Emergency Department Capacity Management Guidance

The Unscheduled Care Steering Group convened the Emergency Department Capacity Management Expert Group, which includes clinicians and managers, to review evidence and contribute their experience and expertise to the development of guidance to eliminate crowding in emergency departments (EDs) in Scotland. The aim was to develop an escalation framework for implementation across NHS Scotland.

3. The 6 Essential Actions to Improving Unscheduled Care

The 6 Essential Actions to Improving Unscheduled Care national programme adheres to the principles of right time, right place and right clinician for each patient through its concurrent work-streams on proactive discharge processes, site management and realignment strategies. Centred on the needs of the patient, it acts as a constant pressure to encourage proactive and predictive capacity management.

The 6 Essential Actions to Improving Unscheduled Care are outlined below.

Essential Action 1. Clinically focused and empowered management

A clear site-management process should be in place with robust communication lines across all services. Responsibility and accountability should be agreed across the NHS board seven days a week, with an appropriate site director appointed to support medical and nursing chiefs and duty managers in all services. This is crucial to ensuring central oversight of safety and flow on a day-to-day basis and supporting effective performance and management.

Escalation plans must give managers and clinicians explicit local guidance on the sequence of priorities to be addressed during times of capacity stress. It is essential that managerial and clinical teams in all services have a full understanding of, and are in agreement with, defined site responsibilities and can demonstrate awareness of, and be accountable for, actions required for standardised processes and escalation. These must be agreed and accepted by all clinical and managerial leads, and monitoring processes must be in place to ensure they are followed as routine.

Robust communication processes across a whole hospital site should include morning hospital-safety huddles, focusing on the day's activity and current status, and afternoon huddles, looking at prediction of capacity and demand for the next day. Such processes help inform standard operating procedures and escalation.

Essential Action 2. Capacity and patient flow

It is crucial to consider optimal patient pathways and ensure beds are available in the correct area at the correct time of day. Boards will examine their current systems, site by site, to see whether capacity in admission/assessment areas and specialist wards matches demand. This process should be based on historic site-specific data by time of day and day of the week. It should allow for surges in activity affecting EDs and acute assessment areas.

To reduce the occurrence of boarding, systems should allow for a locally agreed level of capacity to be available in the system when required, with flexibility in the assessment process to deal with predictable surges in activity. There should be a focus on reducing delays in any part of the in-patient journey. Clinicians and managers should ensure patients are in the right place to access care to meet their needs. Escalation policies should identify surge capacity within the system and how this will be appropriately addressed through the deployment of doctors, nurses and allied health professionals.

Essential Action 3. Managing the patient journey rather than bed management

Following and facilitating the patient journey (flow) rather than bed management should be founded on early morning coordinated planning and hospital safety huddles. Discharge-hub facilities, discharge prescriptions, discharge lounges, professional leadership and liaison with the ambulance service should be planned effectively on a seven-day-a-week basis to ensure no delays in care occur. Discharge should be planned according to the patient's clinical condition. This means that patients should be discharged at the optimal time, with discharges before noon and over the weekend period consequently becoming more common. Using effective processes (electronic where possible) to track patients through their pathways ensures that operational grip and control is maintained.

Essential Action 4. Medical and surgical processes designed to pull patients from ED

Hospital departments should be enabled to rapidly stream patients to appropriate and timely assessment in ED, and processes should be in place to pull patients from the ED to assessment/receiving areas where short-stay assessment or admission is necessary. Access to diagnostics and specialist opinion should be available when required, with workforce and job planning ensuring resources match demand. Twice-daily review by a consultant in acute assessment areas ensures active care management. Delays to care pathways and in discharges from wards can be minimised through daily decision-making reviews and multi-disciplinary rounds focusing on facilitating discharge when patients are deemed medically and therapeutically fit. This process can be supported by criteria-led discharge procedures spanning seven days.

Essential Action 5. Seven-day services

Variations in access to assessment, diagnostic and support services during weekends and other out-of-hours periods should be reduced. Where possible, emergency care cases should be shifted to urgent care, length of stay should be reduced and rates of weekend and early-day discharges (when safe to do so) should be improved. It will also be necessary to "flex" services such as pharmacy, cleaning and transport to match work being undertaken in other seven-day services.

Essential Action 6. Ensuring patients are cared for in their own homes

To sustain unscheduled care, it is important to support patients to manage their long-term conditions and live (and die) well at home. Close working with integrated joint boards and other community-led improvement programmes will enhance this approach. Local and national "Know who to turn to" campaigns, supported by local redirection policies, will educate patients about the most appropriate professional to meet their needs.

Anticipatory care plans will support decisions about optimal care and ensure rapid assessment is available when an unscheduled care episode occurs. This will help to minimise admissions, reduce length of stay if admission is necessary, and ensure transitions of care occur without delay.[8]

It is vital that these Essential Actions are considered and implemented to ensure high-quality, safe and effective flow through the ED and the wider hospital. They should be carried out before ED crowding escalation steps are agreed and should align to the development of standard operating procedures.

The use of full-capacity protocol indicates the standard operating process in place is flawed and repeated use suggests a failing system. It should be considered a never-event requiring a response to untoward and unexpected circumstances.

It is essential that proactive actions are in place across the system to ensure crowding does not occur.


Email: Helen Maitland

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