The GPEMS Blueprint: The RCEM Standards & Recommendations for EMS

 

Guidelines for the Provision of Emergency Medical Services: A Briefing for NHS Emergency Department Professionals

Executive Summary

This briefing document synthesizes the core standards and recommendations from the Royal College of Emergency Medicine's (RCEM) Guidelines for the Provision of Emergency Medical Services (GPEMS). It is intended for emergency medicine clinicians and highly trained professionals working within NHS Emergency Departments (EDs) in England. The guidelines establish best practices, define service delivery standards, and provide pragmatic, patient-centred recommendations to address the significant strains on Emergency Medicine Services (EMS).

Critical Takeaways:

• Emergency Department Crowding is a Systemic Failure: The document identifies ED crowding as the single greatest threat to the timely delivery of safe emergency care. It is framed not as an ED-specific issue, but as a system-wide failure of capacity, particularly a lack of available inpatient beds (exit block). Key standards to mitigate this include maintaining hospital bed occupancy around 85%, completing ambulance handovers within 60 minutes, and ensuring no patient remains in the ED for more than 12 hours. Solutions must be system-wide and prioritize improving patient outflow from the hospital.
• Workforce Crisis Demands Sustainable Practices: The ability to recruit and retain a skilled, multi-professional workforce is a critical threat to emergency care. The guidelines mandate specific staffing levels, including at least one Whole Time Equivalent (WTE) consultant for every 4,000 annual attendances. They strongly advocate for sustainable working patterns, robust job planning with a minimum of 2.5 Supporting Professional Activities (SPA) sessions for consultants, and a sharp focus on staff wellbeing to combat high rates of burnout and moral injury.
• Restoring the Core Function of Emergency Medicine: The primary purpose of Emergency Medicine—the initial assessment and stabilisation of undifferentiated emergency patients—has been compromised as EDs have organically evolved to fill gaps elsewhere in the healthcare system. The guidelines call for a clear definition of the ED's role to prevent harm to emergency patients caused by delays and resource diversion.
• Culture as a Cornerstone of Safety and Quality: A positive organisational culture built on civility, respect, and inclusivity is presented as essential for both patient safety and staff wellbeing. The guidelines establish standards for fair treatment, transparent processes for raising concerns, and compassionate, inclusive leadership. Every ED should appoint an Inclusion & Civility champion.
• Mandatory Standards and Key Recommendations: The document distinguishes between Standards, which are defined as expectations that must be met, and Recommendations, which are more aspirational. Adherence to all stated standards is a fundamental requirement for the safe and effective provision of emergency medical services.

1. The Central Challenges: Crowding and Workforce

The GPEMS document frames ED crowding and workforce sustainability as the two most significant and intertwined threats to the provision of emergency care in the UK.

1.1 Emergency Department Crowding

ED crowding occurs when demand exceeds the capacity of the service, hospital, or health system. It is a marker of systemic failure, with causes and solutions that lie predominantly outside the ED. It leads to increased patient morbidity and mortality and contributes to staff moral injury, burnout, and poor retention.

Standards

• Hospitals accepting emergency admissions must maintain bed occupancy around 85%.
• All hospital handovers must be complete by 60 minutes after ambulance arrival, with most taking place within 15 minutes and almost all within 30 minutes.
• The 4-hour emergency access standard threshold is an NHS constitutional standard and must remain at 95%, subject to formal scientific review.
• To deliver the 4-hour standard, no more than 10% of an ED’s cubicles must be occupied by patients waiting for admission or who have been referred.
• No patient must be in an ED for more than 12 hours after arrival. This must be measured and reported publicly.
• Every ED must have the ability to create a resuscitation bed and a high-dependency adult and paediatric bed at very short notice.

Recommendations

• The management of ED crowding is a whole-system responsibility.
• Interventions should prioritize output (facilitating patient discharge from the hospital) and throughput (improving processes within the ED) over input (demand management strategies), which have little evidence of significant impact on crowding-related harm.
• Health systems should invest in hospital facilities, social care, and community-based capacity to facilitate patient flow.
• Escalation policies should be effective, with cautious support for the use of boarding and full capacity protocols in selected situations to reduce immediate risk.

1.2 The Emergency Medicine Workforce

The ability to recruit and retain sufficient staff with the right skills is, alongside crowding, the biggest threat to effective emergency care.

Standards

• Nurse staffing levels must align with RCEM/Royal College of Nursing (RCN) guidance [1].
• Doctor and practitioner staffing levels must be matched to demand and casemix, in line with sustainable working patterns [2,3].
• There must be at least one WTE consultant for every 4,000 annual attendances [4]. The minimum is 12 WTE consultants for a small department, rising to 48 in the largest EDs.
• A consultant in Emergency Medicine must be available on call at all times for every ED.
• A senior decision maker (tier 4) must be present on the shop floor 24/7/365.

Recommendations

• RCEM supports a balanced multiprofessional workforce, including the development of the Advanced Clinical Practitioner (ACP) workforce along the lines of the RCEM curriculum and credentialing framework [5].
• RCEM does not currently support the development of the Physician Associate workforce within Emergency Medicine [6].
• Working practices for all staff should be legal, sustainable, and designed to enhance recruitment and retention.
• Staffing levels based on permanent staff are safer and more cost-effective than those relying on temporary or locum staff.

1.3 Job Planning for Senior Emergency Physicians

Job planning must reflect the intensity of the role and adhere to sustainable working principles to ensure clinicians can have full, productive careers.

Standards

• Job plans must reflect the needs of a modern EMS, covering both clinical care and leadership/quality activities.
• Direct Clinical Care (DCC) schedules must be designed for sustainable working.
• For consultants, all scheduled time premium working is by negotiation. RCEM recommends rates of 2 hours per Programmed Activity (PA) after 19:00 and 1.5 hours per PA after midnight [7].
• Supporting Professional Activity (SPA) time must adequately reflect the activities required to run and develop the service, train clinicians, and meet CPD needs.

Recommendations

• Consultant job plans should contain a minimum of 2.5 SPAs; 3 SPAs is considered best practice.
• Job plans should be annualised and ideally supported by self-rostering.
• For consultants, a maximum weekend working frequency of 1:8 is ideal (or 1:6 if two or more consultants are on duty). For SAS doctors, it should be no more than 1:4.
• The proportion of SPA to DCC should increase with advancing age. Late night or overnight working should reduce or discontinue from age 55, which requires proactive recruitment planning.
• Sufficient SPA time (0.25 PA per trainee) must be allocated for educational supervision of specialty, ACP, and Portfolio Pathway trainees.

1.4 Staff Wellbeing

Optimising staff wellbeing is a priority, as workplace stress directly affects patient quality of care and staff health.

Standards

• Organisations must promote rest, including facilities to sleep post-nights and take power naps.
• All staff must have 24/7 access to basic and healthy hot food, with clearly rostered breaks.
• Rotas must be designed considering published guidance such as the RCEM EM-POWER guideline [8] and the Good Rostering Guide [9].
• The ED must always have adequate staffing numbers, adhering to RCEM workforce recommendations [3,4].
• Every ED must have a dedicated and proactive Wellbeing Lead.
• ED clinicians must have access to an effective mentoring programme.

Recommendations

• Individuals should take responsibility for their own wellbeing (sleep, exercise, nutrition, boundaries).
• All staff should practice civility and compassion towards colleagues and patients.
• EDs should foster a supportive team environment through regular team activities and training.

2. Clinical Operations and Service Delivery

This section details the standards for core ED processes, from patient arrival and assessment to inter-service interfaces.

2.1 Initial Assessment

A core function of EMS is to provide rapid and safe initial assessment to identify patients with urgent conditions, those at risk of deterioration, and those who can be managed outside the ED.

Standards

• All patients attending the ED must be registered within five minutes of arrival.
• Initial assessment must be provided by a registered clinician with appropriate training and must commence within 15 minutes of arrival.
• Initial assessment areas must facilitate confidential conversations and maintain patient dignity.
• Patients waiting in a See and Treat stream should not wait longer than one hour to be seen by a clinician.
• EDs must use early warning scores for adults, pregnant adults, and children.

Recommendations

• A two-stage assessment process (Primary and Secondary) may be beneficial to quickly identify serious illness or injury.
• Streaming criteria to other services (e.g., SDEC) should be locally agreed and co-owned with those specialties.
• Rapid Assessment and Treatment (RAT) services, led by a senior clinician, should be considered at times of peak demand.

2.2 Interface with Prehospital Services

Effective interaction between ambulance services and EDs is key to safe emergency care. Handover delays are a significant source of harm to patients both in the ED and in the community.

Standards

• All hospital handovers must be complete by 60 minutes, with most within 15 minutes and almost all within 30 minutes [10].
• Responsibility for patient care is joint from the moment an ambulance arrives. There must be a process to register and begin assessing patients, even if they are on an ambulance.
• Hospitals must have an agreed 24/7 escalation policy for rapid offload of ambulances if required.
• Ambulance clinicians must not be asked to supervise or provide care they are not covered for (e.g., administering certain medicines).

Recommendations

• Hospital handover performance data should be a regular governance agenda item with executive-level ownership.
• EDs should appoint leads to oversee clinical handover protocols and relationships with prehospital services.
• A system should exist to provide follow-up information on a patient’s diagnosis and clinical course to prehospital clinicians.

2.3 Observation Units and Same Day Emergency Care (SDEC)

Both Observation Units and SDEC provide pathways to manage specific patient cohorts without requiring a full inpatient admission.

Observation Units

• Purpose: To manage patients with limited medical needs, a need for short-term observation (e.g., minor head injury, simple overdose), or a short-term treatment need (e.g., rate control in AF).
• Standard: Units run by Emergency Physicians are short-stay facilities (typically <24 hours, max 48 hours). They must not be used as a performance management tool or to house undifferentiated patients to avoid breaches of access standards.

Same Day Emergency Care (SDEC)

• Standard: All hospitals with a Type 1 ED must provide an SDEC service, open a minimum of 12 hours a day, 7 days a week.
• Standard: The SDEC unit must be geographically distinct from the main ED.
• Standard: The physical space must not be used for inpatient beds during times of pressure.
• Standard: There must be capacity to accept referrals from multiple sources, including ED, 111, ambulance services, and primary care.
• Recommendation: Key Performance Indicators (KPIs) should be used, including a target of <8 hours stay in SDEC and an admission rate of <10%.

2.4 Clinical Responsibility and Referrals

Clarity over clinical responsibility is essential for patient safety, especially for patients who have been referred to an inpatient specialty but remain physically in the ED.

Standards

• Once a patient has been referred to a specialty, that specialty is responsible for organising ongoing care. It is not appropriate to refer the patient back to the ED or decline the referral [11].
• While awaiting review, the ED team remains responsible. However, specialty teams must have arrangements for assessment by experienced staff within 30 minutes of referral.
• Once a specialty team has seen a patient in the ED, that patient becomes the responsibility of that specialty team.
• In case of a dispute over admission, the on-call Emergency Medicine Consultant must be delegated the authority by the Medical Director to make the final decision.
• ED IT systems must be capable of recording the date and time of referral.

2.5 Minor Injuries

This branch of EM deals with injuries not normally requiring admission. Inadequate treatment can still result in substantial disability.

Standards

• Clear pathways must exist for outpatient specialist follow-up (e.g., fracture clinic, eye units).
• All ED plain radiography must be reported by a radiologist or reporting radiographer, with systems in place to ensure all reports are checked.
• A Statement of Fitness for Work must be issued by the ED for patients who will clearly be unfit for work beyond the 7-day self-certification period.
• Appropriate safeguarding arrangements must be in place for vulnerable patients presenting with minor injuries.

3. Patient-Centric Care

This section details standards for specific patient populations and aspects of the patient journey that are crucial for a high-quality, safe, and positive experience.

3.1 Care of Specific Patient Groups

Older People

• Standard: Hospitals must provide an Acute Frailty service for at least 70 hours a week, aiming to complete a clinical frailty assessment within 30 minutes of arrival.
• Standard: Pain scores must be obtained in all older patients at triage.
• Standard: All ED staff must complete dementia and delirium training.
• Recommendation: The 4AT tool should be used to assess for delirium, which should be treated as a medical emergency.
• Recommendation: Comprehensive Geriatric Assessments (CGA) should be completed after, not during, an ED stay.
• Recommendation: Protocols for the management of ‘silver trauma’ should be in place, with a lower threshold for CT scanning and a high suspicion for occult injuries.

Children

• Standard: Paediatric waiting and assessment areas must be separate from adult areas.
• Standard: Initial assessment must occur within 15 minutes of arrival, including pain assessment.
• Standard: EDs treating children must have at least one consultant with Paediatric Emergency Medicine (PEM) dual accreditation and at least two registered children’s nurses on duty in the children’s area at all times.
• Standard: A specific paediatric early warning score must be used.
• Standard: Clear safeguarding policies for children must be in place.

Mental Health

• Standard: Each ED must have a Mental Health Lead with dedicated time.
• Standard: Patients must have a mental health triage on arrival to gauge the risk of self-harm, suicide, or leaving before assessment. This determines the required level of observation.
• Standard: Patients at medium or high risk must be searched for objects that could be used for self-harm.
• Standard: An assessment of capacity must be documented if a patient wishes to leave or decline treatment.
• Standard: Parallel assessment (concurrent assessment of physical and mental health) must be the default approach.
• Standard: A member of the mental health team must see the patient face-to-face within one hour of referral.

Vulnerable Patients & Health Inequalities

• Standard: ED staff must fulfil their statutory duty to identify patients who are homeless or at risk of homelessness.
• Standard: Up-to-date contact details must be obtained and recorded for all patients who are homeless or at risk.
• Recommendation: Information on local hostels, hubs, and outreach teams should be provided.
• Recommendation: When discharging a homeless patient, staff should consider and document the feasibility of the discharge plan (e.g., follow-up, medications).

3.2 Patient Information, Experience, and Discharge

Patient Information

• Standard: Patients in waiting rooms must have access to updated, stream-specific information on estimated waiting times.
• Standard: Written advice (e.g., patient information leaflets) must be freely available.
• Standard: When medication is altered or added, this must be written down for the patient and communicated to their GP.

Patient Experience

• Standard: The NHS Friends and Family Test (FFT) must be administered, but not relied upon as the sole measure of experience.
• Standard: When feedback is received (e.g., complaints), ED staff must make the substantive contribution to the response.
• Recommendation: EDs should use tools to proactively investigate patient experience across key domains (waiting times, staff empathy, communication, environment).

Discharge to General Practice

• Standard: Do not tell patients to routinely see their GP after discharge. Only advise a GP appointment if there is a specific clinical need.
• Standard: The ED discharge letter must be accurate, contain all appropriate information, and be sent in a timely manner (preferably electronically within 24 hours).
• Standard: GPs must not be asked to chase the results of investigations requested by the ED, with few specific exceptions (e.g., MSU, mast cell tryptase).

3.3 Management of Investigation Results

Standards

• All EDs must have a Standard Operating Procedure (SOP) for handling radiological and non-radiological investigation results.
• The process for reviewing results and taking action must be identifiable, traceable, and timely (real-time for critical results, within 72 hours for non-urgent).
• Responsibility for review and action must be clearly defined and recorded.
• Consultant job plans must include programmed DCC time for reviewing investigation results.
• For patients admitted under a non-ED team, responsibility for reviewing results rests with the admitting team.

4. Infrastructure, Quality, and Governance

The physical environment, information systems, and governance frameworks are foundational to delivering high-quality care.

4.1 ED Estate Standards

Standards

• New EDs must comply with Health Building Note 15-01 [12].
• Areas for children must be separate from the main department and comply with Facing the Future standards [13].
• Every ED must have at least one Psychiatric Liaison Accreditation Network (PLAN) compliant room for adults and a similar room for children [14].
• The environment must be suitable for older persons and those living with frailty [15].
• All staff must have access to an adequately sized break room with facilities for rest and hot food preparation.

Recommendations

• Patients should not be cared for in corridors.
• A linear design for assessment spaces is more efficient than a pod or circular layout.
• Individual rooms should be the norm to ensure patient dignity, privacy, and infection control.

4.2 Clinical Information Systems

Standards

• Information must be submitted in compliance with the Emergency Care Data Set (ECDS) [16].
• Communications with GPs upon discharge must comply with the Emergency Care Discharge Standard [17].

Recommendations

• Clinical information systems should be usable and efficient, minimizing clicks and unnecessary alerts.
• Systems should support core functions including patient registration, access to records, clinical documentation, investigation requests, prescribing, and data reporting.

4.3 Quality, Metrics, and Research

Metrics

• Standard: EDs must have a quality management and improvement program involving measurement against national, RCEM, and local standards.
• Standard: EDs in England must participate in the Getting It Right First Time (GIRFT) programme for emergency medicine [18].
• Recommendation: Metrics should be used for improvement, not just accountability. They should be easy to collect and relate to meaningful outcomes for patient and staff experience.

Quality Improvement (QI)

• Standard: Departments must develop a local programme of meaningful QI activity and promote QI education for all staff groups.
• Recommendation: QI projects should be developed based on data from incidents, complaints, and staff feedback.

Research

• Standard: EDs must have a designated research lead and be actively recruiting to NIHR Portfolio research studies.
• Standard: All major trauma centres and university-affiliated hospitals must have an EM research lead with job-planned time.

4.4 Emergency Preparedness, Resilience and Response (EPRR)

Standard

• Role cards must be available for staff to define actions in the event of a major incident.

Recommendations

• Selected senior staff should complete HMIMMS (or similar) training.
• Separate Medical and Nurse Lead roles for Major Incidents (MI) and CBRN should be established with time in job plans.
• The Ten Second Triage Tool (TST) and Major Incident Triage Tool (MITT) should be rolled out to all EDs.

4.5 Environmental Sustainability

Recommendations

• Departments should aim to become accredited with the GreenED programme [19].
• Staff should be trained in sustainable quality improvement (SusQI) [20].

5. Departmental Culture

A positive organisational culture is a critical determinant of patient safety, staff wellbeing, and overall performance. The high-stress ED environment makes a conscious focus on culture essential.

Standards

• All patients and staff must be treated fairly and with dignity and respect.
• Recruitment processes must be fair and transparent, with diverse representation at all levels.
• Concerns raised by staff must be responded to quickly via a transparent policy.
• Staff must be actively encouraged and empowered to speak up about patient safety concerns.
• Induction systems must be comprehensive and tailored, especially for international staff.
• All staff must strictly adhere to their professional Codes of Conduct [21].

Recommendations

• EM leaders should practice and promote inclusive and compassionate leadership.
• All EDs should appoint an Inclusion & Civility champion.
• Staff should receive training in Equity, Diversity, and Inclusion (EDI), civility, and conflict resolution. Active Bystander Training is also recommended.
• There should be a zero-tolerance policy for violence, threatening behaviour, or abuse of staff by members of the public who have capacity.

References

1. Royal College of Nursing, Royal College of Emergency Medicine. Nursing Workforce Standards for Type 1 Emergency Departments. London: RCEM; 2020.
2. Royal College of Emergency Medicine. Medical and Practitioner Staffing in Emergency Departments. London: RCEM; 2015.
3. Royal College of Emergency Medicine. Medical Workforce Guidelines for Remote, Rural and Smaller Emergency Departments. London: RCEM; 2023.
4. Royal College of Emergency Medicine. Consultant Staffing in Emergency Departments in the UK revised. London: RCEM; 2019.
5. Royal College of Emergency Medicine. Emergency Medicine – Advanced Clinical Practitioner (EM-ACP). London: RCEM; 2017.
6. Royal College of Emergency Medicine. Update on the Royal College of Emergency Medicine’s position regarding Physician Associates. London: RCEM; 2024.
7. British Medical Association. The Consultant Contract and Job Planning for Emergency Medicine Consultants. London: BMA; 2009.
8. Royal College of Emergency Medicine. EM-POWER: A practical guide to flexible working and good EM rota design. London: RCEM; 2019.
9. NHS Employers. Good Rostering Guide. London: NHSE; 2018.
10. Royal College of Emergency Medicine, College of Paramedics. Hospital handover delays for patients in ambulances. Options Appraisal to reduce harm. London: RCEM; 2024.
11. Royal College of Emergency Medicine. The Standards in Emergency Departments. London: RCEM; 2016.
12. University College London, NHS Cambridge University Hospitals, The College of Emergency Medicine. Health Building Note 15-01: Accident & emergency departments planning and design guidance. London: Department of Health; 2013.
13. Royal College of Paediatrics and Child Health. Facing the Future: Standards for children in emergency care settings. London: RCPCH; 2018.
14. Royal College of Psychiatrists. PLAN 7th edition standards. London: RCPSYCH; 2022.
15. Price A, Panzartis E. Silver Book II: Frailty-friendly building design. London: British Geriatrics Society; 2021.
16. NHS Digital. Emergency Care Data Set (ECDS) [Internet]. Leeds: NHS Digital; [cited 2024 Oct 26]. Available from: https://digital.nhs.uk/data-and-information/data-collections-and-data-sets/data-sets/emergency-care-data-set-ecds
17. Professional Record Standards Body. Emergency Care Discharge Standard [Internet]. London: PRSB; [cited 2024 Oct 26]. Available from: https://theprsb.org/standards/emergencycaredischarge/
18. Getting It Right First Time. Emergency Medicine [Internet]. London: GIRFT; [cited 2024 Oct 26]. Available from: https://gettingitrightfirsttime.co.uk/medical_specialties/emergency-medicine/
19. Royal College of Emergency Medicine. GreenED [Internet]. London: RCEM; 2024 [cited 2024 Oct 26]. Available from: https://greened.rcem.ac.uk/
20. Centre for Sustainable Healthcare. What is SusQI? [Internet]. Oxford: CSH; 2024 [cited 2024 Oct 26]. Available from: https://www.susqi.org/the-susqi-education-project
21. Royal College of Emergency Medicine. RCEM Code of Conduct [Internet]. London: RCEM; 2024 [cited 2024 Oct 26]. Available from: https://rcem.ac.uk/code-of-conduct/

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