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Emergency departments must not return to the way they were before the coronavirus crisis with widespread overcrowding and patient and staff safety put at risk, according to emergency care leaders.
The Royal College of Emergency Medicine (RCEM) has warned that people will die if the sector simply goes back to the old way of doing things and has called for a major “reset” of emergency care.
“Going back to how we used to operate is not an option – patients will die if we do”
In a position statement, see attached below, the college set out its recommendations to help prevent further transmission of coronavirus in emergency care, including the need to ensure appropriate personal protection equipment (PPE) for staff.
It also highlighted the need to build on new and innovative ways of working introduced because of Covid-19 in order to reform and improve emergency care going forward.
“Going back to how we used to operate is not an option – patients will die if we do,” said RCEM president Dr Katherine Henderson.
“It was just four months ago when we were seeing overcrowding on a record scale in emergency departments. It was unacceptable then and put lives at risk; to go back to that now will lead to avoidable patient and staff illness or death,” she added.
The Resetting Emergency Department Care position statement sets out five key aims including the goal that A&E departments “must not become crowded ever again”.
There was a “moral imperative” to ensure overcrowding was a thing of the past, the document stated.
“If departments are crowded, we cannot protect patients and staff. Crowding has long been associated with avoidable mortality, and Covid-19 reinforces and multiplies this risk,” said Dr Henderson.
The document also stressed that departments must not “become reservoirs of nosocomial infection” – infections that are contracted within hospitals and other healthcare settings.
“We must have a way to enforce social distancing in emergency departments to ensure that patients do not become infected while seeking healthcare,” said Dr Henderson.
“If supermarkets can get this right, then the very institution that people entrust with their health must do so too,” she added.
Other key goals include ensuring emergency departments are designed to look after vulnerable patients safely and are safe places to work for staff.
The position sets out six key areas for action in order to ensure safety, including improving infection control.
Recommendations include the need to assume all patients who come in via an ambulance or turn up at A&E may have a contagious infection.
“This may mean an end to the waiting room as we know it,” said the document.
It also stressed the need for appropriate levels of PPE for staff and said any outbreaks of hospital-acquired infection affecting staff and vulnerable patients “must be unacceptable”.
“Tests with rapid turnaround of results should be readily available to ensure patients are nursed in appropriate areas of the hospital if admitted,” said the document.
Meanwhile it was important to bear in mind that standard tasks such as taking a patient history, examining them and organising tests would take longer due to segregation of departments and the need to put on, take off and dispose of PPE.
Another key goal was to ensure hospitals as a whole did not return to being overcrowded.
“We have seen significant improvements in the way emergency care has been managed”
Hospital occupancy had fallen due to a combination of fewer “medically fit” patients remaining in hospital, different admission and discharge thresholds, improvement in pathways within hospital and reduction in elective surgery, said the document.
“This illustrates that delayed transfers of care and the resulting exit block is not an insoluble problem and can be fixed where there is a political, financial, managerial and clinical will,” it said.
Dr Henderson said it was vital lessons were learned from the Covid-19 response which had seen a rapid expansion of bed capacity and a “breaking down of barriers” that had seen “different parts of the hospital working better together than ever before”.
She also highlighted changes to discharge practices, better use of same day emergency care and the NHS 111 service.
“All this has resulted in a much more responsive emergency care system,” she said.
She went on to stress that emergency departments must return to their core purpose – the rapid assessment and stabilisation of seriously ill and injured patients.
“They can no longer be used to cover where community, ‘out of hours’, or specialist care has struggled to cope,” she said.
However, she acknowledged this would require leadership at national, regional and local level and changes in the behaviour of the public and within the wider health system including increased investment in primary care and social services.
The NHS Confederation, which represents healthcare organisations, agreed it was important to seize the opportunity to make major improvements to the way services were planned, commissioned and delivered.
“We have seen significant improvements in the way emergency care has been managed in recent weeks but we know the numbers of patients going to their local A&E will ramp up again,” said Dr Layla McCay, director at the NHS Confederation.
“We need to capture the innovations we have seen, such as establishing mental health crisis helpline services and increasing ‘hear and treat’ and ‘see and treat services’ by ambulance staff which means fewer people need to be taken to hospital by ambulance,” she added.
The NHS Confederation is encouraging nurses and others to discuss the future of health and social care on social media using the hashtag #NHSReset.
“We will need to build on the integration of primary care, community services and urgent and emergency services we have seen over recent weeks,” said Dr McCay.
“The challenge will be to make sure that these new services or ways of working are safe for patients and produce the clinical outcomes we want to see,” she added.