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A&E 'crisis' caused by systemic failures, say emergency nurses


Accident and emergency nurses warn that patient safety is increasingly being compromised by growing pressures impacting across the healthcare system this winter.

Widespread problems in hospitals and across the whole health and social care system have combined to create the so-called “A&E crisis”, nurses told Nursing Times.

Trusts have been forced to make financial savings resulting in decreased bed capacity, while cuts to adult social care budgets have left hospitals with limited options for patient discharge, they said.

Addition seasonal factors, such as a four-day Christmas weekend – when social services are “minimal” – and an increase in people with respiratory problems, have also caused a surge in A&E demand across England, Scotland, Wales and Northern Ireland.

“If you ask any A&E nurse what they really would need, it’s extra resources to have extra wards and more nurses on those wards”

Janet Youd

Emergency nurses across the UK told Nursing Times they were becoming increasingly frustrated at being forced to care for patients in corridors or alongside other duties because wards are full.

“Last week I had a shift in triage and I was looking after patients who had been referred from a GP – one who was a really poorly sick young girl and there was nowhere for her to go to in the department. I had to care for her in a wheelchair outside triage for two and a half hours,” said Ema Hughes, a deputy sister at Betsi Cadwaladr health board.

Ms Hughes told Nursing Times that patients were also being kept in ambulances for treatment when wards were full. She said: “It’s been called an A&E crisis, but it’s not – we are not in crisis – it’s the hospital that is in crisis because we can’t move anyone to wards.”

Janet Youd, chair of the Royal College of Nursing’s Emergency Care Association, said nurses were “extremely frustrated and disheartened” by having to nurse patients on corridors. “It’s not dignified and they don’t have the resources to give the care to patients that they need,” she said.

She added that staff were seeing more aggression from people who were having to wait for treatment, and that nurses were having to make increasingly difficult decisions about which patients to prioritise for care.

“Patient safety is being compromised. Emergency nurses always have to prioritise – such as with triage systems – but they’re now having to make decisions about which patients can be in resus and which patients should be in resus but are the least sick of the ones they’ve got.

“They’re not easy decisions to make – it’s a decision about who is in the next cubicle. Is it the man in agony because he needs catheterising or the woman who is miscarrying her baby?” she said.

Ms Youd claimed the pressure on hospitals could have been predicted in October, as many trusts were missing the four-hour A&E waiting target at that point.

“What a lot of trusts have done is pared back the bed base to meet cost improvement programmes,” she said. This also meant that, when additional nurses were needed to brought in to reopen beds, it had been difficult for them to find the right amount, or those with the appropriate skills, she said.

“If you ask any A&E nurse what they really would need, it’s extra resources to have extra wards and more nurses on those wards. What’s happening now is hospitals are opening wards, but don’t have the staff available so the nurse to patient ratio is a bit dangerous in some places,” she said.

“It’s been called an A&E crisis, but it’s not – we are not in crisis – it’s the hospital that is in crisis because we can’t move anyone to wards”

Ema Hughes

As was widely reported in the media earlier this week, quarterly performance figures for October to December showed that, for the first time in a decade, A&E departments missed the four-hour waiting target for 95% of patients from arrival to admission, transfer or discharge, with 92.6% of patients seen within the target timeframe.

These were followed today by the latest weekly statistics – covering the week ending 4 January – suggested the situation had worsened, with 86.7% of patients waiting four hours or less from arrival to admission, transfer or discharge.

In addition, hospitals in Staffordshire, Gloucestershire, Cambridgeshire, London and Surrey have all declared “major incidents” in recent weeks due to high A&E demand.

University College London Hospital

Accident and emergency

A Department of Health spokesman said: “We know the NHS is busier than ever before, which is why we’ve given the NHS a record £700m this winter for more doctors, nurses and beds. The NHS has ensured there are plans in every area to manage the extra demand.”

But Ms Youd claimed that while the government’s injection of £700m to help with NHS winter pressures was welcome, its benefit had not been felt within acute trusts or social care services. She said: “Patients waiting for social services beds or increased packages of care – that £700m isn’t going to touch that.

“Funding the frontline is going to have no effect on the emergency department. Even opening GPs will go some way. But nowhere near as much as freeing the back end of the hospital to discharge patients,” she said.


Readers' comments (18)

  • I wonder what amount of time Jeremy Hunt spends on creating the conditions that allow the private sector to move into the profitable parts of the NHS (with clauses to walk away when they can't eg Circle) rather than his job?
    Roll on May.


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  • michael stone

    Of course this 'A&E crisis' has got a very large 'systemic' element - you can almost always find a 'systemic' element in NHS headline problems (and quite often, the systemic problem seems to be some 'botched political knee-jerk imposition which was made in reaction to an earlier 'NHS crisis'').

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  • Heaven help us if the NHS is privatised, goes down the American route, because we may end up like the 48 million (15.4 0/0 of the population) Americans who do not have health insurance (US census 2012).
    We do not have a perfect healthcare system, but at least it is inclusive and free at the point of need. My nephew was foolish enough to travel to the US without travel insurance, he was attacked, sustained defensive wounds to both forearms which resulted in the extensor tendons and nerves to both hands being severed. An ambulance was called, he was taken to the emergency room the skin was sutured, his tendons and nerves were not. Lesson if you go to an ED in the USA without insurance , they will do enough to save your life nothing more. He was given a $1500 bill for the ambulance journey which wiped out his spending money and then some, I was asked to go collect him as the airline would not allow him to travel alone without the use of both hands. Thankfully a plastic surgery team in the UK patched him upon our return and he now has 85 0/0 function after 5 years.
    Pity the people who are unable to access even the most basic health care, the 6 C's after all includes care and compassion, it does not include cold, cynical and cruel, which is what is offered as comments above and if that IS the way you feel, then perhaps it is time for a career change and leave the caring to those who can Nurse without making judgements about other peoples lives.

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  • I actually think that Johns comments above are sadly true. Too many people use A & E when its not warranted - maybe if they had to pay im sure we would see a sharp decline in inappropriate attenders... The problems do start at the top but sadly filter through to those at the shop floor level. Massive pressure on staff does tend to make you feel slightly aggrevied at people attending an Emergency service for a nosebleed or back pain that they have had for 5 weeks, but then equally folk are unable to get GP appointments so they simply head to casualty... and so the cycle continues!

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  • It's easy to say when you are not the one who cannot get the appointment and you have to deal with the situation, have not had intolerable pain or perhaps been misdiagnosed, eg when I worked in the ED an elderly chap came in with chronic back pain his GP had seen him that morning told him to carry on as normal, by the time he arrived he was tachycardic, bp in his boots he was pale, sweaty and had a visible pulsatile mass, yes you guessed it his GP missed an AAA. Thankfully he ignored his GP, advice.
    Yes there are people who attend the ED with what might be considered trivial concerns, perhaps it is down to a lack of knowledge of options for care, healthcare after all has changed enormously in the last 20 yrs. it is sometimes difficult to keep up with the changes when you are within the system how can we expect the general public to be health experts unless there is a drive to educate the public.
    For a start how about standardising the way we address the Emergancy Department, Stop calling it by various softer names "Casualty" is too vague as is "Accident and Emergancy" after all one mans Emergancy is another's "fractured eyelash" Emergancy Department says exactly what it is ...

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  • It is not one political party at fault as I worked on acute wards in the 80's and standards of care, medical care were generally better. I feel there should be cross party sensible discussions of how to save our, on the whole excellent NHS

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  • As mentioned before this is a result of both widespread closures of local A&E's (by both Conservative and Labour governments) and too many people seeking medical advice for the most trivial ailments!

    There appears to be a perception that Labour is NHS's friend but in reality they are actually no better than the Conservatives! We are being over managed and that is as a result of years of political interference from both parties.

    What is sad when nurse managers support this reckless interference, presumably because they're sitting pretty on high bands which they're desperately trying to protect.

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  • Operating theatres often have to bare the brunt of A&E pressures because critically ill patients that cannot be dealt with in the ED are transferred to anaesthetic rooms or operating theatres to be treated.What is incredible though at University College London NHS Trust is that this has not been just a Winter problem its been going on for several years 365 days of the year

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