synthesis of art and science is lived by the nurse in the nursing act Art & science | | The acute care service pressures
JOSEPHINE G PATERSON
PREVENTING ‘EXIT BLOCK’ IN EMERGENCY DEPARTMENTS Kevin Cairney and Elaine Clancy explain how a site practitioner early warning system can alert urgent care staff to problems with capacity and patient flow Correspondence kevin.cairney@ croydonhealth.nhs.uk Kevin Cairney is head of nursing, 24/7 patient safety team Elaine Clancy is deputy chief operating officer Both at Croydon Health Services NHS Trust, London Date of submission October 1 2014 Date of acceptance October 16 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines rcnpublishing.com/r/ en-author-guidelines
Abstract Overcrowding due to poor patient flow increases risk for more than 500,000 patients a year (College of Emergency Medicine (CEM) 2014) and is linked to increased mortality (Geelhoed and de Klerk 2012). CEM (2014) has called for urgent action to address ‘exit block’ in UK emergency departments (EDs). In October last year, Croydon Health Services NHS Trust designed and implemented a site practitioner early warning system (SPEWS) to alert staff to capacity and flow pressures in the ED, and to initiate escalation to a nurse-led, protocol-driven response. Under pressurised and time-critical conditions, SPEWS ensures rigour and conformity in exchanges between clinical emergency care staff and managers. The result is closer collaboration between clinicians and managers, optimised patient flow and mitigated risk from exit block. Keywords Emergency services, clinical governance, inpatients, patient safety, early warning system, patient flow OVERCROWDING AS a result of poor patient flow in emergency departments (EDs) is linked to increased mortality (Geelhoed and de Klerk 2012), and reduces the capability of ED staff to anticipate surge pressures from adjacent emergency facilities, for example in the event of a major incident (London Emergency Services Liaison Panel 2012). As a result, the four-hour emergency care standard, introduced by the Department of Health (2004), continues as a
20 November 2014 | Volume 22 | Number 7
surrogate marker for a successful and efficient emergency care pathway. The NHS must provide safe patient care within the constraint of a public-sector efficiency drive and increased demand for services (Appleby et al 2014). Emergency care staff and operational managers are required to target resources at service pressure points and bottlenecks along the emergency care pathway, and can achieve these aims by use of an early warning system. Early warning systems are typically used in acute ward areas to help nursing staff to recognise deterioration in patients and escalate their care (Royal College of Physicians 2012). Staff who use these systems give scores based on patient physiology, whereby the further the physiology deviates from normal, the higher the score and the more senior or urgent the clinical response (Royal College of Physicians 2012). Because scores are made according to objective criteria, primary assessments are rarely subjective, and a protocol-driven and patient-focused approach can be adopted (National Institute for Health and Care Excellence (NICE) 2007). The principles of early warning systems can be applied to deteriorating EDs to achieve a ‘track and trigger’ escalation of surge pressures against an algorithm of optimal ED patient flow devised at Croydon Health Services NHS Trust. This algorithm has been adapted for Figure 1.
System development As an integrated healthcare organisation, Croydon Health Services NHS Trust is commissioned to deliver community and acute services to a EMERGENCY NURSE
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Art & science | acute servicecare pressures Figure 1 Optimal emergency department patient flow algorithm 0 Emergency department (ED) nurse triages patient or Initiates rapid assessment treatment and triage and Orders baseline clinical investigations 15
ED nurse refers patient to specialty team or If patient was referred by a GP, notifies specialty team or Implements ambulatory care pathway
30
45
ED doctor, advanced nurse practitioner, emergency nurse practitioner or speciality doctor makes first assessment and Makes further clinical investigations if necessary
Minutes after patient referral
60
75
90
105
ED doctor discharges patient or refers to speciality and ED nurse in charge (NIC) contacts clinical site practitioner (CSP) to make provisional bed request or EDNIC contacts discharge lounge to retrieve patient
120
135 150
EDNIC contacts CSP to confirm that a speciality bed is available
165 180 195 210
EDNIC transfers patient within 15 minutes of the CSP allocating a bed
225 240 (Adapted from Croydon Health Services NHS Trust 2014)
22 November 2014 | Volume 22 | Number 7
diverse population of 363,400 (Croydon Clinical Commissioning Group 2013). Acute services are concentrated at the Croydon University Hospital site, a district general hospital with about 430 inpatient beds. The ED is not a major trauma centre (NHS England 2012), but it is one of the busiest departments in London, and its staff care for between 300 and 350 adult and paediatric type 1 presentations a day (Croydon Clinical Commissioning Group 2013). In 2013/14, 95.35% of patients in the ED were seen, treated and discharged or referred within four hours, thereby exceeding the emergency care standard. This was achieved in part by the introduction of a site practitioner early warning system (SPEWS) to measure safe emergency patient flow, and to ensure timely assessments and clinical interventions in the ED. The SPEWS offers the trust an objective approach to anticipating and managing capacity and flow pressures in the ED, and has enabled trust staff to reduce ‘exit block’, or the inability to reduce overcrowding in EDs, as recommended by the College of Emergency Medicine (CEM) (2014). SPEWS, which has been adapted for Table 1, is a grid with four colour-coded tracker rows, and two columns of triggers and actions. The tracker rows have traffic-light colours to indicate the condition of the department at any one time. Green indicates that the department is functioning normally, amber that the department is functioning but under pressure, red that business continuity is compromised and patient safety is at risk. There are also black tracker criteria, defined in Croydon Health Services’ hospital major incident medical management and support (HMIMMS) procedure, that signify that the department cannot function and site integrity is compromised. When three trigger criteria are met in any of the first three tracking rows, the ED senior nurse contacts the lead clinical site practitioner (LCSP), who in turn initiates step-by-step responses by specific members of staff. In extreme situations, when SPEWS red or black tracker row criteria are met, the trust’s community teams support senior nurses and decision-making doctors to expedite ward discharges and increase inpatient capacity. When the black trigger criteria are met, ED resources have been outstripped by demand to the detriment of patient safety, which is defined by many NHS trusts as an internal major incident. Because SPEWS is part of the trust’s clinical governance programme, its protocol-driven criteria are ratified at board level. These criteria ensure EMERGENCY NURSE
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Table 1 Site practitioner early warning system
Department is functioning normally Department is functioning but under pressure Business continuity compromised and patient safety is at risk Department cannot function. Site integrity is compromised
Black
Red
Amber
Green
Trackers
Trigger criteria: at least three must apply
Actions
■ Ambulance handovers take less than 15 minutes. ■ More than two trolley spaces in resuscitation room. ■ More than five trolley spaces in majors area. ■ More than 20 patients in the department1. ■ The emergency department flow algorithm (EDFA) timeline can be maintained. ■ Triage wait time is less than 15 minutes. ■ Bed predictor result is greater than zero.
■ ED nurse in charge (NIC) to attend inpatient capacity and flow (IPCF) meetings. ■ Majors co-ordinator and area nurse to fulfil their roles and responsibilities. ■ EDNIC to adhere to EDFA. ■ Clinical site practitioner (CSP) to update the capacity management system (CMS) every two hours.
■ Ambulance handovers take more than 15 minutes. ■ More than two trolley spaces in resuscitation room. ■ More than two trolley spaces in majors area. ■ More than 40 patients in the department1. ■ Triage wait time is less than 15 minutes. ■ Bed predictor result is no less than -10 after 1pm.
After green tracker actions have been carried out, EDNIC to: ■ Contact speciality on-call senior practitioner to expedite any review. ■ Ensure patients are admitted in order of clinical need and then waiting time. ■ Report any EDFA compromise to ED matron and CSP. CSP to: ■ Contact duty manager. ■ Update CMS to reflect current status of department. ■ Discuss contacting local ambulance service duty station officer (DSO) with EDNIC. ■ Liaise with head of nursing (HoN) of 24/7 team or deputy2. Senior manager to: ■ Chair IPCAF meeting to consider opening additional escalation areas. ■ Allocate senior nurse lead for escalation procedures.
■ Ambulance handovers take between 40 and 60 minutes. ■ Fewer than two trolley spaces in resuscitation room. ■ Fewer than two trolley spaces in majors area while escalation beds are open. ■ More than 50 patients in the department1. ■ Triage wait time is less than 30 minutes. ■ Bed predictor result is between -11 and -20 after 1pm.
After green and amber tracker actions have been carried out, ED senior doctor to: ■ Consider contacting ED on-call consultant. ■ Review ED referrals with on-call teams and consider consultant-led direct referral. ■ Conduct additional board rounds3. CSP to: ■ Deploy 24/7 team’s clinical assistant and resuscitation practitioners to ED. ■ Consider contacting the local ambulance service DSO. ■ Liaise with integrated discharge team to review potential discharges. ■ Liaise with discharge lounge for nurse-level trawl of definite discharges. Senior manager to: ■ Consider whether on-call manager4 or on-site director should work out of hours. ■ Inform deputy chief operating officer (DCOO) or deputy. ■ Consider activating rapid-response service5. ■ Consider contacting community cluster matron if referring to relevant services. ■ Attend ED or acute medical unit if required. Assistant director of operations to: ■ Consider review of elective list and plans to admit patients from other hospitals. ■ Contact clinical teams and initiate consultant-led review to expedite discharges on the day and review those expected on the next day.
■ Ambulance handovers take longer than 60 minutes. ■ No trolley spaces in resuscitation room. ■ No trolley spaces in majors area and escalation beds open. ■ At least 60 patients in the department. ■ Bed predictor result is -21 or less after 1pm.
Within 15 minutes: ■ Administrative support should be established. ■ A hospital command team (HCT) comprising senior ED doctors, nurses and managers, and the CSP, should be formed. ■ The HoN’s 24/7 team and DCOO should be informed of the declaration. Within 30 minutes: ■ The HCT should meet in CSP’s office. ■ Local ambulance service DSO should be informed. If ambulance service declares a major incident: ■ HCT should consider announcing hospital major incident medical management.
Includes paediatric department and urgent care centre 2Head of nursing of 24/7 team or deputy work during office hours 3Emergency department consultant board rounds are normally at 9am, 1pm, 4pm and 8pm 4The on-call manager is available between 5pm and 8.30am 5Adult patients are referred to the rapid-response service only if they are medically stable with no need for inpatient care, are registered with a local GP, and can be managed at home with additional support. The community cluster matron must be alerted before each referral.
1
(Adapted from Croydon Health Services NHS Trust 2014)
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Art & science | acute servicecare pressures Case study 1: green At 10am on Tuesday, the lead clinical site practitioner (LCSP) reports that four patients in the emergency department (ED) require inpatient beds in the next two hours. There is one intubated patient and four empty bays in the resuscitation room, four cubicles available in the majors area and no ambulances are waiting to offload. Patients are waiting ten minutes for triage In this example, the ED is functioning normally and the green criteria of the site practitioner early warning system (SPEWS) apply. Acuity in the resuscitation room and unplaced patients awaiting admission do not influence SPEWS unless exit-block occurs and ED capacity is reduced. Therefore the ED nurse need only maintain departmental flow and ensure routine tracking assessments are relayed to the LCSP. that all clinical and operational personnel involved in emergency care pathways respond proactively and are fundamental to timely responses to clinical escalation. Such proactive responses are important because staff who adopt a reactive response to pressurised situations often make sub-optimal decisions (Moullin and Copeland 2013), which in the context of emergency care can compromise patient safety. Rescue actions taken to create capacity and increase patient flow are prescriptive and, because they are initiated and controlled by senior clinical and operational staff, conform to the HMIMMS procedure (Advanced Life Support Group 2014). The actions are initiated by an inpatient capacity and flow (IPCAF) group, or bed group, chaired by the LCSP, and including the ED nurse in charge (EDNIC) and senior manager. Bed group meetings, which are held three times a day, are attended by senior nursing and managerial staff from the discharge lounge and critical care outreach teams, who are selected for the contributions they have made to elective and emergency care pathways, meeting the four-hour standard and preventing the cancellation of elective procedures. SPEWS is informed by the trust’s IPCAF operational policy on safe patient flow and care, which has contributed to a reduction of in-hospital cardiac arrest by 25% and unplanned intensive care unit admissions by 20% (Croydon Health Services NHS Trust 2014). Meanwhile, the NHS Institute for Innovation and Improvement (2013) commissioning for quality and innovation payment 24 November 2014 | Volume 22 | Number 7
framework acts a surrogate marker for the 24/7 team to reduce unexpected admission to the intensive care unit (ICU). Like in many district general hospitals, the LCSP is a single-point of contact for operational escalation to an on-call senior manager during the out-of-hours (OOH) period, and the OOH management of SPEWS depends primarily on the working relationship between the LCSP and on-call manager. The on-call senior manager is supported by an on-call director and a range of non-resident consultants as part of the trust’s resilience management programme run by the trust’s emergency planning, resilience and response (EPRR) officer. The corporate impetus behind SPEWS, therefore, was the need for consistent and timely communication throughout the emergency care pathway. From a staff perspective, SPEWS provides a scheme of comprehensive initial actions to deliver a timely response, maintain the operational integrity of the ED and hospital, and ensure patient safety. Because Croydon Health Services NHS Trust is an integrated care organisation, protocols such as SPEWS are followed by staff in and outside hospital.
Case studies The case studies on pages 24 and 25 demonstrate how ED clinical staff have referred to SPEWS when responding to escalation.
Case study 2: amber At 1pm on a Friday, the emergency department (ED) nurse in charge states at a bed meeting that there are 49 patients in the ED. The resuscitation room has four available bays, the majors area has two vacant cubicles and four ambulances are waiting to offload. Patients are waiting 25 minutes for triage. The ED consultant says that the ED is becoming unsafe. In this example, the ED is functioning but under pressure and the amber criteria of the site practitioner early warning system (SPEWS) apply. This means that, according to SPEWS, the ED is not yet unsafe. The ED nurse in charge, lead clinical site practitioner and senior managers have parts to play in restoring green SPEWS criteria or priming the ED for SPEWS red criteria. This involves ensuring triage takes less than 15 minutes per patient, and keeping the bed group informed about increasing or decreasing surge pressures. EMERGENCY NURSE
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Case study 3: red At 4pm on a Thursday, the emergency department (ED) nurse in charge reports that there are 55 patients in the ED, which means it is busy, although no patient is unplaced. The resuscitation room and majors area are full, but no ambulance is waiting to offload. There is a steady ten-minute wait for triage. The lead clinical site practitioner (LCSP) is concerned. In this example, patient safety in the ED is at risk from surge pressure and the red criteria of the site practitioner early warning system apply. Emergency care demand is beginning to outstrip hospital capacity and trust resources, and there is a high probability that, if the situation is not brought under control, exit block will occur. A senior clinical and operational response is needed to ensure the situation does not escalate. Community teams may be needed to assist with inpatient discharge. Elective pathways should be reviewed by associate directors, who should consider whether to initiate actions that affect capacity and patient flow.
Lessons learned In the 14 months since it was implemented, SPEWS has been gradually refined and is likely to be refined further over the next 12 months as the trust’s emergency care pathway evolves. Nevertheless, some lessons about its application to healthcare services have been learned, and perhaps the most salient and quantifiable of these is that the four-hour standard can be achieved through optimising patient safety. The inception of SPEWS has generated a number of adjacent projects to improve understanding of emergency patient flow and increase awareness of the relationship between operational performance and patient safety throughout the hospital. These projects include: ■ Deployment of specialist medical and nursing staff to offset clinical pressure in the ED. For example, the 24/7 clinical assistant team has been deployed to the triage rooms to assist with initial investigations, while the 24/7 critical care outreach team has been deployed to the resuscitation room to help manage high acuity patients or with the transfer of patients who need critical care. ■ Specialist review of referred patients within 30 minutes, for example by altering the hospital’s at-night team. The College of Emergency Medicine (2014) describes this process as ‘front-loading clinical expertise’. EMERGENCY NURSE
■ Deployment of adult community service staff in the acute medical unit or the ED rapid assessment and triage (RATT) rooms while patients are offloaded from ambulances. This allows the trust rapid response service to assess patients deemed to be medically fit and discharge them home safely with increased community based support, which can range from intravenous antibiotics to advanced wound care. ■ Development of an acute hospital escalation management training session based on the HMIMMS course curriculum and SPEWS protocol. The three-hour training session is endorsed by the trust’s chief operating officer and delivered by its EPRR officer.
Conclusion All NHS organisations that deliver emergency care must make patient flow more efficient. This requires the combined efforts of all staff to reduce hospital admissions, support earlier discharges, and prevent the unnecessary transit of patients from home to hospital to avoid overcrowding in EDs. Ultimately, the four-hour emergency care standard requires all trust directorates to meet a defined objective based on safe and efficient patient flow, and improvements to patient flow along emergency care pathways can be regarded as a benchmark of general hospital efficiency.
Case study 4: black At 10pm on a Monday, the lead clinical site practitioner (LCSP) reports that pressure has escalated and there are 80 patients waiting in the emergency department (ED). All resuscitation bays are occupied, the majors area has no vacant cubicles and there are no ambulances waiting to offload patients. There is no wait for triage. In this example, site integrity is compromised to the detriment of patient safety and the black criteria of the site practitioner early warning system (SPEWS) apply. The hospital command team, which comprises a senior ED nurse, senior ED doctor, senior manager and the LCSP, should meet within 30 minutes and draw up a plan to maintain patient safety and departmental integrity. This plan should be based on Advanced Life Support Group (2014) Major Incident Medical Management and Support principles, and should restore SPEWS red criteria as quickly and safely as possible. November 2014 | Volume 22 | Number 7 25
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Art & science | service pressures Croydon Health Services NHS Trust has found that the key to responding successfully to the complexity of emergency care pressure is to suppress the subjectivity associated with decision-making autonomy. SPEWS is not designed to replace clinical or operational judgement, but to provide a framework for responding to increasing demand. This is especially useful to staff who are not confident about, or competent in, managing emergency pressures, and who prefer to make a step-by-step response to escalation. CEM (2014) has stated that every NHS Trust with an ED should have the means to recognise and escalate pressures, and to manage them safely. Hospitals that intend to adopt CEM’s (2014) recommendation could create their own versions of SPEWS criteria to increase the
sensitivity of their emergency care pathways to demand. Decisions about the correct trigger thresholds and responses will depend on local conditions. Imagine being asked to prioritise the available resources of a complex, noisy and busy ED so that you balance patient safety with efficient operational performance. If you are unsure of how you would do it, perhaps it is time you adopted SPEWS.
Find out more The Croydon Health Services NHS Trust 2014 site practitioner early warning system policy document can be accessed at tinyurl.com/osluhhh
Online archive For related information, visit our online archive and search using the keywords
Acknowledgement The authors would like to thank members of the 24/7 team, emergency department team, and inpatient capacity and flow group for their help with implementing the site practitioner early warning system. He would also like to thank Queen Elizabeth Hospital, London, service manager John Ferguson for his contribution to its development Conflict of interest None declared
References Advanced Life Support Group (2014) Major Incident Medical Management and Support: Hospital. tinyurl.com/klxvq9f (Last accessed: October 17 2014.) Appleby J, Galea A, Murray R (2014) The NHS Productivity Challenge. tinyurl.com/ndsk96v (Last accessed: October 17 2014.) College of Emergency Medicine (2014) Crowding in Emergency Departments. tinyurl.com/b4pmawj (Last accessed: October 17 2014.) Croydon Clinical Commissioning Group (2013) Urgent and Emergency Care Plan 2013/14-2016/17: Summary for Members of the Public. tinyurl.com/mbbaxnd (Last accessed: October 17 2014.)
Croydon Health Services NHS Trust (2014) Annual Report 2012-2013. tinyurl.com/qxztfr5 (Last accessed: October 17 2014.) Department of Health (2004) Transforming Emergency Care In England. (Last accessed: tinyurl.com/nz9yao5 October 17 2014.) Geelhoed GC, de Klerk NH (2012) Emergency department overcrowding, mortality and the 4-hour rule in Western Australia. Medical Journal of Australia. 196, 2, 122-126. London Emergency Services Liaison Panel (2012) Major Incident Procedure Manual. Eighth edition. tinyurl.com/bm7pges (Last accessed: October 17 2014.)
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Moullin M, Copeland R (2013) Implementing and Evaluating Behaviour Change Programmes with the Public Sector Scorecard. tinyurl.com/n6dg56l (Last accessed: October 17 2014.)
NHS institute for Innovation and Improvement (2013) Commissioning for Quality and Innovation (CQUIN) Payment Framework. tinyurl.com/lcmqfsu (Last accessed: October 17 2014.)
NHS England (2012) Major Trauma Centres. tinyurl.com/cvsryed (Last accessed: October 17 2014.)
Royal College of Physicians (2012) National Early Warning Score (NEWS): Standardising the Assessment of Acute-Illness Severity in the NHS. tinyurl.com/kq6hccd (Last accessed: October 17 2014.)
National Institute for Health and Care Excellence (2007) Acutely Ill Patients in Hospital. Recognition of and Response to Acute Illness in Adults in Hospital. www. nice.org.uk/guidance/cg50 (Last accessed: October 17 2014.)
EMERGENCY NURSE
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JOSEPHINE G PATERSON
PREVENTING ‘EXIT BLOCK’ IN EMERGENCY DEPARTMENTS Kevin Cairney and Elaine Clancy explain how a site practitioner early warning system can alert urgent care staff to problems with capacity and patient flow Correspondence kevin.cairney@ croydonhealth.nhs.uk Kevin Cairney is head of nursing, 24/7 patient safety team Elaine Clancy is deputy chief operating officer Both at Croydon Health Services NHS Trust, London Date of submission October 1 2014 Date of acceptance October 16 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines rcnpublishing.com/r/ en-author-guidelines
Abstract Overcrowding due to poor patient flow increases risk for more than 500,000 patients a year (College of Emergency Medicine (CEM) 2014) and is linked to increased mortality (Geelhoed and de Klerk 2012). CEM (2014) has called for urgent action to address ‘exit block’ in UK emergency departments (EDs). In October last year, Croydon Health Services NHS Trust designed and implemented a site practitioner early warning system (SPEWS) to alert staff to capacity and flow pressures in the ED, and to initiate escalation to a nurse-led, protocol-driven response. Under pressurised and time-critical conditions, SPEWS ensures rigour and conformity in exchanges between clinical emergency care staff and managers. The result is closer collaboration between clinicians and managers, optimised patient flow and mitigated risk from exit block. Keywords Emergency services, clinical governance, inpatients, patient safety, early warning system, patient flow OVERCROWDING AS a result of poor patient flow in emergency departments (EDs) is linked to increased mortality (Geelhoed and de Klerk 2012), and reduces the capability of ED staff to anticipate surge pressures from adjacent emergency facilities, for example in the event of a major incident (London Emergency Services Liaison Panel 2012). As a result, the four-hour emergency care standard, introduced by the Department of Health (2004), continues as a
20 November 2014 | Volume 22 | Number 7
surrogate marker for a successful and efficient emergency care pathway. The NHS must provide safe patient care within the constraint of a public-sector efficiency drive and increased demand for services (Appleby et al 2014). Emergency care staff and operational managers are required to target resources at service pressure points and bottlenecks along the emergency care pathway, and can achieve these aims by use of an early warning system. Early warning systems are typically used in acute ward areas to help nursing staff to recognise deterioration in patients and escalate their care (Royal College of Physicians 2012). Staff who use these systems give scores based on patient physiology, whereby the further the physiology deviates from normal, the higher the score and the more senior or urgent the clinical response (Royal College of Physicians 2012). Because scores are made according to objective criteria, primary assessments are rarely subjective, and a protocol-driven and patient-focused approach can be adopted (National Institute for Health and Care Excellence (NICE) 2007). The principles of early warning systems can be applied to deteriorating EDs to achieve a ‘track and trigger’ escalation of surge pressures against an algorithm of optimal ED patient flow devised at Croydon Health Services NHS Trust. This algorithm has been adapted for Figure 1.
System development As an integrated healthcare organisation, Croydon Health Services NHS Trust is commissioned to deliver community and acute services to a EMERGENCY NURSE
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EMERGENCY NURSE
November 2014 | Volume 22 | Number 7 21
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Art & science | acute servicecare pressures Figure 1 Optimal emergency department patient flow algorithm 0 Emergency department (ED) nurse triages patient or Initiates rapid assessment treatment and triage and Orders baseline clinical investigations 15
ED nurse refers patient to specialty team or If patient was referred by a GP, notifies specialty team or Implements ambulatory care pathway
30
45
ED doctor, advanced nurse practitioner, emergency nurse practitioner or speciality doctor makes first assessment and Makes further clinical investigations if necessary
Minutes after patient referral
60
75
90
105
ED doctor discharges patient or refers to speciality and ED nurse in charge (NIC) contacts clinical site practitioner (CSP) to make provisional bed request or EDNIC contacts discharge lounge to retrieve patient
120
135 150
EDNIC contacts CSP to confirm that a speciality bed is available
165 180 195 210
EDNIC transfers patient within 15 minutes of the CSP allocating a bed
225 240 (Adapted from Croydon Health Services NHS Trust 2014)
22 November 2014 | Volume 22 | Number 7
diverse population of 363,400 (Croydon Clinical Commissioning Group 2013). Acute services are concentrated at the Croydon University Hospital site, a district general hospital with about 430 inpatient beds. The ED is not a major trauma centre (NHS England 2012), but it is one of the busiest departments in London, and its staff care for between 300 and 350 adult and paediatric type 1 presentations a day (Croydon Clinical Commissioning Group 2013). In 2013/14, 95.35% of patients in the ED were seen, treated and discharged or referred within four hours, thereby exceeding the emergency care standard. This was achieved in part by the introduction of a site practitioner early warning system (SPEWS) to measure safe emergency patient flow, and to ensure timely assessments and clinical interventions in the ED. The SPEWS offers the trust an objective approach to anticipating and managing capacity and flow pressures in the ED, and has enabled trust staff to reduce ‘exit block’, or the inability to reduce overcrowding in EDs, as recommended by the College of Emergency Medicine (CEM) (2014). SPEWS, which has been adapted for Table 1, is a grid with four colour-coded tracker rows, and two columns of triggers and actions. The tracker rows have traffic-light colours to indicate the condition of the department at any one time. Green indicates that the department is functioning normally, amber that the department is functioning but under pressure, red that business continuity is compromised and patient safety is at risk. There are also black tracker criteria, defined in Croydon Health Services’ hospital major incident medical management and support (HMIMMS) procedure, that signify that the department cannot function and site integrity is compromised. When three trigger criteria are met in any of the first three tracking rows, the ED senior nurse contacts the lead clinical site practitioner (LCSP), who in turn initiates step-by-step responses by specific members of staff. In extreme situations, when SPEWS red or black tracker row criteria are met, the trust’s community teams support senior nurses and decision-making doctors to expedite ward discharges and increase inpatient capacity. When the black trigger criteria are met, ED resources have been outstripped by demand to the detriment of patient safety, which is defined by many NHS trusts as an internal major incident. Because SPEWS is part of the trust’s clinical governance programme, its protocol-driven criteria are ratified at board level. These criteria ensure EMERGENCY NURSE
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Table 1 Site practitioner early warning system
Department is functioning normally Department is functioning but under pressure Business continuity compromised and patient safety is at risk Department cannot function. Site integrity is compromised
Black
Red
Amber
Green
Trackers
Trigger criteria: at least three must apply
Actions
■ Ambulance handovers take less than 15 minutes. ■ More than two trolley spaces in resuscitation room. ■ More than five trolley spaces in majors area. ■ More than 20 patients in the department1. ■ The emergency department flow algorithm (EDFA) timeline can be maintained. ■ Triage wait time is less than 15 minutes. ■ Bed predictor result is greater than zero.
■ ED nurse in charge (NIC) to attend inpatient capacity and flow (IPCF) meetings. ■ Majors co-ordinator and area nurse to fulfil their roles and responsibilities. ■ EDNIC to adhere to EDFA. ■ Clinical site practitioner (CSP) to update the capacity management system (CMS) every two hours.
■ Ambulance handovers take more than 15 minutes. ■ More than two trolley spaces in resuscitation room. ■ More than two trolley spaces in majors area. ■ More than 40 patients in the department1. ■ Triage wait time is less than 15 minutes. ■ Bed predictor result is no less than -10 after 1pm.
After green tracker actions have been carried out, EDNIC to: ■ Contact speciality on-call senior practitioner to expedite any review. ■ Ensure patients are admitted in order of clinical need and then waiting time. ■ Report any EDFA compromise to ED matron and CSP. CSP to: ■ Contact duty manager. ■ Update CMS to reflect current status of department. ■ Discuss contacting local ambulance service duty station officer (DSO) with EDNIC. ■ Liaise with head of nursing (HoN) of 24/7 team or deputy2. Senior manager to: ■ Chair IPCAF meeting to consider opening additional escalation areas. ■ Allocate senior nurse lead for escalation procedures.
■ Ambulance handovers take between 40 and 60 minutes. ■ Fewer than two trolley spaces in resuscitation room. ■ Fewer than two trolley spaces in majors area while escalation beds are open. ■ More than 50 patients in the department1. ■ Triage wait time is less than 30 minutes. ■ Bed predictor result is between -11 and -20 after 1pm.
After green and amber tracker actions have been carried out, ED senior doctor to: ■ Consider contacting ED on-call consultant. ■ Review ED referrals with on-call teams and consider consultant-led direct referral. ■ Conduct additional board rounds3. CSP to: ■ Deploy 24/7 team’s clinical assistant and resuscitation practitioners to ED. ■ Consider contacting the local ambulance service DSO. ■ Liaise with integrated discharge team to review potential discharges. ■ Liaise with discharge lounge for nurse-level trawl of definite discharges. Senior manager to: ■ Consider whether on-call manager4 or on-site director should work out of hours. ■ Inform deputy chief operating officer (DCOO) or deputy. ■ Consider activating rapid-response service5. ■ Consider contacting community cluster matron if referring to relevant services. ■ Attend ED or acute medical unit if required. Assistant director of operations to: ■ Consider review of elective list and plans to admit patients from other hospitals. ■ Contact clinical teams and initiate consultant-led review to expedite discharges on the day and review those expected on the next day.
■ Ambulance handovers take longer than 60 minutes. ■ No trolley spaces in resuscitation room. ■ No trolley spaces in majors area and escalation beds open. ■ At least 60 patients in the department. ■ Bed predictor result is -21 or less after 1pm.
Within 15 minutes: ■ Administrative support should be established. ■ A hospital command team (HCT) comprising senior ED doctors, nurses and managers, and the CSP, should be formed. ■ The HoN’s 24/7 team and DCOO should be informed of the declaration. Within 30 minutes: ■ The HCT should meet in CSP’s office. ■ Local ambulance service DSO should be informed. If ambulance service declares a major incident: ■ HCT should consider announcing hospital major incident medical management.
Includes paediatric department and urgent care centre 2Head of nursing of 24/7 team or deputy work during office hours 3Emergency department consultant board rounds are normally at 9am, 1pm, 4pm and 8pm 4The on-call manager is available between 5pm and 8.30am 5Adult patients are referred to the rapid-response service only if they are medically stable with no need for inpatient care, are registered with a local GP, and can be managed at home with additional support. The community cluster matron must be alerted before each referral.
1
(Adapted from Croydon Health Services NHS Trust 2014)
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Art & science | acute servicecare pressures Case study 1: green At 10am on Tuesday, the lead clinical site practitioner (LCSP) reports that four patients in the emergency department (ED) require inpatient beds in the next two hours. There is one intubated patient and four empty bays in the resuscitation room, four cubicles available in the majors area and no ambulances are waiting to offload. Patients are waiting ten minutes for triage In this example, the ED is functioning normally and the green criteria of the site practitioner early warning system (SPEWS) apply. Acuity in the resuscitation room and unplaced patients awaiting admission do not influence SPEWS unless exit-block occurs and ED capacity is reduced. Therefore the ED nurse need only maintain departmental flow and ensure routine tracking assessments are relayed to the LCSP. that all clinical and operational personnel involved in emergency care pathways respond proactively and are fundamental to timely responses to clinical escalation. Such proactive responses are important because staff who adopt a reactive response to pressurised situations often make sub-optimal decisions (Moullin and Copeland 2013), which in the context of emergency care can compromise patient safety. Rescue actions taken to create capacity and increase patient flow are prescriptive and, because they are initiated and controlled by senior clinical and operational staff, conform to the HMIMMS procedure (Advanced Life Support Group 2014). The actions are initiated by an inpatient capacity and flow (IPCAF) group, or bed group, chaired by the LCSP, and including the ED nurse in charge (EDNIC) and senior manager. Bed group meetings, which are held three times a day, are attended by senior nursing and managerial staff from the discharge lounge and critical care outreach teams, who are selected for the contributions they have made to elective and emergency care pathways, meeting the four-hour standard and preventing the cancellation of elective procedures. SPEWS is informed by the trust’s IPCAF operational policy on safe patient flow and care, which has contributed to a reduction of in-hospital cardiac arrest by 25% and unplanned intensive care unit admissions by 20% (Croydon Health Services NHS Trust 2014). Meanwhile, the NHS Institute for Innovation and Improvement (2013) commissioning for quality and innovation payment 24 November 2014 | Volume 22 | Number 7
framework acts a surrogate marker for the 24/7 team to reduce unexpected admission to the intensive care unit (ICU). Like in many district general hospitals, the LCSP is a single-point of contact for operational escalation to an on-call senior manager during the out-of-hours (OOH) period, and the OOH management of SPEWS depends primarily on the working relationship between the LCSP and on-call manager. The on-call senior manager is supported by an on-call director and a range of non-resident consultants as part of the trust’s resilience management programme run by the trust’s emergency planning, resilience and response (EPRR) officer. The corporate impetus behind SPEWS, therefore, was the need for consistent and timely communication throughout the emergency care pathway. From a staff perspective, SPEWS provides a scheme of comprehensive initial actions to deliver a timely response, maintain the operational integrity of the ED and hospital, and ensure patient safety. Because Croydon Health Services NHS Trust is an integrated care organisation, protocols such as SPEWS are followed by staff in and outside hospital.
Case studies The case studies on pages 24 and 25 demonstrate how ED clinical staff have referred to SPEWS when responding to escalation.
Case study 2: amber At 1pm on a Friday, the emergency department (ED) nurse in charge states at a bed meeting that there are 49 patients in the ED. The resuscitation room has four available bays, the majors area has two vacant cubicles and four ambulances are waiting to offload. Patients are waiting 25 minutes for triage. The ED consultant says that the ED is becoming unsafe. In this example, the ED is functioning but under pressure and the amber criteria of the site practitioner early warning system (SPEWS) apply. This means that, according to SPEWS, the ED is not yet unsafe. The ED nurse in charge, lead clinical site practitioner and senior managers have parts to play in restoring green SPEWS criteria or priming the ED for SPEWS red criteria. This involves ensuring triage takes less than 15 minutes per patient, and keeping the bed group informed about increasing or decreasing surge pressures. EMERGENCY NURSE
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Case study 3: red At 4pm on a Thursday, the emergency department (ED) nurse in charge reports that there are 55 patients in the ED, which means it is busy, although no patient is unplaced. The resuscitation room and majors area are full, but no ambulance is waiting to offload. There is a steady ten-minute wait for triage. The lead clinical site practitioner (LCSP) is concerned. In this example, patient safety in the ED is at risk from surge pressure and the red criteria of the site practitioner early warning system apply. Emergency care demand is beginning to outstrip hospital capacity and trust resources, and there is a high probability that, if the situation is not brought under control, exit block will occur. A senior clinical and operational response is needed to ensure the situation does not escalate. Community teams may be needed to assist with inpatient discharge. Elective pathways should be reviewed by associate directors, who should consider whether to initiate actions that affect capacity and patient flow.
Lessons learned In the 14 months since it was implemented, SPEWS has been gradually refined and is likely to be refined further over the next 12 months as the trust’s emergency care pathway evolves. Nevertheless, some lessons about its application to healthcare services have been learned, and perhaps the most salient and quantifiable of these is that the four-hour standard can be achieved through optimising patient safety. The inception of SPEWS has generated a number of adjacent projects to improve understanding of emergency patient flow and increase awareness of the relationship between operational performance and patient safety throughout the hospital. These projects include: ■ Deployment of specialist medical and nursing staff to offset clinical pressure in the ED. For example, the 24/7 clinical assistant team has been deployed to the triage rooms to assist with initial investigations, while the 24/7 critical care outreach team has been deployed to the resuscitation room to help manage high acuity patients or with the transfer of patients who need critical care. ■ Specialist review of referred patients within 30 minutes, for example by altering the hospital’s at-night team. The College of Emergency Medicine (2014) describes this process as ‘front-loading clinical expertise’. EMERGENCY NURSE
■ Deployment of adult community service staff in the acute medical unit or the ED rapid assessment and triage (RATT) rooms while patients are offloaded from ambulances. This allows the trust rapid response service to assess patients deemed to be medically fit and discharge them home safely with increased community based support, which can range from intravenous antibiotics to advanced wound care. ■ Development of an acute hospital escalation management training session based on the HMIMMS course curriculum and SPEWS protocol. The three-hour training session is endorsed by the trust’s chief operating officer and delivered by its EPRR officer.
Conclusion All NHS organisations that deliver emergency care must make patient flow more efficient. This requires the combined efforts of all staff to reduce hospital admissions, support earlier discharges, and prevent the unnecessary transit of patients from home to hospital to avoid overcrowding in EDs. Ultimately, the four-hour emergency care standard requires all trust directorates to meet a defined objective based on safe and efficient patient flow, and improvements to patient flow along emergency care pathways can be regarded as a benchmark of general hospital efficiency.
Case study 4: black At 10pm on a Monday, the lead clinical site practitioner (LCSP) reports that pressure has escalated and there are 80 patients waiting in the emergency department (ED). All resuscitation bays are occupied, the majors area has no vacant cubicles and there are no ambulances waiting to offload patients. There is no wait for triage. In this example, site integrity is compromised to the detriment of patient safety and the black criteria of the site practitioner early warning system (SPEWS) apply. The hospital command team, which comprises a senior ED nurse, senior ED doctor, senior manager and the LCSP, should meet within 30 minutes and draw up a plan to maintain patient safety and departmental integrity. This plan should be based on Advanced Life Support Group (2014) Major Incident Medical Management and Support principles, and should restore SPEWS red criteria as quickly and safely as possible. November 2014 | Volume 22 | Number 7 25
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Art & science | service pressures Croydon Health Services NHS Trust has found that the key to responding successfully to the complexity of emergency care pressure is to suppress the subjectivity associated with decision-making autonomy. SPEWS is not designed to replace clinical or operational judgement, but to provide a framework for responding to increasing demand. This is especially useful to staff who are not confident about, or competent in, managing emergency pressures, and who prefer to make a step-by-step response to escalation. CEM (2014) has stated that every NHS Trust with an ED should have the means to recognise and escalate pressures, and to manage them safely. Hospitals that intend to adopt CEM’s (2014) recommendation could create their own versions of SPEWS criteria to increase the
sensitivity of their emergency care pathways to demand. Decisions about the correct trigger thresholds and responses will depend on local conditions. Imagine being asked to prioritise the available resources of a complex, noisy and busy ED so that you balance patient safety with efficient operational performance. If you are unsure of how you would do it, perhaps it is time you adopted SPEWS.
Find out more The Croydon Health Services NHS Trust 2014 site practitioner early warning system policy document can be accessed at tinyurl.com/osluhhh
Online archive For related information, visit our online archive and search using the keywords
Acknowledgement The authors would like to thank members of the 24/7 team, emergency department team, and inpatient capacity and flow group for their help with implementing the site practitioner early warning system. He would also like to thank Queen Elizabeth Hospital, London, service manager John Ferguson for his contribution to its development Conflict of interest None declared
References Advanced Life Support Group (2014) Major Incident Medical Management and Support: Hospital. tinyurl.com/klxvq9f (Last accessed: October 17 2014.) Appleby J, Galea A, Murray R (2014) The NHS Productivity Challenge. tinyurl.com/ndsk96v (Last accessed: October 17 2014.) College of Emergency Medicine (2014) Crowding in Emergency Departments. tinyurl.com/b4pmawj (Last accessed: October 17 2014.) Croydon Clinical Commissioning Group (2013) Urgent and Emergency Care Plan 2013/14-2016/17: Summary for Members of the Public. tinyurl.com/mbbaxnd (Last accessed: October 17 2014.)
Croydon Health Services NHS Trust (2014) Annual Report 2012-2013. tinyurl.com/qxztfr5 (Last accessed: October 17 2014.) Department of Health (2004) Transforming Emergency Care In England. (Last accessed: tinyurl.com/nz9yao5 October 17 2014.) Geelhoed GC, de Klerk NH (2012) Emergency department overcrowding, mortality and the 4-hour rule in Western Australia. Medical Journal of Australia. 196, 2, 122-126. London Emergency Services Liaison Panel (2012) Major Incident Procedure Manual. Eighth edition. tinyurl.com/bm7pges (Last accessed: October 17 2014.)
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Moullin M, Copeland R (2013) Implementing and Evaluating Behaviour Change Programmes with the Public Sector Scorecard. tinyurl.com/n6dg56l (Last accessed: October 17 2014.)
NHS institute for Innovation and Improvement (2013) Commissioning for Quality and Innovation (CQUIN) Payment Framework. tinyurl.com/lcmqfsu (Last accessed: October 17 2014.)
NHS England (2012) Major Trauma Centres. tinyurl.com/cvsryed (Last accessed: October 17 2014.)
Royal College of Physicians (2012) National Early Warning Score (NEWS): Standardising the Assessment of Acute-Illness Severity in the NHS. tinyurl.com/kq6hccd (Last accessed: October 17 2014.)
National Institute for Health and Care Excellence (2007) Acutely Ill Patients in Hospital. Recognition of and Response to Acute Illness in Adults in Hospital. www. nice.org.uk/guidance/cg50 (Last accessed: October 17 2014.)
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