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Written on 25th November 2021 by Richard Money-Kyrle

The Royal College of Emergency Medicine (RCEM) has published a report calling for urgent action to address the rising level of harm from overcrowding in accident and emergency departments (also called ED or A&E). 

The latest report in the RCEM’s Acute Insight Series: Crowding and its Consequences, responds to current long ambulance delays, high levels of ED crowding and record-breaking numbers of patients experiencing long waits for treatment. It urges the government and the NHS to take system-wide action to deal with escalating numbers of patients waiting for care, staff and hospital bed shortages, disrupted ambulance services, avoidable deaths, and mistakes and delays in patients’ care.

What is the RCEM?

The Royal College of Emergency Medicine or RCEM is the professional organisation which sets and monitors standards of care in emergency departments and A&Es to ensure the safety of patients. RCEM also provides guidance and advice for policy makers and sets training standards for emergency medicine.

What does RCEM’s crowding report say?

The clear message from RCEM’s report is that crowding in A&E departments is a major threat to public health, which needs to be tackled urgently.

Rise in A&E attendances and delays in treatment

A&E crowding in the UK has worsened significantly in recent years due to a severe shortfall in NHS’s capacity to meet patient demand. Visits to A&E have risen in the last few months and in June 2021 were the highest since records began.

RCEM say that increased visits to A&E should not cause crowding if there is a good flow of patients through the hospital system. However, more patients are arriving and they are staying longer in A&E, leading to overcrowding. In September 2021 only 64% of A&E patients in England, and 57.9% in Wales, were admitted, transferred or discharged from A&E within 4 hours. This summer, 12-hour ‘trolley waits’, where patients are left waiting in A&E after the decision has been made to admit them to wards, matched the worst winter figures on record. 12,540 patients this year waited in A&E for more than 12 hours after the ‘decision to admit’ had been made.  

In September 2021 the average treatment time for patients from the time they arrive at A&E was 79 minutes, an all-time high, with some waiting a record 5.4 hours. RCEM point out that this creates a dangerous vicious cycle in which crowding causes longer waits which in turn create more crowding. It is particularly dangerous for patients who appear well but have a serious underlying cause for their visit to A&E.

The total time that patients spend in A&E has also increased, adding to crowding in A&Es. In September 2021, the average time spent by patients in A&E was 3.1 hours, with some waiting more than 11 hours. Total time spent in A&E by patients who are not admitted has also increased over recent months, with recent average stays of 2.8 hours, and some waiting nearly 9 hours. Non-admitted patients should spend less time in A&E than those who are admitted, but these figures are amongst the highest on record.

Time spent in A&E by admitted patients has long exceeded recommended levels but in September 2021 was at an average of 5.2 hours, with some in A&E for more than 16 hours. RCEM say that as there is rarely any clinical need for a patient to be in A&E for 6 hours, these delays must be due to overcrowding.

Exit block

RCEM say that the main reason for overcrowded A&Es is ‘exit block’. This is where A&E can’t transfer a patient to a ward because the ward cannot take any more patients. Exit block results in patients waiting a long time to be seen, or being treated in corridors or waiting in ambulances.

Disruption to ambulance services from crowding in A&E

When A&Es become crowded, they can no longer accept patients who arrive by ambulance, and the ambulances holding these patients are forced to wait. Delays in ambulance handovers, over the national target time of 15 minutes, but also over an hour, have increased dramatically over recent months. Figures to July 2021 show that a record half of ambulance arrivals are assessed within 10 minutes, compared with 6 to 9 minute previous figures. In September 2021, longest waits were at 104 minutes, higher than the waits from winter 2019. This means that A&E capacity and crowding are already worse than in one of the worst NHS winters on record.

RCEM points out two patients are at risk for every ambulance that cannot offload their patient into A&E - the patient in the ambulance and the next patient waiting for ambulance care. However, ambulance handover delays are not solely an A&E issue, they are caused by system-wide exit block problems.  

Hospital bed availability

Crowding is directly related to bed capacity in the hospital system. Patients can’t be admitted to wards, and must wait on A&E, until a bed is available for them.  Bed availability depends on factors such as the number of beds, staffing levels and the discharge process. 

13,570 beds were lost from the NHS between 2010/11 and 2021/22. RCEM says this cannot be blamed solely on steps taken to prevent infection during the pandemic, as 8,374 beds were lost from 2010/11 to 2019/2020. The UK has one of the lowest, (still decreasing), number of beds per 1,000 population of all economically developed countries. This leaves UK hospitals overwhelmed by surges in demand, leading to longer patient stays in A&E and overcrowding. In addition, the proportion of occupied beds continues to rise.  

RCEM point out that whilst the government’s recent spending review allocated £1.5bn to improving bed capacity for surgical hubs, the pandemic Nightingale initiatives demonstrated that safe care can only be provided if the NHS can also keep and recruit enough staff.  RCEM highlighted the need for 2,000-2,500 more emergency medicine consultants across the UK and urged the government to act now to address this shortage and achieve safe A&E staffing levels.

Discharge from hospital

Exit block arises from delays in discharging patients from hospital whilst they are waiting for ongoing social care. RCEM say this is caused by lack of integration and funding between the hospital system and social care sector. RCEM calls for significant investment into community and social care. With 1 in 5 hospital beds currently occupied by long-stay patients, RCEM estimates the number of people waiting for hospital treatment could rise from 5.72 million (now) to 14 million.

RCEM says A&E crowding is dangerous and causes medical errors

RCEM has campaigned about the dangers of crowding for many years. Their report highlights that waiting on trolleys, in corridors or in ambulances is undignified and inhumane, but also puts patients at risk from poor standards of care. Emergency medicine is one of the leading sources (11%) of litigation claims in the NHS, costing the NHS the equivalent to 14% of the running costs of emergency care each year. In 2019/20, 8% of medical negligence claims arose from A&E care. Whilst it is not known how much crowding directly contributes to litigation, delays and dilution of medical care inevitably contribute to avoidable error.  RCEM also estimate that A&E crowding has probably led to more than 4,500 excess deaths in hospital in England alone in 2021 so far, compared to 1,827 deaths from road traffic collisions across the entire UK in 2019.

Overworked clinical staff are more likely to make mistakes. In an RCEM survey, 73% of A&E physicians said that workforce pressure affected patient safety in their departments before the pandemic. Other crowding-related dangers to staff come from increased violence and aggression towards them, infection-risk for ambulance staff waiting in ambulances with sick patients, demoralisation, burn-out and staff choosing to leave the NHS. When RCEM surveyed emergency staff about what could be done to improve their wellbeing at work, the overwhelming response was to fix problems such as increasing the number of staffed beds, improving flow and eliminating exit block, all of which are linked to crowding. RCEM say that fixing these issues would allow patients to receive a better standard of care,  whilst helping keep staffing at safe levels.  

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