Royal College of Emergency Medicine – Page 3 – The NEN

Tip of the Iceberg: New report exposes real number of A&E waits

Over 1,000 patients faced a 12-hour wait in A&E every day in 2021

A new report by The Royal College of Emergency Medicine ‘Tip of the Iceberg: 12-Hour Stays in the Emergency Department’ reveals that on average 1,047 patients waited 12-hours or more from their time of arrival every day in a major Emergency Department in 2021 in England, equalling a total of 381,991 patients experiencing these 12-hour waits in 2021.

There is a total of 124 NHS Trusts in England. The College received responses from 74 NHS Trusts that were contacted. The figures above are only representative of 60% of NHS Trusts in England. The true total figure of 12-hour waits from time of arrival in major Emergency Departments in England in 2021 will be even higher.

These figures show the deep crisis facing the NHS and the Urgent and Emergency Care system. The alarming number of 12-hour waits are an indicator of the serious and dangerous levels of crowding occurring in Emergency Departments.

Crowding is unsafe, inhumane, and undignified for patients, our previous report Crowding and its Consequencesfound that patients can come to associated harm and even death.

The NHS in England currently measures 12-hour waits from decision to admit (DTA). The Decision to Admit is the decision to admit a patient to a hospital bed made by a clinician. Measuring from decision to admit is a gross underrepresentation of the reality of patient waits, as many patients will have already waited for a long period in a busy Emergency Department before this decision is made.

12-hour DTA waits have been increasing substantially, so much so that in the first four months of 2022 alone (January – April 2022) there were a total of 79,610 12-hour DTA waits; nearly as many as the cumulative total of the 11 years since data collection began (82,746 12-hour DTA waits between August 2010 – December 2021). It is evident that while the pandemic has contributed to the current situation somewhat, long waiting times have clearly been rising for over a decade.

Our recent report Beds in the NHS found that 25,000 staffed beds have been lost since 2010/11 and this has contributed to the steady increase in long waiting times in Emergency Departments since 2010/11 as detailed in Tip of the Iceberg.

Commenting on the FOI findings, Dr Adrian Boyle, Vice President of The Royal College of Emergency Medicine, said: “These figures are staggering and show the critical state of the Urgent and Emergency Care system.

“They also make clear that measuring 12-hour waits from decision to admit masks the reality facing patients and staff. Clearly, it is misleading to measure 12-hour waits in this way, and it is detrimental to staff efforts to improve A&E waiting times.

“NHS England have previously promised to make 12-hour data measured from time of arrival in the Emergency Department public and publish it alongside monthly NHS performance figures. We are still waiting for them to fulfil their promise.

“We recently wrote to Amanda Pritchard, Chief Executive of NHS England, about this, questioning why the data has not yet been published and when it will be. We have not received a response. Until it is published the NHS cannot hope to drive meaningful change and improvement in Emergency Care. Publishing this data will bring about greater accountability, and help all stakeholders understand the extent of crowding, long stays, and corridor care.

“NHS England must publish 12-hour data from time of arrival as a matter of urgency, this is the first step towards meaningfully tackling this crisis. At present, we fear that the full scale of this crisis is either being ignored or inadvertently misunderstood by the government.

“To truly tackle the problem, you must understand the scale of the task at hand. This data should facilitate better understanding of the challenges facing Urgent and Emergency Care and the wider health system and allow us to take the steps towards tackling it.

“In the short-term, the government must set out a meaningful plan for social care that includes recruitment and investment in the social care workforce and paying a wage that values and reflects significance of their role.

“In the medium-term, the government must finally commit to publishing a fully funded long-term workforce plan that recruits new staff into the health service and includes measures to retain existing staff who are burned out and questioning their careers. Then will it be possible to open the 13,000 staffed beds required to drive meaningful improvement within the health service.

“The health service is failing, and failure to act will take it deeper into crisis and inevitably lead to another ‘worst winter on record’ and further patient harm. The government can talk about phantom new hospitals all it likes, but political unwillingness to tackle the deepest health crisis in NHS history costs; the cost is both deteriorating patient health and patient lives, and an undervalued workforce struggling to deliver.”

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Emergency: New report shows 13,000 staffed beds required across the NHS

Of 25,000 beds taken out of active service across the UK since 2010, 4,227 have been lost in Scotland

A new report by The Royal College of Emergency Medicine ‘Beds in the NHS’ shows that 13,000 staffed beds are required in the NHS across the UK to drive meaningful change and improvement.

Meaningful change and improvement would constitute a significant improvement in A&E waiting times, ambulance response times, ambulance handover delays, and a return to safe bed occupancy levels.

The report details that since 2010/2011 the NHS has lost almost 25,000 beds across the United Kingdom, and since then the health service and its staff have faced accumulating pressures resulting in a sharp increase in long-waiting times, ambulance handover delays, delayed ambulance response times, cancelled elective care operations, and unsafe bed occupancy levels. This has also had severe consequences on mental health care provision.

The College has stated that the current crisis is both a patient safety crisis and a workforce crisis. The fall in bed numbers and deteriorating metrics have a real terms impact on patient care. The health service is not functioning as it should, the challenging circumstances mean that staff are unable to provide the quick and effective high-quality care they are trained to provide. Patients are distressed by long-waiting times, as are staff who face increasing levels of burnout, exhaustion, and moral injury.

Dr Adrian Boyle, Vice President of The Royal College of Emergency Medicine, said:

“The Urgent and Emergency Care system is in crisis. The situation is dire and demands meaningful action. Ultimately, there are widespread staffing shortages leading to a shortage of staffed beds in the system. Our latest report “Beds in the NHS” shows that 13,000 staffed beds are required in the NHS across the UK to drive actual change and meaningful improvement.

“Since 2010/11 the NHS has lost 25,000 beds across the UK, as a result bed occupancy has risen, ambulance response times have risen, A&E waiting times have increased, cancelled elective care operations have increased. All evidenced by the fall in four-hour performance, the increase in 12 hour waits, the increase in delayed ambulance response times and rise in ambulance handover delays.

“In April 2022 in England, 24,000 patients were delayed by 12 hours or more (from decision to admit to admission), in April in Scotland, 4,000 patients faced a 12 hour wait (from time of arrival), in Wales, 11,000 patients faced a 12 hour wait (from time of arrival), and in March 2022 in Northern Ireland, 8,581 patients faced a 12 hour wait (from time of arrival).

“These numbers are grim; they should shock all health and political leaders. These numbers translate to real patient harm and a serious patient safety crisis. The health service is not functioning as it should and the UK government must take the steps to prevent further deterioration in performance and drive meaningful improvement, especially ahead of next winter.”

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RCEM: ‘Now is the time for an Urgent and Emergency Care plan’

Responding to the latest Emergency Department performance figures published by NHS England for April 2022, Dr Katherine Henderson, President of the Royal College of Emergency Medicine, said: “The crisis in Urgent and Emergency Care continues to deteriorate.

“The data show 24,000 patients were delayed in an Emergency Department for 12-hours or more (from decision to admit to admission). This is a staggering and grim number and should seriously alarm all political and health leaders. Patients are coming to harm; now is the time for an Urgent and Emergency Care plan to tackle this crisis.

“The situation is more serious than it has ever been. Patients face long waits for an ambulance, long waits in an ambulance outside an Emergency Department, and long waits in the Emergency Department. These long waits delay care and treatment to patients who may be in a critical condition, and they prevent our highly skilled paramedics from returning to the community and responding to urgent and emergency calls.

“At the heart of the issue are reduced bed capacity in hospitals mixed with an increase in the number long-stay patients – social care patients who do not have sufficient support to return home or to the community – and widespread workforce shortages throughout the system.

“To tackle the crisis the government must publish a fully funded workforce plan that includes measures to retain existing staff, and open 10,000 more beds across the UK.”

Responding to the government’s announcement of more funding for nursing in care homes, Dr Henderson continued: “This announcement is welcome. Social Care nurses have long been undervalued and under-acknowledged. This increase in pay is a welcome step towards showing them the appreciation and gratitude they highly deserve.

“However, it is a shame to see that this increase in funding is limited to NHS-funded nursing care. The entire social care workforce deserves the same acknowledgement and reward. It is critical that during this crisis we attract and retain social care workers and value their time and effort by paying a wage that reflects the significance of their role.

“Good social care supports an efficient health service. Good social care can help prevent A&E attendances. Good social care will support patients moving in and out of hospital in a timely way. Crucially, good social care frees up space for other patients and increases flow throughout the hospital.”

Royal College: Urgent and Emergency Care ‘in dire crisis’

RCEM urges action to address failing A & E system

The latest monthly Emergency Department (Major EDs) performance figures for Scotland for February 2022 show:

There were 95,692 attendances
Four-hour performance was 71.7%, 1.9% lower than the previous month, January 2022, and the second lowest on record
27,087 patients were delayed by four hours or more, this is means more than one in four patients were delayed by four hours or more
6,248 patients were delayed by eight hours or more
2,230 patients were delayed by 12 hours or more, this represents the highest proportion of attendances experiencing 12 hour waits since records began

Dr John Thomson, Vice President of the Royal College of Emergency Medicine Scotland, said: “The crisis in Urgent and Emergency Care is dire. The health system in Scotland is ceasing to function as it should. Patients are at risk of severe harm and staff are facing stress, distress, burnout and moral injury on a daily basis.

“This is unsustainable and dangerous. The first step to tackling this crisis is opening 1,000 beds that are desperately needed across the system and recruiting senior decision makers in Emergency Medicine. In addition, the crisis in social care, which is resulting in the most vulnerable patients residing in hospital for extremely long periods of time before being discharged means that the system is unable to cope.

“This patient safety crisis must be a priority for the Scottish Government, and they must take meaningful action now before more patients come to severe harm.”

One in four ambulances delayed 30 minutes or more as Emergency Care falls deeper into crisis

The latest Winter Sitrep data for the week ending 27 March show:

There were 79,588 ambulance arrivals, 2.7% less than the previous week.
More than one quarter of ambulances experienced delays of 30 minutes or more, equal to 21,051 ambulances – an increase of 7.4% on the previous week
This is the highest proportion of ambulance delays on record
More than one in nine ambulances were delayed by more than 60 minutes, a 10.2% increase on the previous week, setting a new record high for this reporting period.
The average number of delays for this winter has continued to creep up, increasing from 0.3% up to 21.3%. The previous highest weekly average number of delays was 14.3% in 2019-20.

The Royal College of Emergency Medicine and The College of Paramedics have collaborated on this Ambulance Handover Options Appraisal guidance that details the ways in which Paramedics and Emergency Medicine staff can reduce ambulance handover delays.

Dr Ian Higginson, Vice President of The Royal College of Emergency Medicine, said: “The data show Emergency Department crowding, long “hidden” within the walls of EDs, has become more visible as handover delays have dramatically increased, leading to ambulances waiting outside EDs with their patients still inside.

“It is vital that ambulances return to active service whenever possible and safe to do so. Delaying ambulance handovers should be a last resort. Holding patients in ambulances leads to unnecessary delays to their care, leaving seriously ill or injured patients in the community requiring an ambulance to wait longer.

“Ambulance handover delays are almost entirely caused by dangerous crowding in Emergency Departments. The root cause of these problems is “exit block” where there are delays for patients to be admitted to inpatient beds from the ED. Patients suffer harm or die unnecessarily when they cannot get an ambulance in time, when they are held in ambulances on arrival in ED, or when they are treated in crowded EDs.

“Emergency Departments must have sufficient capacity to meet demand, and constant flow from the Emergency Department into inpatient beds, otherwise they will not be able to keep patients and staff safe. This means that risk must be properly shared within organisations, and through systems.

“When this does not happen leadership teams tend to look for mitigation. Unfortunately, this mitigation is usually focused at the front door of the hospital, rather than being directed at the root cause of the problem. The Royal College and The College of Paramedics have produced this joint guidance to support good decision making when managing ambulance handover delays in an effort to tackle ambulance handover delays and dangerous Emergency Department crowding.”

Tracy Nicholls, Chief Executive of The College of Paramedics, said: “We hear from our members how consistently challenging this situation is and, whilst we can see that paramedics, ambulance clinicians and hospital ambulance liaison officers are doing everything they can, the system is now at breaking point.

“Those who need an ambulance are continuing to wait an unacceptable length of time and those paramedics and ambulance clinicians who are running to their next job can clearly see how long their next patient has been waiting and know they are going to be met with frustration, anxiety or fear.

“It seems incongruous that additional measures are being taken at the front door when the whole system flow of patients still needs to be addressed, but we suspect that there are now few options left without further risk to both those who are using the ambulance services and those who are working within them.

“Ambulance operations centres are still fielding calls at record numbers because callers want to know when an ambulance will arrive and are often calling back time and time again.

“It is difficult to hear that an ambulance might be delayed but imagine how a caller feels when their 999 call isn’t answered straight away. The moral injury is not just with the paramedics, but also with all of those involved directly with patients and their care.

“The College supports RCEM’s call for both the reduction in ambulance handover delays and in ED overcrowding. It is only by working together as a system that we will see this much-needed change and this guidance document outlines the risks associated with the current challenges.”

Weekly Scottish Emergency Department waiting times are ‘worst on record’

Serious concerns for patient safety

The latest weekly update (w/e 20 March 2022) of Emergency Department activity and waiting time statistics show:

There were 25,506 attendances in week ending 20 March 2022
Four-hour performance was 66.2%, the lowest on record
8,610 patients were delayed by four hours or more, this is the highest on record and means one third of all patients were waiting for four hours or more in an Emergency Department
2,615 patients were delayed by eight hours or more, this is the highest on record and means more than one in 10 patients were waiting for eight hours or more in an Emergency Department
1,015 patients were delayed by 12 hours or more, this is the highest on record and means one in 25 patients were waiting for 12 hours or more in an Emergency Department

Dr John Thomson, Vice President of the Royal College of Emergency Medicine Scotland, said: “Each week the Urgent and Emergency Care crisis worsens.

“Scotland’s Emergency Care system is failing patients who are coming to harm, and failing staff who are overworked, exhausted, and burned out but are left to cover the widespread shortcomings of the health system. Shortages of beds, shortages of staff, the social care crisis; existing staff do all they can to keep patients safe in these exceptionally challenging circumstances.

“It is an untenable and unsustainable situation. This week saw the highest number of long waits on record yet again. Data show that there is one excess death for every 82 patients delayed for more than six hours.

“This week 2,615 patients were delayed by eight hours or more, from this we can estimate that over 30 patients in this week alone could have come to associated harm or death as a result of their delay to admission.

“The significance of this appalling harm must not go unnoticed and must be met immediately with effective and meaningful action. The Scottish Government must understand the severity and extent of harm befalling our patients, and see that existing staff facing moral injury, going above and beyond, running on goodwill and adrenaline is not reasonable or acceptable.

“This can no longer be the sole answer to the biggest patient safety crisis in Emergency Care for a generation. This must not continue.”

Emergency Care faces continued pressure as Scottish Government publishes workforce strategy

The latest weekly update of Emergency Department activity and waiting time statistics show:

There were 24,920 attendances, the highest since week ending 10 October 2021
70.5% of attendances were seen and resulted in subsequent admission, transfer or discharge within four hours
7,347 patients were delayed by four hours or more, this is the third highest on record
1,825 patients were delayed by eight hours or more
643 patients were delayed by 12 hours or more, this is the second highest on record

Dr John Thomson, Vice President of the Royal College of Emergency Medicine Scotland, said: “The data show the stark picture of the health system in Scotland right now and the serious crisis Urgent and Emergency Care is facing.

“There are extremely high numbers of patients being delayed for long periods of time, and we know that these long waits are associated with a high risk of harm or even death.

“This is a critical time. The pandemic is not over. Covid is ever present in the community, with increasing numbers of covid patients in hospital and a high level of covid related staff absences. The workforce is burnt out and overwhelmed, every shift is extremely demanding with staff covering for absent colleagues and managing high numbers of patients, doing their best to keep them safe and minimise harm. The moral injury to our colleagues working in our Emergency Departments cannot be underestimated.

“We welcome The Health and social care: national workforce strategy published last week by the Scottish Government. It is a positive strategy for the next five years. We especially welcome the commitment to grow the NHS workforce by 1,800 WTE staff and increase the number of medical school places by 500.

“However, we are disappointed both not to have been consulted on this strategy and by the limited mentions of Urgent and Emergency Care. We look forward to the Cabinet Secretary for Health and Social Care consulting with The Royal College on the meaningful details for Emergency Medicine including staffing and capacity needs.”

Emergency Departments continue to face severe pressures as RCEM calls for meaningful action

The latest A&E activity and waiting times for major Emergency Departments in Scotland for January 2022 show:

73.7% of attendances were seen and resulted in subsequent admission, transfer or discharge within four hours
There were 96,338 attendances, a 1.4% decrease when compared to the previous month, December 2021
More than one in four patients were delayed by four hours or more
6,682 patients were delayed by eight hours or more, a 23% increase when compared to the previous month, December 2021
This is equal to 6.2% of all attendances
2,155 patients were delayed by 12 hours or more, a 30% increase when compared to the previous month, December 2021
This is equal to 2.1% of all attendances

Dr John Thomson, Vice President of the Royal College of Emergency Medicine Scotland, said: “The health service in Scotland continues to face severe system pressures.

“Emergency Departments remain dangerously crowded with many patients facing extremely long waiting times as ambulances still face delays in offloading patients. These long waits are leading directly to harm for our patients.

“Despite the challenges of widespread bed shortages and staff shortages, Emergency Medicine staff continue to do all they can to keep patients safe. It is the hard work and dedication of EM staff who are preventing urgent and emergency care from tipping over the edge and falling deeper into crisis.

“Frontline workers continue to be pushed to their limit and are experiencing significant moral injury as a result of inadequate bed capacity and patient flow. It is clear that without significant, immediate change, both patients presenting to our Emergency Departments, and the staff working in them, face ongoing harm.

“Emergency Medicine staff will continue to be pushed to their limit unless an adequate urgent and emergency recovery plan is set out by the Scottish Government – this would prevent any threat of derailing elective care recovery.

“In the longer term, the Royal College continues to call for a fully funded long-term workforce plan and for 1,000 additional beds to be opened in the system. The current status quo is not sustainable for patients or staff, it is time to see meaningful action.”

Long waiting times continue to put patient safety at serious risk

The latest A&E activity and waiting times for major Emergency Departments in Scotland for December 2021 show:

73.7% of attendances were seen and resulted in subsequent admission, transfer or discharge within four hours
There were 97,644 attendances, a 6% decrease when compared to the previous month, November 2021
More than one in four patients were delayed by four hours or more
5,342 patients were delayed by eight hours or more, equal to 5.5% of all attendances
1,605 patients were delayed by 12 hours or more

Responding to these figures, Dr John Thomson, Vice President of the Royal College of Emergency Medicine Scotland, said: “With fewer attendances performance has plateaued but be in no doubt that the health service and its staff in Scotland remain under unprecedented pressure and increasing burnout.

“One in four patients face delays over four hours, while both eight- and 12-hour waits are still at record high levels not seen before 2021. What is deeply concerning is the pattern and the potential for these long waiting times to become the status quo in perpetuity.

“Both our own report Crowding and its Consequences (below) and a recent article in the Emergency Medicine Journal ‘Association between delays to patient admission from the emergency department and all-cause 30- day mortality’ detail the real harm, and in some cases death, that long waiting times can cause patients.

“The impact of this continued poor performance is distress and moral injury to staff and serious discomfort and risk to the safety of patients. This must be an urgent signal and call to action for system change. We have long called on the government to open 1,000 more beds in the system in Scotland, and to commit to publishing a long-term workforce plan. While there remains an urgent need to address the social care crisis to help patients be discharged from hospital in a timely way.

“Quite simply things cannot continue as they are, more patients will come to harm and staff will face increasing distress at the quality of care they are or, more significantly, aren’t able to provide. The government must recognise the severity of the situation and the risk that continued poor performance, long waiting times, patient harm, and sinking quality of care will continue to spiral.”

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RCEM response to worst Scottish weekly performance figures ever

The latest weekly update of Emergency Department performance figures for Scotland show:

There were 21,163 attendances at A&E services in NHS Scotland.
67.4% of attendances at A&E services were seen and resulted in a subsequent admission, transfer or discharge within 4 hours.
2,079 patients spent more than 8 hours in an A&E department.
690 patients spent more than 12 hours in an A&E department.

This data shows the worst weekly four-hour performance since records began. The highest number of (weekly) eight hour waits since records began, and the highest number of (weekly) 12-hour waits since records began.

More than one in eight patients were delayed in an Emergency Department by eight hours or more.

Responding to this data, Dr John Thomson, Vice President of the Royal College Emergency Medicine, Scotland, said: “This data is deeply concerning and distressing. More than one in eight patients have been delayed by eight hours or more; this is shocking.

The health service is in the middle of a serious crisis. Staff are working exceptionally hard but are burnt out and overwhelmed and face moral injury on every shift.

Patient safety is frequently compromised. We know long waiting times increase the risk of death and patient harm. The exit block that exists in our Emergency Departments which prevents patients moving in a safe, timely manner to an appropriate ward is worsening, causing even more harm to our patients.

“It is a critical time for the health service, and we must see a vision for the future. The government must acknowledge the shortfall in staff and beds as the root of this crisis, and this must lead to a commitment to publish a long-term workforce plan that includes measures to retain existing staff who may be thinking of leaving our NHS following this exceptionally challenging period.

“The government must also commit to opening 1,000 more acute beds across Boards in Scotland, which will promote timely patient flow through the hospital. Lastly, a key cause of exit block are the patients who remain in hospital when they no longer require ongoing Hospital care.

“The ongoing crisis in social care means patients are unable to be discharged home following the completion of their treatment. It is vital social care is resourced and adequately staffed to support the most vulnerable patients in their return to the community.”