Voices from emergency care

As we move into the winter months, we asked people working in emergency care what winter pressures mean to them, and what can be done to relieve the pressure on emergency departments.

All were in agreement that the key issues facing emergency departments are patient flow through hospitals and capacity in other services – being able to find a bed in hospital to admit a patient to, or being able to discharge a patient with the support of social care. They identified a range of winter issues (from bad weather affecting driving conditions for ambulances to increased rates of respiratory infections) and suggested practical solutions (from changes to triage to better planning of elective services).

The four Health Foundation Fellows we spoke to were:

• Paul Jarvis, Emergency Medicine Consultant and Lead for Innovation, Calderdale and Huddersfield NHS Foundation Trust
• Jay Banerjee, Consultant in Emergency Medicine & Associate Medical Director for Clinical Quality & Improvement University Hospitals of Leicester NHS Trust
• Richard Lee, Assistant Chief Ambulance Services Commissioner at NHS Wales Emergency Ambulance Services Committee
• Simon Mackenzie, Medical Director, St George’s University Hospitals, London.

What are the main challenges you face during the winter months?

Paul: ‘We feel the winter pressures more than most, as the emergency department tends to be the barometer of the whole acute health service. Patients attending the emergency department tend to be sicker, the proportion of patients requiring admission increases and their inpatient stay is longer. There are also more elderly and complex care patients waiting in inpatient beds for placement into social care.

‘With no empty beds, patients will be waiting on trolleys for long after their emergency care has been completed. This prevents new patients being assessed as there is no space and this introduces clinical risk.’

Jay: ‘Previously, winter pressure meant more sick people and higher admissions to hospital. This was typically combined with poor outflow from emergency department and hospital due to decreases in staff in all other services for the holidays. This year, the poor outflow with high inflow has continued over the summer from the previous winter.’

Richard: ‘Ambulance services see increases in both the demand placed upon them and the acuity of patients’ conditions (how severe their conditions are) over the winter months. Poor driving conditions make it more difficult for ambulances to travel to calls – snow, rain and fog slow down responses.

‘The increased acuity leads to higher admission rates in hospitals and this leads to capacity issues. These issues spill backwards into the emergency department and then ambulances cannot handover incoming patients.’

Simon: ‘The system is now under pressure nearly all year and winter exposes it. This is partly capacity but is mainly flow. Seasonal fluctuations – respiratory infections in the elderly in particular – are coupled with decreased efficiency in hospitals and out.’

What do you think could be done to manage winter pressures differently in the future?

Paul: ‘The biggest challenge we have in tackling winter pressures is changing our mindset. Culturally, we expect winters to be bad so we accept it and we've become desensitised to it. Essentially the problems we have are of our own making. The way the acute care/social care pathways are set up and our inability to mitigate means that winter pressures are entirely of our own creation.

‘The problem with traditional emergency department working is it relies on triage to risk-stratify patients (categorise patients according to how seriously ill they are) and correctly allocate limited resources. Unfortunately, this fills the department with well patients, as the ill patients get seen preferentially. We have put a consultant at the front door, so that well patients are identified early and discharged home where appropriate. (See also this project on advanced triage, funded by the Health Foundation.)

‘Another area which helps alleviate winter crowding is to use point-of-care blood testing, rather than centralised laboratories.’

Jay: ‘There needs to be more integration of primary care with emergency departments.’

Richard: ‘Patients with a minor injury should be able to book an appointment to attend the emergency department, rather than having to just turn up. Ambulance services must bolster their hear-and-treat telephone services over the winter. GP out-of-hours services must ensure that the increased demand is managed by their service and not passed to emergency services or 999.’

What changes outside acute care will help relieve pressure on A&E departments?

Richard: ‘Health and social care must make sure there are business-as-usual services over Christmas. Ensuring that supported discharge is available seven days a week is key.

‘Nursing homes should be able to manage outbreaks of vomiting bugs in their facilities to prevent infection spreading to the hospital.’

Simon: ‘We could do better by creating capacity in community and social services to ensure timely discharge. The demand is predictable and allowing queues to build up harms patients.’

Jay: ‘Care home support, better planning of elective services, and commission outcomes in the longer term as current provision is process driven.’

What are your answers to these questions? Join the debate by leaving a comment below.