Patient FIRST: Reduced patients in emergency departments

1. Introduction
2. Flow
3. Infection prevention and control
4. Reduced patients in emergency departments
5. Staffing
6. Treatment
7. Appendices

Aim

Emergency departments need to focus on the critically unwell or injured patients who need rapid assessment and interventions.

Background

Each year emergency departments have been seeing an increase in the number of patients attending. Demand is exceeding capacity. Patients are being cared for in inappropriate areas. And there are delays to assessment and treatment. For safe and effective care this must not continue. The need to reduce the number of patients attending the department is even more important to protect all patients.

Local areas have put in place systems to reduce attendances before the patient reaches the emergency department. Through our work, we have seen:

• actively encouraging patients to ‘talk first’ via GP practice or NHS 111
• active engagement of patients with GP and other support services
• primary care and secondary care coming together to make sure patient needs are being met
• review, support and investment in community services
• engagement and feedback with NHS 111 services to improve referrals
• support for local ambulance crews with ‘hear and treat’ or ‘see and treat’
• trusts providing links and support to pre-hospital systems - for example NHS 111, GP practices and care homes
• a move away from the patient coming to secondary care with more services moving into the community
• dedicated services to support specific patient population needs - such as community falls teams and admission avoidance schemes.

The system work needs to include liaison with the ambulance service to:

• make sure they bypass the emergency department so patients access the correct place first time - direct pathways to plastics, vascular, and ear nose and throat specialities
• reduce attendances for patients both self-presenting and arriving via ambulance - by supporting ‘see and treat’ and ‘hear and treat’, and keeping patients well in the community
• offer alternative pathways to crews - helplines, specialty clinics, same day emergency care, early pregnancy assessment units, and delivery suites.

In good emergency departments we have seen

Effective redirection and streaming systems in place so that patients can be safely streamed to the following by a senior led team:

• external to the trust
  • self-care
  • pharmacy
  • NHS 111
  • GP and primary care services
  • community services
  • urgent treatment centre (if external)
  • mental health services (if external)
• internal to the trust
  • urgent treatment centre if internal
  • emergency pregnancy services
  • delivery suite
  • same day emergency care
  • mental health services (if internal).

The emergency department and specialty teams have an agreement, with medical director support. Patients are taken to the ‘best team to see’ after their initial review. There’s an expectation that:

• a patient known to a service will be directly seen by that specialty team
• a patient with a complication from a procedure will be directly seen by that team
• a patient assessed by the emergency department team as needing specialty assessment is accepted directly by that team and reviewed in a timely fashion.

The specialty teams should have time scheduled to make sure this is feasible. They should provide feedback on outcomes to the emergency department. Particularly if the patient could have better served by another specialty team. The specialty team refers the patient on if needed. Specialty teams must be open to receiving referrals from each other as well as from the emergency department.

For the trust to actively support and encourage patient and staff behavioural change:

• encouraging patients to call GPs or NHS 111 first
• using coordinators within emergency departments and GPs to make sure patients have a GP - and support them through the registration process
• at the point of discharge from hospital, advising patients how to get help if needed and to only ‘go to A&E’ in an emergency.

To link with local primary care clinicians to encourage:

• good communication and support networks between primary and secondary care - such as dedicated helplines - secondary care consultants advise GPs how to avoid hospital attendances and admissions
• GPs to ‘call before they send’ patients to ensure the patient is seeing the right specialty first time.

Specialty teams should make sure their patients do not attend the emergency department when possible. For example, for post-operative complications.

To develop pathways for specific groups of patients whose needs may best be met elsewhere

• percutaneous endoscopic gastrostomy (PEG) tube problems
• catheter problems
• peripherally inserted central catheter (PICC) line problems.

Specific to reducing demand for emergency care from those children and young people who attend more frequently, we have seen:

• joint working with local hospital at home teams, so nurses can deliver ‘emergency department care’ at home
• developing education packages for children with long-term illnesses - highlighting pathways to access appropriate care when unwell or community review by specialist community nursing teams
• health visitors, school nurses and GPs providing education packages to families with young children who frequently attend emergency departments
• consultant paediatricians in GP hubs in the community
• remote access to specialist advice for parents, carers and GPs - avoids delayed presentations of children and young people needing urgent care
• local public information campaigns clarifying when and where to seek help.

Next:
Staffing