A&E Crisis ‘Biggest in over a decade’: what can be done?
The care that people receive in our Emergency Departments is one of the measures by which the NHS as a whole is judged. Although many improvements have been made over the years, the mounting pressure on these hospital departments illustrates the need for change, both inside and outside the hospital.
According to official figures we are experiencing the biggest A&E crisis in over a decade. Statistics from all NHS hospital trusts show that in Q4 of 2014, 92.6% of patients were seen within four hours. It is the worst figure since records started in 2004, overshadowing a particularly bad performance in spring 2013.
Last week I spent a fascinating morning with the ED Director of a large Acute Trust in the South East. I saw first-hand the challenges that they face and learnt more about what is needed to successfully run a busy A&E department and continually achieve the target of 95% of patients being seen within four hours.
It was also a good opportunity to ask the ED Director his thoughts on the A&E Crisis, and what challenges he faces in his day.
1. What does a typical day look like for an ED Director?
First thing in the morning I would attend the nursing night shift handover meeting to understand how the previous night in the department had been, understand any operational difficulties and identify any issues with staffing for that day. Once I had addressed any issues, I would look at the overall four-hour performance for the previous day and seek to identify areas which may have contributed to reduced performance, i.e. lack of bed capacity, staffing shortages, ambulance hand over delays, etc. The main part of the day would be spent seeking resolutions to patient flow issues and ensuring the department doesn’t become overcrowded.
2. What is the biggest challenge you face in running a busy A&E Department?
Currently the biggest challenge facing most acute trusts, specifically within Emergency Department settings, is the volume of patient attendance and the availability of inpatient beds. Our population is ageing and living longer with more complex health conditions, which in turn gives rise to higher emergency patient attendance, particularly in those aged over 75. Ensuring that patients are seen, treated and either discharged or admitted within the four-hour target is at the forefront off all staff working within the ED, but as we have seen from recent headlines, this isn't always easy.
3. What advice would you give to other Trusts struggling to achieve the four-hour performance?
My advice would be: ensure your clinical staffing is matched to patient attendance levels, specifically at peak times. Think creatively about the space in the department and if possible optimise its use for patient assessment. Think creatively about how to reduce 'bottlenecks' in your department. Ask yourself: can you make better use of Ambulatory care pathways, have a GP or consultant triaging at the front door etc.? It is always worth considering developing relations with other ‘high-performing’ Trusts to learn from them and adopt relevant practices.
4. Why do some trusts find it so hard to treat, discharge or admit patients within four hourswhile others do not?
There is no easy answer to this one, as there are many variables. In order to meet the four-hour standard (95% target), you need the physical capacity to assess and treat patients. Many A&E departments reside in ageing buildings and space is often constrained. Coupled with the optimum physical footprint, 'patient flow' out of the A&E department is also critical to achieving performance and delivering a good patient experience, this isn't always easy owing to a lack of available inpatient beds. It has become increasingly difficult for many Trusts to safely discharge certain patient groups back in to the community owing to cuts in social care budgets. Other factors which can delay patients being seen, is the arrival of trauma patients. Some A&E departments act as Major Trauma centres or are regional centres for conditions such as stroke, these trusts will therefore treat patients with the most urgent needs first. These life critical situations involve the same clinical teams working within the department and therefore trauma cases will be given priority meaning that other less urgent cases will wait longer, extending the four-hour wait. Acuity (severity) of certain patients attending an A&E is also a factor, some patients will therefore require more complex interventions by the clinical teams and these interventions can't always be completed within four hours owing to varying complexities. So in summary, there are many factors which can contribute to a long wait in A&E, but be assured, staff are working hard behind the scenes to see patients as quickly as possible.
A&E departments all over the UK are working hard to achieve the four-hour target. I am interested in your thoughts on the A&E crisis? Why are some parts of the county performing well and other not so? What advice do you have for Trusts that are facing challenges?
Claire Carter is the Principal of Healthcare at Interim Partners.