Four Hour Emergency Access Standard: Expert Working Group Recommendations Report

4. Recommendations and Next Steps

4.1 Accident & Emergency Care

14. To enable greater consistency in reporting of A&E performance across Scotland, it is recommended that the current definition is amended to include all acute, medical, surgical and mental health emergencies. The definition should be centred around available facilities, as opposed to patient conditions, to provide a clearer overarching national framework and aid understanding. This would bring the definition more in line with current frameworks in other parts of the UK.

15. The following definition has been developed and endorsed by this expert working group -

Accident and Emergency (A&E) is the collective term for describing all A&E services. These are facilities that provide services primarily for the reception, assessment, examination, and treatment of patients who have been involved in an accident or have sustained an injury or who have an acute surgical, medical or mental health emergency which may require hospital facilities.

Accident and Emergency

• Type 1 – Core – Emergency Department. 24/7 Service. Consultant led. Includes full resuscitation and other facilities to treat serious and life-threatening conditions. Emergency departments can also provide treatment for minor injuries and less serious conditions, and some are co-located with a minor injuries unit; it is not possible to accurately differentiate the type of activity in the data.
• Type 2 – Single Specialty Emergency Department. (Ophthalmology / Dental / Psychiatry / Obstetrics etc.)
• Type 3 – Non-core - Minor Injuries Unit/Other. Dedicated minor injuries units are usually GP or nurse-led. Services may only be available for limited hours and may refer patients onto a Type 1 Emergency Department if more acute care is needed. MIUs are not designed to treat patients with acute medical emergencies, rather to provide advice and treatment for injuries that are not anticipated to be critical or life-threatening in nature. In some, usually rural locations, the MIU is co-located with a community hospital, and a broader A&E service may therefore be available.

16. The group recommend that this new definition of A&E care be adopted nationally. Types 1 and 3 will be included on the EAS and data for Type 2 will be used for quality monitoring and improvement purposes. For clarity, all Type 1 and 3 facilities should be recorded and submitted to the AE2 and include the required timestamps. Further work will be undertaken to define Type 2 services and improve national data capture.

17. The 4 hour EAS is designed to improve patient safety and the EWG are clear that all guidance should support prioritisation of seeing the most unwell patients first. It is recommended that the Scottish Government and Health Boards monitor time to triage and time to first assessment in the admitted and non-admitted cohorts. This data is already included in national reporting to PHS, but further work is needed to improve recording completeness and consistency.

4.2 Planned Urgent Care Attendances

18. With the introduction of the Redesign of Urgent Care, appointments can now be scheduled for patients, in need of urgent but not immediate care, to attend A&E and other front door services. Related pathways and the extent to which planned attendances have been adopted varies from health board to health board as does the means of recording of these attendees.

19. The EWG believe that including planned attendances on the four hour clock will:

• Provide a more accurate picture of A&E activity and performance
• Reflect the full workload of consultants and A&E staff
• Ensure equity of care with unplanned attendees as both patient groups would contribute to a sites performance against the EAS
• Support standardisation of reporting across sites and Health Boards
• Enable better assessment of the effectiveness of planned attendance in terms of reducing the time people need to wait in A&E for treatment

20. Guidance to be issued by PHS which sets out the following and should be adopted by all NHS Boards.

• All planned attendances to A&E Types 1 and 3 to be included on the EAS.
• The following attendance category definitions should be on the clock from point of arrival at A&E:
  • New – Unplanned
  • Return – Unplanned
  • New – Planned
• The small number of ‘Return Planned’ attendees will not be included on the EAS as these patients will have already been assessed an example being minor injury review clinics which operate in some A&E departments. This will prevent double counting of patients.
• The Recall code will no longer be a valid option and will be retired from the dataset. Systems should be updated accordingly and Boards should instead use the Return Unplanned option.
• For clarity, New Planned recordings must be an in person assessment. Virtual consultations should not be recorded on the EAS. If a patient attends an ED or MIU following advice from a virtual consultation they should be recorded as New Planned.

21. To enable data comparisons with other UK nations, PHS should ensure planned and unplanned data can be disaggregated and consider what changes may need to be made to the A&E publication to ensure continued comparability.

4.3 Admission Alternative Pathways (Ambulatory Care, SDEC, Acute Assessment Units etc.)

22. It is recognised that admission alternative pathways vary between Health Boards and individual sites and that further guidance is required to address inconsistencies in recording against the EAS within these pathways. It is difficult to achieve true standardisation of activity recording in Scottish AAU/AMUs with the current situation of services using different patient management systems.

23. Some of these services operate between specific hours whereas others operate 24 hours a day and are not dissimilar to an inpatient ward. Patients will be admitted to a bed and can remain there for an extended period of time depending on the individual’s care needs.

24. The EAS is an emergency care safety standard and as such may not be the appropriate measure for these services. It is noted that there are already clinical quality care measures which have been set by the Society for Acute Medicine.^[2]

25. Further consideration is needed by clinical experts who work in these areas to determine suitable national safety standards.

26. The following recommendations have been endorsed by the EWG.

A separate group of Acute Medical Clinicians and Information Leads is required to develop and agree recommendations to support consistency in the recording of Admission Alternative Pathways. The group will consider –

• Service definitions, agreed data collection and national submission route for admission alternative pathways to promote consistency between sites and boards
• Clarifying how transfer into admission alternative services should be recorded
• The Society of Acute Medicine will be consulted on any changes to any definitions.

If a patient is transferred to an admission alternative service following a clinical assessment in A&E that episode of care should be discharged and a new episode created

• If there is no room to admit the A&E patient to an alternative acute medical service, these patients should remain on the EAS until they can be transferred
• This will better reflect the work of the ED department staff where a patient has been referred to another service following an episode of care in A&E

Boards should ensure accurate recording of timestamped data for these pathways for local monitoring purposes until an agreement has been reached on which national data return they should be submitted under. This data will be used to inform decision making in the future group.

• This should include: time of admission, time of assessment and time of discharge.
• This will not be on the Four Hour clock at this time. PHS will need to consider and advise on how / if this can be reported within current IT and reporting systems.