Patient FIRST: Flow

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

Flow in and out of the emergency department is vital for the safe and effective care of patients.

Good flow prevents crowding within the department. It reduces the risk of harm to patients and prevents poor outcomes.

Background

Trusts with capacity issues are more likely to see crowding in their emergency departments as a result of poor flow. As crowding is a symptom of flow and capacity issues, it requires change across the whole organisation, with high executive engagement. Taking this approach at a system-wide level has a much greater and sustainable impact on all trusts within the region.

Maintaining good and efficient flow requires a trust-wide culture of safe and efficient patient care. It needs engagement from the trust board and all teams throughout the hospital. From our inspection activity, we know that delivering high quality care needs enough capacity to enable safe and timely movement of patients.

In good trusts we have seen

Managing flow into the emergency department

There are times when patients with non-time critical presentations attend the emergency department. But the emergency department cannot add value to their care. Developing urgent and emergency care pathways avoids this. These pathways include:

  • direct access to community services - for example district nurses, virtual ward, urgent community response teams and acute respiratory hubs
  • direct access to primary care - including GPs
  • direct specialty access for GPs - through telephone, email or ‘hot’ clinic appointments
  • direct access pathways for ambulance services and GPs into same day emergency care
  • acute hospital outreach to care homes - avoids unnecessary transfer of elderly and vulnerable patients. See Reduced number of patients to the emergency department section for more detail
  • frailty in-reach into emergency departments to prevent admission and care back into community services.
Specific examples of good practice
  1. Same day appointments are available in primary care. Patients can use these or clinical staff can redirect patients into primary care.
  2. Falls and re-enablement teams work across acute trust and community services. Teams manage patients at home and avoid hospital attendance where possible.
  3. Frailty teams in in-reach services to all ED patients over 75 or with a raised Rockwood score.
  4. Availability of resource to provide virtual ward services to reduce likelihood of hospital admission and early discharge from ward areas reducing LOS.
  5. Effective discharge lounge facilities with social care support to enable release of beds early in the day.

Managing flow within the emergency department

Patients could self-present to the emergency department or be referred. They need to see the right person at the right time. Robust clinical assessment and redirection pathways make sure this happens. Trained emergency department front door staff use agreed local protocols to access alternative care pathways. These alternatives could be within the hospital, trust or external services:

  • external to the trust:
    • timely primary care appointments
    • community services
    • dentistry
    • pharmacy
    • other supporting services such eye services.
  • within the trust:
    • same day emergency care services 7 days a week for a minimum of 12 hours a day
    • specialty assessment units, for example medical and surgical assessment unit, paediatric assessment unit, early pregnancy unit, obstetric service, labour ward and delivery suites, ophthalmology assessment service, sexual health services.
  • within the department:
    • co-location and good flow between the emergency department and urgent care centre
    • patients see their existing specialist teams - if they are under active specialty care and have a problem relating to that specialty. This might be a post-operative problem, or complications of their chronic disease or its treatment
    • assess patients with no immediate need for intervention and stream them to the appropriate specialty
    • patients presenting with mental health problems, but no acute medical needs - see them in a suitable assessment area staffed by mental health professionals
    • patients presenting with non-critical musculoskeletal problems - see them in a designated area staffed by advanced physiotherapist or nurse practitioners.

Early clinical assessment of a patient by a senior clinician ensured rapid senior decision making to facilitate appropriate investigation, referral or discharge and reduced the risk of nosocomial infection.

Specific examples of good practice
  1. Co-located access to a GP or urgent treatment centre stream. The model and flow between the two services was paramount. Joint governance permitted a better buy-in for delivering the same aims.
  2. Establishing a separate mental health ambulatory unit. Patients presenting to the emergency department, and then referred to the mental health liaison team, all received a rapid initial contact. If the patient was medically suitable, they transferred to a separate area within the psychiatric unit. This was on the same site but in a different building. The mental health liaison team approved the transfer. Thus they avoided very disruptive or acutely unwell patients being transferred there. This provided an area where the lower risk mental health patients were able to wait. The area was a less crowded and calmer environment. It was staffed by mental health support workers. Patients who needed psychiatric admission did not wait long within the emergency department. The teams involved felt this improving flow, patient experience and patient safety. Patients were more closely observed. And they were less likely to abscond before their full assessment.
  3. Consultant care of the elderly in-reach to the emergency department. Early care of the elderly has been trialled in many hospitals. As has multidisciplinary team input to urgent care services for people who are frail. These services provide support for both early discharge and admission avoidance. They aim to keep frail patients out of hospital. And they can link into ongoing care and social needs such as homecare visits. For example, if a patient can go home but needs some further follow up or monitoring, they can visit them at home in the next few days.

Managing flow within and out of the hospital

Trusts with clear policies and strategies within the hospital(s) maintain flow. Those with early and dynamic discharge planning were more successful in preventing crowding. As were those that developed specialty ambulatory pathways. They audit and analyse delays in moving patients through pathways of care. This helps them to identify and deliver improvements.

Actions that some trusts have taken to improve flow include:

  • patients are moved from the emergency department as soon as they were ready to go - ‘Ready to Admit’ or ‘Ready to Progress’ concept
  • support from senior teams including medical director and chief operating officer is paramount
  • patients do not wait in the emergency department for test results that were not critical to their emergency care
  • specialty medical and nursing services do not physically review patients in the emergency department - helping to improve flow
  • services that support the emergency department such as same day emergency care are consistently available - as required by the emergency department
  • different clinical specialities came together to make sure that:
    • ward flow is optimal
    • patients’ length of stay within hospital are as short, of good quality, and as effective as possible
    • issues for the inpatient teams are resolved in a timely fashion.
      For example early consultant involvement and board rounds, regular review of length of stay, and review of patients in hospital more than seven days
  • admission avoidance schemes - such as early consultant care of the elderly input, frailty service, falls services, specialty ‘virtual wards’
  • ward discharge teams (early and weekend discharges)
  • emergency department observational unit beds are not included within the bed management pool. They are under the control of the emergency department team. Specialty patients are never admitted to these beds under any circumstances. This would reduce internal flow
  • good support services are imperative including:
    • pharmacy
    • portering
    • rapid turnaround times of laboratory tests
    • immediate access to the full range of radiological investigations required, for example CT, MRI with a report available within one hour
    • social services
    • psychiatric services
    • community and other support services, for example district nursing.

Actions to maintain flow for non-admitted patients include:

  • availability of transport home
  • ‘take home, tuck up’ service for elderly or vulnerable patients to prevent unnecessary admission
  • rapid COVID-19 tests for patients discharged back to care homes where required.
Specific examples of good practice
  1. Flow escalation. The entire trust needs to be aware of the flow issues in a timely manner to resolve them. Many small ‘things’ might be needed to avoid more significant impacts in flow. A flow escalation manager can be an individual based in the emergency department. They tackle any issues relating to delays by other specialties or patient transport, chasing beds and making various phone calls. This person needs to be empowered to escalate delays to specialty consultants and senior executives. So issues are highlighted and resolved early. This allows medical and nursing staff to use their clinical time more efficiently to focus on patient care and reduce decision fatigue.
  2. Bed management meetings should be held at least twice a day. A clear, recognised scoring framework should be used. An example of this is Operating Pressures Escalation Levels (OPEL) framework. The relevant action cards should be completed and followed to mitigate and relieve pressures across the whole system.
  3. Clear escalation procedures for supporting initial assessment of infants, children and young people. These patients are assessed within 15 minutes of arrival when wait times increase. Rapid assessment is initiated and physiological observations maintain safety at such times.
  4. Adopting standard operating procedures that allow for nurse-led discharge for children and young people in defined circumstances. See examples of supporting documents for nurse-led discharge, such as for minor head injuries

Example data sets that can drive possible safety improvements

The suggested data sets below evolved from discussions at the 2021 workshops and may be useful in assessing patient safety.

  • Ambulance offload time
    • Ambulance offload time is an important measure for safety across the Urgent and Emergency Care (UEC) system. This can be considered both locally and across the integrated care system (ICS).
    • Reducing offload times at hospitals is critical. It enables paramedics and ambulance crews to spend more of their time responding to 999 callouts.
  • Time to initial assessment / time to first clinician
    • Time to initial assessment is time elapsed between patient arrival in the ED and the initial assessment.
    • Time to clinician measures how quickly the clinician's full assessment of the patient occurs.
  • Clinically ready to proceed (CRTP)
    • Research shows there is a risk of harm to patients if they are not transferred to inpatient areas when needed, as quickly as possible. There is a recognised risk when patients are left waiting on trolleys for long periods.
    • The ability to view a live feed of patients’ CRTP status allows clinicians, co-ordinators and managers to plan ahead. They can then escalate when, and where, necessary to optimise flow.
  • Data on acuity and dependency within ED
    • Keeping track of specific data sets that measure acuity and dependency within the ED gives clinicians an overview of acuity levels in their department. This allows the urgency and escalation necessary for downstream care.
  • Time to definitive treatment
  • Total time in the emergency department
  • Use of same day emergency care
  • Number of patients who are in the emergency department more than 12 hours after arrival
  • Number of patients cared for in a corridor and the number of hours spent there
  • Hospital bed capacity

Next:
Infection prevention and control

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)

Listen

Podcast: Emergency departments responding to COVID-19 - Flow

References

Position Statement: Winter pressures in children’s emergency care settings (November 2019)

RCEM: Tackling Emergency Department Crowding

AMRC Clinical Guidance: Onward Referral

RCPCH Facing the Future: Standards for children in emergency care settings June 2018

Under pressure: safely managing increased demand in emergency departments

Safety alerts

RCEM Safety Alert: Early to Bed

RCEM Safety Newsflash: Time Critical Medicines

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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