Delays in the handover of patients from ambulance crews to emergency departments (EDs) across England is causing avoidable harm and knock-on care issues, a healthcare watchdog confirmed.
A report by the Healthcare Safety Investigation Branch (HSIB) highlights the risk of poor outcomes if patients cannot access timely and appropriate hospital care, including their condition deteriorating, increased risk of dying, acquiring new illnesses, and increased risks of falls because of extended stays in hospitals.
The investigation also focused on the knock-on impact from handover delays such as delayed ambulance response times and surgery cancellations.
Emergency departments across England are routinely at, or exceeding, their maximum capacity, while delays in discharging medically-fit patients means there are not enough free beds to accommodate new patients, which is having a serious impact on the ability to provide safe care, the watchdog noted.
The HSIB's national investigation report brings together the findings of three interim reports published over the last 15 months. These examined the systems in place to manage patients into, through and out of hospital; gaps in accountability for patient safety between ambulances, hospital, and social care systems, and how the impact of staff wellbeing impacts patient safety.
Key Findings From the HSIB's Combined Investigation Reports
In summary, the findings were that:
- The movement of patients into, through and out of hospitals has a direct impact on ambulances queuing at EDs and creates patient safety risks and issues throughout the healthcare system
- Patient safety is managed differently across the healthcare system and does not consider how the 'air gap' between health and social care contributes to handover delays and harm
- There is no patient safety accountability framework which identifies individuals accountable and responsible for patient safety
- The wellbeing of staff is poor due to stress, moral injury, incivility, and burnout
The Case of Patient 'Kim' Highlighted Challenges to Acute TrustsInvestigators highlighted what happened to 'Kim' — a patient with complex medical needs — who was treated in the back of an ambulance for 163 minutes before being directly admitted to the ICU because an ED was full and not able to care for her. The experience of Kim, who has since sadly died, highlighted challenges which the HSIB said illustrated those found across other acute trusts in England. These included:
- Acute trusts not being able to accept new patients because their hospital is full, despite a significant number of patients being medically fit for discharge
- Ambulance crews caring for patients in the back of their ambulances for over 12 hours
- When hospitals are unable to accept new patients, this has a direct impact on flow on other hospitals who will see these patients in addition to their own
- Previous initiatives to improve patient flow have focussed on performance targets in EDs, such as the 4-hour standard, rather than whole-system changes to improve the flow of patients
Conclusions of the Investigator
Neil Alexander, a national investigator with the HSIB, said: "We brought together our findings into one national report to provide an overview of the work we have done over the last year or so – it is important to highlight the findings and recommendations we have already made to the system, especially as we head into what could be another challenging winter for the NHS.
"The report also gave us the chance to tell Kim's story in more detail. Sadly, hers is just one of many where a patient suffering from potentially life-threatening conditions or complications has had a significant delay in receiving the crucial care needed."
The HSIB made a number of recommendations and safety observations, including that the Department of Health and Social Care leads an immediate strategic national response to address patient safety issues across health and social care arising from flow through and out of hospitals to the right place of care.
"We recognise that there has been limited time since our reports were published to implement and evaluate a full system change," Mr Alexander said. "However, the evidence continues to show that there is an ever-present risk to patient safety and staff wellbeing, and that improvement needs [to be] prioritised to ensure that people are in the right place of care, for the right treatment, by the right health or social care staff."