The Model Emergency Department: high performing urgent and emergency care pathways (NHS England, 9 February 2026)

Summary

This guidance sets out the core principles and components of high-performing emergency departments.

It is accompanied by a detailed guide to the core operating principles for extended emergency medicine ambulatory care (EEMAC) activity.

Together, they offer a structured, actionable approach to improving urgent and emergency care pathways and patient experience, as well as reducing waiting times.

Content

This guide is designed for providers, including:

• emergency department leaders (medical, nursing and operational leaders) considering implementing an EEMAC model
• hospital managers responsible for service implementation and resource allocation
• emergency department workforce (medical, nursing, allied health professions and administration) involved in patient triage, assessment and treatment.

How to implement EEMAC successfully

• emergency department leadership team should establish the intended role and desired outcomes of EEMAC
• emergency department leadership team should ensure there is a well-understood model of emergency medicine, purpose and direction of travel
• Board-level medical, nursing and operational leadership should ensure multidisciplinary collaboration between local service teams
• emergency department clinical leaders and wider clinical teams should define clear patient pathways that align with the inclusion and exclusion criteria
• Estates teams and the ED team should together design the physical environment to optimise patient flow and comfort
• emergency department leadership team should establish a dedicated staffing model with appropriate clinical leadership
• Business intelligence and analytics teams should support the ED team to implement robust data recording practices for tracking and evaluating service performance.

Core principles

These principles apply to patients who attend the ED with an acute presentation.

• this EEMAC model applies to adult patients only
• the term EEMAC applies to patients expected to be discharged on the same day and whose care can be concluded by the ED team within 8 hours of transfer to the EEMAC unit. Patients requiring longer periods of observation will usually require admission to an inpatient area (for example, a CDU or short-stay ward)
• in common with other forms of SDEC, some EEMAC patients will require hospital admission – between 5% and 15% is expected
• patients suitable for existing medical, surgical, frailty or other SDEC pathways should be managed within those pathways as usual.

Inclusion criteria

• patients who at initial assessment or via the rapid assessment and treatment (RAT) process are classified as acuity 3 or 4. Some acuity 2 patients, depending on individual patient needs and local departmental factors
• patients requiring advanced diagnostics, for example, CT or MRI or troponin result and senior clinical decision-making, but who have a high likelihood of being discharged within 8 hours
• patients whose investigation, management and treatment of their clinical condition is likely to take more than 4 hours, but who are likely to be suitable for discharge within 8 hours

Exclusion criteria

• patients under the age of 16
• patients suitable for existing medical, surgical, frailty or other SDEC pathways should follow those established routes
• low-risk primary care presentations should be directed to urgent treatment centres (UTCs). Acuity 5 patients are excluded
• patients requiring resuscitation facilities, those who are clinically unstable or those with presentations highly likely to result in admission should remain in the ED or be directed to appropriate alternative assessment and inpatient pathways
• patients with an acute mental health crisis who are at risk to themselves or the public or who are likely to require a medical or mental health admission
• patients who are acutely confused or intoxicated
• patients who are awaiting discharge or transfer; an EEMAC area is neither a discharge lounge nor an ‘overflow’ unit for other services
• patients awaiting admission to an inpatient bed
• patients who are being transferred from the ED without a valid clinical reason, where the only benefit from doing so would be to improve service time-based metrics – that is, the 4-hour standard
• patients requiring planned care (for example, follow-up or hot clinic activity).

Location and environment

• EEMAC should ideally be co-located with ED but not within the ED footprint
• this estate should not be used for additional inpatient capacity or as an escalation space as part of a full capacity protocol
• the environment should be designed as an ambulatory clinic model, with chairs and minimal reliance on trolleys promoting efficient patient turnover. Comfortable waiting areas with access to refreshments should be available, and all other estate requirements should comply with the standards set out in the SDEC specification
• patients should have access to toilet facilities
• there should be no thoroughfare for staff or the public
• EEMAC facilities and estate should not compromise delivery of existing SDEC services or the ED.
• there should be provision for private discussions with patients, and the design of examination facilities should ensure patient comfort and support patient mobility (for example, access to recliner chairs and trolleys).

Staffing and process

• the EEMAC area should have dedicated staffing, including a designated senior clinical decision-maker available during opening hours to ensure patient safety and maintain flow by ensuring rapid assessment and decision-making. There should be a separate, dedicated staff roster for EEMAC that includes, but is not limited to, senior decision-makers, medical and nursing staff, supported by administrative and operational support staff
• investigation and diagnostic turnaround times must be the same as for the ED
• all patients must have observations recorded at initial assessment to support assessment of acuity before transfer to the EEMAC area
• patients should be transferred to the EEMAC area as soon as possible after initial assessment
• patients who deteriorate while in EEMAC should be returned to the ED, following the hospital’s local standard process used in other specialty SDEC areas. Patients requiring admission should only remain in EEMAC while they wait for a bed and only if bed allocation is anticipated within the 8-hour time standard.