Emergency Department Capacity Management Guidance

6. Tips for implementation

NHS Lanarkshire offered to test the implementation of guidance on eliminating crowding in July 2015, initially in Hairmyres Hospital and then in Monklands and Wishaw hospitals. These tips for implementation are based on NHS Lanarkshire's learning. The Scottish Government recognises that they represent good practice in guidance implementation and recommends their use by NHS boards.

1. Working group

The first step should be to form a short-life working group. This will help focus direction and momentum and provide a forum for engagement and a sense of shared ownership of ED crowding.

2. Senior leadership

Strong senior leadership is essential for agreeing and leading development of the standard operating procedure. The NHS Lanarkshire working group was chaired by the chief executive and included clinical leaders, managers and directors, consequently providing strong senior leadership and support for the work.

3. Clinical engagement

It is vital that clinical staff are fully engaged. Clinical leads from across all areas of the organisation should be members of the working group, ensuring that progress is clinically led and understood across the whole hospital. The group should also include senior nurses.

4. Test and measure

Measures for eliminating crowding need to be agreed and tested at local level. Having a quality improvement lead working alongside a clinical lead helps ensure a robust process for tracking and measuring cycles of change and testing measures, local definitions and trigger points.

5. The 6 Essential Actions to Improving Unscheduled Care

Successfully eliminating crowding relies on wider work across the system to improve unscheduled care. It is crucial that this work does not sit in isolation, but is considered within the context of the 6 Essential Actions, particularly in relation to daily site management and effective discharge planning.

6. Clinically agreed local definitions

NHS Lanarkshire agreed clear definitions of what "crowding" and "overcapacity" meant locally, clearing any misconceptions staff may have held prior to the work commencing. Defining terms helps provide a structured framework for eliminating crowding at an early stage, before the department reaches full capacity.

7. Clear decision matrices

Clear decision matrices with defined routes of action and accountability should be in place for occasions in which escalation is triggered. Escalation steps should be agreed at executive director, management and clinical levels.

8. Clinical responsibility

To ensure patients are kept as safe as possible at all times, it is vital that clinical responsibility for individual patients when handing over is clearly understood. Strong clinical leadership and engagement should help support these discussions.

9. Implementing stage 3

A recommendation to enact a full-capacity protocol should only be made after the ED lead nurse and doctor have discussed the situation in detail with the site director, lead nurse and lead doctor or on-call manager who, in turn, will require the chief executive or formal deputy (on-call director or deputy) to authorise any patient movement out of the ED to a full ward.

This action, or any variation of a full-capacity protocol, is considered a never-event and must be subject to an immediate significant adverse event review.