• CQC will use existing assessment framework but focus on newly identified key themes
  • Eight key themes include ambulance arrivals, first assessments and specialist referrals
  • The areas were identified at summit for leading A&E performers

Urgent and emergency care providers have been set eight major priority areas to focus on this winter by the Care Quality Commission.

They include warnings against putting patients in corridors and other ”inappropriate physical spaces”, “poor leadership and culture”, and against delaying “clock starts” when ambulance patients arrive.

Chief inspector of hospitals Ted Baker told hospital trusts that their boards must “review their own processes and policies” to ensure requirements, particularly in certain highlighted areas, are being met, in a letter seen by HSJ.

The eight “key themes” the CQC will focus on this winter

  • Ambulance arrivals: Any patient on the hospital site should be regarded as under the care of the emergency department and should be booked into the department without delay; the clock should start ticking at that point. There should be no “two tier” system whereby patients who arrive independently are booked in on arrival.
  • First clinical assessment: Patients needing urgent care should be consistently identified in a timely way. First clinical assessment of all patients attending the emergency department should again be undertaken without delay.
  • Use of inappropriate physical spaces: Patients should receive safe and effective care in an environment that allows for their privacy and dignity to be protected. This means, for example, they are always in sight of clinical staff and there are sufficient numbers of clinical staff in that area to care for them. The CQC does not endorse the use of inappropriate areas, such as a corridor, for patient care.
  • Specialist referrals: There should be no undue delay to patients being seen by the appropriate specialist team once they have been referred. Once referred, the patient should remain under the specialist team’s care and should not be referred back to the emergency department. It is not acceptable for patients to be held for prolonged periods in the emergency department waiting for specialist assessment.
  • Escalation: There should be a consistent and effective trust wide escalation process that enables an adequate and safe response to unexpected surges in demand. It is the responsibility of trusts as a whole, and potentially the wider health system, to deal with these surges, not just the emergency department.
  • Deteriorating patients: Emergency departments need a consistent, effective and audited system for identifying patients whose condition is deteriorating. This may be by means of early warning scores, a safety checklist – which have been found to be effective in some trusts – or by another method suited to local circumstances.
  • Patient outcomes: Information about effectiveness of people’s care and treatment should be routinely collected, monitored, and used to drive quality improvement. Trusts should consider incorporating the Royal College of Emergency Medicine and other relevant clinical standards into their patient outcome monitoring systems.
  • Staff: Effective and consistent clinical leadership is essential for both patient safety and staff wellbeing. Staff are working under great pressure in most emergency departments and poor leadership and culture can add to the difficulties they face.

The letter comes amid huge concern about delivery this winter, and following signs last year that safety and quality were compromised in very busy hospitals.

The regulator said the themes were identified at a meeting of 34 senior clinicians and nursing staff from 16 trusts that had good or outstanding ratings for their urgent and emergency care services.

The new quality guidance follows NHS Improvement setting out its expectations for accident and emergency this winter in July, and calls for a fresh winter funding boost from providers and Labour, which have so far proved unsuccessful.

Professor Baker said in the letter sent to all trusts on 29 September that more details on “key themes” would be published “in the near future”.

“The issues we have outlined here are those identified as most important to clinicians from good and outstanding departments,” he added.

The regulator will continue to assess emergency department performance “in line with our published assessment framework; however, recognising the pressures that services are facing, we will focus on key elements of safety which we have outlined above”, the letter said.

It continued: “It is important that boards recognise that solutions related to safety incidents lie in ensuring the whole hospital has an effective response to pressures within emergency departments.

“Trust boards should review their own processes and policies to ensure the safety of their emergency departments, including all the key areas outlined above.”