- Introduction
- Flow
- Infection prevention and control
- Reduced patients in emergency departments
- Staffing
- Treatment
- Appendices
Aim
Staff will be in the right place, at the right time with the appropriate skills to care for patients and keep them safe.
Background
Staffing models need to be invested to deliver a safe and effective service for all patients.
Staffing models will depend on many things including:
- attendances
- skill sets and competencies of staff
- number of junior staff including trainees
- departmental layout
- trust layout of urgent care flow and admission processes
- acuity of workload
- case mix of patients
- additional needs such as teaching and training
- coronavirus impact:
- changes to flow
- segregation
- shielding staff.
In good emergency departments we have seen
Staffing models for the next 12 months that are supported by the trust to enhance the urgent care pathway. There needs to be an increase in staffing numbers where appropriate to incorporate new roles such as:
- redirection
- streaming
- early senior decision makers
- specialty support.
For all staff joining both a new trust and new department, there needs to be:
- a clear induction programme that must include vital elements such as:
- fit checking/testing
- risk assessments (COVID-19 or otherwise)
- support within the local environment
- wellbeing to all individuals and how to access help when needed
- regular teaching sessions
- regular appraisal
- regular communication to share information with all staff on time.
Paediatrics staffing
All departments where children attend should have:
- a paediatric emergency medicine (PEM) consultant with dedicated clinical floor time in the paediatric emergency department (PED)
- at least two children’s nurses per shift
- a play specialist.
Read the guidance for mitigating challenges with children’s nurse staffing.
Clinical and executive feedback from the workshops we held in 2021
Suggested processes and ideas for improving patient safety
Make use of recognised standards and regional benchmarking
Use recognised standards and regional benchmarking, such as the baseline emergency staffing tool (BEST-RCN) for:
- staffing
- assessing the skills mix throughout the department.
Consider new or extended roles in EDs
Consider new or extended roles in emergency departments including:
- allied health professions (AHPs)
- scribes
- housekeepers
- additional admin staff
- receptionists and admin staff
- physician's assistants (PAs)
- paramedics
- army medics
- security
- porters
- medical students.
Create or rethink use of models and job plans
Acute trusts can create or rethink existing models and job plans for non-ED consultants and workforce to:
- place appropriate value on generalists and medical on call
- ensure consultants are available to treat the increasing numbers of complex presentations. For example, those with multi-organ disease
- equate the focus on urgent and emergency care with elective care
- support specialists to provide 'in-reach' and senior specialty review to ED
- support admission avoidance.
Support staff wellbeing
Support staff by providing robust, clearly signposted ways to report and manage moral injury.
Introduce new initiatives that promote and support ED staff wellbeing.
ED nursing capacity and skill sets
A real-time overview of nursing capacity and deployment across the ED allows you to:
- safely prioritise patients, to deliver safe and timely care to the sickest patients in the ED
- retrospectively look for correlations between staffing patterns and adverse incidents
- assess and optimise the deployment of nurses and specific skill sets across the department.
Your capacity and deployment plans should meet the national standards.
Examples of good practice
Staff feedback/temperature check
Staff are the department’s most valuable commodity. Organisations can collect staff feedback on a regular and frequent basis. The responses then need to be acknowledged and responded to as appropriate and able.
Staff feedback indicates the 'heat' or stress levels of the department. Understanding this can help management make informed decisions and take action.
Good examples of live monitoring exist in other industries. This is relatively easy to put in place. For example, staff feedback could be checked, recorded and included as part of regular ED huddles.
Workshop attendees also supported introducing exit surveys for leaving staff.
Mandatory training
A high-quality training programme with good compliance levels is essential for safety-led organisations.
Safety-led trusts provide:
- mandatory inductions for all ED staff, including locums
- mandatory ongoing training that is clinically relevant
- protected time to enable mandatory training and other development needs.
Example datasets that can drive possible safety improvements
- staff sickness rates
- Staff sickness rates - and changes in those rates – can be regularly monitored and interpreted on a local and national level.
- Rates can also be assessed for correlation with staff satisfaction, recruitment and retention.
- Undertake regular reviews of establishment requirements for all staff groups
- Reviews of consultant staffing levels to make sure they follow Royal College of Emergency Medicine (RCEM) and the Royal College of Paediatrics and Child Health (RCPCH) guidance
- Consultant vacancies
- Locum use at all grades
- Nursing staffing numbers and compliance with national guidance including those for paediatric nurses
- Nursing staff vacancies and use of bank and agency staff
- Review of incident reports raising concerns about number and skill mix of staff
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.
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References
NICE: Safe Staffing for Nursing in Accident and Emergency Departments
NHS Improvement: Safe, sustainable and productive staffing in urgent and emergency care
RCEM Workforce Recommendations 2018: Consultant Staffing in Emergency Departmentsin the UK
RCEM Consultant Working and Job Planning
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.
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