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Emergency doctors say A&E performance ‘deteriorating’

Report reveals patients cannot be moved from A&E due to bed shortages

Mark Gould

Monday, 16 February 2015

A new report by the Royal College of Emergency Medicine reveals that this winter has seen a big rise in breaches of Accident and Emergency four hour waiting time targets. In its report Exit Block in Emergency Departments – 6 month review, the college reports in big rise in a phenomena it terms "Exit Block" where patients cannot be moved from A&E because of a shortage of hospital beds.

The new report brings together the latest research on crowding and exit block in emergency departments, including national statistics on the impact of exit block, alongside personal accounts from A&E consultants of the impact of crowding and exit block in their departments.

The report reveals that, this winter, performance against the target that 95% of patients are seen in A&E within four hours has deteriorated across all four nations of the UK. The college says this means that exit block has worsened.

NHS England has reported that in the first three quarters of 2014-15 there have been more four hour target breaches, than in the totality of 2013-2014. This equates to 189,863 individual breaches, an increase of 13%. It also reports that the number of breaches of the 12 hour target is similarly worse for the first three quarters of 2014-15.

The college says exit block:

  • increases patient mortality - the magnitude of the effect is about 13 deaths a year per department seeing 50,000 patients
  • increases the length of stay of admitted patients - self-perpetuating the problem
  • delays time critical interventions - with less frequent and less adequate pain relief, and delayed antibiotic administration
  • is associated with increased risk of adverse events
  • decreases departmental function – ‘under triage’, inferior care in terms of standard performance measures and delays to departures
  • decreases patient satisfaction
  • increases staff stress and burnout
  • increases the number of patients whose operations are cancelled - wasting surgical capacity

The President of the Royal College of Emergency Medicine, Dr Cliff Mann, said: “Exit block remains a serious problem and is continuing to impact severely on patient safety. We know that where exit block occurs, mortality rates increase, operations are delayed, and overworked staff in A&E departments experience stress and burnout. We’re calling on hospital chiefs across the country to implement our recommendations for tackling this pernicious problem.”

And in the light of the recent announcement by Health Secretary Jeremy Hunt to reduce the number of avoidable deaths in the NHS, the college says that tackling exit block must be part of this initiative as it accounts for hundreds of deaths per year. The college has made eight specific recommendations to NHS acute trusts to assist them in dealing with crowding and exit block in emergency departments.

  1. Emergency Department capacity should be capable of meeting demand.
  2. Non-Emergency Department staff should not "gatekeep" access to the Emergency Department.
  3. A patient who attends an Emergency Department is entitled to an assessment by a clinician.
  4. Emergency Departments should have systems that can monitor the degree and impact of crowding.
  5. Streaming patients does not help with Emergency Department crowding if the cause of crowding is inadequate hospital capacity.
  6. Investigations should be ‘front loaded’ to reduce delay to disposition decisions.
  7. Senior doctors of all specialities should be involved with rapid assessment and treatment.
  8. Hospitals with Emergency Departments should have a hospital wide escalation policy for when the Emergency Department becomes crowded with locally agreed triggers.

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