What is the problem?
Crowding is mainly caused by exit block - when patients cannot move on to the next stage of their treatment. This is usually because the acute hospital does not have enough beds to admit their patients.
Emergency Departments across the UK are overcrowded. The number of patient attendances increases every year, with roughly a third of these patients requiring admission to a hospital bed.
However, the physical size of hospitals and departments have not increased with most now stretched beyond the capacity they were designed and resourced to manage at any one time. Bed numbers within hospitals have reduced consistently over several years.
The result of this is that many patients are being cared for in corridors, as there are no available beds to admit them to – the hospitals are full. This is inhumane and undignified for patients and puts huge pressure on staff, as Emergency Departments are not resourced or designed for this type of care.
Staff are then less able to provide safe, timely and efficient care to those patients, and any subsequent patients who attend the department, resulting in further overcrowding. Ambulances then cannot offload, meaning longer waits for these patients.
Patients who are admitted through crowded EDs are more likely to end up on the wrong sort of ward and have a longer hospital stay.
Many patients are being kept in hospital for longer than necessary due to a lack of social care. While medically fit to leave, many patients need help to recover in the form of a social care package, which may not be immediately available. This means that their hospital bed is unavailable to the next patient, resulting in further ED crowding.
Crowding is consistently linked with lower quality care for patients and increased mortality, with elderly and vulnerable patients most affected.
What is the solution and who should take action?
- Increase the staffed acute bed capacity in hospitals to maintain flow in Emergency Departments. We estimate that around 5,000 extra staffed beds are needed across the UK to achieve 85% bed occupancy, which allows adequate flow. This will need to increase alongside population growth.
- In England, invest at least £4.4 billion in adult social care by 2023/4 so hospitals are able to discharge people promptly when their medical care is complete.
- Set, monitor, and review metrics that promote patient flow and prioritise care of the most seriously ill and injured patients.
- Introduce a metric which monitors and improves ambulance offload times.
- Replace the 12-hour Decision to Admit metric with a metric on 12-hour stays from point of registration. No patient should need to stay in an Emergency Department for over 12 hours.
- Research and benchmarking are required to ascertain the optimum level of clinical involvement with call handling.
- Improve clinician involvement with call handling services. Referral rates drop if there is ready access to an experienced clinician to provide advice.
- Performance standards should be a hospital wide priority.
- Hospital wide acute services need to match patient need throughout the whole week.
- Internal Professional Standards should be negotiated and delivered.
- Ensure patients can be discharged promptly from inpatient wards throughout the week, focussing on improvements in daylight and weekend discharges.
- Agree and evaluate escalation plans during times of overcrowding with the Trust Board
EM Clinical Leads
- Advocate on behalf of patients on the harms that are caused by crowding.