Mounting Patient Safety Crisis in Urgent and Emergency Care

Dr Sheena Meredith

November 26, 2021

The scale of the continuing crisis in emergency care has been revealed in a new survey from the Royal College of Emergency Medicine (RCEM), which shows that every day in the past week, almost two-thirds of A&Es reported ambulances having to wait to transfer patients. More than half of emergency departments were forced to provide care in corridors and other non-designated areas. A separate report found that more than 4500 patients died during 2020-2021 as a result of dangerous crowding in A&E departments.

Ambulances Not Meeting Targets

The RCEM survey, covering November 8-14, was sent to clinical leads in A&E departments across the UK. Of the 70 responses received, 43 (61%) said they had been holding ambulances every day for the past week.

The NHS target states that all ambulance handovers to A&E must be completed within 15 minutes, with none waiting for more than 30 minutes.

Yet according to a report by the Association of Ambulance Chief Executives (AACE), also published this month, since April 2018 an average of 190,000 handovers – about half of the total – have missed this target every month, and the problem is getting worse. In September 2021 over 208,000 handovers exceeded the 15 minutes target, with the duration of delays increasing.

In a clinical review that looked at samples of handovers delayed beyond 60 minutes across the country on 4th January 2021 - typical of most days – 85% of patients involved were assessed as potentially having experienced some level of harm, and 9% of them severe harm. This translates to about 160,000 patients potentially harmed every year, with 12,000 cases of severe harm.

"For Some Hospitals, Every Day is a 'Bad Day'"

AACE described its report as “a clarion call” and stressed the need for rapidsystem improvement to avoid preventable severe harm, including deaths that have occurred while waiting for an ambulance response in the community, as well as during or after delayed handovers.

All hospitals experience 'bad days' in terms of matching capacity to surges in demand, the report acknowledged, but "for some hospitals, every day is a ‘bad day’".

“There is still not enough being done to adequately address this risk,” and "firm and immediate action" must be taken at national, regional and integrated care system level "to eliminate these delays once and for all".

"All handover delays over 60 minutes must be viewed as completely unacceptable."

Long Waits in Crowded A&E Departments

Once transferred from the ambulance, patients face potentially long waits in A&E. Asked about the longest stays in A&E in the RCEM survey, only four departments (6%) reported this at less than 12 hours, and as many said it was more than 72 hours. Stays of 12-24 hours were recorded by 27 departments (39%); 24-48 hours by 25 departments (36%), and 48-72 hours by 10 departments (14%), while 34 (49%) admitted to providing care in non-designated areas such as corridors.

In addition, 14% of respondents stated that there was no effective same day emergency care available in their department, and 50% said that same day care had limited availability, less than 12 hours a day, or weekdays only.

A separate RCEM report this month found that at least 4519 patients died as a result of dangerous crowding in emergency departments in England in 2020-2021.

Noting the backdrop of long ambulance delays, the report described high levels of crowding in A&Es and record-breaking numbers of patients experiencing long waits due to "severe mismatch between demand and capacity in the NHS". This it blamed on "increasing patient demand coupled with high hospital bed occupancy" and resulting 'exit block' – "the key reason for crowded Eds". This represented a major threat to public health, the RCEM report said.

"Crowding is dangerous. It is undignified and inhumane for patients who are left waiting for treatment in precarious circumstances," the report stated. "Crowding is associated with increased mortality and increased hospital length of stay. As well as impairing the efficiency of hospitals, it contributes to staff burnout, moral injury, and to the loss of highly skilled emergency care professionals."

Staffing and Bed Shortfalls

Dr Katherine Henderson, president of the RCEM commented: "These results show the serious state that our urgent and emergency care system is in. None of us want to have patients held in ambulances, treated in corridors, or waiting very long times to go up to a ward bed."

"We all need to work together to solve this acute patient safety problem...  This winter is going to be a huge challenge unless we can get flow back into the system."

In the short-term, she said, this means expanding capacity and making same day emergency care available across all trusts. In the long term, there must be action to recruit new staff and retain existing ones.

"Across the UK there is a shortfall of 2000 to 2500 whole time equivalent emergency medicine consultants, and crucially, there are also widespread shortages of emergency medicine nurses and both junior and supporting staff. At the same time capacity is severely depleted across the UK." An additional 7170 beds are needed across the UK to restore capacity to pre-pandemic levels.

"This is only the beginning of winter and of what may come. We are facing a crisis in urgent and emergency care and a crisis of patient safety."

Situation "Unsustainable"

Responding to the RCEM survey, Patricia Marquis, Royal College of Nursing Director for England, said: "This kind of warning cannot be ignored. The alarm has been ringing for far too long and the situation is unsustainable."

"Nursing staff working in emergency departments are feeling increasingly desperate and are crying out now for urgent intervention. The experience for patients, waiting hours in pain and discomfort, is poor and too often unsafe."

Tracy Nicholls, chief executive of the College of Paramedics, said: "We must not forget that behind all these mounting figures are real people, both staff and patients, who are bearing the brunt of this continuing strain on services."


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