Patient FIRST: Treatment in the emergency department

Page last updated: 8 September 2023
Categories
Organisations we regulate
  1. Introduction
  2. Flow
  3. Infection prevention and control
  4. Reduced patients in emergency departments
  5. Staffing
  6. Treatment
  7. Appendices

Aim

Clinical care and treatment will be delivered on time - aligned with best practice. Safety is never compromised.

Background

Emergency departments need to be able to focus on the critically ill and the injured. And they need to provide care and treatment in line with national guidance and evidence base.

In good emergency departments we have seen

  • awareness and recognition of life-threatening conditions with the use of national alerts to educate all staff groups
  • use of NEWS
  • use of checklists
  • robust and effective initial clinical assessment by senior decision makers
  • effective handover processes
  • efficiencies within processes, for example single clerking
  • improved IT solutions, for example for observations, medical records
  • good practice units apply early intervention for patients who need timely investigations. For example:
    • ECG for patients presenting with chest pain - performed and reviewed by clinician within 30 minutes of arrival
    • Sepsis 6 - delivered in first hour
    • CT for possible stroke - performed within an hour
    • hip X-ray for patients with fracture neck of femur (NOF) - performed in first hour
  • effective identification and management of the deteriorating patient
  • effective delivery of time critical medication - including new prescriptions (antibiotics) and medication that the patient is already taking - for example medication for Parkinson’s disease, epilepsy, diabetes
  • hospital-led responses and ownership of the urgent care pathway to ensure treatment is provided in the most appropriate setting
  • an active and responsive local governance system
  • use of point of care (POC) for time critical bloods - for example gases, full blood count (FBC), electrolytes, lactate.
Specific examples of good practice
  1. An all emergency department staff WhatsApp group for teaching, training and regular updates. All staff have access to the group to receive information. But only a few staff can post information - limiting less important information.
  2. Positive feedback. Make sure all staff receive positive feedback - as a team and as individuals for portfolios.
  3. A full, locally led and delivered governance process. It feeds into the trust wide governance structure that all senior staff are aware of. This should include:
    1. an urgent care risk register
    2. incident reporting and trends
    3. serious Incidents – reports and learnings
    4. mortality data
    5. patient experience to include complaints and compliments
    6. safety alerts
    7. clinical audit programme.
  4. Use of urgent care standard operating procedures. Linked within the governance system to sign them off and review them when updates are needed.
  5. Active use of National Safety Standards for Invasive Procedures (NatSSIPs 2).
  6. An adult mental health triage tool. This helps risk stratify a person who presents with a mental health crisis. It includes recording of 15-minute observations - reducing the chance of harm to themselves and the risk of absconding.
  7. ECGs are only checked and signed off by ST3 or above. So the ECG is interpreted correctly and timely management starts if needed.
  8. Immediate review and sign off of POC blood results so that timely management can begin.
  9. Senior clinician review of patients with high or increasing NEWS.
  10. Early senior review of infants, children and young people presenting with red flags for sepsis. Or for a child with complex needs or child protection concerns.

Example data sets that can drive possible safety improvements

  • time to diagnostics
    • Using national targets for processing laboratory diagnostics can help you benchmark performance.
    • Trusts with mature IT systems could create reports that display bottlenecks in real-time. This will identify potential issues and help you introduce changes that improve your processes.
    • Escalation processes need to be in place with a responsive outcome.
    • Mitigation procedures and resilience need to also be considered into any plan of action. For example, efficient use of POCT can mitigate against delays.
  • time to antibiotics for sepsis
    • This measure gauges the speed of diagnosis, senior review and treatment for sepsis. An important emergency presentation.
    • Combining this data with patient outcomes could help refine future use of antibiotics. It would also help identify areas of education needed at local and national level.
  • time to ECG (electrocardiogram) and sign off for chest pain
    • Emergency departments across the country are seeing increased patient numbers. Despite this challenge, quick access to ECGs for patients with chest pain must continue.
    • Delays in ECG testing can impact the speed of diagnosis for myocardial infarction. Monitoring this is an important part of ensuring patient safety.
  • frailty/dependency score in ED
    • Workshop attendees supported the collection of frailty and dependency data from undifferentiated patients. In the short term, this enables trusts to assess the reach required by frailty teams. It also helps them plan for the longer term. For example, planning services to incorporate within EDs.
    • This data set is essential for planning and designing in the future. Ensuring services are effective and that EDs are safe, dementia-friendly environments.
  • medication errors
    • It is important to promote a culture of reporting medication errors and near misses in an accurate and timely way.
    • Reports can note circumstances such as when, where and why the incident occurred. This will enable review of the conditions in the ED at the time that may promote errors occurring. Such things can be reviewed within governance processes and ensure that such processes reflect the issues occurring. For example, reflective within the risk register.
    • This data can also be used to inform learning and action plans, or as a benchmark to monitor future performance.
  • left without being seen (LWBS)
    • When patients wait long times to see a clinician, some choose to leave without being seen (LWBS). Whereas some may seek help at another place or time, some will inevitably come to harm.
    • For this reason, you can monitor this by tracking:
      • number of patients who LWBS
      • percentage of total patients who LWBS
    • These are considered good quasi-measures of potential risk to patient safety.
    • More mature systems will be able to trace and flag patients, particularly children, who fall into this category. For example, contacting those who received diagnostic tests or informing their GP.
    • They can also use data to identify patterns and predict future spikes in ED attendances. This data can also be viewed alongside staffing levels to improve future staff provision. Getting your staffing levels right will directly improve patient safety.
  • Time to definitive treatment
  • Length of wait for specialty review
  • Observations and National Early Warning Score (NEWS2) completed at correct interval for patient’s condition
  • Senior sign off for RCEM recommended clinical presentations
  • Local review of processes:
    • local audits such as ECG sign off
    • sepsis audits
    • RCEM audits.
  • Review of incidents relating to treatments

Publications and guidance released since the 2020 launch of Patient FIRST

NHSE: UEC recovery 10 point action plan (PDF)

NHS: National framework for healthcare professional ambulance responses (PDF)

RCEM & College of Paramedics joint statement: ambulance handover delays (PDF)

National infection prevention and control manual (NIPCM) for England

RCEM CARES

NHS: Getting it Right First Time (GIRFT)

Next:
Appendices

Version history

Updated September 2023

We updated references to infection control procedures that have changed since the height of the COVID-19 pandemic. We also updated other minor references to the pandemic.

Updated October 2021

We held two workshops in 2021 for emergency clinicians and NHS executives. We added suggestions and good practice examples from those events. These updates refer more specifically to the pandemic.

Read more about the workshops we held

Download and print

Patient FIRST (September 2023) (pdf, 338.19kB, English)

References

Facing the Future: Standards for children in emergency care settings (PDF)

RCEM Position Statement: Sepsis and the Emergency Department (November 2019)

RCEM Position Statement: Cauda Equina Syndrome (25 February 2020)

RCEM Position Statement: Clinical Responsibility for Patients within the Emergency Department (29 November 2016)

RCEM Guidance: The Patient who absconds

RCEM: Invasive procedure checklist for EDs

Imperial College Healthcare: The ABC of Handover

NHS England: National Safety Standards for Invasive Procedures (NatSSIPs)

Sharing best practice from clinical leaders in emergency departments

For paediatrics

The RCPCH Report ‘Reimagining the future of paediatric care post-COVID-19’

The care environment

RCPCH: Facing the Future - standards for children and young people in emergency care settings

RCPCH: Winter pressures in children’s emergency care settings - position statement

“Supersuits” by Katie Chappell

Dani Hall. The smile behind the mask, Don't Forget the Bubbles, 2020

Patient flow

http://bit.ly/proformashare

RCPCH: Winter pressures case studies

Safeguarding

RCPCH: COVID-19 - guiding principles for safeguarding partnerships during the pandemic

The Facing the Future standards

Emergency care this winter

RCPCH &Us is working with young people to reflect on their experiences of COVID-19 and the lockdown

RCPCH wellbeing hub - a collection of useful wellbeing resources

RCPCH QI Central: example of a quality improvement initiative during COVID-19

Safety alerts

RCEM Safety Flash: Buddy System

RCEM Safety Alert: Missed aortic dissection

Improvement toolkit

Produced by front line clinicians in response to CQC’s Patient FIRST, this toolkit suggests a framework that NHS trusts can use to monitor and assess their progress in applying good practice principles.

Emergency department good practice improvement toolkit (xlsx, 2.93MB, English)

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