This diagram can be found on page 7 of the document which is accessible via the attached document below. 

• Awareness of the range of UEC options is generally good but patients and the public are sometimes confused about the difference between A&E and walk-in centres, minor injuries units and urgent treatment centres. Confusion is compounded by the patchy availability of some of these, in terms of both locations and opening times.
• A key driver of attendance at A&E is the difficulty of getting appointments or advice from GPs and NHS 111. Another is that people are not getting the support they need in the community - for example to manage long term conditions. Some of those going to A&E are clear that they would have preferred a GP appointment.
• Some evidence suggests that referrals to UEC might not always be appropriate. Between 2019 and 2021, GP referrals in general increased significantly (179%), but avoidable attendances from GP referrals more than doubled (255%). Care homes might be taking an overly cautious approach - 41% of care home referrals may be avoidable. NHS 111 might also be over-cautious.
• Patients enduring long waits in A&E seem less concerned about adherence to the four hour target (if they are even aware of it) than about unpleasant experiences in waiting areas - some with possible clinical or patient safety risks. Some discomfort could be mitigated by better communication - for example regular updates on anticipated waiting times.

• Developing and disseminating patient safety and risk management strategies for the speciality of Emergency Medicine.
• Advising and collaborating with NRLS, NICE, DH, CQC, the Royal Colleges and other national bodies who have an interest in risk management and patient safety in Emergency Departments.
• Developing and identifying resources for patient safety.
• Informing Fellows and Members of patient safety research, key publications and resources.
• Reviewing of significant incident reports in Emergency Medicine.

To see the terms of reference and committee members e-mail safety@rcem.ac.uk.

1. Reduce handover delays by increasing hospital capacity and flow through hospital with more beds, more staff and investment in out-of-hospital care, including social care.
2. Increase ambulance service capacity by further increasing staff numbers and reducing sickness absence by addressing the causes of poor mental health.
3. Reduce demand for ambulances through greater investment in community services, such as mental health services, which can prevent health conditions becoming crises.

To improve the experiences and outcomes of patients with mental health needs in accessing urgent and emergency care (UEC), change needs to be instigated at three distinct levels of policy and decision making: by the UK Government, NHS England, and by Integrated Care Systems.

For the UK Government and devolved administrations:

• Significantly increase adult, children, and young people Mental Health bed capacity in NHS Trusts.
• Provide funding to expand the provision of Children and Adolescent Mental Health services, ensuring they are available 24 hours a day, seven days a week to assess or at least triage children and young people presenting to the ED in crisis.
• Workforce planning should be in place to train professionals for these services, to ensure they are staffed overnight and at weekends, enabling the units to accept emergency admissions out of hours.
• Continue to invest in Liaison Psychiatry services, to honour the commitment to provide not just minimum Core 24 services but to deliver enhanced and comprehensive services in bigger trusts.
• Provide funding for preventative and community mental health services, especially eating disorder services, to keep up with growing demand.
• Amend the Mental Health Bill in order to introduce standards, national reporting and scrutiny of the quality and access to care provided to patients detained or due for assessment for possible detention under Emergency Mental Health legislation.

For NHS England:

• Publish, on a regular basis, the number of patients presenting with Mental Health symptoms experiencing stays over 12 hours from their time of arrival to when they leave the department to be admitted, transferred, or discharged.
• Introduce the one-hour standard to be seen by a mental health professional from referral from ED, for all ages, as recommended in the Clinical Review of Standards.
• Introduce standards for hospital security teams and mandatory training in Mental Health, so all teams can provide safe restraint when there is no other option and is absolutely necessary.
• Review and improve how Section 12 (2) doctors are commissioned and paid in order to ensure timely assessments for patients detained under the Mental Health Act.
• Carry out a national review of the numbers of Approved Mental Health Professionals to ensure patients detained under the Mental Health Act have timely access to assessment.

For Integrated Care Systems (ICS):

• Ensure universal coverage of crisis response services in every community. These include ambulance – mental health joint response cars, 24/7 phone lines and crisis cafes.
• Prioritise early intervention multidisciplinary services to address the underlying unmet need in High Intensity Use. There should be robust evaluation of services to see which models work best.
• Hold Mental Health and Acute Trusts jointly accountable for patients with mental health needs enduring delays of 12 hours or more in EDs from their time of arrival to when they leave the department to be admitted, transferred, or discharged.
• Support Mental Health trusts and Emergency Departments to develop acute assessment spaces with Mental Health Professionals to care for patients.  

1. Document the swallow status of all patients with PD at the point of referral to hospital
2. Screen patients with PD for swallowing difficulties at admission
3. Refer patients with PD who have swallowing difficulties (or who have problems with communication) to speech and language therapy
4. Notify the specialist PD service (hospital and/or community) when a patient with PD is admitted, if there is any indication from the notes, or following discussion with the patient or their relatives/carers, that there has been a deterioration or progression of their clinical state
5. Provide written information at discharge on how to manage swallowing difficulties

New research from Bion et al. challenges this assumption. It shows that people admitted as emergencies at weekends are sicker and more likely to be near the end of life than those who come in during the week. A large 5-year study found hospital care at the weekend is, if anything, better than weekday care. However, markers of community care were worse at weekends than on weekdays. 

The study found that the numbers of consultants did not account for the weekend effect. There was no evidence that errors in hospital care were more common at weekends. Over the course of the study, consultants worked increasing hours in hospital at the weekends caring for emergency admissions. But this increase in their hours was overtaken by the increase in the numbers of people admitted at the weekends.

The weekend effect is likely to be a result of insufficient care in community settings at the weekend, the researchers say. This could mean, for example, that people nearing the end of life, who would be better cared for at home, end up in hospital because community services are not available.

Using an expert panel, and computer modelling, the study found that investing in more consultant hours at the weekend could be cost-efficient. But this was only because it might speed up discharge decisions rather than reducing death rates. However, there was also evidence that earlier discharge may be associated with transferring hospital deaths into the community.

The study concluded that the best way to bring weekend care up to weekday levels would be to invest in community services.

95% of participants felt the hot debriefing tool duration was ‘just right’, while 100% felt the process helped with their clinical practice, and 90% felt they benefited psychologically from the process.

In 2020-21, the number of people visiting the A&E department at the East Kent University Hospital Trust (EKHUFT), one of the largest trusts in the south east, increased by up to 25%. At that time, we noted a surge in cases of falls in A&E, particularly those resulting in severe harm.

The risk factors were clear:

• A&E departments were busier than they had ever been
• The quality of health in patients seeking help at A&E was declining
• Those seeking help had longer-than-usual waiting times in A&E departments
• There was no clear way for staff to indicate which patients they had assessed as having a high risk of falling

Falls with harm are not only devastating to patients and families, but they also have considerable financial implications for healthcare providers. For example, the estimated cost of a single fractured neck of femur (NoF) or hip is £26,000.[1] In 2020 alone, EKHUFT recorded five NoF cases in just one A&E department, representing a bill of £130,000, excluding possible litigation costs.

Implementing Yellow Kits to prevent falls in A&E

To try and tackle the increasing number of falls we were seeing, we decided to trial the use of yellow kits in A&E. These kits act as a visual cue for staff, helping them to quickly identify patients at risk of falling. Each yellow kit contains a small yellow fleece blanket and a pair of yellow double-tread falls prevention slipper socks.

We used our FallStop four-step approach to introduce the yellow kits:

Step 1: Ensure you have the support of everyone in the department and senior management

It is very hard to identify effectively, at a glance, whether a patient is at risk of falling, and I am aware of how upsetting patient falls incidents can be for staff. Issues often arise at handover as it happens very quickly and information about patients most at risk of falling is often not passed on - until it’s too late. I knew A&E staff would welcome an intervention to help raise their awareness and keep them vigilant.

We made sure we had the support of all A&E staff - senior management, healthcare workers, porters and housekeeping staff - which meant that as the results of the evaluation emerged, everyone involved could see the benefit and share in the success of the initiative. 

Step 2: Integrate visual cues into the care protocol to help staff manage patients at high risk of falling

We chose blankets and socks for the yellow kits as they are items that stay with the patient throughout hospitalisation, regardless of location. They can also go home with the patient.

The bright yellow colour reminds all staff that extra precautions need to be taken with particular patients, and that they should act decisively if they see these patients trying to move around unassisted or attempting to get off the trolley. The yellow kits also help ward staff during patient transfers, as each patient has already been identified as a falls risk, triggering a full fall risk assessment, in line with Trust guidelines.

Step 3: Make the case for the financial impact of not taking action

There is nothing more frustrating than knowing there is a simple solution that works, and being unable to implement it as others - whose support you need - just see additional costs.

I needed to show the financial burden of ignoring the problem, or only addressing its symptoms, to hospital management. As mentioned, the total cost of care for a hip fracture is £26,000 and there have been five NoF fractures in our A&E during 2020.

We needed to prove the effectiveness and value of visual cueing as an intervention, so we developed a single site evaluation of the intervention, with clear outcomes. The program started to develop its own momentum as we demonstrated that yellow kits could help us protect our patients and cut long-term costs at the same time. 

Step 4: Ensure education before, during and after the intervention

To make the intervention effective, we spent time with staff in A&E, particularly in the early stages, to ensure they fully understood when to use the kits and what they mean. We ensured that all staff in the department knew which patients they should issue yellow kits to. We developed a clear protocol for issuing kits:

• Presenting due to a fall
• Acutely unwell (for example, respiratory compromised, diabetic ketoacidosis, heart problems)
• Patients with confusion due to dementia or delirium with any of the following features: agitation, wandering, inability to use the call bell reliably, challenging behaviour, reduced safety awareness and disorientation
• Likely to attempt to mobilise on their own and unsafe to do so
• Alcohol or drug misuse causing challenging behaviour

We also ensured that staff from other departments working with A&E understood the need for extra vigilance around patients with yellow kits. Medline, the company that supplies the kits, provides educational materials such as posters for staff notice boards, storerooms and public spaces, which we used to promote the initiative. We also involved our communications team to help promote yellow kits through the staff newsletter and intranet, and even got our Chief Executive on board to promote the project through her podcast!

The impact of yellow kits on falls in hospital

So, did the yellow kits work? In short, 100% yes! The kits empowered A&E staff to think and work differently, and they were pleased to be part of this highly effective initiative.

The trial ran for six weeks, and over this period, we lowered the number of falls by 50%. In fact, the only patients who fell were those who did not have a yellow kit.

The story was the same for patients admitted to wards - not one fell in the first 24 hours, which is the period when most falls would usually happen on wards. Since the evaluation, we have continued using the kits in A&E and have also been given funding to use them in our Acute Medical Unit.

I shared the results of the trial on Twitter and the yellow kits went global! There are now yellow kits being used in A&E departments up and down the UK and some trusts are trialling the scheme in their frailty units. There are also hospitals in Chile, Spain and Australia now using yellow kits.

To find out more about yellow kits and the FallStop programme, follow Jayne on Twitter.

Related reading

East Kent Hospitals University NHS Foundation Trust's FallStop programme
FallStop: Winner of the 'Professionalising patient safety' category 2019
National Audit of Inpatient Falls (NAIF) Annual report 2021
How do occupational therapists contribute to patient safety?
Community thread: Red walking aids

References

1 NHS Digital. October 2021

94% of ambulance staff in this study reported a sense of personal achievement within their professional role; however, more than 50% were experiencing varying levels of burnout with 87% displaying moderate or high levels of depersonalisation towards their work.

Causes of stress were complex: themes attributed were a perceived lack of management support, the public's misuse of the ambulance service, involuntary overtime and a poor work-life balance.

Burnout poses a genuine threat to retention in the ambulance service and needs addressing. Proactive screening, better communication between practice staff and management and access to counselling services are recommended. This problem of burnout is beginning to be acknowledged but further evidence is needed to understand it in more depth in order for effective solutions to be developed.