Why is patient flow so important to NHS emergency departments? RCEM explains

Posted On: 
16th September 2019

The Royal College of Emergency Medicine explains that unless better metrics can be developed, the four hour standard should be retained.

Another area that needs a focus from the Clinical Review of Standards is that in England measurements for how long a patient can wait are not the same as in other nations, writes RCEM.
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The Royal College of Emergency Medicine exists to maintain and raise standards in the delivery of care to emergency department patients with acute severe illness and injury. ‘Emergency Departments’ are what are sometimes called NHS A&E departments. This task is increasingly more challenging and more imperative. The issues facing emergency departments are stark, widespread and common to all four nations of the UK.

This summer, press articles detailing record numbers of patients attending NHS Emergency Departments (EDs) featured. These challenges are being faced across the UK. The pressure facing EDs has been steadily rising for years, with new records being broken for numbers of patients presenting and worsening four hour performance. This is because hospital are often operating at full capacity which increases the risk to patients and is increasing the burn out risks for NHS employees.

In this busy environment, it is vital that patient flow from arrival at the ED through to either being admitted, transferred or discharged is maintained. A lack of patient flow through an ED is the single most pernicious way to render the system both inefficient and ineffective. Not only are paramedics unable to attend other 999 calls but patient outcomes are worsened; there is more pain, less care and more deaths. These conditions all arise when the exit from an Emergency Department is effectively blocked because of a lack of available hospital beds for those patients requiring admission. This situation is known as ‘Exit Block’.

Maintaining patient flow is vital to the effective functioning of the emergency department. That is why this College has spoken out so strongly against ‘Exit Block’ urging the NHS to ensure that a reliable flow metric is created in the interests of patent safety. 

The four hour standard is under review in England and Wales. This standard has been for many years a useful proxy measurement of patient flow. It encourages patient flow up to the point the four hour point is passed.  For those patients who have been waiting for more than four hours for admission into a hospital ward for ongoing treatment, it provides little incentive to hospital systems to prioritise that patient. This can be particularly problematic in those hospitals that have management deficiencies or insufficient clinical workforce. So far various ideas are being tested and we very much hope this will be addressed: the results of the testing are awaited.

This work is being led by NHS England/Improvement in its Clinical Review of Standards project. Alongside some overall measurement of performance, they are seeking to bring in metrics that support the work of the emergency departments in prioritising the treatment for those most in need. However they have chosen to focus on only certain conditions for time based metrics rather than develop a metric that describes patient acuity (those who are most sick). 

This is made more complex because some patients present who are clearly very ill but extensive testing and clinical work is needed to diagnose their condition before treatment can commence.  These patients may not neatly fall into one of the categories the new metrics are focussing on.  For many patients, they are not simply presenting with this or that condition but complex bundles of symptoms and conditions which need urgent clinical expertise to deal with.  That is why this College prefers a focus on continuing to prioritise those patients who are most at risk regardless of which particular condition, symptom or illness they have.

Another area that needs a focus from the Clinical Review of Standards is that in England measurements for how long a patient can wait are not the same as in other nations.  There is a 12 hour wait metric which only starts the clock ticking from when a decision to admit a patient is made.   This decision denotes that the patient is intended to be admitted to a Hospital Bed, either immediately or subsequently in the future. In Scotland, Wales and Northern Ireland this clock starts ticking when the patient arrives, not when a decision is made to admit them into a ward. We expect the new metrics to remove this anomaly.

We are eagerly awaiting the results of the testing and it is our view that unless better metrics can be developed then the four hour standard should be retained.

We appreciate that NHS resources are stretched and that it is proving increasingly difficult to achieve the four hour standard.  We understand why that in itself leads to calls for it to go.  There is an opportunity within the NHSE/I Clinical Review of Standards to define new metrics that take us on from what we have now. We are participating in the review on the basis that the outcome of the review will be based on clinical evidence rather than political expediency.