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Understaffing by nursing staff in hospitals is linked to patients coming to harm and dying unnecessarily. There is a vicious cycle whereby poor work conditions, including understaffing, can lead to nursing vacancies, which in turn leads to further understaffing. Is hospital investment in nursing staff, to eliminate understaffing on wards, cost-effective? This longitudinal observational study analysed data on 185 adult acute units in four hospital Trusts in England over a 5-year period. The study found that exposure to registered nurse understaffing is associated with increased hazard of death, increased chance of readmission and increased length of stay, while exposure to nursing support understaffing is associated with smaller increases in hazard of death and length of stay but reduced readmissions. Rectifying understaffing on inpatient wards is crucial to reduce length of stay, readmissions and deaths. According to the National Institute for Health and Care Excellence £10 000 per QALY threshold, it is cost-effective to eliminate understaffing by nursing staff. This research points towards investing in registered nurses over nursing support staff and permanent over temporary workers. Targeting particular patient groups would benefit fewer patients and is less cost-effective.

Across the NHS, patients are receiving care in spaces that are not designed, staffed or equipped for care delivery such as waiting rooms, corridors, chairs on wards, ambulances outside emergency departments (EDs), and other areas of the hospital not designed for in-patient care. The Royal College of Physicians (RCP) has termed these spaces ‘temporary care environments’ - reflecting a lack of capacity within health and care systems to manage the demand for patients requiring urgent and emergency care. The RCP is one of many healthcare organisations calling for an end to this unsafe and unacceptable practice that is compromising patient safety and dignity, as well as risking staff burnout/morale. The RCP the Department of Health and Social Care, and arms-length bodies across the four nations of the UK to: formally measure and nationally report the prevalence of care being delivered in temporary care environments all year round put systems and processes in place to eliminate corridor care support patients and staff when care is delivered in temporary care environments adopt a ‘zero tolerance’ approach to this inadequate care. NHS England’s recent announcement to record data on the use of temporary escalation spaces across all NHS trusts from January 2025 is a welcome step forward. These data must be clearly defined, published as soon as possible, and reported regularly all year round through NHS England monthly performance statistics. These incidents of care are no longer a problem confined to the winter months. Until appropriate action is taken to eliminate care delivery in these inappropriate spaces, the RCP recognise that clinicians and systems alike need greater support to manage when these incidents occur. As such, the RCP’s statement sets out practical recommendations for hospitals and local healthcare systems, as well as clinicians to manage in these situations. Hospitals and local healthcare systems should: regularly review demand and capacity for in-patient care and assessment. develop robust plans to expand in-patient capacity when that capacity is required, using appropriate facilities designed and staffed for in-patient care. work with system partners and patients to ensure timely discharge or transfer from the acute hospital when patients are well enough. provide operational support to clinicians to ensure timely interventions that maximise patient flow, with a focus on the most vulnerable or unstable patients. Clinicians should: work as multi-professional teams to ensure timely assessment, management and transfer of patients, identifying those most in need of care. work with other clinical departments to ensure timely assessment and patient flow, including response to referrals and clinical in reach to other departments e.g. acute medical units and emergency departments. prioritise the sickest patients, followed by those who might be discharged and transferred in their regular assessments. ensure temporary care environments support patient privacy and dignity if medical photography is required to support rapid virtual review by other clinical departments. ensure timely discharge and flow in line with expected discharge and admission times and rates.

This study in the Journal of Patient Safety aimed to determine the incidence and types of adverse events (AEs) in patients transitioning from the emergency department (ED) to the inpatient setting. A second objective was to examine the risk factors for patients with AEs. The authors found that AEs were common for patients transitioning from the ED to the inpatient setting. They conclude that further research is needed to understand the underlying causes of AEs that occur when patients transition from the ED to the inpatient setting. Understanding the contribution of factors such as length of stay in the ED will significantly help efforts to develop targeted interventions to improve this crucial transition of care.

Nurses play a crucial role in maintaining the safety of surgical patients. Few nurse staffing studies have looked specifically at surgical patients to examine the impact of exposure to low staffing on patient outcomes. The study, published in the British Journal of Surgery and conducted by University of Southampton researchers, analysed data from 213,910 NHS hospital admissions of surgical patients between April 2015 and February 2020, to see the relationship between nurse staffing and adverse outcomes. According to the research, the relative risk of a surgical patient dying was increased by 9% for each day where registered nursing shortages were reported. This additional risk increased to 10% when the shortage was of nursing support staff. Risks for specific hospital-related conditions also increased when nurse shortages were reported. The study found evidence that registered nursing shortages correlated with 5% increased risk of deep vein thrombosis, 6% for pneumonia and 6% for pressure ulcers. Too few nursing assistants also increased the risk of these conditions.

All health overuse implies an unnecessary risk of patients suffering adverse events (AEs). However, this hypothesis has not been corroborated by direct estimates for inappropriate hospital admission (IHA). The objectives of the study were (1) to analyse the association between IHA and the development of subsequent AEs; and (2) to explore the distinct clinical and economic implications of AEs subsequent IHA compared to appropriate admissions. It found that patients with IHA have a higher risk of subsequent occurrence of AE. Due to the multifactorial nature of AEs, IHA is a possible contributing factor. AEs developed after IHA are associated with scheduled admissions, prolonged ICU stays, and resulted in significant cost overruns.

Successful day surgery requires a day surgery team with the correct knowledge and skills to enable safe, early recovery and discharge but there is an absence of national guidance on supporting competencies. Applying in-patient competency criteria is inappropriate as this pathway is not aimed at promoting early discharge. This joint publication between AfPP and BADS (the British Association Of Day Surgery) provides recommendations for core competencies for adult day surgery through (1) admission, (2) anaesthetic room, (3) theatres, (4) first-stage recovery and (5) second-stage recovery and discharge. They are relevant for staff new to or after a long absence from day surgery and acknowledge some members of the day surgery team may include non-registered practitioners. All can be used as a reference for workbook competency documents in place or in development.

Over the two decades before the pandemic, the number of NHS patients admitted to hospital increased year-on-year, despite a reduction in the number of hospital beds. Since the Covid-19 pandemic, fewer patients have been admitted to NHS hospitals and length of stay has risen, raising questions about NHS productivity, quality of care and the prospects of meeting ambitions to recover services. This report by the Health Foundation analyses data around hospital admissions and suggests reasons for these trends. Key findings In 2022, there were 800,000 (12%) fewer hospital admissions than in 2019, with elective admissions down by 279,000 (21%) and emergency admissions by 521,000 (9%). Despite this, the number of bed days has declined only slightly by 2.5%, from 36.2 million in 2019 to 35.3 million in 2022. Average length of stay in hospital increased from 7.3 days in 2019 to 8.3 days in 2022 (13%). Length of stay for emergency admissions grew from 7.9 to 9.1 days (15%), while length of stay for elective admissions decreased slightly from 5.2 to 5.1 days (3%). There were 41,000 (8%) more emergency admissions lasting more than 14 days in 2022 than in 2019. With hospitals already operating at or near capacity, this resulted in a reduction in the number of shorter stays, with 560,000 (11%) fewer emergency admissions lasting up to 14 days in 2022 than in 2019. While the number of emergency admissions fell and average length of stay increased for all age groups, the most significant change was among older patients, with average length of stay increasing from 10.8 to 12.5 days among those aged 85 years and older. Although emergency admissions fell in all areas, the most significant reductions were seen among people living in the most deprived areas, who also experienced the greatest decreases in elective admissions. This raises significant concerns about inequalities in access to care and whether commitments made by national leaders to tackle health inequalities are being met. Our analysis indicates, in response to pressures on beds and longer hospital stays, that hospitals have been forced to increase admissions thresholds, in effect rationing care by admitting fewer patients. It is not clear what has happened to more than half a million patients who would have been admitted for short emergency stays in 2019. Some are likely to have been treated elsewhere, potentially increasing the pressure on other services, while some are likely to have gone untreated. This is further evidence of a system operating under intense strain. While we cannot be certain about the combination of factors that explain these trends, it is evident that insufficient hospital capacity and barriers to patient flow – including high bed occupancy, delays in discharging patients and the continued need to treat patients with COVID-19 – have played a significant role. It is clear that reductions in hospital beds went too far. Policymakers have set ambitious targets for recovering NHS service standards that are predicated on hospital services working more productively to treat more patients. Understanding the factors contributing to the fall in hospital admissions and increase in length of stay – and whether they are amenable to intervention – will be critical to achieving these targets.

Urgent funding is required to clear waiting list backlogs and drive Northern Ireland's long-term healthcare transformation, the Northern Ireland Audit Office has said in a new report which outlines the health service's "critical situation" after almost a decade of worsening waiting lists for elective care. The NI Audit Office looked at waiting list data from 2014 to 2023. It found the number of patients waiting for elective care has risen by 452,000 during that nine-year period. The Audit Office also said: "Available information suggests waiting list performance levels are significantly worse in Northern Ireland compared with the other UK regions." The report makes a series of recommendations: The very long waiting times across all the main elective specialisms further underlines the range and scale of difficulties facing stakeholders. The Department and trusts should review the key causal factors influencing outcomes across the various elective specialisms and assess if action plans in place to address these need to be radically strengthened. Waiting list pressures are currently particularly acute for Neurology, Dermatology, ENT and General Surgery (initial outpatient appointments) and ENT, T&O Surgery, and General Surgery (hospital admission). To support the introduction of local RTT measurement and targets, DoH must strive to ensure that the Encompass programme remains on course for implementation by its scheduled deadlines, and that it is fully capable of such reporting. In the interim, it should use the December 2022 comparative figures as a baseline and continue regularly monitoring performance on that basis, to determine if the HSC performance gap with England and Wales is narrowing or increasing, and also identify if any best practice there, which has helped ensure performance has not deteriorated to the same extent, can be further implemented locally. Whilst action is underway to try and address issues around trust performance and patient DNAs, and the Department is now trying to centrally drive improvements, the Department and trusts now need to explicitly quantify the increased capacity and activity required to sustainably reduce waiting times, and assess how this can be achieved at each trust, through both improving the efficiency of current operations and progressing HSC transformation. It recommends that the Department identifies the investment necessary to ensure the HSC sector can function more efficiently and sustainably, including reducing waiting times to targeted levels. It should also demonstrate and quantify, in business case terms, if such investment can ultimately secure better longer-term value for money and patient outcomes, and the likely implications of failing to secure such funding. This will help DoH demonstrate how more sustainable funding arrangements can better support its objectives. As DoH and the Trusts seek to incrementally build increased dedicated elective capacity, they should monitor its impact on waiting times, and assess whether the additional facilities are having the desired success and impact. If waiting times are not reducing appreciably, they should assess the extent of further dedicated capacity required across key specialisms. Given the current situation, the Department should firstly confirm the robustness of its estimate of the funding required to fully implement the Framework in preparation for any potential introduction of long-term budgets. Until it has greater certainty on the availability of recurrent funding, it should rank or prioritise the actions likely to have greatest impact on waiting times and allocate available recurrent and non-recurrent funding towards these on this basis. The Department should set revised Framework targets as soon as feasible. The limited implementation of previous strategies means the Department’s regular progress assessments on the Framework is welcome. Going forward, these should identify the specific work which must be progressed over the next reporting period to ensure milestones are met, who is responsible for driving this, progress against targets and timelines, and whether emerging evidence means any actions should be redesigned or reprioritised. Progress should continue being publicly reported, setting out why any actions are behind schedule, and whether, and how, this can be rectified. Close working between the various stakeholders involved in workforce-related issues is required, to ensure stronger elective care workforce planning. The stakeholders should now take stock of how their work is progressing and collectively agree the priority areas which require further attention to ensure the HSC elective workforce has the right capacity and capability to drive HSC transformation. Based on the current situation and workforce deficits, revised projections and plans should be developed, together with targets and strategies for achieving these. Increased use of the IS is likely to be necessary for the foreseeable future to address the colossal patient backlog. In preparation for any progress in approving multi-year budgets, DoH should set out its strategic plans for expanding use of the IS, and continue to clarify with the sector the degree to which it can build additional capacity to help clear the backlogs.

Hospitals can significantly elevate patient satisfaction and enhance the delivery of healthcare services by incorporating best practices from adjacent and non-adjacent sectors. Chetan Trivedi explores several solutions, from multiple sectors, that can serve as a blueprint for hospitals across every key step of the patient journey, spanning from admission to discharge.

Physicians raised a concern to the Quality Department about patients who were diagnosed in the emergency department (ED) with a urinary tract infection (UTI) but who later were clinically reviewed and found to be without disease. These patients were often admitted and treated with potentially unnecessary antibiotics. Literature reviews show patient and staff education of a clean catch urine culture collection technique alone is not always effective at consistently reducing urine culture contamination. The intervention team hypothesised that an effective multifactorial method to reduce urine culture contamination would be a combination of staff education on appropriate midstream and straight catheter collection techniques, verbal and visual education for patients, and staff and physician identification of patients who would provide more accurate urine cultures via straight catheterisation than clean catch. The goal of this process improvement was to reduce unintended patient consequences of unnecessary admissions, unnecessary antibiotic treatment, and repeat urine cultures through reducing contaminated ED urine samples to ≤10% monthly contamination. The results found that combined interventions resulted in a six-month decrease of contaminated urine samples from the initial 51% to <10%, resulting in an 80% decrease. The authors concluded that urine culture contamination in an acute care ED was sustainably decreased through multiple process improvement interventions. Secondary outcomes included reduction in unnecessary antibiotic use and unnecessary admissions.

New research by the Health Foundation shows that the amount of hospital care received by those living in care homes in England rapidly declined in the first three months of the pandemic in 2020 and was substantially lower than in the same period in 2019.   The research, which is due to be peer reviewed, provides the first comprehensive and national analysis of all hospital care provided to care home residents during the first wave of the pandemic. It appears to substantiate concerns that care home residents (including those in nursing homes and residential care) may have faced barriers to accessing hospital treatment as the NHS rapidly reorganised to free up hospital capacity to care for critically ill COVID-19 patients. 

This study from Baseggio Conrado et al. describe time trends for hospital admissions due to food anaphylaxis in the United Kingdom over the past 20 years. The authors found that hospital admissions for food induced anaphylaxis have increased from 1998 to 2018, however the case fatality rate has decreased. In school aged children, cow’s milk is now the most common single cause of fatal anaphylaxis.

The VIP scheme is supported by the learning disability liaison team in the acute hospital to improve health outcomes. The scheme promotes reasonable adjustments, person centred surgical care pathways, accessible information and decision making care plans to support those who may lack the capacity to make health decisions. It also includes VIP champions and promotes evidence based training. The scheme is supported by the Wakefield Patient Experience Group, made up of people who have a learning disability.  The VIP scheme has improved health outcomes of patients with learning disabilities at Mid-Yorkshire Hospitals Trust. The scheme, all though multi-faceted, has one common aim; achieving equality for patients with a learning disability.

An informational video for people being admitted to a ward at the Royal Derby Hospital, designed for our patients with learning disabilities.

Reasonable adjustments to the care of people with learning disabilities who receive hospital care are beneficial for all involved. This article, published in the Nursing Times, uses two case studies to demonstrate their benefits.  Author, Linda Phillips, is a learning disability health liaison nurse at Hywel Dda University Health Board.

Dr Hein Le Roux is Primary Care Patient Safety GP Lead at the West of England Academic Health Science Network. Here Hein interviews Dr Emma Redfern on their programme to encourage the use of the National Early Warning Score (NEWS), followed by a conversation with Dr Sheena Yerburgh on a standardised admission sheet they have helped to develop, which is being used by GPs in the Gloucestershire area when referring patients to emergency departments.