Patient Safety and Emergency Room Care in the NHS

By John Tingle

UCL A&E entrance — Pedestrian entrance to the Accident and Emergency Unit at University College Hospital as viewed from the pavement on the Euston Road. (Amanda Lewis/Thinkstock)

In the UK, emergency and urgent care patients visit the A & E (Accident and Emergency) units of local hospitals (known as ERs in the U.S.) A & E service provision is the public face of the NHS. It is seen by many as the bellwether of the national health care system and the basis on which its performance is judged.

The Health and Social Care Regulator of England, the Care Quality Commission (CQC), which maintains important patient safety and health quality reviews, has recently published a report on A & E urgent care that found that the 2017-2018 winter season saw an unprecedented demand for emergency services, continuing a year-over-year increase. The number of emergency admissions has grown by 42 percent over the last 12 years, adding pressure to the NHS.

CQC inspectors found:

“In some of our inspection reports we have highlighted how increasing pressure on emergency departments have led to patients receiving care that is wholly unsatisfactory and in some cases unacceptable. Where we have found this, we have acted to protect people and make sure that services take the necessary immediate steps to improve. “(p3).

For the report, the CQC worked with more than 70 frontline clinicians across two workshops to identify best practices, risks, pressures, and ways forward. The CQC found that as at April 2018, 4 percent of urgent and emergency care services were rated as inadequate and 46 percent were rated as “requires improvement” overall. Safety remains a key CQC concern.

Patient safety can be seen to be compromised in these broad risk areas identified in the report:

Ambulance arrivals
First clinical assessment
Deterioration
Escalation
Specialist referrals
Use of inappropriate physical spaces
Staffing
Patient outcomes (p7)

First clinical assessment, deteriorating patient

CQC inspection reports for the last three winters showed that patients in most emergency departments were not having a first clinical assessment within 15 minutes of arriving.

Escalation

The CQC found that escalation policies and procedures were generally in place but were not always followed or ineffective in coping when demand increased.

Specialist referrals

CQC Inspectors found many examples of poor working relationships with mental health speciality teams and poor processes for referring patients to medical and surgical specialities.

Use of inappropriate physical spaces

CQC inspectors found that many hospitals were using inappropriate and unsafe spaces to treat and care patients, such as corridors.

Staffing

The CQC found that nursing staff levels were a challenge and that many hospitals continued to use a high level of bank and agency staff. Often there was not enough suitably qualified, skilled, and experienced nursing staff on duty.

Recommended improvement steps

In the report the CQC state a number of recommended steps to address demand on A & E units. Helpful advice is also given on addressing capacity, capability and output. The report also includes several case studies which show good practice in action.

The report is very welcome as it provides an excellent route map for effecting positive changes in this care area and firmly addresses patient safety issues in A & E (Emergency Room) care.

John Tingle

John Tingle is a regular contributor to the Bill of Health blog. I am a Lecturer in Law, Birmingham Law School, University of Birmingham, UK; and a Visiting Professor of Law, Loyola University Chicago, School of Law. I was a Visiting Scholar at Harvard Law School in November 2018 and formerly Associate Professor at Nottingham Law School, Nottingham Trent University in the UK. I have a fortnightly magazine column in the British Journal of Nursing where I focus on patient safety and the legal aspects of nursing and medicine. I have published over 500 articles and a number of leading texts in patient safety and nursing law. My current research interests are in global patient safety, policy and practice, particularly in African health care systems. My most recent publication is: "Global Patient-Safety Law Policy and Practice," edited by John Tingle, Clayton O'Neill, and Morgan Shimwell, Routledge 2018.