed through with the right workforce and skillset to ensure patients are not simply held in ED but move through the system. This is more nuanced than may appear, however, with practitioners pointing out that in hospitals where performance to the four-hour target is under scrutiny there can be a feeling that they need to ‘do’ something with the patient. There is a tension between how much patients are being moved along because it is the right thing for their safety and ED experience, and how much it is because clinicians are measured against this standard. In some cases it may not possible to look after patients within the four-hour slot.
Tackling ambulance handover delays through innovation
With unprecedented pressure on admissions in A&E leading to delays in ambulance drop-off times and, as a result, rising ambulance response times, there are examples of Trusts using innovations with space to tackle this challenge.
Health Spaces has also developed its own concept; modular Ambulance Receiving Centres to alleviate ambulance drop-off delays, allowing patients to be dropped at a safe space rather than waiting in vehicles. This is an effective way of rapidly reducing ambulance waiting and handover times while safely caring for patients. It can be implemented in under 12 weeks, freeing up vehicles to respond to calls faster and reduce response times.
“Ambulance handover delays are risky because they delay assessment and treatment for those waiting in an ambulance queue at hospitals. Such delays also compromise safety in our community by reducing the availability of ambulances to respond to emergencies.” – NHS England.
Busting the elective backlog
Delays to elective surgery as a result of COVID-19 backlogs are another factor increasing pressure on emergency and urgent care. Clinicians report that, “It feels like there are sicker patients now – due to treatments cancelled or being under-doctored during the pandemic.” Benign conditions such as an arthritic hip become more serious, and leading to falls, fractures and obesity co-morbidity because of reduced mobility, which in turn have a knock-on impact on ED.
It is in this context that the Government has set up an Elective Recovery Taskforce to help unlock spare capacity in the independent sector to, in the words of Health and Social Care Secretary Steve Barclay, “turbocharge our current plans to bust the backlog and help patients get the treatment they need.” Made up of academics and experts from the NHS and private sector, it is charged with recommending ways to reduce waiting times for patients and eliminate waits for routine care of over a year by 2025.
Best use of hospital space
Design and use of space offer invaluable opportunities to help reduce pressure. Having flexible spaces and making better use of all space available can be key to maintaining patient flow in different streams without impacting patient safety when EDs are dealing with very high numbers of people.
Having appropriate spaces is part of the solution, and one idea is the SDEC Adjacencies Model presented by Archus (see webinar clip here). This concept uses the waiting space as a place other than solely as a waiting room; instead it is a base, with flow of patients back and forth to and from this main area. Co-location of services plays an important part, and the essential point is the need for flexibility.
“Having the ability to use spaces in a number of ways can be extremely useful,” says Paul Sheldon, specialist in healthcare facility planning at Archus. “You need the right spaces there to be able to use them in the right way.” An example is using a rapid assessment space as a waiting space, or having a treatment cubicle that doubles as a chair area for patients awaiting diagnostic assessment. He adds: “Having somewhere for patients to go where they are not taking up critical space for your majors or minors – your ‘shop floor’ of your ED – is key. It’s being able to identify correctly in the early stages, when you are doing your demand and capacity modelling, what level of patients you can move along to get rid of that bottleneck. Is it a chair or bedded area? I would suggest it is both. It’s about having an ability to move around in the space.”
Bringing staff into a waiting area also has benefits:
“It’s the perception of the space in the patient’s eyes. If you have been sat in a waiting room for four hours, that can have a negative connotation for the patient. But if you have staff in that area that are reassuring and talking to people while they are in that waiting space – monitoring and reassuring patients – that can be seen as a positive experience.”
Having a versatile space allows EDs to flex between majors and minors, integrating the two services in a way that caters to the unpredictability of urgent and emergency care. Some clinicians, however, prefer to keep minors in one area, majors in another, and argue that the number of patients coming into A&E can be predicted, even if their specific problems cannot.
Risk management, governance and caring for staff
Prioritising risk for patient safety is a key issue that EDs talk about every month and boards discuss at every meeting. Risk management has to be backed by clinical governance and corporate governance. The problem is that best practice looks very different to what is currently being seen in hospitals, Dr Jenkins says.
“Personally, I suspect we are talking about doing the least bad thing. And that’s a really difficult concept for healthcare professionals because we don’t do the least bad thing; we do the right thing. But if you focus only on doing the right thing for the patient in front of you now, you risk doing the wrong thing for the patients that are not immediately in your line of sight. One of the things I find the most frustrating day to day is trying to help teams on the ground to have a wider picture of what is going on in the system.”
It is not because the system is uncaring or because staff are being difficult, he underlines. In fact, good governance and risk management need to be in place to take care of both patients and staff.
“It is important that we acknowledge that this is very difficult for staff,” Dr Jenkins says. “This suboptimal care we are providing some of the time is really difficult for people who pride themselves on delivering the best possible to patients, when they go home at end of shift and know some patients haven’t had the standard of care they would want for their mum or granny or their brother. It is important that we acknowledge that and look after the staff as well as the patients.”
The pressures on staff are magnified when, for example, the staff room is now smaller than it used to be because space has been hived off for clinical care. The ability for staff to even have a rest on their shift is more remote because of competing clinical imperatives.
Potential solutions to leverage the wider system
Emergency and urgent care does not exist in isolation. There are several ways in which the wider health and social care system can help to ease demand. These include:
- Catching patients earlier through the 111 service. This operates better in some areas than others, so standardisation upwards is required.
- Greater collaboration throughout the wider system – so the patient journey is seen as a whole rather than in sections, from arrival at A&E through to discharge and follow-up care.
- Local flexibility to adapt practice as needs arise. In an example discussed in this webinar, a patient was assessed in an ambulance and then taken back to their care home, freeing up the crew quicker than if they had waited to offload the patient into ED.
- Workforce solutions to increase capacity – using non-clinical team members such as Red Cross volunteers to provide reassurance and look after patient welfare, freeing up nurses.
- Pathway-zero discharges – encouraging doctors to discharge a patient without any extra support. This requires local support and training.
Re-watch webinar: Reducing Pressure in Emergency Care
Many of these ideas were discussed in the recent Health Spaces webinar Reducing Pressure in Emergency and Urgent Care.
One of our thought-leadership series of webinars to share best practice with NHS executives, it explored the strategies and potential resources required to manage demand all year round across the urgent and emergency care system. The webinar recognised that every NHS Trust is individual and has its own bespoke pressures to navigate, and will in turn have its own solutions.
*Statistics and quotes from webinar correct at time of live event – 22nd November 2022.
To find more thought-provoking webinar recordings and download game-changing resources, visit our Learning Hub.