EDs across Scotland have experienced significant difficulties in achieving the emergency access standard in recent years. There are many reasons for this, including input, throughput and output issues in relation to patient flow. Poor patient flow results in crowding in EDs and assessment areas, and has negative implications for patient experience, quality and safety.
The Cabinet Secretary for Health, Wellbeing and Sport has made the delivery of the four-hour emergency access target a ministerial priority. The Unscheduled Care Steering Group, which includes representatives of the Academy of Medical Royal Colleges and the Scottish Government, consequently defined the 6 Essential Actions to Improving Unscheduled Care.
The symptoms of poor patient flow are evident in EDs which become crowded when patients cannot be transferred to admission wards because of capacity issues. In a crowded ED, new patients are not able to be safely assessed and existing patients are neither being managed in an ideal environment nor receiving specialist input. Those with an acute need for specialist input are often elderly and are among the most vulnerable members of the ED population.
The causes of poor patient flow - and therefore the solutions - are system-wide and require a whole-system approach if they are to be addressed.
This documents was revised in April 2016 to reflect the experience of Boards in developing their plans.
Published evidence shows that ED crowding is linked to increased morbidity and mortality. 1-5 Each NHS board and hospital must ensure urgent engagement with local clinicians and managers across medical, surgical and diagnostic services to develop a comprehensive interdisciplinary plan to address the causes of crowding and minimise harm to patients. 4
The many inter-related types of crowding include the following. 5
- ED crowding that delays the assessment of undifferentiated, unwell patients who have not been seen by a clinician. This can be experienced as:
- ambulances unable to offload/transfer patients to the care of the ED
- a locally determined number of patients waiting longer than two hours after referral for admission
- physical occupancy in majors and resuscitation units in EDs being greater than 80 per cent.
- Admission ward crowding that risks causing delay in the further assessment and treatment of acutely unwell patients can be experienced as:
- a delay of two hours or more between the decision to move a patient and admission to a specialty bed
- occupancy of more than 100 per cent, meaning new admissions either cannot be transferred from ambulances or are diverted to another area or hospital.
- Hospital crowding affecting the delivery of non-urgent elective care can be experienced as:
- cancellation of less urgent elective surgery such as joint replacement and non-cancer cases (for example, cholecystectomy and transurethral resection of the prostate).
- Hospital crowding seriously affecting the delivery of safe in-patient care can be experienced as:
- cancellation of urgent elective surgery (such as for breast and bowel cancers)
- boarding  (A patient who occupies a borrowed bed is described as boarding) in clinically inappropriate services, interfering with the delivery of safe and effective care
- transferring/diverting acute patients to other hospitals and into inappropriate specialty beds
- use of unfunded and/or understaffed beds
- unplanned or short-notice discharge of other in-patients
- inappropriate use of day-case facilities for in-patient care.
The inability to transfer patients who require admission is known by different terms, including access block, 6 ED boarding 7 and patient turnaway. 5 It is a reflection of problems across the whole system and relates to, among other things, demand management, streaming of GP referrals, capacity management and the timing of discharges.
The concept of access block is important. It can be defined as a patient being held in a queue and unable to progress to the next stage of care (such as an appropriate bed) within a defined timeframe. ED crowding may develop as a consequence.
Crowding is unacceptable and demonstrates poor patient flow through the whole system. It has negative implications for patient experience, safety and quality, and must be addressed in the context of the whole system. The 6 Essential Actions national programme supports NHS boards to work proactively to improve unscheduled care across the whole system. Local improvement plans must be implemented to ensure safe and effective flow through ED and the wider system, but contingencies in conjunction with local escalation policies should be in place for situations in which crowding occurs.
Email: Alistair Pollock, Alistair.Pollock@Gov.Scot