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.

Next:
Appendices

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.

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