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Making A&E a better place

Improving the quality of A&E services at Whittington Hospital in North London
Why was the initiative launched?
How was the work taken forward?
A new nursing role in A&E
Pathways to better care
Creating a better environment in A&E
Has A&E performance improved?
Tips for success
For more information contact

Why was the initiative launched?


Problems in the A&E at Whittington Hospital were highlighted by an Audit Commission study in 1996. The Department performed poorly on a number of counts, including waiting times. Morale was low, budgets overspent, and the rest of the hospital thought it provided a poor service. An internal review suggested the main problems to be the wrong balance of medical and nursing staff, and a mismatch of staffing levels and workload. Changes were needed if A&E was to meet expectations of staff and community.

How was the work taken forward?


In 1998, senior Trust managers agreed that the development of A&E was a top priority. Improvements were needed in staffing, the service provided, and to its relationship with other Departments. Over the following two years five parallel tasks have been tackled.

A new nursing role in A&E


The first and most significant task was to develop the nursing role in A&E. Dee Hackett, a senior nurse, was appointed to lead the work. She faced two main problems.

Nurses were not on duty when most needed . The internal review showed that the nurse complement at night was 70% of the day but consultations were much lower (Table 1). Rotas were unchanged for many years and staff worked in the same groups. There was little flexibility and staff movement. Implementation of new rotas encountered a few problems. Some staff were reluctant to change, and left. The majority adapted quickly to the new rotas.

Table 1: Staff number and workload


  Figures for one 24-hour period in 1997
  8.00 am – 4.00pm 4.00pm – 00.00 00.00 – 08.00am
Arrivals 75 68 19
Departures 61 86 36
Staff on duty 26 32 18


Nursing skills were not used to the best effect . The solution was to develop a new role for the Emergency Nurse Practitioner. A specification was drawn up and agreed by senior nurses and medical staff. The aim was to give the emergency nurse practitioners autonomy to deal with minor problems, order investigations and discharge patients. Five volunteers from existing staff of F and G grade nurses trained for the new posts. In 1998 there was no recognised training course for this role so they were trained in house initially (courses are now organised by the English National Board). Other front line nurses were trained to perform triage to the Emergency Nurse Practitioner or doctor.

Pathways to better care


The second piece of work was to create a series of care pathways. This work, led by Dr Jennifer Worrall in cooperation with Dee Hackett, created a series of protocols to guide and improve quality of care for patients admitted through A&E. Teams from across the Trust contributed. Topics covered include MI, unstable angina and fractured neck of femur.

Building on the work on pathways, the third task was to improve liaison between staff in A&E and the other departments. This prompted new arrangements for multi-disciplinary teaching. It also led to the introduction of new arrangements for managing medical admissions. Consultants are now more involved in these decisions as they are taken within A&E. They are regular visitors to the Department.

The fourth task was to review medical staffing in A&E. The internal review highlighted excessive use of locums as one of the factors contributing to the continuing overspends. Training was improved with protected time for all medical staff and a new permanent SpR post approved. Three staff grade doctors have since been appointed providing better supervision for senior house officers.

Creating a better environment in A&E


The fifth task was to look at the physical condition of the Department - was it good place in which to work or to be a patient? The A&E manager decided to use environmental consultants to help redesign the facilities, including discussion with patients as ideas were developed. Their recommendations included soothing colours, new curved seating, removal of all the 'Do not' signs, more privacy for patients and separation of children from adult patients. Screens now separate blue light ambulance arrivals from the waiting room. The overall cost of the changes was about £50,000.

Has A&E performance improved?


The initiatives have had a marked impact on the performance of A&E. It is no longer a place to avoid for staff or patients. Some key indicators of that success are:


Table 2: Reducing transit time in A&E: selective months


  Mar-98 Jun-98 Sep-98 Dec-98 Mar-99 Jun-99 Sep-99 Dec-99
Average waiting time (mins) 110 105 95 95 90 85 90 90

Table 3: Staffing costs (£)


  1997-98 1999-00
Medical staff 619,000 724,000,
Medical locums 80,000 (13%) 66,000 (9%)
Nursing staff 1,179,000 1,412,000
Bank and agency nurses 362,000 (31%) 359,000 (25%)

The Department is now seen as a good place to work. There are no vacancies. Morale in the Department has improved dramatically with more smiling faces!

Tips for success



For more information contact


Dr Jennifer Worrall, Consultant Rheumatologist
Director of Audit, Effectiveness & Risk
The Whittington Hospital NHS Trust
Highgate Hill, London N19 5NF
Telephone 020 7288 5740 Fax 020 7288 5550

 

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