The authors found that between April 2016 and March 2018, 26 738 514 people attended an ED, with 7 472 480 patients admitted relating to 5 249 891 individual patients, who constituted the study’s dataset. A total of 433 962 deaths occurred within 30 days. The overall crude 30-day mortality rate was 8.71%. A statistically significant linear increase in mortality was found from 5 hours after time of arrival at the ED up to 12 hours (when accurate data collection ceased). The greatest change in the 30-day standardised mortality ratio was an 8% increase, occurring in the patient cohort that waited in the ED for more than 6 to 8 hours from the time of arrival.

The study concludes that delays to hospital inpatient admission for patients in excess of 5 hours from time of arrival at the ED are associated with an increase in all-cause 30-day mortality. Between 5 and 12 hours, delays cause a predictable dose–response effect. For every 82 admitted patients whose time to inpatient bed transfer is delayed beyond 6 to 8 hours from time of arrival at the ED, there is one extra death.

1. Putting in place more dedicated ‘High Intensity Use’ services across the country. Integrated Care Systems should develop strategies for addressing high intensity use across their areas, ensuring that there is adequate provision to meet need across acute settings, with a particular focus on areas of deprivation.
2. Improving access to community-based support, to prevent people reaching crisis point. Investment is needed in VCSE provision linked to social prescribing and other key services, such as community mental health. Training and support should be put in place for GPs and other health professionals to identify and respond to those at risk of high intensity use.
3. Taking action to address health inequalities and wider determinants that affect people’s health. The British Red Cross is calling on the Prime Minister to commission a national cross-government strategy to reduce health inequalities.

Governments should:

• increase NHS multiyear funding to recover the healthcare service.
• ensure that the upcoming public inquiry examines the resilience and capacity of the urgent and emergency care system in the run up to the pandemic, as well as the performance of the system, to enable lessons to be learned for the future.
• ensure that there is adequate capacity for COVID-19 testing for ED staff (and their households), with short turnaround times that allow quick and safe return to work.

NHS England and devolved equivalents should:

• ensure robust coordination of safety information produced by the new HSIB, Coroner Prevention of Future Deaths reports, NHS Resolution, National Reporting and Learning Service (NRLS), NICE, and alerts currently available on the Central Alerting System.

Regulators should:

• regularly disseminate examples of good practice occurring in EDs to support quality improvement.
• use the RCEM Best Practice Guideline on ‘Infection Prevention and Control (IPC) during the Coronavirus Pandemic’ to inform inspections.

1. Supporting 999 and 111 services.
2. Supporting primary care and community health services to help manage the demand for UEC services.
3. Supporting greater use of Urgent Treatment Centres .
4. . Increasing support for Children and Young People.
5. Using communications to support the public to choose services wisely.
6. Improving in-hospital flow and discharge. 
7. Supporting adult and children’s mental health needs.
8. Reviewing Infection Prevention and Control (IPC) measures to ensure a proportionate response.
9. Reviewing staff COVID self isolation rules.
10. Ensuring a sustainable UEC workforce.

You will need a FutureNHS account to view this report, or you can watch a short video summary which includes key recommendations.

• NHS 111
• Ambulance response times
• Ambulance handover delays
• A&E waiting times
• Potentially preventable emergency admissions
• Hospital bed occupancy
• Violence in A&E
• Patients’ overall experience of NHS and social care services
• Mental health crisis care.

The MTS is now an integrated series of tools used in the following domain: 

• Emergency triage: Emergency departments.
• Telephone triage and advice: Urgent care desks.
• Pathfinder: Paramedic ambulances.
• Nursing and residential triage: Nursing and residential homes.
• SAFE pathways: Community-based HCPs.

The 5 triage tools all share: 

• A reductive methodology identifying life threatening illnesses and injuries first.
• A clinical risk management tool used Worldwide to safely manage patient flow when clinical demand exceeds capacity. 
• A common set of discriminators defined in a discriminator dictionary. 
• A shared language and common understanding. 
• Underpinning training packages and e-learning modules for practitioners. 
• A method of streaming for local implementation.

The Manchester Triage System is now the International Gold standard for Emergency Triage, used worldwide to triage millions of patients per year.

Planning: Despite normally being stable prior to transfer, by nature, critical patients are unstable and may deteriorate. Plan for this and know where you are going, expected journey time accounting for traffic conditions and what hospitals are along the route in case of emergency. 

Equipment: If a team is not travelling, you ideally won’t take unfamiliar devices. If you do, the least you should know and plan for/discuss is how to manage failure; i.e. a syringe pump giving inotropic support or ongoing sedation that may be able to be given manually.

Equipment: Is different in subtle ways and it won’t be a simple case of copying hospital settings. If moving a patient from hospital equipment to yours, don’t leave straight away. Give the patient time to “settle” on your equipment and make any changes to setting necessary to maintain the patient. 

Vehicle: Ensure normal vehicle checks are complete, you know where your own equipment is and that it is working. Also make sure that electrical/12V/USB ports all work in case they are needed for transfer equipment. Have all rescue kit (airways, BVM etc.) to hand.  

Oxygen: An oxygen dependent or ventilated patient can use a lot of O2 and this needs to be calculated along with extra in case of delays. Formulas that can be used:

• 2 x flow (L/min) x length of transfer (min)
• 2 x transport time in minutes x (minute volume x FiO2) + ventilator driving gas.

Airway: Always important but vital for a patient who has an airway adjunct in place prior to transfer. Plan for immediate actions if the patient loses this adjunct during transfer. Have emergency kit laid out PRIOR to transfer and allocate pre-planned roles in case of an airway emergency during transfer.

Breathing: A patient on a ventilator will have a ventilation strategy depending on their condition. Try to have a basic understanding of this in case you need to take over with a BVM in the event of a ventilator failure. ALWAYS have rescue kit laid out and to hand in case of emergency enroute. 

Circulation: The patient may be on some sort of circulatory support (fluids, pressors, inotropes etc) dependent on their underlying condition. Again, try to understand their current fluid status and support needs in case you need to intervene or have an equipment failure enroute. 

Disability: If a patient is sedated/anaesthetised, be vigilant for signs this may be wearing off. Some signs to look for are tearing, increase in heart rate or BP or a Curare cleft on waveform capnography. Be aware that patient sedation needs may change due to movement during transfer.

Monitoring: In the sedated/anaesthetised patient, monitoring may be your first indicator that something is changing. Don’t just assume strange values are due to movement and constantly check your patient. If something changes, start at the patient and work back to the monitor to look for issues. 

Redthread, a Youth Violence Intervention Programme, runs in hospital emergency departments in partnership with the major trauma network. The innovative service aims to reduce serious youth violence and has revolutionised the support available to young victims of violence.

Every year thousands of young people aged 11–24 come through hospital doors as victims of assault and exploitation. It is then, at this time of crisis, that our youth workers use their unique position embedded in the emergency departments alongside clinical staff to engage these young victims.

Redthreads extensive experience tells us that this moment of vulnerability, the ‘Teachable Moment’, when young people are out of their comfort zone, alienated from their peers, and often coming to terms with the effects of injury, is a time of change. In this moment many are more able than ever to question what behaviour and choices have led them to this hospital bed and, with specialist youth worker support, pursue change they haven’t felt able to before.

Redthread workers focus on this moment and encourage and support young people in making healthy choices and positive plans to disrupt the cruel cycle of violence that can too easily lead to re-attendance, re-injury, and devastated communities.

Redthread and the Homerton

Redthread is embedded within Homerton’s A&E department. The Redthread youth work team work hand in hand with the emergency department team to safeguard young people between the ages of 11-24 who are at risk of violence or exploitation.

Emergency department clinicians send referrals for at-risk young people to the Redthread team, who work on an individual basis with the young people to support them and endeavour to alleviate the risk in their environment. Redthread achieves this by liaising with statutory services such as CAMHS, Children’s Social Care and Housing to ensure that the young person is being placed first. By linking up services, Redthread ensures that the young person is the focal point and that help is being given, without duplicating existing services.

Redthread works in several major trauma centres across the UK; however, the Homerton practice is the first community hospital based service. 

The Redthread service would not be possible without the support of the emergency department staff. Not only is the clinical and non-clinical body supportive of the service and actively referring young people, the emergency department as a whole takes an active interest in Redthread’s work – talking to Redthread staff about their work, fundraising and attending training sessions.

Thanks to the initial efforts of emergency department doctors and nurses in gaining funding and support for this project at Homerton, and the continued work and collaboration by the emergency department and Redthread, the service has excellent track record after its 1 year of service. 

The Redthread youth workers work closely with young people in a way that clinicians do not have time to. This means that patients are cared for both medically and holistically. Though difficult to quantify results, a strong qualitative difference to the service is that there is a caring external presence within the emergency department. For young people in crisis, being seen one-to-one by someone in a non-clinical role means that there is someone solely on their side. In a lot of cases, a Redthread worker might be the first person in a long time to ask if they are ok, and to see them for who they are as opposed to the trauma that they have suffered.

For the emergency department team, having a constant youth work presence acts as a reassurance that when a safeguarding issue does arise, this will be followed up and the young person will continue to be cared for.

The emergency department safeguarding has improved as awareness has grown among staff members of safeguarding procedures. The Redthread collaboration has also prompted staff to be more inquisitive with the patients they see, and to consider how that patient’s behaviour may be a manifestation of underlying problems. As such, young people coming into the emergency department are safer as they are more likely to be seen and understood by clinicians, as well as receiving long term assistance as part of the emergency department care package.

As the first community hospital in the Redthread network, the Homerton Redthread team have tailored and changed their service to best fit the community it serves. The team spend longer working with young people, in addition to working more closely with them than in other hospitals – taking on a constant role in our young people's lives. The breadth of presentations seen at Homerton has also resulted in a broader case-load. The result is a service which is ready to adapt to individual cases to best serve young people both in hospital and out in the community.

Redthread at Homerton are also innovating and adding value structurally by meeting young people at the earliest opportunity – the statistic is that young people present to hospitals like Homerton four to five times on average before they are injured to the extent that they have to be taken to a major trauma centre. By being embedded in a local hospital such as this, we have an opportunity to engage people and help them to change their trajectories and avoid escalating harm. We’re also pioneering work around contextual safeguarding, by listening to young people and feeding back to local authorities when for example unsafe spaces in the community are identified.

• How to use the safety toolkit
• Designing a risk register
• Learning from practice
• Safe leadership
• Supporting the Second Victim
• Education
• Safety scorecard
• Safety culture
• Team working
• Departmental activity resources
• Integrating safety checklist