The number of people attending A&E departments has increased steadily since 2002/03². The guidance will help hospitals to plan safe staffing for nursing and best meet demand for their A&E services.
Professor Mark Baker, director of clinical practice at NICE said: “From being involved in a major trauma such as a car accident to the sudden worsening of a chronic condition like heart failure, medical emergencies can affect anyone at any time. Over 14 million people attended A&E departments1 in England last year. Nursing staff are often among the first to see patients and we know the care they provide is essential for successful treatment of every patient. Ensuring there are enough available nursing staff, with the right skills, helps to make sure people in need of immediate medical help, will get safe care, whatever the time of day or night.”
This guideline was commissioned by the Department of Health and NHS England in November 2013 and is part of a series of guidelines which NICE will develop on safe staffing in the NHS.
The new draft recommendations set out the responsibilities of senior nurses and hospital managers, and the actions organisations can take, to ensure there are enough registered nurses and non-registered nursing staff to provide safe care at all times to patients attending A&E. This includes making sure that the department has the capacity to provide all necessary emergency care, as well as specialist input for children, older people or those with mental health needs.
The draft guideline includes recommendations for minimum ratios which can be considered by organisations when planning what nursing staff they need to fund in advance (also known as the establishment3) or they can also be used on a shift-by-shift basis to help work out what services can be made available at that time. These are based on the seriousness of a person’s condition and the level of care they need, for example:
- 2 registered nurses to 1 patient in cases of major trauma or cardiac arrest
- 1 registered nurse to 4 cubicles in either ‘majors’ or ‘minors’4.
Miles Scott, chief executive officer, St George’s Healthcare NHS Trust said: “Thousands of people come to major A&E departments every week with a range of serious injuries and illnesses, from blood loss after an accident, to severe chest pain, to loss of consciousness. Organisations not only need to deal with this variety of patients they also need to be prepared for unpredictable peaks in attendance numbers.
“Getting nursing staffing right is one of the ways to help A&E departments cope with the challenges of changing demand and still provide safe care to patients regardless of service pressures.
“This draft guideline advises hospital managers and senior nurses on how to allow for flexibility and the actions to take to enable responsiveness. It also includes recommendations for A&E nursing staff on the signs to look out for when patients’ needs are not being met and when to escalate issues to senior staff.”
Demand in A&E can change rapidly and the draft guideline recommends that when planning the number of nurses for the establishment, departments should allow for enough nursing staff to care for higher than the average number of patients who attend the department on a daily basis. By increasing weekly nursing staff hours to cover above average attendance numbers, staff can deal with unexpected peaks in the demand for A&E services and be moved around the department flexibly to respond to changing situations.
The draft recommendations also cover the process for senior nurses on each shift to check whether there are enough nursing staff at that time. Throughout the shift, nurses are also advised to look out for red flags that may show something is wrong, such as patients falling or leaving the department without being seen, or the department being crowded. These should be reported immediately to the nurse in charge who can take action to stop the situation getting worse. Organisations should also publicise red flags to patients, family members or carers, and ensure they are able to report incidents such as untreated pain or delays receiving food and drink, to the nurse in charge.
Professor Baker added: “As demand on A&E services continues to increase, we want to ensure that each and every A&E department across the country is clear on how to get nurse staffing right and is able to provide safe care to the millions of patients who walk through the door. We now need feedback from nursing staff and all other healthcare professionals working in emergency care, hospitals trusts and also members of the public to help us ensure all relevant views are considered for the final guideline.”
The draft version of this guideline has been published for consultation. NICE encourages comments from stakeholders with an interest in this guideline. Organisations can register as a stakeholder on the NICE website and have until Thursday 12 February 2015 to submit their comments. Individuals are ideally advised to pass comments through a registered stakeholder organisation that most closely represents them but are also welcome to submit comments directly via the NICE website.
Further details on all the safe staffing guidelines are available on the NICE website.
For more information call the NICE press office on 0300 323 0142 or out of hours on 07775 583 813.
Notes to Editors
- The draft guidance focuses on type 1 A&E departments which are consultant-led 24-hour services with full resuscitation facilities and designated accommodation for the reception of A&E patients. Nursing staff refers to registered nurses and non-registered nursing team members whose titles may include healthcare assistant, healthcare support worker, nursing auxiliary, nursing assistants and assistant practitioners.
- A&E Attendances and Emergency Admissions 2014-15. NHS England.
- The nursing staff establishment is the number of nursing staff funded to work in the A&E department. This includes all nursing staff in post, as well as unfilled vacancies or vacancies being covered by temporary staff. Nursing staff establishments are usually expressed in numbers of whole-time equivalents.
- When patients receive initial assessment in the A&E department they are assigned a triage category that allocates them to different areas of the department according to their needs. The ‘majors’ department will see patients presenting with urgent health needs that need immediate attention upon arrival. The ‘minors’ department will see patients presenting with less urgent health needs, whose condition is not immediately life threatening.
- The draft guidance is available at /Guidance/InDevelopment/GID-AccidentAndEmergencySettings.
- The final guideline is expected to be published in May 2015.
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