Initiatives

The NHS is currently facing a number of unprecedented challenges and one of these is maintaining the safety of patients at the front door of A&E.

Difficulty accessing community and GP care, rising numbers of emergency attendances and an ageing population with complex health needs often result in demand outstripping capacity in Emergency Departments (ED), increasing the challenge of maintaining safety.

When emergency departments are overwhelmed, flow becomes blocked, queues start to back up and long waits occur, leading to increased risk of patient harm.

At the front door of the ED patients can often queue and wait for 1-2 hours for triage. This undifferentiated queue holds considerable risk as the clinical team do not have any visibility of clinical need, who should be treated quickly, and who is safe to wait.

eTriage is an automated self-check in and triage platform developed by NHS emergency clinicians to address this. Walk-in patients check in on a tablet in the ED waiting room, enter their demographic data to validate their identity through the NHS number look up. The system collects Emergency Care Data Set information with a short, focused triage history using a clinical algorithm of over 10,000 questions, with inbuilt flagging managed through a clinical governance process. Patients are automatically categorised into Priority 1-5 acuity criteria and their eTriage pushed instantly into the Hospitals Electronic Patient Record system.

Within six minutes of arrival, patients are checked in and triaged and the clinical team know exactly who and what acuity level is in their waiting room.

Over the last five years just under 900k patients have been safely triaged this way at 11 ED/UTCs and a further 10 sites are going in the next three months.

There are a number of benefits digital check in and triage brings to the EDs:

• Improved Patient Flow – through earlier identification of unwell patients and highlighting those suitable for early redirection to more appropriate services
• Improved Patient Safety – elimination of pre-registration queues, clinical visibility of the waiting room within six minutes of arrival, red flagging of individuals with high risk presentations moving them to the top of the triage list as P1, improved time to initial assessment, treatment and analgesia
• Freeing up resources – through reduced check-in times and triage durations.

eConsult has an internal team of clinicians that work with each ED to help improve front door safety including:

• redesigning patient triage and assessment pathways
• training and standardisation of triage process
• incident reporting and response
• under/over triages and agreed levels of error
• a robust and strict clinical governance process
• pathways that reflect latest clinical guidance, with monthly review of NICE updates and their relevance
• DCB0129/0160 and regulatory MHRA compliance
• specific accessibility training to ensure that patients who are not suitable for eTriage do not have their care delayed.

eTriage has picked up serious life-threatening conditions within minutes of arrival, such as Subarachnoid haemorrhage in 24-year-old male, a heart attack in a 63 year old male in the waiting room, a stroke in a 77 year old female patient.

A recent paper published by the lead academic ED consultant at University Hospitals NHS Trust showed sensitivity for prediction of high acuity outcomes was 88.5% for eTriage and 53.8% for nurse Manchester Triage System. The specificity for predicting low risk patients was 88.5% for eTriage and 80.6% for nurse MTS. See https://journals.lww.com/euro-emergencymed/citation/2022/10000/agreement_and_validity_of_electronic_triage_with.11.aspx.

There is currently no standardized acceptable triage accuracy rate, although the American College of Surgeons has suggested an acceptable rate of undertriage (those patients who are triaged incorrectly) for trauma patients of 5% (https://www.jmir.org/2022/6/e37209/). eTriage accuracy falls within this level. eTriage delivers a standardisation of accuracy to the triage process.

We are now planning:

1. Virtual Observations to develop technology that can automatically capture a patient’s vital signs along with their triage history, providing a NEWS2 score along with the eTriage priority giving an even more accurate picture of a patient’s presenting complaint.

2. To identify patients suitable for particular treatment pathways such as same day emergency care or early pregnancy assessment to get patients to the right clinician as quickly as possible.

Dr Mark Harmon is an emergency department doctor and the Chief Strategy Officer at eConsult Health.

Across my fourteen years as a patient safety researcher, I have been involved in research studies exploring how to meaningfully engage with patients and families to support healthcare safety. I have learned just how much patients and families can share about problems about safety, both before things go wrong, and especially when they or their family member have sadly been harmed. So even before we began the Learn Together Programme, I knew that if patients and families were not involved in safety investigations, important information which could help services was being neglected.  Services were missing a vital piece of the jigsaw.

But when I met Scott Morrish in 2018, my perspective changed. Scott talked so eloquently about the tragic events surrounding his son Sam’s death and the problems he and his family experienced in trying to get an investigation, and have their questions answered. It was clear from Scott’s moving testimony, that they had important information that could have supported learning from what happened. What struck me most was that by having to fight for an investigation, and to be involved in it, Scott and his family experienced additional layers of trauma – what might be called compounded harm.

Fast forward to 2019 and Scott became a key member of our brilliant research team, funded by the National Institute for Health and Care Research to develop and test new guidance to support involvement of patients and families in incident investigations. Across an ambitious, four-year research programme, we have had the pleasure of working with many people with lived and professional experience of things going wrong in healthcare and subsequent investigations.

As part of this, we interviewed over forty patients and relatives, healthcare staff and investigators; examined over 45 NHS investigation policies; reviewed the scientific literature; brought together a community of over fifty people to co-design draft guidance for investigations; trained nearly 50 investigators; followed 29 real-time investigations across five healthcare institutions (including the Healthcare Safety Investigation Branch); and, finally, took all of this on board and revised our final guidance. We have also been lucky enough to help support the development of national policy, with our work integrated into the new guidance for compassionate engagement of families that accompanies the new Patient Safety Incident Response Framework (PSIRF).

We have launched the guidance along with the new Learn Together website at https://learn-together.org.uk/.  The guidance, associated materials and videos are free to download, and healthcare organisations can adapt them for use. I am proud that we have supported a small shift towards prioritising listening and supporting patients and families, alongside learning from safety investigations.

Jane O’Hara is Professor of Healthcare Quality and Safety at the University of Leeds.

What do patients really know about healthcare safety? Last year, a paper from the London School of Economics addressed this question.  Researchers used machine learning to analyse over 146,000 stories on our website, Care Opinion. The surprising results showed that online patient reports of safety issues were a better predictor of hospital mortality than staff reports via the UK National Reporting and Learning System.

So, patients are reporting significant issues which staff either do not see or do not act on. And, in organisations that respond well, you can see such issues being addressed openly and in near real-time. In one story the author reports inconsistent and potentially unsafe care for her husband’s autoimmune condition. A doctor in the Accident and Emergency Department responds. She helps both to resolve the issue for this patient, and at the same time improves care in her department. Staff, patients, and relatives alike can read this story and the responses – and everyone can learn something from this.

Online feedback can be used in other ways too. For example, recent research used stories on Care Opinion as part of a study of ‘systemic safety inequities’ for people with learning disabilities.  And we have worked with colleagues at the Yorkshire and Humber Patient Safety Translational Research Centre to pilot the idea of a ‘research community’ on Care Opinion, where authors opt into invitations to participate in studies relevant to their feedback. Our pilot has successfully supported four studies so far and we plan to grow our community substantially in the year ahead.

Of course, safety in healthcare is about far more than simply focusing on what goes wrong. Over 70% of the stories people share on Care Opinion are positive, and these too can play an important role in supporting better, safer care. For example, a forthcoming scoping review of studies on positive patient feedback shows multiple benefits for staff: lifting morale, improving relationships at work and even at home, reducing burnout and possibly even improving clinical performance. We also think that teams engaging well with online patient feedback seem to become less defensive, more open to feedback, and more able to learn from complaints. All of these things foster and support an open, learning culture which is likely to result in safer care.

Patients share their stories online because they want to praise staff and improve care.  The evidence to date suggests they are succeeding.  Online feedback fosters trust, understanding and safer care. Therefore, it is a win for patients and staff alike.

For the past 18 years we have been offering this non-profit service in pursuit of our mission: to enable people to share their experiences of health and care in ways which are safe, simple, and lead to learning and change.  Thousands of staff across the UK are reading, responding, and using this feedback from patients to improve their services.

Dr James Munro is CEO of Care Opinion CIC https://www.careopinion.org.uk/

The London Complex Mesh Centre (LCMC) is one of nine mesh removal centres around the country that provide treatment for women who have experienced complications from pelvic mesh insertion and want it removed.

The LCMC was set up in 2021 at University College London Hospital (UCLH) in central London, which has a long history of providing treatment in this area.  This was in response to NHS England’s call for women with pelvic mesh complications to be treated by multi-disciplinary teams of clinicians.  Since opening, it has received 420 referrals.

Every woman is treated as an individual and every stage of patient treatment from referral to follow-up care, is determined by a team of experts working closely together to provide individualised and holistic care.

The centre covers all pelvic mesh complications, and the multi-disciplinary team includes surgeons, specialist nurses, imaging specialists, pain management specialists, physiotherapists, psychologists, and anaesthetists. The service is supported by a dedicated administrative resource.

Patients undergo a range of non-surgical (including pain management, psychology, and physio treatment) and/or surgical treatment depending on their needs and preferences.

For patients on the surgical pathway, there is a follow up process tailored to their individual needs which usually includes Clinical Nurse Specialist and consultant follow up and may also include physiotherapy, psychology, or pain management.

More information is available at London Complex Mesh Centre : University College London Hospitals NHS Foundation Trust (uclh.nhs.uk).

Tim has always lived with epilepsy.  He describes it as a hidden disability which has had a massive impact on his education, relationships and working life.  He has been on the receiving end of ignorance, fear and prejudice. At one point, his girlfriend’s father believed he was possessed by a demon. In his many dealings with the NHS he has encountered some fantastically kind nurses and a GP who is ‘more happy to give out some pills than she is to talk about it’.

Kauri’s father spent his final days at home after a diagnosis of pancreatic cancer. The clinical care and care coordination was excellent. His daughter’s main challenge as his primary carer was managing the competing demands of his large, extended family for access to him.  She describes a pivotal intervention by the GP: ‘…She comes downstairs and she has a very blunt conversation with some of the wider family….she says that…the best thing you can now do is support the immediate family….. it was very brave of her to do that….and that message carried authority.’

Rabiya was looking after her mum with early onset dementia and often in pain. She experienced a number of obstacles and instances of racism in trying to get a diagnosis and find care for her mum. But one day she took her mum to see a physiotherapist: ‘She just got it. She just listened to me and she said, I understand….She was laughing along with Mum, engaging with her, and Mum just responded really well and it put me at ease as well.’ Tim’s, Kauri’s and Rabiya’s stories (all names have been changed) are three out of twenty-five accounts that we have brought together in our book Organising Care Around Patients.

We wanted to find out what patient-centred care and its absence is really like for patients and carers. The accounts of our storytellers invite reflection on a number of themes, including the mental toll of long-term physical conditions, experiences of racism and ageism, power hierarchies between professions, the confusion about who is in charge and the pros and cons of labels and diagnoses. Above all, these stories illuminate five key aspects of care that is organised well for patients: kindness, attentiveness, empowerment, professional competence, and organisational competence. Listening underpins all of these – the will to get to the heart of what really matters to patients and their loved ones.

No-one doubts that stopping and listening is a huge challenge in a service that is as complex, overstretched and waiting-list-backlog-battered as the NHS. But listening to patients is where the magic can happen. Alongside the principle of first, do no harm we would argue that stop and listen to your patient is vital for helping staff as well as patients to navigate a safer and a kinder way through.

The sign above 18-month old Josef’s bed, which was brought to our attention recently, is a lovely example of noting what matters to patients. Josef’s parents saw this as exemplifying what they had experienced in Josef’s care, which they thought was very patient-centred.  An active little boy, the staff allowed Josef the run of the ward when he was feeling better, and chose carefully with him what tractor-themed cartoons he would like to watch when they had to carry out personal care that he was less keen on. The clinicians also used tractors as a way of engaging with Josef when he was unfamiliar with an individual member of staff.

The book Organising Care Around Patients is free to access and some of the stories are also available on audio at https://www.manchesterhive.com/display/9781526147448/9781526147448.xml

Naomi Chambers is professor of healthcare management at the University of Manchester and Jeremy Taylor is director for public voice at the National Institute for Health and Care Research.