Our aim is always to deliver high standards of care for patients in the right place and at the right time.
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.
A survey and subsequent report by the Royal College of Nursing (RCN) showed the detrimental impact of this care setting on patients and staff and calls for total eradication.
TES do not include spaces that are opened as part of winter pressure planning and refer to care given in any unplanned settings (such as corridors).
However, the current healthcare landscape means that some providers are using temporary escalation spaces more regularly – and this use is no longer ‘in extremis’.
The use of TES is never acceptable when caring for children.
These principles have been developed to support point-of-care staff to provide the safest, most effective and highest quality care possible when TES care has been deemed necessary.
The principles should be applied alongside any local standard operating procedures and arrangements governing flow pathways and safe staffing.
Core principles
- assessment of risk
- escalation
- quality of care
- raising concerns and reporting incidents
- data collection and measuring harm
- de-escalation
1. Assessment of risk
Patients should, where possible, be seen, assessed, and treated within a clinically appropriate bed or chair space. Care given outside of these bed or chair spaces should only be used when all other options have been exhausted.
It is imperative that all healthcare partners across the whole patient pathway, from pre-hospital care to point of discharge, work collaboratively, have clear and open lines of communication and have processes for the escalation of concerns.
Assessments of risk for potential harm and safety for staff and patients that are being considered for care in TES bed and chair spaces must be completed and organisational governance processes and full capacity protocols must be followed. Local patient safety checklists should be used to ensure the patient is safe to be cared for in this setting. This should include an inclusion and exclusion checklist.
Providers should refer to NHS England’s Emergency Care Improvement Support Team (ECIST) guidance (FutureNHS login required), which details best practice measures, principles, tools, and evidence. It will support decision making that balances patient and organisational risk across a system in extremis.
The Care Quality Commission’s (CQC) fundamental standards should be adhered to.
Consideration should also be given to:
- 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
- appropriate staffing and skillsets that ensure the safe monitoring of patients and the ability to recognise deterioration
- the provision of daily senior nurse quality rounds and safety huddles. The huddles should include a review of the staffing requirements for the additional patients and their individual needs in line with expectation 3 of the National Quality Board (NQB) Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time (2016).
- access for staff and equipment to the space and the ability to provide good quality care and emergency response within it
- adherence to local infection control policies
- full environmental assessment (including the assessment of fire hazards and exits)
- the identifiability of the space for staff, ensuring clear visibility of the patient’s location for all personnel (patient tracking)
- the ability for patients, families and care partners to easily get staff attention
It is imperative that executive teams and departmental senior accountable clinical staff are visible and support staff caring for these patients and taking decisions in this area.
The level and profile of risks will continually change and will need to be assessed using a dynamic risk assessment (DRA) approach. This assessment should also consider risk across the pathway or system, recognising that increasing a risk in one area may reduce a risk in another part of the pathway, which may be the ‘least worse scenario’.
For example, the decision to increase early discharge for ‘pathway zero’ patients may increase the risk of patient harm, but this may be a lower risk than if the patients were being treated in TES.
A decision to divert ambulances to another provider may increase risks to patient safety due to travelling longer distances but may lead to significantly reduced pressure in the emergency department and reduced need for TES.
Integrated care boards (ICBs) should be supporting providers to manage using a risk-sharing approach.
Providers and systems can use the GIRFT-developed Summary emergency department indicator table (SEDIT) dashboard.
This enables clinicians and managers to evaluate their emergency department’s current demand, capacity, flow and outcomes, to understand why problems are occurring and to target the root causes.
2. Escalation
All providers must have working escalation models in place and follow organisational governance and reporting structures.
Local policies on internal escalation should be triggered once a patient’s care has been allocated to TES. This should include the senior clinical and management teams (triumvirate) responsible for the department, along with the trust board.
Escalations should adhere to organisational governance processes. Providers should follow any local policies regarding patient flow and safe staffing.
Providers should escalate to system quality groups and use the NHS England Operational pressures escalation levels (OPEL) framework to allow systems to have a clear vision of urgent and emergency care pressures and awareness of the potential risks and harm.
Systems should also consider reporting the number of patients in TES. They should follow their local escalation policies to inform regional teams (including through regional quality groups). Regional teams will be able to escalate to national teams.
3. Quality of care
It is essential to maintain the delivery of high quality care throughout the entire episode of care in TES. The following principles should be followed:
- patient safety is imperative and patient selection is key. All patients who are being considered for this setting must be reviewed against a safety checklist
- the care should be person-centred, focussing on the needs of the individual and ensuring that patient’s preferences and values guide any clinical decisions made
- while it is recognised that patient experience will not be optimal, it is important to always maintain privacy and dignity during their episode of care
- easy access to bathrooms should be maintained and hourly comfort rounds should be undertaken. Personal hygiene requirements should be identified
- patients should have access to nutrition, including hot meals and hydration. Reasonable adjustments should be made for any patients identified as requiring support
- patients must be able to get quality sleep
- communication with patients, families and care partners is essential. There should be regular conversation informing patients about their treatment plan, condition and any progress to moving to a bed or cubical or to being discharged. Patient confidentiality must be maintained throughout this communication
- clinical staff should maintain regular reviews, observations and NEWS2 scoring of patient’s conditions to identify early any changes or deterioration that may require the patient to be moved to another area of the emergency department. Medications should be given as per prescription plan and should be monitored
4. Raising concerns
Staff should have the freedom to speak up (FTSU) and have access to FTSU guardians.
It is imperative that staff delivering care in TES have a voice and feel heard. Staff should be encouraged to raise concerns immediately and these concerns should be dealt with in a timely manner.
Staff should always feel safe to report and raise concerns and be reassured that these are being taken seriously. Staff should not be fearful of raising concerns and reporting complaints.
Senior management teams should promote this and embed it in their organisation’s culture.
Staff should have the opportunity to debrief and to discuss areas of concern further.
Staff need to be heard and supported. Areas should have mechanisms to address staff psychological and welfare support (for example, open door policies, drop-in sessions, visible senior staff support and allocated 1-to-1 time). Local staff surveys can also be used.
Patient experience must be monitored, and patients, families or care partners should be given the opportunity to raise concerns and complaints in real time. Local policies on raising concerns and complaints should be followed.
Patient welfare must be measured. This can be done using surveys (such as the Friends and Family Test) or a trust might develop a specific survey about their TES care.
Trusts should consider developing leaflets and information about TES care.
5. Data collection and measuring harm
Trusts need to monitor the risks of potential harm, the actual harm that has occurred and the impact on patients and staff of the use of TES.
This should include, but should not be limited to, complaints, ‘duty of candour’ incidents and information from external sources such as patient and staff surveys.
Real-time quantitative and qualitative harm data should be visible to senior clinical and management teams and to trust executives. Providers should apply their own processes and incidence reporting systems. These can be used to escalate concerns to system, regional and national colleagues
There must be mechanisms in place to evaluate any harm caused (for example, after-action reviews). These mechanisms should allow learning to be fed back to frontline staff and to trust executives.
The SEDIT dashboard can also support analysis of demand, capacity, estates space and outcomes to evaluate potential harm and realised harm.
6. De-escalation
It is essential that providers and systems have robust models of de-escalation.
De-escalation should mirror escalation plans in reverse and use the dynamic risk assessment approach. The same communication channels used for escalation should be used for de-escalation. Situation reports should be provided for senior teams and trust executives, and system leadership.
The chief executive or board should oversee de-escalation and ensure care is delivered in appropriate areas immediately. The trust board’s quality committee should also be sighted, given the risk that the provider is breaching CQC registration in using TES.
There should be a process in place to de-brief staff, identify lessons and review internal standard operating procedures, policies and processes.
Publication reference: PRN01560