Crowding and flow in the ED

 

Emergency Department Flow & Crowding: A Practical Guide to Escalation and Safety

Executive Summary

Emergency Department (ED) crowding is not an operational inconvenience but a persistent, state of active patient harm and a marker of systemic failure in health policy and leadership. It represents a significant threat to the timely and safe delivery of emergency care within the UK's National Health Service (NHS). This document synthesizes evidence and expert guidance to provide NHS Emergency Medicine clinicians with practical, evidence-based strategies for managing crowded environments, articulating clinical risk, and escalating effectively to restore patient safety.

The primary driver of ED crowding is exit block—the inability to move admitted patients from the ED to inpatient beds due to a lack of hospital capacity. This systemic failure, rooted in a severe mismatch between demand and available staffed beds and social care, creates a dangerous "vicious circle" where delays lead to patient deterioration, further increasing admissions and exacerbating crowding.

The consequences are severe and quantifiable. Studies demonstrate a direct, linear relationship between delays to admission and patient mortality. Data from the Getting it Right First Time (GIRFT) report shows that for every 67-82 patients delayed in the ED for 6-12 hours, there is one excess death. This harm extends to delayed critical treatments, increased medication errors, and profound moral injury and burnout among staff, threatening the sustainability of the Emergency Medicine workforce.

Effective management requires a shift in mindset and language: from describing "risk" to declaring "harm," and from viewing crowding as an "ED problem" to articulating it as a "corporate safety failure." This guide provides clinicians with the necessary tools, including specific escalation scripts, in-department safety protocols, and whole-system flow strategies like the Full Capacity Protocol (FCP) and Continuous Flow Models. By mastering these strategies, clinicians can move from passively absorbing systemic risk to actively and professionally compelling a hospital-wide response to regain safety for both patients and staff.

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Definition and Classification of ED Crowding

Definition

Emergency Department crowding is a state that occurs when the demand for emergency services exceeds the capacity of the department, the hospital, or the wider health system to provide quality care within an appropriate timeframe [1]. It is a complex, system-wide problem that manifests visibly as ambulance handover delays, patients treated in corridors and non-clinical spaces ("corridor care"), and prolonged waits for assessment, treatment, and admission [2, 3].

Crucially, crowding must be understood and articulated not as a "risk" of future problems but as a state of active, ongoing harm. The environment of a crowded ED is clinically toxic, directly causing demonstrable negative outcomes for patients and staff [3, 4].

Classification: The Input-Throughput-Output Model

The causes and potential interventions for crowding are best understood using the Input-Throughput-Output model. To underscore the priorities for effective solutions, this model should be considered in reverse order of importance [3]:

1. Output (Highest Priority): This refers to the process of patients leaving the ED. The primary cause of crowding is failure at this stage, known as exit block or access block. This is the inability of admitted patients to be transferred to an inpatient ward due to a lack of available staffed beds in the hospital. Solutions are primarily the responsibility of hospital and system-level leadership [3, 8].
2. Throughput: This encompasses all processes within the ED, from patient arrival to disposition. It is influenced by departmental staffing, physical space, process efficiency, and access to diagnostics. While ED teams have some control here, improvements are severely limited by the presence of exit block [3, 8].
3. Input: This describes the demand for ED services, including patient arrival patterns and the effectiveness of alternative care pathways in the community. While often a focus for health policy, there is little evidence that input-focused interventions have a meaningful impact on the harm resulting from ED crowding [3, 9].

This model highlights that crowding is not an "ED problem" but a "system problem" with its locus of failure outside the ED's direct control.

The Four Harms of Poor Urgent Care Flow

The systemic nature of crowding is illustrated by the concept of the "four harms," a cascade of delays where failure in one part of the system directly impacts the others [10]:

1. Harm 4: Delay to disposition from a ward for patients who no longer require inpatient care.
2. Harm 3: Delay to admission from the ED.
3. Harm 2: Delay to initial assessment in the ED and the offloading of ambulances.
4. Harm 1: Delay to disposition for patients contacting emergency services (999/111).

This framework clarifies that delays experienced at the "front door" of the hospital are a direct consequence of failures at the "back door" [10].

Epidemiology & Aetiology

Incidence and Predominance

ED crowding has steadily worsened over the past decade in the UK, moving from a seasonal "winter crisis" to a year-round state of emergency [1, 11].

• Attendances: In 2019/20, there were over 19 million attendances to Type 1 EDs across the UK. Attendances in 2021 reached the highest levels on record for their respective months [1].
• Performance Decline: In September 2021, 4-hour performance in English Type 1 EDs fell to 64%, the lowest on record at the time. This meant one-third of all patients stayed longer than four hours [11]. The constitutional standard is 95% [3].
• Prolonged Stays: The number of patients waiting over 12 hours from their time of arrival has increased dramatically. In 2020-21, despite the pandemic-related drop in overall attendance, thousands of patients experienced these extreme waits [11]. No patient should stay in an ED for over 12 hours [1, 3].
• Ambulance Delays: Ambulance handover delays have worsened significantly, with the 95th percentile for handover in September 2021 reaching 104 minutes [11]. The national target is 15 minutes [4].

Vulnerable groups, including the elderly, children, and patients with dementia, mental health conditions, or learning difficulties, are disproportionately affected by the stressful and chaotic environment of a crowded ED [3]. Furthermore, deprivation is the single most important factor in determining ED demand; the most deprived communities use ED services significantly more than the least deprived [1].

Aetiology (Causes)

The root cause of ED crowding is a systemic mismatch between demand for urgent care and the capacity of the health and social care system to meet it [1].

Factor	Aetiological Contributors
Output Failure (Primary Driver)	Insufficient Staffed Bed Capacity: Since 2010, over 29,000 hospital beds have been removed from the system. The UK has one of the lowest numbers of beds per capita among OECD nations (2.4 per 1,000 inhabitants in 2020) [1, 11]. <br> High Hospital Occupancy: Recommended bed occupancy is below 85% to ensure flow; however, NHS England hospitals consistently operated above this level pre-pandemic and are returning to it post-pandemic [3, 11]. <br> Delayed Discharges: A lack of funded social care and community services prevents medically fit patients from being discharged, occupying beds needed for emergency admissions [1, 3].
Throughput Failure	Workforce Crisis: There is a shortfall of 2,000-2,500 Whole Time Equivalent (WTE) Emergency Medicine consultants in the UK. Shortages of ED nurses, Allied Health Professionals (AHPs), and Staff and Associate Specialist (SAS) doctors are also severe [1]. <br> Process Inefficiency: Delays in accessing diagnostics (radiology, labs), receiving specialist reviews, and duplication of processes between the ED and admitting teams impede patient flow [3, 12]. <br> Physical Environment: Many EDs are too small, run-down, and not designed to manage current patient volumes. A third of EDs are too small for their current workloads [1].
Input Pressure	Increased Demand: Rising and more complex patient presentations contribute to overall system pressure [1, 8]. <br> Lack of Primary Care Access: Many patients attend the ED after failing to get timely care elsewhere. Areas of high deprivation often have poor provision of primary and preventative care, driving ED use [1, 8].

The "Vicious Circle" of Crowding

Crowding is a self-perpetuating phenomenon. Exit block prevents new patients from being seen, prolonging their time to treatment. These delays can lead to clinical deterioration, increasing the likelihood of admission and the length of subsequent hospital stay. This, in turn, reduces bed availability and fuels further exit block, creating a "vicious circle" of system failure and patient harm [3].

This dynamic can be understood through the lens of Self-Organised Criticality. Like a sand pile where adding one more grain can trigger a massive avalanche, an ED operating near its capacity threshold is in a critical state. In this state, a small increase in patient numbers can cause a disproportionate and unpredictable collapse in performance, leading to catastrophic crowding events far more frequently than linear models would predict [13].

Risk Stratification and Prognosis

The most critical consequence of ED crowding is an increased risk of patient death. The language used in escalation must reflect that this is not a theoretical risk but a statistically certain harm affecting the patient population.

Prognosis and Mortality Evidence

Multiple studies have established a direct causal link between ED length of stay and mortality.

• The GIRFT Emergency Medicine Report identified an increase in the Standardised Mortality Ratio (SMR) for patients with ED delays beyond 5-6 hours from arrival. Their logistic regression model found an associated 30-day mortality rate for 1 in every 67 patients delayed by 8-12 hours [1].
• Jones et al. (2022) found a linear increase in all-cause 30-day mortality for admitted patients with ED stays between 5 and 12 hours. The analysis equates to one extra death for every 82 patients whose admission is delayed by 6 to 8 hours (Number Needed to Harm = 82) [5, 14].
• The RCEMLearning blog "Combatting the Crowd" summarises this as "For every 72 patients waiting in your department for longer than eight hours, one will die" [15].

These figures, while slightly different, point to the same grim conclusion: delays are lethal. Applying this data, the RCEM estimated that in 2020-21, over 4,519 excess deaths occurred in England due to crowding, a figure that unfavorably compares to the 1,827 deaths from road traffic collisions in 2019 [11].

Key Metrics for Measuring Crowding

Objective measurement is essential for demonstrating the severity of crowding and for effective escalation. Key metrics include [3, 12]:

• Ambulance offload time: Delays beyond the 15-minute target.
• Time to initial assessment and treatment.
• ED occupancy: The number of patients in treatment spaces versus the designated capacity.
• Waiting room occupancy and acuity.
• ED length of stay (LOS): Particularly for admitted patients.
• Number of boarded patients: Admitted patients awaiting an inpatient bed.
• Admitted Patient Delay (APD): A GIRFT metric measuring exit block [5].

Complications of Crowding and Treatments

Crowding creates a cascade of harms that affect patients, staff, and the entire healthcare system.

Category	Immediate Complications	Delayed Complications
Patient: Clinical	- Delayed analgesia for severe pain [16]. <br> - Delayed antibiotics for sepsis [16]. <br> - Increased risk of medication errors [14]. <br> - Care in inappropriate, undignified spaces (corridors, ambulances) [3]. <br> - Suboptimal monitoring and failure to recognise deterioration [14]. <br> - Increased risk of falls and pressure sores [10].	- Increased 30-day all-cause mortality [5, 11]. <br> - Increased overall hospital length of stay [11]. <br> - Higher risk of readmission [3]. <br> - Deconditioning due to immobility [10]. <br> - Nosocomial infections from exposure in crowded spaces [4].
Patient: Experience	- Loss of autonomy and helplessness [17]. <br> - Unmet expectations (lack of information, food, water, toileting facilities) [17]. <br> - Feelings of vulnerability, fear, and being depersonalised [17]. <br> - Loss of privacy and dignity [14].	- Reluctance to seek future emergency care, even when necessary [17]. <br> - Increased likelihood of formal complaints [3, 11].
Staff	- Inability to provide safe, high-quality care [11]. <br> - Increased exposure to violence, aggression, and inter-specialty conflict [3]. <br> - Physical and cognitive overload [3, 12].	- Moral injury and distress: Psychological harm from being unable to take ethically correct actions [11]. <br> - Burnout: Emotional exhaustion and depersonalisation, with levels consistently higher in EM than other specialties [11]. <br> - Attrition: Staff leaving the profession, retiring early, or reducing hours, worsening the workforce crisis [1, 11].
System	- Ambulance ramping, preventing crews from responding to community emergencies [4, 11]. <br> - Breakdown of departmental processes and efficiency [3].	- Increased litigation: Emergency Medicine accounts for 12% of all NHS litigation liabilities, with an average liability per ED attendance of £19.39 [1]. <br> - Cancellation of elective surgery due to lack of beds, hampering elective recovery [11]. <br> - Increased costs from locum/agency staff and legal action [3]. <br> - Reputational damage to the hospital and the NHS [3].

Management: Practical Strategies and Escalation

The management of a crowded ED requires a dual approach: implementing whole-system solutions to address the root cause (exit block) and employing in-department tactics to mitigate immediate harm. The shift leader's role is to act as a "system operator," making strategic decisions about flow and escalating clearly and professionally to compel a hospital-wide response [12].

A. Whole-System Interventions (Output-Focused)

These are the most effective long-term solutions and require engagement from the entire hospital leadership.

1. Full Capacity Protocol (FCP) / "Reverse Corridor"
   • Concept: Instead of concentrating all risk in the ED, the FCP distributes it across the hospital. It is a triggered escalation process where admitted patients are sent to their destination ward before a physical bed is available. They may be temporarily held in a ward corridor, treatment room, or discharge lounge [3, 14, 18].
   • Rationale: This is a "least-worst" option. The principle is that a stable, assessed patient boarding in a ward environment presents a lower overall risk than an accumulation of unassessed, undifferentiated patients in ambulances or ED corridors [3]. It makes the problem of exit block visible to the entire hospital.
   • RCEM Position: Cautiously supports the practice as part of a suite of measures to tackle crowding, recognising it is a response to, not a solution for, the problem [3].
2. Continuous Flow Models (CFM)
   • Concept: A proactive approach that moves from reactive escalation to a hard-wired system of predictable patient flow. Based on data of average daily admissions, a set number of patients are "pulled" from the ED to inpatient assessment units at regular intervals (e.g., one patient per hour) [3, 19].
   • Example (North Bristol Model): One patient is transferred from the ED to the Acute Medical Unit every hour, and one every two hours to the Acute Frailty Unit. This smooths the flow of admissions across the 24-hour period, preventing dangerous peaks [3].
   • Benefit: Allows the ED to maintain an empty cubicle for the next ambulance arrival, dramatically improving handover times and safety [3].
3. Enhanced Same Day Emergency Care (SDEC) / Ambulatory Emergency Care (AEC)
   • Strategy: Rapid expansion of SDEC and AEC services to be available 12 hours a day, seven days a week, with the same access to diagnostics as the ED. These services are cost-effective and reduce avoidable admissions [1, 11].

B. In-Department Strategies (Throughput-Focused)

These are tactical measures to improve flow and mitigate harm within the ED during periods of crowding.

1. Senior Clinical Leadership
   • Emergency Physician in Charge (EPIC): A designated senior clinician responsible for overseeing the entire department, maintaining situational awareness, and coordinating the operational response. They should not be expected to carry an individual caseload [3, 12].
   • Consultant-Led "Front-Loading" / Rapid Assessment and Treatment (RAT): A senior decision-maker performs an initial, time-limited assessment of new arrivals to identify "quick wins," initiate definitive investigations early, and stream patients appropriately. This reduces delays and overall LOS [14, 15].
2. Structured Safety Huddles
   • A non-negotiable process at the start of each shift to establish a shared mental model. The huddle must be multidisciplinary and follow a structured script [12]:
     • Looking Back: Review issues from the previous shift.
     • Looking Forward: Proactively identify current risks (capacity, acuity, staffing).
     • Finalise: Assign accountability for actions and set clear shift goals.
3. Tactics to Create Capacity
   • "Fit to Sit": Aggressively identify patients who do not require a trolley and can be safely managed in a chair, freeing up cubicles for sicker patients [18, 20].
   • Reverse Triage: Actively move stable patients out of high-acuity areas (Resus, Majors) to lower-acuity spaces (ambulatory areas, waiting room chairs) to create capacity for new critical arrivals [6].
   • Prioritise Pulls to Wards: When a specialty bed becomes available, prioritise seeing patients with clear admissions for that destination to facilitate a quick move [20].

C. The Escalation Toolkit: Scripts & Phrases

Effective escalation requires shifting the narrative from subjective appeals ("we're busy") to objective, evidence-based statements of clinical harm and corporate risk.

Scenario	Weak Language (to avoid)	Strong, Safety-Centred Escalation Phrase	Why it Works
Escalating to Site/Hospital Management	"We are really busy and stressed. We need beds."	"I am escalating this because the department is currently clinically unsafe. We have [Number] patients waiting over 12 hours, which is a known determinant of increased 30-day mortality and is now a corporate safety risk. The ED cannot safely absorb any more risk. I require you to enact the Full Capacity Protocol now." [6, 14]	Cites evidence, frames the issue as a hospital-wide safety failure, links it to corporate risk, and requests a specific, pre-agreed action.
Escalating to a Specialty Team	"Can you just come and see them now?"	"This patient has a time-critical condition. Due to overcrowding, I cannot guarantee their safety while they wait in the corridor. I am formally handing over clinical risk to your specialty now. If you cannot attend within 30 minutes, I require you to come and personally document the decision and assume clinical responsibility for the wait." [6, 14]	Centers the conversation on patient harm, transfers professional accountability, and forces the receiving team to co-own the risk of delay.
Ambulance Handover Delays	"The crews are stuck outside."	"We have zero physical capacity to offload and are operating at OPEL 4. This is a system critical incident. The delay is preventing ambulance response to patients with suspected cardiac arrests in the community. I require immediate activation of the escalation plan to create space." [6, 14]	Links the ED issue to wider public harm, uses official incident language (OPEL 4), and creates urgency for a system response.

D. Documentation for Safety

When forced to provide care in a compromised environment, documentation is a professional and medico-legal necessity. It creates an audit trail and highlights systemic failures.

The "Crowding Note" Template:

"Patient seen and assessed in [e.g., Corridor / Ambulance Bay / Non-clinical area] due to severe departmental overcrowding (Department at OPEL 4 status). A full and private examination was not possible, and the patient's dignity could not be fully maintained. Clinical monitoring was limited by the environment. The significant clinical risk this situation poses to this patient and others has been escalated to the Duty Consultant, Site Manager, and [Specialty] team at [Time]." [14]

Learning Aids and Practical Tools

Mnemonic: The "CARES" Bedside Check

When managing a department under pressure, use this framework derived from the RCEM's strategic pillars to guide your situational awareness [6]:

• Crowding: Are we unsafe? Do I need to escalate NOW?
• Access: Is flow blocked? Who owns the delay?
• Retention: Are my staff Hungry, Angry, Late, or Tired (HALT)? Have they had a break?
• Experience: Are patients and relatives informed of delays?
• Safety: Is the waiting room visually triaged? Who are the sickest patients?

Mnemonic: Time-Critical Medications ("MISSED")

In a crowded ED, medication errors are common. Prioritise patients on these time-critical medications to avoid harm [3]:

• Movement Disorders: Parkinson’s, myasthenia gravis medications.
• Immunomodulators: Including HIV medications.
• Sugar: Diabetes medications (insulin, etc.).
• Steroids: For Addison’s, adrenal insufficiency.
• Epilepsy medications.
• DOACs and warfarin.

RCEM CARES Shift Leader Checklist

This tool condenses key safety actions for the shift leader [6].

Operations & Flow (The "Hard" Skills)	People & Culture (The "Soft" Skills)
1. START OF SHIFT (The Setup) <br> ☐ Sitrep: Total in dept? Resus capacity? Wait times? <br> ☐ Staffing: Review skill mix. Identify gaps. <br> ☐ Safety: Who are the sickest 3 patients? <br> ☐ Huddle: Set a calm tone. Assign breaks.	1. RETENTION (Staff Care) <br> ☐ HALT Check: Is the team Hungry, Angry, Late, or Tired? <br> ☐ Hydration: Have I and the triage nurse had a drink? <br> ☐ Civility: Correct rudeness immediately but privately.
2. HOURLY SCAN (Crowding & Access) <br> ☐ Input vs. Output: Are ambulances offloading? Is Exit Block worsening? <br> ☐ Trigger: If offload delay >15m → ESCALATE. <br> ☐ Reverse Triage: Move stable patients out of Resus/Majors. <br> ☐ Waiting Room: Visual safety check.	2. EXPERIENCE (Conflict & Comms) <br> ☐ Conflict (DESC): Describe behaviour → Express concern → Specify change → Consequences. <br> ☐ Relatives: Update them early. "We are crowded, but we are safe." <br> ☐ Debrief: After any critical event.
3. END OF SHIFT (The Handover) <br> ☐ "Clean" Handover: Use SBAR. Handover plans, not problems. <br> ☐ Thank You: Give specific praise to team members. <br> ☐ Datix: Log any system failure. (No Datix = It didn't happen).

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References

1. Royal College of Emergency Medicine. RCEM CARES: The next phase. London: RCEM; 2021.
2. International Federation for Emergency Medicine. Report from the Emergency Department Crowding and Access Block Task Force. IFEM; 2020 June.
3. Royal College of Emergency Medicine. The Management of Emergency Department Crowding. London: RCEM; 2024 Jan.
4. Royal College of Emergency Medicine, College of Paramedics. Ambulance Handover Delays: Options Appraisal to Support Good Decision Making. 2021 Mar.
5. Moulton C, Mann C. Emergency Medicine. GIRFT National Programme Speciality Report. 2021.
6. Mastering RCEM SLO 12: Manage, Administer, Lead [Source Document].
7. Royal College of Emergency Medicine. Clinical Responsibility for Patients within the Emergency Department. 2023 Aug.
8. Asplin BR, Magid DJ, Rhodes KV, et al. A conceptual model of emergency department crowding. Ann Emerg Med. 2003;42(2):173-180.
9. Kirkland SW, Soleimani A, Rowe BH, Newton AS. A systematic review examining the impact of redirecting low-acuity patients seeking emergency department care: is the juice worth the squeeze? Emerg Med J. 2019 Feb;36(2):97-106.
10. Bruijns S. Speaking urgent care flow fluently. St.Emlyn's [Internet]. 2023 Nov 15.
11. Royal College of Emergency Medicine. RCEM Acute Insight Series: Crowding and its Consequences. London: RCEM; 2021 Nov.
12. Mastery of Command: A Practical Guide to Achieving RCEM SLO 8 – Lead the ED Shift [Source Document].
13. Bruijns S. Self-Organised Criticality: Why your ED is like a Sand Pile. St.Emlyn's [Internet]. 2025 May 24.
14. This comprehensive practical document is written for UK NHS Emergency Medicine doctors [Source Document].
15. Fielding P. Combatting the Crowd. RCEMLearning [Internet]. 2021 Nov 9.
16. Pines JM, Hollander JE. Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med. 2008 Jan;51(1):1-5.
17. Crowe L. Patient experience in the Emergency Department. St.Emlyn's [Internet]. 2024 Sep 3.
18. Escalation ideas & Actions [Source Document].
19. Vaughan LK, Bruijns S. Continuous flow models in urgent and emergency care. BMJ. 2022;379:o2751.
20. Bruijns S, Boulind C. JC: Improving patient flow. St.Emlyn's [Internet]. 2020 Mar 22.

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Appendix: Example Electronic Health Record (EHR) Documentation Structure

This structure is designed for use in an EPIC EHR system to provide robust documentation during periods of severe crowding, focusing on safety actions and medico-legal clarity.

ED Crowding Safety Note

1. Departmental Status (Tick Box)

• [ ] Department at OPEL 4 / Critical Incident Declared at [Time]
• [ ] Full Capacity Protocol (FCP) Activated at [Time]
• [ ] Ambulance Diversion in place
• [ ] Ambulance handover delay > 30 minutes
• [ ] Number of patients in department: [Enter Number] (Designated capacity: [Enter Number])
• [ ] Number of admitted patients boarding in ED: [Enter Number]
• [ ] Longest patient wait in ED: [Enter Hours]

2. Patient Assessment Context (Tick Box)

• [ ] Patient assessed in non-clinical area: [e.g., Corridor, Waiting Room Chair, Ambulance]
• [ ] Full privacy and dignity could not be maintained
• [ ] Examination limited by environment
• [ ] Continuous monitoring not available/sub-optimal

3. Escalation and Risk Mitigation Actions (Tick Box)

• [ ] Escalated to ED Consultant / EPIC at [Time]
• [ ] Escalated to Site Management regarding clinical risk and capacity at [Time]
• [ ] Escalated to [Specialty] team regarding delay in review/admission at [Time]
• [ ] Clinical risk formally handed over to [Specialty] team at [Time]
• [ ] Repeat vital signs and safety check performed at [Time]
• [ ] Patient/Family informed of delays due to systemic pressures
• [ ] Time-critical medications ("MISSED" doses) checked and administered

4. Medical Decision Making / Summary

Situation: This patient was assessed during a period of severe departmental overcrowding (OPEL 4), with the department operating significantly beyond its designated capacity. The primary driver is hospital-wide exit block, with [Number] admitted patients boarding in the ED.

Assessment: The patient was located in [e.g., the main corridor], which limited the ability to perform a comprehensive and private examination. The environment poses a significant clinical risk due to suboptimal monitoring, potential for delayed recognition of deterioration, and an increased risk of errors.

Plan & Rationale: All immediate life threats have been addressed based on the available assessment. The plan is [Insert clinical plan]. The significant risks posed by the crowded environment have been explicitly communicated to the Site Management team and the admitting [Specialty] team. The responsibility for ongoing safety and the harm caused by delays in admission has been escalated accordingly. Will continue to perform regular safety checks while the patient remains in the department.

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