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When you need hospital care in an emergency you need the reassurance of knowing the care you receive will be prompt, appropriate to your needs and of high quality.

Unfortunately, press reports over recent years suggest the quality of care can vary significantly between different regions, with some A&E departments struggling to cope under the pressure. Reports of patients left untreated on trollies in corridors for hours on end have become worryingly commonplace.

Now the Chief Inspector of Hospitals, Professor Ted Baker, has written to all of England’s NHS Trusts setting out examples of best practice from the most successful emergency care departments. These beacon examples come from a recent event staged by the Care Quality Commission and attended by senior clinical and nursing staff from 16 NHS Trusts rated as ‘good’ or ‘outstanding’ for their urgent and emergency care services.

It is hoped that by sharing these examples of where things are working well, all areas can benefit from the positive lessons learned and use them to improve their own standards. Prof. Baker’s letter identifies several key areas where patients could be at risk from poor practice and how these pitfalls can be avoided. His key themes are:

  • Ambulance arrivals: The clock should start ticking on a patient’s care as soon as they are physically on a hospital site, not when they are booked into the emergency care department. Keeping the patient waiting in an ambulance to delay the clock’s start is not acceptable and creates a two-tier system with patients who arrive independently and are booked in on arrival.
  • First clinical assessment: An initial assessment of all patients attending A&E should be undertaken without delay to assess the seriousness of each patient’s condition. This ‘triage’ approach gives the whole department confidence in prioritising care according to need and urgency.
  • Use of inappropriate physical spaces: Patients should receive safe and effective care in an environment which protects their privacy and dignity. Corridors and other passageways or public spaces should only be used in extreme cases and it should never become routine.
  • Specialist referrals: Once a patient has been referred to a specialist team they should be seen without undue delay and not referred back to the emergency department. Waiting for long periods in the emergency department after referral is not acceptable.
  • Escalation: There should be a consistent and effective ‘escalation process’ in place which will enable the emergency department to respond safely to unexpected surges in demand. It is the responsibility of the whole Trust, not just its emergency department, to deal with these surges.
  • Deteriorating patients: An effective system must be in place to identify any patient whose condition is deteriorating while in the department, and to respond appropriately.
  • Patient outcomes: Departments should routinely collect and monitor information about the outcomes for patients who pass through the department, and use the information to drive quality improvement. Knowing which patients fare best can help to identify which treatments are most effective.

Prof. Baker’s letter to the NHS Trusts adds: “For many acute Trusts, their greatest risks to patient safety are likely to be in their emergency departments. These risks will be increased when the department is working under pressure.

“It is essential that Trust boards are aware of the safety of their emergency departments. It is important that boards recognise that solutions related to safety incidents lie in ensuring the whole hospital has an effective response to pressures within emergency departments.”

The Care Quality Commission is responsible routinely inspecting and evaluating NHS Trusts and the standards of care they provide. Prof. Baker advises that the “key elements of safety” outlined in his letter will form the focus of inspections on Trusts’ emergency departments.

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