A nurse's response to the NHSE guidance on their principles for providing safe and good quality care in temporary escalation spaces

Summary

In this blog, an anonymous nurse reflects on the recent NHS England (NHSE) guidance on the use of "temporary escalation spaces" and why this is so far removed from 'work as done' on the frontline.

Content

Working in a busy teaching hospital as a person who works in patient safety and as a nurse, I have a unique perspective on corridor care.

I have reflected on my experience working in the emergency department (ED) in a previous blog.[1] However, I would like to respond to the new NHS England (NHSE) guidance that came out this week on the use of “temporary escalation spaces”. Overall, I feel that this guidance is very much ‘work as imagined’, far removed from 'work as done'.

By reflecting on the NHSE core principles of providing safe and good quality care in temporary escalation spaces, we can quickly come to the conclusion that the words "safe" and "good quality" do not belong in the same sentence as "temporary escalation spaces".

"NHS England believes the delivery of care in temporary escalation spaces (TES) in departments experiencing patient crowding (including beds and chairs) is not acceptable and should not be considered as standard."[2]

The hospital where I work have had patients in the ED corridor—up to 20 at a time—throughout the summer months. Admittedly, this is not every shift; however, it is at least once a week.

Patients are not on beds; they are on trolleys and chairs. We often have 10 patients on trolleys in the corridor. We haven’t reached the winter months yet.

The Care Quality Commission's (CQC) fundamental standards that NHSE quote are unachievable, for example:

• the clinical, psychological and functional suitability of the patient 
  – patients admitted due to mental health should be automatically excluded.
• the existence of a clear clinical plan for the patient
  – staff allocated to TES patients must be able to provide ongoing care for the duration of that stay.

I am unsure which patients are ‘suitable’ for the corridor. I am not aware of anyone who would like to be cared for in an open space, with no privacy or dignity, with no access to emergency equipment or appropriate staffing.

• appropriate staffing and skillsets that ensure the safe monitoring of patients and the ability to recognise deterioration.

The staff I have worked with in ED have low morale, the lowest I have seen. They are being forced to work in situations where their professional registration is at risk on a daily basis. They perceive they are giving patients poor quality care on a daily basis—this is not what they signed up for. Nurses are leaving, doctors are leaving. This is not emergency medicine.

NHS England guidance tells trusts to monitor harms caused by care in “unplanned settings.”

There is no provision to monitor patients in corridors—there is not enough equipment, not enough plug sockets and not enough staff to analyse the monitoring.

A large observational study has demonstrated that there is one additional death for every 72 patients that spend 8–12 hours in the ED.[3]

I have seen patients who have deteriorated in the corridor. Once a patient has deteriorated, life saving treatment needs to be given by a team of clinicians and specialist nurses frequently with monitoring equipment. There is no physical room in the corridor to access the patient, which causes delays in the patient receiving treatment and distress to the surrounding patients.

Corridor care not only causes physical harm to the patient, but also psychological harm and compounded harm is experienced by other patients and their loved ones.

Reporting these harms, near misses and safety incidents is vital. NHSE is correct in telling us to monitor these figures. However, many of these incidents go unreported, for many reasons:

• It takes time to report—time we haven’t got.
• To report we need access to a computer—computers are in use more than ever since we have electronic patient records.
• It takes faith in the value of reporting. Why should we report?— nothing improves.
• It takes courage—if I report the poor care/harm by patient has experienced, will I be reprimanded?

In conclusion, the NHS is in crisis. We are serving an expanding ageing population; a population who have more complex health problems than ever before. Primary care is unable to cope with demand and complexity of their caseload; therefore, patients are turning to EDs for advice and treatment.

The healthcare landscape has evolved over time. There are many ways to access healthcare: NHS 111, GP services, walk in centres, nurse/Allied Health Professional led clinics and minor injury units. To gain access to these services, the general public are often not aware of them or even know how to navigate their way through. This navigation takes time and often the quickest ‘safest’ option for the general public is to attend the ED.

EDs have robust triage systems in place so that the sickest patients are seen in a ‘timely’ way; however, with patients living longer with multiple co-morbidities, a population with marked health inequalities and a mental health crisis upon us, demand for the ED had outstripped capacity.

NHSE admits that corridor care is not acceptable; however, they have issued guidance on principles to provide safe and good quality care—this seems contradictory.

If NHSE could take a systems-based approach in reviewing the healthcare system and make systems-based recommendations rather than focussing efforts in patching over the cracks we would have a more sustainable NHS.

References

1. Anon. A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift. Patient Safety Learning, 22 February 2024
2. NHS England. Principles for providing safe and good quality care in temporary escalation spaces, 16 September 2024.
3. Jones S, Moulton S, Swift S, et al. Association between delays to patient admission from the emergency department and all-cause 30-day mortality. Emerg Med J 2022; 39: 168–73. doi:10.1136/emermed-2021-211572.