COVID-19 Insight 9: The impact of the pandemic on urgent and emergency services

Introduction

In the last edition of this Insight series, we looked at the evidence so far about how urgent and emergency care services have been affected by the pandemic during this winter, and discussed what action CQC has been taking to provide constructive support.

Part of this support was working with frontline clinicians from emergency departments to publish the Patient FIRST framework in October 2020, as a tool to help support those working in NHS trusts and the wider health and care system to understand learning from the pandemic and share good practice.

The framework contains a number of practical examples of actions that can be taken at a departmental, trust and wider system level to maximise capacity, maintain effective patient flow, and keep staff and patients safe.

During October and early November 2020 we applied our ‘transitional regulatory approach’, through which our inspectors held discussions with executive directors of trusts with major emergency departments around our key questions of safe, responsive and well-led.

Informed by the transitional regulatory approach process, the monitoring of situation reports data, and intelligence from local inspections teams, we have identified around 13 emergency departments for inspection from winter last year.

This article looks at the first five of those inspections, which took place between 30 November and 21 December 2020, seeking to identify the key factors affecting services’ ability to provide a good standard of care, as well the challenges they faced. The full inspection reports can be found on our website:

• Medway NHS Trust – Medway Maritime Hospital
• Norfolk and Norwich NHS Trust – Norfolk and Norwich University Hospital
• North West Anglia NHS Foundation Trust – Peterborough Hospital
• Pennine Hospitals NHS Trust – Oldham Hospital
• Wye Valley NHS Trust – Hereford County Hospital

The inspection reports emphasise the extremely challenging circumstances that providers have faced during the pandemic. This, combined with the fact that all of the inspections were based on risks, mean it is not surprising that inspectors identified concerns with waiting times, delays and other issues.

While the detail varied across inspections, the key factors identified as affecting services’ ability to provide a good standard of care in emergency departments were:

• Environment
• Onward capacity
• Delayed transfers of care
• Staffing levels and staff absence
• Leadership and governance
• Systems to mitigate risk.

Environment

All of the hospitals were undergoing, or had recently undergone, physical changes to the urgent and emergency care departments, including the children’s emergency department. This generally meant a change in the use of spaces to allow for the triage and streaming of patients down COVID and non-COVID pathways. These changes were constantly being reviewed to meet the changing number of patients attending with COVID.

There were examples of this working well, but for others it was causing confusion, and issues with crowding and the ability to social distance. This had an impact on flow and, in turn, delays.

In one department a ‘warm pathway’, designed for people with possible symptoms but no diagnosis, had set up rapid testing. However, as only three tests could be completed per hour, and the average wait for a result being four hours, this was causing delays and risk of exposure to COVID-19.

Two of the hospitals were struggling with the triage and assessment of patients. Inspectors found the process was not well-embedded and witnessed patients waiting too long for triage and ineffective systems to identify if patients were in pain or deteriorating. Assessments were not always done while people waited to be admitted, treated or discharged, which meant they were at increased risk of harm, for example pressure damage to patients’ skin.

Most of the departments were not queuing or cohorting patients in corridors to avoid overcrowding and maintain social distancing during the pandemic. However, this had a knock-on effect on ambulances. Patients were being held in ambulances, either awaiting treatment or until a place on a ward could be found.

The implementation of rapid assessment and treatment (RAT) systems was helping to address problems in some departments. However, progress was slow in one case, with just under half of patients not meeting the hospital’s 15-minute handover target in December 2020. At another hospital there were long ambulance handover delays where medical and nursing staff were not able to ensure patients waiting in the ambulances always received timely clinical intervention. The delays also had an impact on ambulance crews’ wellbeing and their ability to respond to other patients in the community.

At one hospital, inspectors did witness queuing in corridors. They raised concerns, as this did not allow for adequate social distancing and, at times, patients’ privacy and dignity was compromised. In another, the children’s emergency department did not allow for a one-way system and the corridors were too narrow to allow for adequate social distancing.

In some departments, reconfigurations had caused problems for mental health services. For example, a safe and private room for patients presenting with mental health needs was now being used as an area to don and doff personal protective equipment, and the identified replacement was not suitable. A similar situation was found at another department where a repurposed ‘plaster room’ was not fit for purpose as a mental health ‘privacy room’.

There were positive examples where trusts had put in place systems or mitigations to improve the impact on patients, for example:

"We observed improvements in the physical environment where patients were rapidly assessed and treated (RAT). The new RAT process was introduced in August 2020, was now consultant-led between the hours of 10.00 to 20.00, with the ED consultant cover continuing for 16 hours out of every 24.

"There were clear clinical care pathways and protocols in place, with pre-agreed parameters for patients being seen in designated areas.

"Due to the small size of the department, while some areas were permanently ‘green’ or ‘blue’, others changed according to the proportion of patients categorised as ‘green’ or ‘blue’ as it altered throughout the day. This was done against a written standard operating procedure. We found this system effective and intuitive."

The trusts in these examples were seen to have good processes for triage and assessment to ensure patients were seen in an appropriate order. We also saw ongoing monitoring to ensure that any deterioration in patients’ conditions, while they were waiting, was identified and responded to swiftly. One member of staff described their pride in the new triage system, which had created more space and improved patient flow.

Onward capacity

At all the hospitals inspected, inspectors found that the wider capacity of the hospital was a factor on delays in the emergency department.

Hospitals wards were operating routinely at capacity, often having been reconfigured themselves to allow for the social distancing and streaming requirements of the pandemic, and this was affecting patient flow.

"Staff told us there had been significant delays in ambulance turnaround times, as patients were being held on ambulances due to capacity issues within the emergency department and the wider hospital."

There was one example of a patient who had spent 19 hours in the emergency department as they waited for a side room to become available on a ward. At another, inspectors saw three people waiting for an inpatient bed. They were told by nursing staff that there were lengthy delays for patients waiting for an inpatient admission, due to limited bed flow. They said this was across the trust as a result of limited daily discharges. The increased number of patients in departments waiting for admission meant that other patients could wait longer to be seen and treated because of the impact on space and staff availability.

Delayed transfers of care

Incidents of delayed transfers of care were part of the flow problems in hospitals. The factors explicitly referenced in these inspection reports that prevented patients moving on were:

• waiting for patient transport
• delays in discharging patients into the community
• delays in COVID-19 testing to enable discharge to an external care provider.

Transfers from A&E to external mental health providers was an issue for one department. The waiting time for a crisis bed and for travel arrangements to be made could take between two hours and three days.

These issues tended to be problems outside of the emergency department, but caused flow problems that impacted on their performance.

Staffing levels and staff absence

Some of the hospitals we inspected were not able to meet the intended staffing levels due to a shortage of staff. At some, this shortage was attributed to recruitment and retention issues and staffing levels were maintained through using locum doctors and agency staff.

Other hospitals were experiencing increased levels of sickness and absence linked to the pandemic. Incidents of self-isolation, shielding requirements, positive COVID cases and staff absence due to stress and anxiety directly impacted on some hospitals’ ability to cover all the shifts in the emergency department.

"Staff told us there were frequent closures of assessment areas, often due to staff shortages, which contributed to increased delays in the emergency department. Managers told us the surgical assessment unit was frequently blocked and at the time of the inspection, the clinical decision unit was taking no patients due to a lack of staff."

The staffing challenges in the emergency department were causing delays. Inspectors were told of an example where staff shortages at night placed additional pressure on incoming staff, with higher numbers of patients in the morning and delayed discharges. Other issues were the ability of staff to access senior staff for support, and the capacity to progress initiatives designed to reduce delays, such as pathway development. One hospital had a mitigation plan where it reduced or cancelled medical training to increase staff availability and provide clinical cover.

Other impacts were on staff morale, with some staff describing how it affected their ability to provide well-timed care, as well as feeling unsupported by other departments and the executive team.

Leadership and governance

All the themes identified so far link back to the leadership and governance at the services, the oversight they had, and what actions and mitigations they were taking to manage the risk.

Some hospitals did have oversight and risks were well managed.

"We reviewed the emergency department (ED) risk register and found this was up to date and reflected the existing risks within the ED. These included patients waiting for more than 12 hours on trolleys, overcrowding in the ED, offloading times for ambulances, managing social distancing, and maintaining safe staffing levels. The trust had action plans and mitigation in place, for example, social distancing guidance, ED risk assessments and dedicated risk and safety escalation plans to manage capacity and flow."

However, at other hospitals there was no clear governance structure in place and risks were not effectively managed.

"Managers were able to describe the three biggest risks to the department. However, the team did not include recurring delayed handovers of patients from ambulance crews as one of their biggest risks. Although they were aware of the issue, they did not appear to take ownership of the risk or have a system to mitigate it."

In practice this meant inspectors witnessed site meetings that didn’t result in any actions for patients who had been in the department for 12 hours, illustrating clearly how poor oversight and governance contributed to the delays.

Another hospital had defined the risks in the emergency department. There was a governance route and documented evidence of root cause analysis, lessons learned and action plans; however actions then remained outstanding. Similar situations were found at other hospitals where the actions taken to try and address known risks and issues were not always effective.

Findings were polarised on the standard of leadership and culture across the services. In some services leaders were visible and approachable and staff spoke positively and with pride about working in the department. At others, staff felt unsupported by the executive team and low morale was a problem.

Systems to mitigate risk

Most of the hospitals had appropriate systems and new initiatives in place to try and address the challenges in their emergency departments. Inspectors were told of regular on-site meetings and designated posts in the department to address and anticipate demand. An example of this working in practice is described below.

"Appropriately senior staff were present, and the meeting was organised and well chaired. At the time of our inspection, the department and the hospital were experiencing stress from the number of patients attending. The meeting noted that the emergency department’s majors area was full, and that the department was ‘just coping’. Because it was expected that the department would reach capacity later in the day, staff were reminded of the standard operating procedure to enable patients to be cared for in the corridor or waiting ambulances. The planned staffing level for the nightshift was in place, but because of the expected demand the status was flagged as ‘amber’ and two additional members of nursing staff were requested."

There was work to develop pathways to identify clear routes for patients, but also to divert patients from A&E to more appropriate or specialised treatment.

"There were a variety of pathways to enable patient flow, including same day emergency care for non-frail acute medicine, surgical assessment unit, gynaecology assessment unit, and a primary care service, depending on the need to reduce admissions and support earlier discharges."

Much of this, however, was still in development. Some examples, such as the ‘navigation project’, are detailed below.

Some had digital systems to track patients through hospital, which helped with patient flow. There were standard operating procedures to address known issues. Examples of these were also seen in action and illustrated the pressures departments were facing.

"There were standard operating procedures in place to allow patients to be cared for in ambulances or, in extremis, in the corridor should the emergency department capacity be exceeded. Observed in practice on the day, there was a situation that meant patients were unable to be sent to a ward as planned because of an emergency that was taking place on the ward."

Some of the hospitals were demonstrating good partnership working with ambulance trusts. Emergency department staff worked with hospital ambulance liaison officers (HALO) to support patient flow. Ambulance crews could pre-alert departments to the arrival of certain conditions and be greeted by HALO to divert patients for speedy treatment. They attended hospital meetings to support good communication and could oversee patients in corridors during busy times so ambulances could be released.

However, inspectors often found staffing pressures and increasing demand had an impact on the effectiveness of many of these systems.

"The leaders described the initiatives the service was implementing internally, such as the new nurse co-ordinator role in the department and in-reach from medical consultants and therapy teams. Similarly, they described initiatives with external partners to reduce demand on the service, including a range of community and primary treatment pathways to deflect patients to more appropriate care services, and to improve flow within the hospital and the department. However, we did not see these reflected in the service’s key performance figures which, due to increasing demand on the service, were continuing to deteriorate."

"There were clear and effective arrangements for transfer to other services. The service worked with others in the wider system and local organisations to plan care. The trust was participating in a national ‘Navigation Project’ to reduce congestion in the ED waiting room. The trust told us this enabled them to appropriately redirect 20-30% of walk-in attendances to alternative appropriate care facilities, not just internally within the trust but also to other services located in the community, for example the city centre care or the patients’ own general practitioner (GP).

"As the COVID pandemic progressed and staff sickness increased, the ability to cover the ED navigation process reduced as direct nursing care was prioritised to ensure safety in the department."

Inspectors also saw initiatives that were yet to be fully embedded or ‘currently under-utilised’, which meant any impact on performance was yet to be seen.