Winter Planning

All year round pressure

1. Emergency Department patient demand has risen by at least the equivalent of 13 new emergency departments in the UK
2. Patients are stranded in hospitals awaiting discharge
3. The number of patients waiting more than 12 hours before admission into a hospital ward bed has increased substantially

Escalating demand over a number of years

In England

• From Quarter 1 2011-12 to Quarter 4 2017-18, the number of people waiting more than 12 hours from decision to admit to admission increased by 2,248 (11,831%)
• From Quarter 1 2010-11 to Quarter 4 2017-18, the number of people waiting more than four hours from decision to admit to admission increased by 211,367 (1,468%)

In Scotland

• From 2011-12 to 2017-18, the number of people who spent more than 12 hours in an Emergency Department increased by 2,282 (300%)
• From 2011-12 to 2017-18, the number of people waiting more than eight hours in an Emergency Department rose by 9,159 (184%)

In Wales

• From 2013-14 to 2017-18, the number of people who spent more than 12 hours in an Emergency Department increased by 27,421 (238%)
• From 2011-12 to 2017-18, the number of people who spent more than eight hours in an Emergency Department rose by 52,878 (205%)

In Northern Ireland

• From 2013-14 to 2017-18, the number of patients waiting longer than 12 hours rose by 14,238 (458%)
• From 2013-14 to 2017-18, average four-hour performance at all Emergency Departments fell by 4.6 percentage points to 73.5%

• High quality patient experience
• Adequate staffing
• Wider system engagement
• Excellent system leadership

1. Maintaining safety, time-critical care (based on clinical acuity) and dignity for all patients
2. Supporting system performance (adequate staffing and acute bed capacity for system flow)
3. Ensuring training is always supported

What good systems do

• Hospital-wide ownership of four-hour emergency care system performance, including early capacity planning to avoid excessive inpatient occupancy
• Clear patient ‘pull strategies’ into the hospital
• Better co-ordination of bed capacity, so that more beds are available by late morning
• Active strategies and resourced community planning to reduce delayed discharges from hospital, including social care bundles in place
• Enhanced planning for holiday periods to maintain system flow
• Joint ambulatory emergency care strategies in place in the Emergency Department and hospital to help ‘gate-keep’ and better manage patient flow
• Integrated flow – ‘SAFER‘ care on wards and streaming of stable GP referrals to relevant assessment areas for specialties to manage
• Cost effective co-location of relevant services (including primary care, mental health & frailty)
• Short and medium term Emergency Department workforce planning instituted as per national guidance

What challenged systems should do

Actions

• Identify the risk as the highest priority on the hospital risk register
• Boost patient flow: improve medical and nursing staffing on the emergency care pathway including medical wards, to reduce the number of patients who have to wait in Emergency Department corridors and to safely manage those that do
• Initiate and risk assess a ‘Full Capacity Boarding’ option for acute wards as per national guidance in order to share the hospital’s acute care risk for patients rather than leaving it in the crowded Emergency Department alone
• Consider and plan for seasonal cancellation of elective operations to free-up acute capacity
• Seek active community support solutions to care for ‘medically optimised patients’ awaiting community care

Staying safe in the Red Zone

1. Ensure board recognition that the crowded Emergency Department is the highest level of risk for patient and staff harm and act upon it
2. Enhance the level of medical and nursing staff (using locum and agency personnel) to support both the Emergency Department functioning and the wider hospital emergency care pathway
3. Focus on making sure that those at the frontline feel valued and supported
4. Create solutions to share the acute risk during periods of sustained surge, including:

• Better streaming and ownership of acute patient load between the Emergency Department and other parts of the hospital (e.g. stable GP referrals go straight to relevant specialty teams and there are minimal delays to find a bed after an Emergency Department decision to admit has been made)
• Better engagement strategies for primary care services via the 111 (or equivalent) service in and out-of-hours
• Creation of a patient pull culture to speed patients through the hospital system

Winter Checklist for Trust Boards and Leaders

1. How will you maintain safety, quality and dignity for patients in your crowded Emergency Department this winter?

2. What are your plans for safe staffing in your Emergency Department this winter in order to cope with demand?

3. What are your plans for safe staffing of assessment and escalation areas, medical wards and for ‘outliers’?

4. Does your hospital and system respond to demand in the evenings, at weekends and over holiday periods?

5. Is the wider system engaged to support achievement of the four-hour emergency care standard?

6. Is safety and performance against the four-hour standard at the highest level on your hospital risk register if your ED is in the Amber or Red Zone?

7. How will you value staff and maintain morale during periods of sustained pressure?