Emergency department checklists

Across the English NHS, emergency departments are coping with increasing demand, an ageing population with increasingly complex needs and a shortage of inpatient beds. Facing a national workforce shortage, they are increasingly reliant on locums and non-specialist staff.

The pressures on emergency departments reach a peak during winter, with overcrowding, patients being managed in makeshift overflow areas, and insufficient staff numbers for the volume of patients being seen. During these periods, there is an increased risk that staff fail to monitor and treat patients appropriately. As a result, patients have been allowed to deteriorate, leading to more severe illness, prolonged hospital stays and, in some cases, avoidable deaths. 

In 2014, Emma Redfern, a consultant in emergency medicine at University Hospitals Bristol NHS Foundation Trust set about finding a solution to these challenges. She started with a review of serious untoward incidents in the trust’s emergency department from 2011 to 2014, which revealed basic failings in the provision of care in periods of overcrowding. Patients with chest pain had not received regular electrocardiograms to ensure treatment for heart attacks; patients with Parkinson’s disease had not received appropriate drugs rapidly, leading to lengthy, unnecessary hospital stays; patients with sepsis had been allowed to deteriorate significantly before action was taken.

Emma’s response was to develop a simple checklist of tasks that had to be completed for every patient who presented to the emergency department, whether the department was experiencing overcrowding or not. The purpose was to provide guidance for staff who were not used to working in the emergency department and to ensure that no essential tasks were missed, even during busy periods. For example, it included checking that vital signs are measured on admission to the department, completing an early warning score to identify high-risk patients, taking blood tests, carrying out an electrocardiogram, and continuing to monitor vital signs hourly. It also included specific requirements for stroke, fractured neck of femur, sepsis and other conditions. 

The next stage was to implement the checklist within the trust’s emergency department. The team ran engagement and teaching sessions with nurses and doctors to explain the process, seek feedback and address their concerns. Experienced nurses were initially offended that they were being asked to confirm that they were carrying out basic tasks. It was important for the team to spend time discussing the trust’s performance data and recent incidents to convince nursing staff of the case for change. Nurses were also concerned that the checklist would create more paperwork, leading the team to replace traditional handwritten notes with the checklist.

In a subsequent phase, the team secured funding from the Health Foundation’s Shine programme to measure impact and improve the model. They used the grant to recruit a research nurse who would compile baseline data on performance in carrying out the tasks in the checklist and monitor its impact. Over the first six months, this led to refinements such as ensuring that patients received food and drink and that next of kin were informed that they were in hospital. 

Following adoption, the trust delivered 5 to 25 per cent improvements in compliance with the different activities on the checklist. For example, there was a 5 per cent increase in patients with suspected strokes receiving a CT scan within an hour; an 11 per cent increase in stroke patients being treated within the appropriate pathway; and a 25 per cent increase in completion of early warning scores and hourly vital signs monitoring. Since introduction of the checklist at the trust, there have been no clinical incidents related to failure or delay in recognising that a patient is deteriorating. However, there was also evidence that compliance rates began to drop once the enthusiasm associated with the new project had died down. As well as instituting the checklist, the team found that they needed to put in place a routine process for senior nurses to review a sample of notes from the day and feedback problems to colleagues. 

Since 2015, Emma has been working with a team from the West of England AHSN to ensure adoption of the checklist across the region. As Emma explained, organisations need to invest between £15,000 and £18,000 to implement the checklist effectively. The main cost involved is allocating staff to collect baseline data on the emergency department’s performance, collect new data as the checklist is introduced and provide feedback on the impact to staff every six weeks. The West of England AHSN has provided this funding for adoption of the checklist in the region’s seven emergency departments and within the ambulance service. The national bodies have also played a useful role in raising awareness of the toolkit, including through a case study on NHS Improvement’s website.

As Emma explained, some of the adopting sites made rapid progress in developing the checklist. Others needed more active encouragement and support; at these sites, it was particularly important to collect data and for senior staff to make the case for change to their colleagues. One unit was unconvinced of the need for the checklist and only engaged actively after a series of serious incidents highlighted the need for improvement. The team had also helped sites to adapt the checklist to local challenges, for example, introducing new requirements and key performance indicators to address specific problems highlighted by complaints or incidents.

In addition to supporting adoption, the AHSN has created a network for the seven sites and the ambulance service to benchmark progress and share learning. The consultant leads, nursing leads and data collectors for each of the sites meet annually and join a conference call every six weeks to share information on challenges they are facing, approaches they are testing and performance data. In the past, there had been a high degree of rivalry and unwillingness to learn from neighbouring sites. The collaborative is helping to develop a more collegiate relationship, with each of the sites recognising that they can support and learn from others. 

Where AHSN support was not available, it was very difficult for sites to find the funding needed to deliver the project. This was despite the fact that the actual amount of funding was extremely small, the benefits for the adopting organisation were significant, and the impact was seen almost immediately. There were few emergency departments in a position to release staff from operational duties to support the project. From October, it was usual for trusts to cancel study leave, cancel meetings and pull any staff working on other issues back into service delivery. A number of consultants at trusts outside the West of England had planned to implement the checklist but were unable to secure funding to do so. 

In addition to supporting the seven sites, the West of England AHSN has supported the development of a toolkit that other emergency departments can use to adopt the checklist. This should help sites with access to resources and improvement capability to apply the toolkit in a systematic way. However, Emma was sceptical about how many sites would be able to do so on their own, even with publicity on the need for improvement and the benefits of the model. ‘The problem is that emergency departments are fire- fighting all of the time and unless somebody goes to help them, it is unlikely that they are going to pick this up.’ She was in discussion with three other AHSNs that were considering whether they could support adoption in their regions.