Accident and emergency (A&E) waiting times hit the headlines this month when NHS England announced it had missed its four-hour A&E waiting time target with performance dropping to its lowest level for a decade.

From October to December, 92.6% of patients were seen in four hours—below the 95% target. The performance is the worst quarterly result since the target was introduced at the end of 2004. The rest of the UK is also missing the target and a number of hospitals have declared ‘major incidents’ recently.
The Government has blamed the drastic decline in hospital performance on growing numbers of frail, older patients, but charities supporting the elderly, including Age UK and Independent Age, said that cuts to council care budgets were now having a knock-on effect upon the NHS. Charities were quick to highlight that these new A&E figures demonstrate ‘deepening problems in our whole health and social care system, not just A&E departments’. 

Independent Age said that cuts to social care, which is funded not by the NHS but by councils, mean fewer frail elderly patients receive the support they need to stay out of hospital. Once in hospital, there are too few support services available for them to be quickly and safely discharged. As a result, the entire system is in danger of becoming blocked at times of increased demand, such as we are seeing now.

In the two weeks over Christmas, 20,962 A&E patients waited up to 12 hours on trolleys—almost four times as many as the 5,573 over the same period last year. The official statistics show that in the last three months, more than 90,000 A&E patients waited up to 12 hours on trolleys.

NICE has recently outlined draft guidance to help A&E departments ensure there are enough nursing staff available to provide safe care at all times to patients. It aims to ensure that A&E departments have the capacity to provide all necessary emergency care, as well as specialist input for children, older people or those with mental health needs.

It recommends that organisations consider minimum ratios when planning what nursing staff they need to fund in advance. Minimum ratios 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:
Two registered nurses to one patient in cases of major trauma or cardiac arrest
One registered nurse to four cubicles in either ‘majors’ or ‘minors’.

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.

Professor Mark Baker, director of clinical practice at NICE said: “Over 14 million people attended A&E departments in England last year. Nursing staff are often among the first to see patients and we know the care they provide is essential for the 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. 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.”

As Miles Scott, chief executive officer at St George’s Healthcare NHS Trust, said A&E departments not only need to deal with a variety of patients they also need to be prepared for unpredictable peaks in attendance numbers. He is right when he says 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.