Posted on January 17, 2022

Patient crowding in Emergency Departments (EDs) makes it difficult for staff to monitor all patients for signs of clinical deterioration. University Hospitals Bristol and Weston developed an innovative ED Safety Checklist to respond to these challenges.

Supported by Health Innovation West of England, the checklist was adopted by all seven EDs and the ambulance service in the region through the formation of an ED Collaborative, bringing together staff to work collaboratively, sharing ideas, experiences and data around implementation.

Following NHS Improvement’s recommendation for the checklist to be used in all EDs, it was rolled out nationally through our Patient Safety Collaboratives in 2018-20.

Further work around managing patient deterioration in the West of England has evolved from the success of our ED Collaborative and the development of the checklist, including adoption of the National Early Warning Score (NEWS2) in urgent care and use of ReSPECT (Recommended Summary Plan for Emergency Care and Treatment).

“International evidence, highlighted in the ‘Keogh Review’ of Urgent and Emergency Care clearly demonstrates the risks that crowded EDs pose to patient safety and outcome. This intervention is designed to directly address these challenges and has already been shown to be effective: it is entirely consistent with national policy in emergency care.”
Professor Jonathan Benger CBE, National Clinical Director for Urgent Care, NHS England


You can also catch our Emergency Department (ED) Safety Checklist video here.

The challenge

The UK and other countries have seen an unprecedented increase in demand for ED services in recent years.

Crowding in the ED has a profound impact on staff’s ability to deliver safe and high-quality care. This can lead to delay in recognition and treatment of patients with severe conditions, such as stroke, heart attack and sepsis with associated poor outcomes.

Staffing problems in the ED workforce can lead to reliance on agency and non-ED-trained staff. As demand and workload rise, staff can become overwhelmed by the tasks they need to complete in a timely fashion, whilst managing frequent interruption, and the risk of undetected patient deterioration increases.

Patients sometimes have to wait several hours in the ED for diagnostic tests and inpatient beds, as well as in the ambulance at peak times. The number of healthcare staff who interact with a patient increases and so does the risk of communication errors.

Sources: Paper published in the Journal of Clinical Nursing 

Our approach

Designed to address the challenge of ensuring patient safety during periods of crowding, University Hospitals Bristol and Weston NHS Foundation Trust, led by ED Consultant Dr Emma Redfern, developed and tested an innovative ED Safety Checklist in 2014, initially with support from the Health Foundation and then subsequently the Health Innovation West of England through its Patient Safety Collaborative.

The checklist helps to standardise and improve the delivery of basic care in EDs, systemising the observations, tests and treatments that need to be completed in a certain order. It also addresses quality of care issues, such as provision of pain relief, nutrition and hydration. It serves as an aide-memoire for busy staff, and any doctor, nurse, bank or agency staff can join the department and provide the right care by following the time-based framework of tasks.

Following the success of the initiative at University Hospitals Bristol and Weston, the West of England Patient Safety Collaborative supported all seven EDs and the ambulance service in the region to successfully adopt, adapt and refine the checklist through the formation of an ED Collaborative in 2016, using the IHI breakthrough collaborative model and quality improvement methodology.

The ED Collaborative brought together clinical and non-clinical representatives from all the trusts to work collaboratively, sharing ideas, experiences and data around implementation.

Health Innovation West of England developed a suite of resources, including a toolkit to support adoption. The toolkit includes a project plan, educational/promotional material, data collection tools, role specifications and a generic dashboard.

Impact to date

In July 2017, the ED Safety Checklist won the HSJ Patient Safety Award for ‘Best Patient Safety Initiative in A&E’. The judges felt the checklist had achieved a significant impact on patient safety and, having already spread across multiple organisations, could see the potential for wider adoption across the country.

There was a rapid move towards national adoption when NHS Improvement wrote to all trusts in England in October 2017 to recommend implementation of the ED Safety Checklist, unless they already had an equivalent evidence-based system in place.

From 2018 to 2020, the ED Safety Checklist was rolled out nationally through our Patient Safety Collaborative adoption and spread programme, commissioned by NHS Improvement. In 2019/20 the we found that the number of trusts using the checklist was 76%, a site adoption increase of 50%.

ARC West evaluated implementation and use of the ED Safety Checklist in the West of England during 2017. The evaluation found that dedicated training time and full integration with existing clinical documentation led to the best outcomes.

As a result of adoption of the checklist across the region, the number of majors / resus patients having their NEWS calculated within an hour of admission to ED had improved from an average of 55% to 84% in the first year, while those having their pain score calculated had increased from 59% to 93%. The number of ECGs requested within 10 minutes of arrival increased from 36% to 71% in appropriate patients. There was an increase of 5% in CT scanning within an hour for patients with a suspected stroke.

In February 2020 ARC West published a paper evaluating the Emergency Department Checklist to enhance patient safety. This resulted in updates to Health Innovation West of England’s toolkit.

Use of the checklist (or an equivalent) is now supported and endorsed by NHS England and NHS Improvement, the Royal College of Emergency Medicine, the Royal College of Nursing, and the Care Quality Commission.

“We are delighted to have been involved – the checklist has been a great tool to help us improve both safety and patient experience in the ED. Led by our clinical staff, a multidisciplinary team has been involved in making this checklist work at its best in both our emergency departments.”
Quality Improvement & Safety Director, Gloucestershire Hospitals NHS Foundation Trust

Next steps

While this Health Innovation West of England programme has now ended, the ongoing impact of our ED Collaborative continues to be felt today in the work of the Health Innovation West of England and our Patient Safety Collaborative, particularly around managing patient deterioration.

For instance, the establishment of the ED Collaborative marked the start of our work in urgent care with the National Early Warning Score (NEWS). Our programme to support the use of ReSPECT (Recommended Summary Plan for Emergency Care and Treatment), also evolved from insights gained through the ED Collaborative around inappropriate end of life ED attendance and conveyance, alongside our wider work around NEWS and Structured Mortality Reviews.

Our work on the ED Safety Checklist began in April 2016 and ended in March 2020.

Find out more about the ED Safety Checklist here or email us:

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