Hospitals should ensure they meet minimum nurse to patient ratios in accident and emergency departments according to the National Institute for Health and Care Excellence.

Draft guidelines from NICE, published today, outline new nurse staffing requirements for consultant led major A&E departments across England, aimed at ensuring safe care.

It is the first time NICE has recommended minimum ratios for nursing establishment and follows an earlier refusal to set minimum levels for hospital wards.

The draft guidelines follow the Francis report into failures of care at Mid Staffordshire Foundation Trust and come as A&E departments struggle to meet performance targets.

According to the proposals, which are out to consultation until 12 February, A&Es should have sufficient nursing staff to meet the following ratios:

  • one registered nurse to one cubicle (triage);
  • one registered nurse to four cubicles (minors and majors);
  • two registered nurses to one patient (major trauma);
  • two registered nurses to one patient (cardiac arrest);
  • one registered nurse to one patient (priority ambulance calls);
  • one registered nurse to two cubicles (resuscitation); and
  • one registered band 7 nurse on every shift to “lead, supervise and oversee the shift”.

It also includes making sure departments have capacity to have nurses trained in specialist care for children, older people and those with mental health needs.

As part of the guidance, NICE says directors of nursing should sign-off on A&E nursing establishments to embed accountability within each trust. It also sets out a toolkit for staff to use to assess their need for extra staff beyond the minimum levels.

It says by increasing weekly nursing staff hours to cover above average attendance numbers, staff should be able to deal with peaks in demand and be moved around the department to respond to changing situations.

The guidelines also set “red flag” events to trigger a review of the nursing establishment, such as patients not receiving pain relief, delay in meeting toileting needs, falls and violence.

Mark Baker, director of clinical practice at NICE, said: “Nursing staff are often among the first to see patients. 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.”

A Department of Health spokesman said the nursing ratios were “typical of current practice in A&E” but did not provide evidence for this claim when asked to do so by HSJ.

Peter Carter, chief executive of the Royal College of Nursing, said A&E departments had been understaffed for years, adding: “Setting the minimum number for a given department is a step in the right direction but minimums should never become maximums.”

Danny Mortimer, chief executive of NHS Employers, said: “Employers know the importance of having sufficient numbers working well together in teams. We will be encouraging employers to look at these guidelines and engage with the consultation process.”

One A&E nurse told HSJ he was concerned staffing guidelines could “promote complacency” and encourage trusts to meet “a bare minimum” of staffing with the guidelines, not accounting for “pressures at different times and the differing acuity of patients”.

He added: “A&E departments are very fluid environments with patients moving constantly. One issue we have is who takes responsibility for the patients in the waiting room, on the corridors, and the patients in other waiting areas? I feel there should be a designated nurse for these patients.”

He suggested the use of “float nurses” who are not assigned to specific areas could help alleviate pressures.

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