4. Developing a standardised process for managing ED capacity
Crowding affects various parts of the hospital in different but interrelated ways. Locally agreed definitions of crowding must be developed and must be clear, specific and detailed about when triggers are activated.
Developing a standardised process for managing ED capacity will help to reduce variation and embed a culture of early referral and proactive capacity management, ensuring that patient flow is high-quality, safe and effective.
There should be agreed standard actions during the daytime and a clear plan in place for escalation out of hours. Senior staff in the hospital overnight should have the ability and authority to action these plans.
Thresholds for capacity stress should be agreed and defined locally. They must take into account incremental delays to moving patients from the ED or assessment areas, together with escalating markers of crowding.
Monitoring and managing every patient journey may require a tracking system. Escalation at specific points, such as first assessment, diagnostics and treatment, should be considered; escalation should be clearly defined at an early stage in the patient's journey to prevent crowding.
A standardised process should consider the following key components:
Clear and visible department management
Leadership and management of the ED and assessment areas ensures a focus on every patient, every time and monitors steps in the patient's journey to minimise delays. Some departments have used the role of flow coordinator as an alternative to robust electronic systems to good effect. Both approaches monitor patient care pathways and inform escalation processes where necessary.
A monitoring tool may need to be developed locally for each agreed journey point.
Decision to admit
Patient journeys cannot be delayed in the ED by waiting for specialist review or requests for tests that are not going to influence the decision to admit. Tests or investigations in the ED should nevertheless be prioritised to reduce delay in disposition decisions. 4 A key role of the ED is to identify patients who do not require in-patient care and to discharge them safely with appropriate follow up.
The decision to admit a patient should rest with a senior emergency medicine clinician at level ST4 (specialty training year 4) or above who has the necessary knowledge to assess risk in undifferentiated patients presenting to EDs. This is clearly dependent on staffing levels locally and may not be feasible 24 hours a day on all sites. When a senior emergency medicine clinician is available, there should be an expectation that he or she reviews all referrals for admission.
Once the decision to admit is taken, the patient should be moved to the ward when clinically appropriate without further delays for secondary review. The same should be true of patients in other direct-access receiving units (such as acute medical units) who have been reviewed by the admitting consultant and deemed appropriate for transfer (and take-over of care) to a downstream ward. This might involve the use of locally agreed, clinically relevant admission, transfer and discharge criteria to reduce variation.
Sites should ensure they have robust systems in place to monitor and manage capacity proactively on a daily basis. With improved communication of capacity and demand, early notification has been seen to be an effective early escalation step
and will alert clinical teams to capacity and demand alignment issues earlier in the day. While the focus of all early assessment should be the conversion of unscheduled to scheduled care and admission avoidance, nonetheless in a proportion of cases it will be evident from very early in the process that admission is inevitable.
The receiving ward should be notified and a predetermined process followed if it is expected from initial triage or first assessment that a patient will require admission. It is accepted that some of these referrals may later be cancelled: the proportion of such cancellations should be reviewed as part of process evaluation.
As an example, a triage nurse may refer from the ED and be presented with three responses from the admitting ward:
- a bed is available and is now allocated to your patient - transfer when ready
- a bed will be available within an hour - transfer at or after this time
- no bed is available and it is unlikely that one will be available in an hour - this issue will be escalated.
A policy to describe how this information informs the escalation process should be in place. The key element is that a standard operating procedure should monitor each patient's journey every day to review capacity, and the system should respond at an early stage of delay to prevent crowding.
A mutually agreed pathway of care should be implemented for "to be admitted" patients (including those referred by a GP). Investigations in the ED should be limited to those required for emergency management or those that would immediately influence management on the patient's arrival in an acute admission unit.
A pull policy describes a process by which specialist clinical areas try to match their capacity to a predicted demand as early in the day as possible as part of a standard operating procedure.
Understanding the expected specialty demand and therefore how much capacity is needed will allow specialties to plan and design pathways for optimal care, and at an individual ward level, would enable medical and surgical pathways to ensure the maximum number of patients are cared for by the most appropriate clinical team at the earliest opportunity in the assessment process.
Once these pathways are in place a process to support movement of patients to the appropriate specialty avoiding unnecessary waits and delays would be established. The particular specialty would identify appropriate patients and operate a pull policy from ED or acute assessment matched to their capacity and demand profile described above.
For the pull policy to be effective, individual clinical areas must ensure adequate capacity is achieved as early in the day as possible. This requires NHS Boards to ensure their local site 6EA improvement plans include work on developing Basic Building Blocks to determine demand and proactive discharge processes such as effective use of Daily Dynamic Discharge measures including; Estimated Dates of Discharge; multi-disciplinary whiteboard meetings, daily ward round and utilization of criteria led discharge to increase morning and weekend discharges, and use of discharge lounges to facilitate this process.
On occasion a pull policy may be included within an escalation approach where specialty consultants are instrumental in pulling patients from ED and /or assessment areas to specialty beds in a more timely manner.
This describes the transfer of a patient from a receiving area to a continuing care area where a patient has been identified for discharge but the bed is not currently ready or still occupied. For example, when a patient will be discharged that day but it is not appropriate to wait in the discharge lounge. In these circumstances the patient arriving on the ward will require to be managed outwith a bed space for a period of time. This would reflect serious stress in the system and would require close cooperation between senior clinical teams in the admitting and continuing care areas with careful balancing of the relative risk. Where proactive daily dynamic discharge approaches and pull policies are routinely enacted, core to daily capacity planning, the requirement for push policies to be activated will be minimised.
The requirement to use "push" policies where crowded ED and Assessment Units move patients to in-patient areas in advance of planned confirmed discharges should be seen as a sign of capacity stress. Patients 'pushed' to downstream wards from assessment units should have had a locally agreed level of work up, which is likely to include a consultant decision that the patient is ready to move. Local arrangements should be in place to determine safe and acceptable time limits, within which a bed is expected to become available.
This should however be distinguished from a "Full Capacity Protocol" where A&E or Assessment Unit patients are moved to in-patient units as "extra patients" in response to a particularly severe risk through crowding. The requirement to activate a Full Capacity Protocol should be considered a critical incident requiring a response to untoward and unexpected circumstances with a similar threshold to declaring a major incident.
It is essential that proactive actions are in place across the system to ensure crowding does not occur.
Escalation steps to eliminate crowding
NHS boards should develop their standardised processes for managing ED capacity in the context of this guidance and the 6 Essential Actions to Improving Unscheduled Care. The steps should ensure that patient flow is effective, safe and high quality, thereby proactively avoiding crowding and its negative implications for patient care.
Escalation steps must be agreed across executive, management and clinical levels to ensure agreed standard actions are in place in the event of crowding. They should cover daytime hours, with a clear plan for escalation out of hours. Senior staff in the hospital overnight should have the ability and authority to action these plans.
Based on the agreed standard operating procedure, thresholds for capacity stress and crowding should be defined locally: the agreed limits should be reached before escalation steps are activated.
The advised escalation steps take into account incremental delays to moving patients from ED or assessment areas and escalating markers of crowding. Three distinct stages must be clearly identified in the plan. The following steps should be considered the minimum standards for escalation.
1. Clinically appropriate beds are not available for a predetermined number of patients defined locally (this is likely to be 10 to 30 per cent of a, fully occupied ED/Assessment Area/trolley spaces) within two hours 4 of the senior clinician's decision that the patient is ready to move. The following actions should be considered by senior operations managers at this time:
- alert senior clinicians and managers across affected teams and convene in the ED or assessment area affected by crowding
- initiate proactive discharges across all wards and departments including check, chase, challenge to identify all additional discharges
- open additional acute staffed beds
- review non-urgent elective care such as operations, infusions or investigations, and consider deferral.
- implement a 'sit out' process as part of a pull policy where the bed is made available before the previous patient has left the hospital
2. Clinically appropriate beds are not available for a predetermined number of patients defined locally (likely to be 10 to 30 per cent of a fully occupied ED/Assessment Area/trolley spaces) within four hours of the senior clinician's decision that the patient is ready to move, or the ED is operating at more than 100 per cent capacity, or ambulances are unable to unload for more than 30 minutes due to lack of appropriate space. The senior operations manager continues with actions in Step 1. The medical director and senior management team should consider immediately:
- cancelling all non-critical surgery across all specialties to free beds for admission and boarding
- implement push policy
- diverting GP referrals or stable emergency patients waiting for beds to neighbouring hospitals.
3. If clinically appropriate beds are not available for a predetermined number of patients defined locally (likely to be 10 to 30 per cent of fully occupied ED/Assessment Area/trolley spaces) within eight hours of the decision by senior clinicians that a patient is ready to move, or the ED is operating at more than 100 per cent capacity (that is, using non-clinical space), the following actions are required:
- immediate notification to the chief executive
- emergency incident group convened (to include senior clinicians from acute and in-patient specialties, emergency medicine and social work).
The emergency incident group should consider the following responses to ensure the rapid protection of patients from further harm:
- activation of a locally agreed full-capacity protocol(a patient being transferred to a ward or unit without a bed being available) to transfer safely acute workload to in-patient areas to avoid critical overload of the ED or assessment areas
- closure of the ED to new patients and diversion to neighbouring hospitals where possible (including discussion with neighbouring boards and the Scottish Ambulance Service).
Note The group does not endorse these approaches as part of normal management. The implementation of either of the last two actions detailed in bullet 3 above should be considered an exceptional response to untoward and unexpected circumstances and must be authorised by the Chief Executive/Medical Director or formal deputy at the request of the triumvirate leadership team. A Level 5 serious incident review will be necessary. Scottish Government Performance Management must be informed and the board and government press offices notified.
It is essential that all steps are taken to develop a standard operating procedure that monitors each patient to ensure crowding is avoided. All steps should be taken to understand decision-to-admit processes, capacity planning and early notification requirements.
Use of escalation step 3 indicates the standard operating process is flawed and repeated use suggests a failing system.
Email: Alistair Pollock, Alistair.Pollock@Gov.Scot