Although the main A&E service at Queen's Hospital is provided by the hospital trust, Barking, Havering and Redbridge University Hospitals Trust (BHRUT), patients arriving at the department are first seen by streaming staff who triage them as to whether they require treatment by A&E (for more serious conditions) or in an Urgent Treatment Centre (UTC) (for lesser conditions), or can be referred elsewhere, to their own GP or, perhaps, a pharmacy.
Patients who are streamed to the Urgent Treatment Centre are seen in accommodation that is part of the Hospital but is provided by PELC ( a co-operative of GPs), as is the streaming and triage function.
This report complements our recent report on the A&E department itself.
As a result the visit, we made the following recommendations:
1 The signage in the department requires improvement:
(a) In the waiting area, an explanation of the booking-in process and the possible treatment pathways is needed, particularly regarding waiting for initial assessment before proceeding to the booking in clerks;
(b) The arrangements for queueing for assessment need to be clearer;
(c) Directions to and from the treatment area to X Ray needs to be clearer.
2 Standing in a queue awaiting initial assessment is acceptable for most patients, but there will always be some who, because of the nature of their injury or illness, or because of existing disability, cannot stand. Yet they risk losing their place in the queue if they cannot stand until called forward.
Accordingly, consideration should be given to the provision of a simple number queue control system, such as issuing timed and numbered tickets and calling people forward by reference to such numbers rather than simply calling “next please”. A display screen showing the number and informing patients who is next would be helpful, especially to those with hearing difficulties. This would also be able to provide a more accurate note of time of arrival, which is important for government waiting time statistics.
3 That consideration be given, as and when accommodation becomes available, to providing separate waiting areas for those who are arriving and awaiting Streaming, and those who have been Streamed and are awaiting treatment.
4 That means of calling patients forward for streaming, other than calling “next please”, be explored as a matter of urgency.
5 That all staff be trained to be confident in responding appropriately to those patients who are vulnerable, such as recognising Hospital Passports, have Learning Disabilities or other special needs, or have current conditions that require urgent attention.
PELC have told us
that, in response to the report, they have taken the following steps:
1. Improved signage has been designed and ordered, and some has been installed. Installation of the remainder is awaited.
2. The OPEL escalation plan has been introduced when queues are long to move resources to reduce waiting times.
- Congestion has been reduced because the waiting room only has PELC patients queuing, as all ED patients book in at their respective reception desks.
- Apart from true unpredictable surges, queues do not extend out of the door; in the rare cases of lengthy queues, OPEL kicks in and resources are moved to the front door to assist in streaming.
- A third streaming room has been equipped to allow more streaming capacity during surges.
- Electronic streaming has been implemented
- An electronic ticket machine has been ordered and its installation is awaited.
- Electronic feedback kiosks have been installed.
- A joint major incident plan has been developed.
PELC has expressed thanks for the feedback in this report, which has been really helpful in helping them to further design their services to improve care for patients.
A second, unannounced, visit was carreid out in June 2019. In additon ot the main A&E/UTC, the team also visited the Children's A&E, which is located separately (although all patients including children go through the intial screening process).
As a result of this visit, we made the following recommendations - that:
- Children coming into A&E must initially go through the same registration process as adults before being signposted to the children’s A&E waiting area. The team were told that there were no plans to change the process for registering children but it is strongly recommended that consideration be given, in the interests of child protection and safeguarding, to creating a more child-friendly process by moving children’s registration elsewhere and that they be sent thence directly to the children’s A&E area.
- Signage within the waiting area still requires updating. It is recommended that, when the new ticketing system is introduced, all existing signage be replaced. A sample of an easy read sign that could with advantage be introduced is set out on the following pages.
- While acknowledging that there are severe physical constraints to the waiting room accommodation, the team observed a number of companions of patients taking up space that ought to have been available for use by other patients. It is recommended that all possible effort be made to improve conditions in the waiting area and, in particular, although it is understandable that patients should want to be accompanied by friends or family, they should be encouraged to have only the absolute minimum of companions waiting with them.
- A member of staff should be tasked to monitor in an obvious way as a means of reassuring patients and ease any anxieties they may experience.
- A more child-friendly process be developed, enabling children to go straight to the dedicated A&E service, with adequate signage to ensure that the risk of confusion is minimised.
This report relates to the Emergency Department (A&E) Streaming and Urgent Treatment Centre as it was observed during the visit on 12 June 2019. Between then and the publication of this report, various changes and improvements were made in day-to-day operation, so that the circumstances reported are not necessarily reflective of current conditions. Although the ticket machine referred to in the report has still not, at the time of publication, been installed, it is understood that it is due to be installed soon, and that improved signage will also then be provided.
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