Standard 36: Hospital Emergency Department

Why it matters. In the emergency department, the patient who looks well may be the one who is most ill. Triage on arrival, by a trained person with a recognised tool, puts the sickest first.

Sample. Review arrival and triage records for 30 emergency department attendances across three shifts, including night and weekend.

1. Each arrival is triaged on arrival by a trained clinician.

Method. Check each attendance for a triage entry with the time of arrival and the time of triage.

Evidence to show. Emergency triage (HOS-SOP-001, existing, reused).

Pass when. Every sampled arrival is triaged on arrival.

2. A recognised triage scale is used and the category is recorded.

Method. Check each triage record for the scale named and the category given.

Evidence to show. Triage record and log (HOS-FRM-001, existing, reused).

Pass when. Every triage record names the scale and the category.

3. The triage category sets the waiting time and is re-checked while waiting.

Method. Check each high-category patient for the target time and the re-check entries.

Evidence to show. Triage on arrival (URG-POL-001, existing, reused).

Pass when. Every sampled patient is seen within the target for their category.

Immediate fail (any one means the criterion is not met)

• A patient with chest pain waits three hours in the waiting room without triage.

Why it matters. A resuscitation area that is not ready when a patient arrives in cardiac arrest costs minutes that cannot be recovered. Equipment and drugs checked on a schedule are ready when needed.

Sample. Review resuscitation area checks and drill records for the last 3 months and 10 staff training records.

1. The resuscitation area is checked at the set schedule and the check is recorded.

Method. Check the record for each scheduled check in the period.

Evidence to show. Resuscitation equipment checks (HOS-SOP-015, existing, reused).

Pass when. Every scheduled check is recorded.

2. Equipment and drugs are in date and complete at each check.

Method. Check the latest check record against the list of equipment and drugs.

Evidence to show. Resuscitation area readiness register (ED-REG-001).

Pass when. No item is out of date or missing at the last check.

3. Staff on every shift are trained in resuscitation and a drill is held.

Method. Check the drill record and the training record for staff on sampled shifts.

Evidence to show. Rehearsal and drill record (HOS-REG-004, existing, reused).

Pass when. Every sampled shift has trained staff and a drill in the period.

Immediate fail (any one means the criterion is not met)

• A cardiac arrest with the resuscitation drugs out of date.

Why it matters. When something goes wrong in the department, someone senior must be in charge and reachable. Without a named senior clinician, decisions are delayed or made by nobody.

Sample. Review the senior clinician duty rota for 30 days, and the escalation log for 10 specialist calls.

1. A named senior clinician is responsible for the department at each time.

Method. Check the rota for a named senior clinician in every period.

Evidence to show. Senior clinician responsibility and specialist escalation (ED-POL-001).

Pass when. No period in the sample has an unnamed senior clinician.

2. Each specialist call follows the defined escalation pathway.

Method. Check each call for the pathway step and the response time.

Evidence to show. Senior clinician on duty record (ED-FRM-001).

Pass when. Every call follows the pathway and has a recorded response.

3. The stated response time for specialist review is met.

Method. Check each call for the time from request to review against the stated time.

Evidence to show. Senior clinician on duty record (ED-FRM-001).

Pass when. Every call meets the stated response time.

Immediate fail (any one means the criterion is not met)

• No senior clinician on duty overnight and a specialist call goes unanswered.

Why it matters. A decision to admit, transfer or discharge a patient should be recorded with its reasons. A handover that is not made clearly is where the next team misses the problem.

Sample. Review admission, transfer and discharge decisions for 30 attendances, and handover records for 15 of them.

1. Each decision to admit, transfer or discharge is recorded with its reason.

Method. Check each attendance for the decision and the reason recorded.

Evidence to show. Disposition decision record (ED-FRM-002).

Pass when. Every sampled decision has a recorded reason.

2. Handover to the receiving ward or facility is structured.

Method. Check each handover for the structured elements.

Evidence to show. Structured verbal handover (HOS-SOP-004, existing, reused).

Pass when. Every sampled handover uses the structure.

3. Interfacility transfers carry the records and the handover.

Method. Check each transfer for the records sent and the handover given.

Evidence to show. Handover record (HOS-FRM-004, existing, reused).

Pass when. Every interfacility transfer has the records and handover.

Immediate fail (any one means the criterion is not met)

• A patient discharged with no reason recorded and no handover to the GP.

Why it matters. Patients who leave before they are seen may be seriously unwell, and the department must know who they are to follow them up. Recording and following up those patients is part of safe care.

Sample. Review the register of patients who left before assessment for the last 6 months, and the follow-up records.

1. Each patient who leaves before assessment is recorded.

Method. Compare the department attendance log with the register for each shift.

Evidence to show. Left-before-assessment register (ED-REG-002).

Pass when. Every departure before assessment is recorded.

2. The department makes reasonable attempts to follow up each recorded patient.

Method. Check each record for the follow-up attempts and their dates.

Evidence to show. Patients who leave before assessment (ED-SOP-003).

Pass when. Every recorded patient has follow-up attempts recorded.

3. The rate and the reasons are reviewed at a set interval.

Method. Check the review entries for the rate and the reasons.

Evidence to show. Left-before-assessment register (ED-REG-002).

Pass when. The rate and reasons are reviewed at the set interval.

Immediate fail (any one means the criterion is not met)

• Patients who walk out before being seen are not recorded and no one is told.