Ensuring the right nurse staffing levels is key when it comes to safely dealing with winter pressures on emergency departments, says a new report by the Care Quality Commission.
The report, which sets out number of key concerns about the quality and safety of emergency care during winter, calls for urgent action “to make sure that next winter is different” and sets out a range of measures to help trusts both prepare for and cope with the seasonal surge in demand.
“During an unprecedentedly challenging winter, we have seen staff going above and beyond to deliver safe care to patients”
It draws together findings from inspections of emergency department carried out by the regulator during winter 2017-18, alongside feedback from workshops attended by more than 70 frontline clinicians aimed at understanding the issues facing staff and what needs to change.
Staffing “was a particular area of concern” noted by CQC inspectors, revealed the report, which highlighted the impact of working in an over-stretched and hectic environment.
“We remain concerned about the wellbeing of staff working under considerable pressure in clinically high-risk environments,” said the report. “This is made worse by shortages of key staff in many departments.”
The report found some trusts had used staff modelling tools – including the Safer Nursing Care tool adapted for emergency care – to look at nurse staffing levels, leading to an increase in numbers.
“However, nursing staff levels remained a challenge and many trusts continued to use a high level of bank and agency staff to maintain planned staffing levels both in the emergency department and also in inpatient escalation areas,” it said.
“Often there were not enough suitably qualified, skilled and experienced nursing staff in these areas,” warned the report – titled Under pressure: safely managing increased demand in emergency departments.
“Inadequate funding means services and staff are stretched to the limit, and patients are being put at risk”
Among measures to improve staffing capacity in emergency departments, the report said trusts should consider investing in advanced nurse practitioners and give them the “opportunity of a promotion by investing in training and development”.
Another key concern was that patients who came to accident and emergency were often waiting a long time before their first clinical assessments, which meant patients needing urgent care were not always identified swiftly.
“In our guidance to trusts, we have stressed the importance of early clinical assessments of every patient,” said the CQC in its new report, citing previous documents that it has published.
“Our inspection reports for the last three winters showed that patients in most emergency departments were not having a first clinical assessment (for example by a nurse) within 15 minutes of arriving,” it said.
Where emergency departments were working well, it noted there was a “suitably clinically-qualified member of staff, working in an allocated space, who prioritised people according to clinical need”.
“This winter saw the NHS frontline and its staff working at full stretch”
The CQC also found evidence of good practice at a number of A&E departments and examples of hospitals that have been better able to plan for and manage increased patient attendances.
However, it stressed that the quality and safety of urgent and emergency care remained a concern, with 50% of these services rated as “requires improvement” or “inadequate” overall and 8% rated “inadequate” for safety.
Other specific concerns identified in the report included delayed ambulance handovers, inadequate escalation policies or a failure to properly implement those policies when needed.
In addition, the CQC found that many hospitals were routinely caring for patients in “inappropriate spaces”, such as corridors, with no plans in place for alternative safer accommodation.
As well as examining at conditions in A&E, the report also looked at the wider picture of how different sectors and settings working together during winter.
It noted that a series of government-commissioned reviews of how local health and care systems prepared for surges in demand had revealed variation in how well services worked together.
“The adult social care system is under severe strain and community based services are being reduced”
While the CQC had seen some examples of good planning, there was concern about timeliness and the extent to which all partners were involved with independent social care providers and voluntary, community and social enterprise organisations often less engaged.
Professor Ted Baker, the CQC’s chief inspector of hospitals, said staff had gone to extraordinary lengths to care for patients in challenging circumstances, but that care varied in quality and was sometime “wholly unsatisfactory”.
“During an unprecedentedly challenging winter, we have seen staff going above and beyond to deliver safe care to patients – their commitment and efforts in such difficult circumstances must be commended,” he said.
“Our inspections of urgent and emergency services have found evidence of good practice and of individual providers that have been able to make improvements,” he said. “However, we have also found too much variation and we have seen how increased pressure has led to some patients receiving care that is wholly unsatisfactory.”
The report contains case studies and practical examples of successful initiatives to maintain safe care even in tough times (see below).
However, Professor Baker said these kind of solutions were only “part of the answer” and a system-wide approach was needed to address ever increasing demand on services
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“We cannot accept that each winter will be worse than the one before – we are already seeing the impact on both patients and staff,” said Dr Baker.
“It is clear that what used to work doesn’t work anymore – new ways of collaborating and planning for surges in demand need to happen now to ensure that next winter is different,” he added.
Unison head of health Sara Gorton said working in unsafe conditions was a “nightmare” for staff.
“This is the umpteenth warning that the NHS is under extreme pressure,” she said. “Inadequate funding means services and staff are stretched to the limit, and patients are being put at risk.
“For staff working in an unsafe environment on a daily basis it’s a nightmare, when all they’re trying to do is deliver compassionate care,” she noted.
Saffron Cordery, deputy chief executive of the organisation NHS Providers, said: “This winter saw the NHS frontline and its staff working at full stretch.
“One of the driving factors behind this unprecedented rise in demand is the realities of an ageing population, many attending emergency and A&E services with complex and multiple conditions,” she said.
“This, together with a lack of capacity across community, primary and social care, hospital and mental health services, meant that trusts lacked the necessary resources to meet this additional demand,” she noted.
Ms Cordery highlighted her organisation’s own report, published earlier this week, which called for more to be done to resource community services to help avoid unnecessary hospital attendances.
She added: “The CQC rightly recognises good practice within emergency departments. Trusts need to be supported to share practice and lessons learnt from their experiences last winter to ensure services are safe and resilient next time.”
Izzi Seccombe, chair of the Local Government Association’s community wellbeing board, said councils needed “urgent funding to invest in effective prevention work to reduce the need for people to be admitted to hospital in the first place”.
Ms Seccombe added that councils had also been “doing all they can to get people discharged from hospital in a safe and a timely way, not just during winter, but all year round”.
“However, due to significant funding shortfalls, the adult social care system is under severe strain and community based services are being reduced, which is impacting on inpatient services,” she said.
“The government needs to plug the funding gap facing adult social care which is set to exceed £2bn by 2020,” she said. “The majority of this pressure is now with an estimated £1.3bn of that shortfall needed to stabilise the care market.
“Reductions in councils’ public health grants – which fund essential prevention work and early intervention services – also need to be reversed by the government, which will help to further reduce NHS pressures and costs increasing,” she said.
Good practice examples involving nurses highlighted in report
Nurses managing queues: Bristol Royal Infirmary
Managing the queue Bristol Royal Infirmary has put in place the queue nurse model to manage the flow of patients through the emergency department. In this model, the emergency department supports the first three patients in the queue, after which ward staff are called on to support patients.
Bristol Royal Infirmary
Source: Linda Bailey
Divisions have devised a timetable for queue support, with each ward covering two-hour blocks. This makes sure that the clinical site management teams, duty matrons and wards in each division are aware which ward will be called on to support the queue and when. Over the winter, the emergency department has a band 6 nurse employed in the afternoons and nights to coordinate and support the queue.
This registered nurse is peripatetic and makes sure that ward nurses supporting the emergency department queue are able to care for their patients. The nurse also makes sure that equipment is available. All patients are managed using the emergency department safety checklist to maintain their safety and there have been no serious incidents associated with the queue or undetected deteriorating patients since this was implemented.
Nurses organising escalation procedures: Luton and Dunstable University Hospital
Escalation wards and contingency beds Patient flow through a hospital is key to preventing a backlog of patients, and the efficient use of beds helps to achieve this. Luton and Dunstable University Hospital developed a new proactive approach to the use of contingency beds over several years, and now have a constantly evolving strategy, with an improved approach to contingency beds year-on-year.
One of the first principles involves dual purpose planning. Whenever an area of the hospital was being updated or modernised, the hospital considered what other functions the area in question could perform.
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For example, an area used from 9am to 5pm on weekdays for the recovery of planned minor procedures was built to be able to accommodate patients overnight in times of surge. This included ensuring there were adequate shower and toilet facilities, storage areas and IT provision. These areas are well described and contained in the escalation plan.
The hospital is able to flex bed capacity up and down as needed, and once opened the escalation ward should be closed as quickly as possible. Luton and Dunstable also look closely at staffing for escalation wards. Every day the chief nurse and operational matron assess the bed state, and with the use of prediction tools plan extra staff to cover any contingency areas that may be needed over the next 24 hours.
The hospital never staff these areas with agency nurses, instead substantive staff are moved into these areas and backfill the base wards with an agency or bank nurse to maintain the numbers.
Anticipating the need and identifying in advance the staff who will go is key. These areas often have a higher nurse to patient ratio than base wards, but identifying suitable patients to go there can be challenging. At times of peak demand, matrons liaise with ward managers and consultants during working hours to provide a list of patients who may be suitable to move if required.