Briefing: RCEM Best Practice Guideline on Patient Care in the Emergency Department
Executive Summary
This briefing document synthesizes the November 2021 Royal College of Emergency Medicine (RCEM) Best Practice Guideline on Patient Care in the Emergency Department (ED). The guideline was developed in response to key inquiries, including the Francis Report (1), to re-emphasise a culture where a safe, committed, compassionate, and caring service is paramount, shifting focus from purely target-based metrics. It serves as a comprehensive checklist for medical and nursing staff to benchmark, audit, and improve patient experience and quality of care.
The standards are categorised into two levels:
- Fundamental (F): Standards that every Emergency Department should routinely achieve.
- Developmental (D): Standards that departments should be actively working towards.
The guideline is structured around four core themes: the patient environment, the patient pathway (from arrival to discharge), care for specific patient groups, and departmental/staff requirements. Key takeaways include the critical importance of effective communication at every stage, maintaining patient dignity and privacy, proactive symptom management, and fostering a supportive and well-led departmental culture that values staff wellbeing. Departments are expected to use this document for regular self-assessment and to escalate any standards that cannot be met to ensure appropriate action is taken.
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1. The Patient Environment: Core Standards
The physical environment of the ED profoundly impacts patient perception and experience. The guideline stresses that a clean, well-maintained, and dignified setting is a fundamental aspect of care.
- Cleanliness and Condition (Fundamental): All areas of the ED, including waiting rooms and entrances, must be clean and well-lit. The physical state of the department should be in good order, as poor maintenance (e.g., stained ceiling tiles) can negatively affect patient confidence in the quality of their clinical care. Toilet facilities must display a completed daily cleaning log, with cleaning recommended at least twice daily.
- Navigation and Information (Fundamental): Signage must be sufficient to enable easy navigation. The ED can be disorienting, and clear information about the patient "pathway" is essential.
- Privacy and Dignity (Fundamental): Clinical areas must be designed to protect patient privacy. This includes preventing sensitive questions or clinical handovers from being overheard and providing a securable, private cubicle (with solid walls, not curtains) for intimate examinations, religious observance, or end-of-life care.
- Waiting Area Provisions:
- Fundamental: The waiting area should be furnished with reading materials and a television (e.g., a silent news channel).
- Developmental: Departments should work towards providing WiFi access, clear information about the ED process (e.g., triage, the four-hour target), updated waiting times, and refreshments (with planning for patients who may need to be 'Nil by Mouth').
- Support for Relatives and Carers:
- Fundamental: Sufficient seating must be available in cubicles for relatives and carers.
- Developmental: Patients should be informed they can use their phones, and a bank of phone chargers should be available. Staff should establish and meet patient wishes regarding communication with relatives. Refreshments should be offered regularly to relatives, and bereaved relatives should be routinely offered a follow-up appointment with a senior ED physician.
- Patient Feedback (Fundamental): A robust system must be in place to seek, act upon, and share patient feedback (both positive and negative) with staff. This can be achieved through channels like the Friends and Family Test, care rounds (5), a monthly care newsletter, or involving Lay Representatives in departmental meetings.
- Specialised Environments:
- Psychiatric Assessment (Fundamental): A dedicated psychiatric assessment room conforming to PLAN (Psychiatric Liaison Accreditation Network) standards is required (4).
- End-of-Life Care (Fundamental): In the event of a dying or recently deceased patient, the clinical area must be quiet and private. A laminated symbol (e.g., a butterfly) can be used to discreetly indicate the need for staff to maintain an appropriate atmosphere (Developmental).
2. The Patient Pathway Through the ED
The guideline provides a structured approach to the patient journey, emphasising communication, early intervention, and continuity of care.
2.1 Arrival
- Warm Greeting (Fundamental): All patients, regardless of arrival method, must be warmly greeted by a named person. The "#CallMe" initiative is highlighted, encouraging staff to use a patient's preferred name.
- Staff Introduction (Fundamental): All staff must introduce themselves by name and role, clearly stating the reason for the interaction (e.g., "I am here to take your blood pressure").
- Process Explanation (Fundamental): The patient journey and departmental processes must be explained clearly, using various formats (posters, written materials, displays). Patients must be told how to access staff for needs or concerns, and call bells should be placed within reach.
2.2 Early Assessment
- Senior Access (Fundamental): Nursing staff at patient entrances must have timely access to a senior doctor for managing critically ill patients and prescribing analgesia for severe pain.
- Forecasting (Fundamental): Patients should be given clear "forecasts" about their expected care pathway, investigations, and timeline. For example, "You’re likely to have broken your hip...and will need surgery tomorrow..."
- Time-Critical Conditions (Fundamental): An early and effective process must be in place for both the identification (e.g., using NEWS2) and rapid treatment of time-critical conditions such as Trauma, Sepsis, Stroke, and Myocardial Infarction.
- Early Symptom Treatment (Fundamental): Symptoms such as pain, nausea, vertigo, and urinary retention must be treated early.
- Patient Preferences (Fundamental): Patient expectations, previous decisions (e.g., DNAR/RESPECT forms, accessible electronically), and bespoke care needs (dietary, language, religious) must be established early in the visit.
2.3 Assessment and Diagnosis
- Regular Reviews (Fundamental): Patients require regular reviews to check on comfort, clinical status (to identify deterioration), and the effectiveness of treatments. This should be documented.
- Regular Updates (Developmental): New information, such as test results or changes in the care plan, should be communicated to the patient and relatives in a timely fashion.
2.4 Continuing and Ongoing Care
- Comfort Rounding (Fundamental): Comfort rounds should be routine, and pillows should be offered to patients likely to be admitted.
- Amenities (Developmental): A trolley round offering food, drink, and toiletries, potentially run by volunteers, should be considered.
- Practical Information (Developmental): The department should display up-to-date information on taxis, public transport, and local amenities.
- Translation Services (Developmental): Easy access to translation services, including British Sign Language (BSL), should be available.
2.5 Discharge
- Comprehensive Discharge Planning (Fundamental): A discharge checklist should be used by all staff. Planning must include:
- Bespoke verbal and written advice.
- "Safety netting" advice on when to return.
- Information on fitness to drive/work.
- Clear explanation of the diagnosis (and any uncertainty).
- A check of social and welfare concerns.
- Communication of the plan to carers and other healthcare providers.
- Follow-Up and Prescriptions (Fundamental): Follow-up appointments should be arranged before discharge where possible. If not, the process must be clear and robust. Prescriptions should be provided to avoid the patient needing to return.
- Results Management (Fundamental): An effective system must exist for reviewing investigation results and communicating them to patients. This must cover delayed results (e.g., microbiology), addendums, and incidental findings.
3. Care for Specific Patient Groups
The guideline mandates tailored approaches for vulnerable patient populations.
3.1 Care of the Elderly Patient
- Dementia Training (Fundamental): Dementia-friendly training is mandatory for all ED staff, including non-clinical personnel.
- Dementia-Friendly Environment (Developmental): The department should be assessed by a group like the Alzheimer's Society. Standards include dementia-friendly toilets, clear signposting, and distraction therapies (e.g., twiddlemuffs).
- Clinical Assessments (Fundamental): A skin vulnerability assessment must be performed on arrival for all frail, elderly patients. A falls prevention policy specific to the ED must also be in place.
- Screening (Developmental): Routine screening for cognitive impairment is a developmental goal.
- Guideline Adherence (Developmental): EDs should follow RCEM guidance on end-of-life care and the "Silver Book II" for quality care for older people.
3.2 Care of Children
- Safeguarding (Fundamental): There must be demonstrable evidence of safeguarding children. All staff must be trained to the required levels, know the escalation process, and be able to identify the Trust safeguarding lead.
- Distraction and Facilities (Fundamental/Developmental): Facilities for distracting distressed children (e.g., tablets, Starlight distraction boxes) are a fundamental standard. Meeting the full RCPCH standards for emergency care is a developmental goal.
- Prompt Care (Fundamental): All children must be offered appropriate and prompt analgesia. Parents of children with vomiting and diarrhoea should be encouraged to start oral rehydration therapy upon arrival.
3.3 Patients with Complex Requirements
- Learning Disabilities (Fundamental): The department must have and use access to learning disability healthcare staff.
- Guideline Compliance (Fundamental): EDs must demonstrate compliance with a wide array of RCEM guidelines for managing patients with complex needs. This includes guidance on:
- Absconding patients
- Patients in police custody
- Suspected internal drug traffickers
- Sexual assault and rape
- Domestic abuse (with availability of Independent Domestic Violence Advocates)
- Mental Capacity Act and Acute Behavioural Disturbance
- Homelessness, alcohol, and drug misuse
- Frequent attenders (requiring multidisciplinary case management for very high-frequency attenders).
4. Departmental and Staff Requirements
A positive patient experience is underpinned by a well-supported, educated, and well-led ED team.
4.1 The ED Team and Wellbeing
- Staff Value (Fundamental): All staff must feel valued. This can be achieved through sharing positive feedback, offering recognition (e.g., care awards), and senior staff thanking teams for their efforts. Support systems must be in place for those involved in stressful situations.
- Teamwork (Fundamental): Regular, scheduled, combined medical and nursing handovers are essential for effective team collaboration.
- Senior Support (Fundamental): Senior doctors must be approachable and available, with clear processes for juniors to contact them.
- Staff Breaks (Fundamental): Staff must be routinely able to take breaks to prevent burnout and clinical errors.
- Staff Wellbeing (Fundamental): The ED should have an active wellbeing champion and systems to prevent, identify, and support staff burnout.
- Inter-specialty Support (Fundamental): Staff from other specialties working in the ED must be welcomed and supported.
4.2 Departmental Operations
- Equipment (Fundamental): Equipment must be easy to locate, clearly organised, and re-stocked daily.
- IT and Estates (Developmental): An effective process for reporting and responding to problems with IT, estates, and equipment is a developmental standard, with a nominated IT/Informatics lead recommended.
4.3 Education and Governance
- Compassionate Care Training (Developmental): All staff should receive training in customer care and compassionate care.
- Embedding Care Culture (Fundamental): "Care" must be a core component of ED induction and ongoing teaching for all staff.
- Raising Concerns (Fundamental): Staff must be encouraged to report concerns regarding care and know the correct escalation procedure (e.g., line manager, Freedom to Speak Up Guardian).
- Duty of Candour (Fundamental): Registered staff must be aware of their statutory obligation to observe a duty of candour when a patient has come to harm or death due to clinical error.
4.4 Measuring Care and Leadership
- Quality Improvement (Developmental): The ED must demonstrate measurable improvements in care in response to CQC reports, audits, and patient feedback, and engage with national benchmarking projects.
- Departmental Leads (Developmental): The department should have designated leads for care and for significant patient groups (e.g., dementia, frequent attenders).
- Population Health (Developmental): The ED should understand the population it serves and tailor its services accordingly (e.g., providing access to HIV screening or frailty in-reach services based on local need).
- Safety Culture (Fundamental): Safety must be embedded in the department's culture, processes, and structures, supported by a departmental risk register and clear policies on clinical responsibility.
- Infection Prevention and Control (Fundamental): The department must demonstrate adherence to IPC guidelines through measures like hand hygiene audits and staff compliance with mandatory training.
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References
- Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry 2013. https://www.gov.uk/government/publications/reportof-the-mid-staffordshire-nhs-foundation-trustpublic-inquiry (accessed 28 March 2017)
- Robinson S, Brown R. The Francis Report: a call to arms. Emerg Med J 2013;30;783
- Berwick D. A promise to learn – a commitment to act. Improving the Safety of Patients in England 2013. https://www.gov.uk/government/publications/berwick-review-intopatient-safety (accessed 28 March 2017)
- Psychiatric Liaison Accreditation Network (Royal College of Psychiatrists). PLAN Standards. Available at: http://www.rcpsych.ac.uk/workinpsychiatry/qualityimprovement/ccqiprojects/liaisonpsychiatry/plan.aspx (accessed June 2017)
- Lloyd G. Care rounds: hot patient feedback enabling team care education. Br J Hosp Med 2016;77:262
- Lloyd G, Reuben A. Improved emergency department patient care via rapid assessment and triage. Br J Hosp Med 2017;78:500
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MEM-EM PODCAST
1.9 The ED Compassion Roadmap: RCEM Patient Care Standards in the ED
