Overcoming the 247 challenge looking at emergency departments and the whole system

Emergency departments are often the focus of media and political attention, and recent performance by the NHS in England has fuelled debate. The NHS recently recorded its worst yearly results for four-hour A&E waits since the target was introduced in 2000. The original target was to treat 98 per cent of patients within four hours, but this was amended to 95 per cent in 2010. Data released by NHS England found that performance against the four-hour target dropped to 87.9 per cent in 2015/16. According to the Kings Fund, attendances rose by a quarter that year, from 12 million to 15 million, while admissions rose from 2.5 million to 4.1 million.

The causes of problems in the emergency department are complex. It is often assumed that the deterioration in performance results from an increase in attendances, sometimes by people who are in the wrong place, or who are attending unnecessarily. While there are no data available on unnecessary attendances in emergency department, the closest proxy used is the percentage of people who are discharged without requiring treatment, which is around 13 per cent. This, however, does not mean those patients attended unnecessarily.

An audit by the RECM found that while patients are often aware of alternatives to the emergency department, they end up there because they couldn’t access timely help elsewhere. The college found patients attend emergency departments because they have been advised to by other healthcare providers.

The availability of community services and social services outside hospitals can cause pressure in emergency department. Hospitals have reported difficulty in discharging frail and elderly patients because there is no support for them in the community, particularly in parts of the country with a shortfall in services. The Care Quality Commission has found clear regional variation in the provision of council-funded adult social care services.

A report by the Parliamentary and Health Service Ombudsman10 shows poor planning, co-ordination and communication between hospital staff and health and social care services are failing patients and compromising their dignity. The report highlights the issue of patients being discharged with no home care plan in place, or having to stay in hospital due to poor co-ordination across services. The King’s Fund’s Quarterly Monitoring Report showed that, in 2015, more than 5,000 patients experienced a delayed discharge – the highest level since 2007. Nearly a third of such delays were caused by problems accessing social care services, a 21 per cent rise on the previous year.

The best trusts, recognising that delayed discharge can have a major impact on patient flow, focus on early discharge by using short stay and discharge wards. They also know that frail elderly care is critical to how well emergency departments function, especially as around 8 per cent of people who attend the emergency department are over 85 years of age.

There is a clear link between increases in occupancy within emergency department units and a rise in breaches of the four-hour target. Crowded departments take longer to process patients and slower treatment inevitably means greater occupancy. Increased length of time spent in the emergency department can result in harm, with multimorbid older patients more likely to be at risk. Research has shown a 43 per cent increase in mortality at 10 days after admission through an overcrowded emergency department.

Where improvements are being made measures have been taken to ensure that the emergency department is not the default place for patients to attend and also that those who do attend are seen promptly and referred to the right departments.

These units often have rapid-response frailty services, with teams including occupational therapy workers and social care teams that can quickly address care needs.

Emergency care centres can give patients the care they need without having to admit them to a ward.

The best emergency departments also fast-track patients where indicated, such as in the case of abdominal pain, chest pain or hip fracture.

Some trusts are setting up ambulatory care units to deal with common presentations that can be treated without admission. Frail elderly wards are also often seen within top emergency departments, where specialist care teams, often involving early intervention from a consultant, can ensure that patients are not admitted if they don’t need to be. Social care and community teams can also put the right care package in place once the patient returns home.

Central Manchester University Hospitals NHS Foundation Trust has an ambulatory care unit linked to the emergency department, with distinct clinical pathways designed to avoid admission. At the Dudley Group NHS Foundation Trust, the ambulatory emergency care unit has a large throughput of more than 200 patients a day – almost as many as the emergency department itself.

Good emergency departments work with community services and social care to find ways to improve the whole system. Joint working with primary and community care is essential to help improve patient flow. Urgent care boards bring together the hospital (including emergency department doctors and consultants), social care and GPs to optimise care for patients, and good contacts within the community, such as in social care, pharmacy, care homes and general practice, can also help fast-track patients to where they need to be.

Good work and innovation is already taking place in successful trusts around the UK and it is essential that this best practice is shared; organisations need to take the lead in looking to see what is working elsewhere.

This blog is taken from the CHKS Best Practice in 24/7 Care report which you can download here.
Emergency departments are often the focus of media and political attention, and recent performance by the NHS in England has fuelled debate. The NHS recently recorded its worst yearly results for four-hour A&E waits since the target was introduced in 2000. The original target was to treat 98 per cent of patients within four hours, but this was amended to 95 per cent in 2010. Data released by NHS England found that performance against the four-hour target dropped to 87.9 per cent in 2015/16. According to the Kings Fund, attendances rose by a quarter that year, from 12 million to 15 million, while admissions rose from 2.5 million to 4.1 million.