Standard 29: Hospital Emergency Department (Version 11)

Every patient arriving at the emergency department is triaged on arrival by a trained clinician, using a recognised triage scale. The triage category decides the maximum time to clinical assessment.

Rating: Must in humanitarian settings; Must in transition and fragile settings; Must in standard settings.

Not assessed (N/A) for: ambulatory clinic, aesthetic and procedure clinic, primary health clinic, long-term care, telemedicine, home care, fitness and wellness, dental clinic.

Guidance

Triage is the first clinical decision for every person who comes to the emergency department. A trained clinician assesses each arrival on a recognised triage scale, and the category decides how soon the patient must be seen.

Triage happens on arrival, before the patient waits. A patient who arrives by ambulance or walks in is triaged in the same way, and the triage record is completed at the time of the assessment, not later.

What good looks like

• A triage procedure (ED-SOP-001) that names the scale in use and who may triage.
• A triage record (ED-FRM-003) completed for each attendance, with category and time.
• Triage completed before the patient is asked to wait, in every shift, including nights and weekends.
• Regular review of triage times against the maximum time for each category.

Common mistakes

• Triage done only on busy shifts, or by staff who have not been trained in the scale.
• Triage recorded on paper and not filed, so the time cannot be checked.
• A patient who looks well is not triaged, or is triaged without a recorded category.
• Maximum times for each category are not set, so the triage category has no effect.

Questions the surveyor asks

• Every arrival is triaged before waiting. The surveyor checks the arrival and triage records for each attendance in the sample.
• Triage is carried out by a trained clinician on a recognised scale. The surveyor checks the training record of each clinician who triaged in the sample, and the scale named in the procedure.

How the surveyor verifies this criterion

References

1. WHO (2021). Emergency Triage Assessment and Treatment (ETAT): Manual for Participants. Child-specific (ETAT). https://news.gmj.ge/guideline/emergency-triage-assessment-and-treatment-etat-manual-for-participants/
2. WHO (2020). Paediatric emergency triage, assessment and treatment: care of critically-ill children. Paediatric emergency triage and resuscitation; child-specific. https://news.gmj.ge/guideline/paediatric-emergency-triage-assessment-and-treatment-care-of-critically-ill-children/

A resuscitation area is available at all times. Its equipment and drugs are checked on a documented schedule, and staff on every shift are trained in immediate life support.

Rating: Must in humanitarian settings; Must in transition and fragile settings; Must in standard settings.

Not assessed (N/A) for: ambulatory clinic, aesthetic and procedure clinic, primary health clinic, long-term care, telemedicine, home care, fitness and wellness, dental clinic.

Guidance

The resuscitation area is the place where a patient in cardiac arrest or immediate threat to life is treated. It is available at all times, and its equipment and drugs are present, in date and complete.

Readiness is shown by a documented check on a set schedule. Each check is recorded in the readiness register against the list of equipment and drugs, and any missing or out-of-date item is replaced before the next shift.

What good looks like

• A readiness policy (ED-POL-002) that sets the check schedule and who carries it out.
• A readiness register (ED-REG-001) with each check dated and signed.
• Equipment and drugs listed, checked against that list, and replaced when out of date.
• Immediate life support training for staff on every shift.

Common mistakes

• A check recorded as done with no items listed.
• Drugs past their expiry date left in place because no one checked them.
• Checks done only before inspections, not on the set schedule.
• Training recorded for some staff, but not for those on night shifts.

Questions the surveyor asks

• Equipment and drugs are in date and complete at each check. The surveyor checks the latest check record against the list of equipment and drugs.
• Staff on every shift are trained in immediate life support. The surveyor checks the training records of the 10 staff in the sample against the shift rota.

How the surveyor verifies this criterion

References

1. No external reference is cited for this criterion. Its requirements are set out in the criterion, the checks and the evidence listed.

A named senior clinician is responsible for the department at all times. Escalation to specialist services follows a defined pathway with a stated response time.

Rating: Minimum in humanitarian settings; Must in transition and fragile settings; Must in standard settings.

Not assessed (N/A) for: ambulatory clinic, aesthetic and procedure clinic, primary health clinic, long-term care, telemedicine, home care, fitness and wellness, dental clinic.

Guidance

The department must always have a named senior clinician who is responsible for decisions and for the staff on duty. The duty rota shows who it is for each period, including nights and weekends.

When a specialist service is needed, the call follows the escalation pathway in the policy, with the stated response time. Each call is recorded on the senior clinician on duty record with the time of request and the time of review.

What good looks like

• A policy (ED-POL-001) that names the responsible clinician and the escalation pathway.
• A duty rota that names the senior clinician for every period.
• A senior clinician on duty record (ED-FRM-001) for each specialist call.
• A stated response time for specialist review, checked against the record.

Common mistakes

• A rota that names a senior clinician for day shifts only.
• Specialist calls made by telephone with no record of the time.
• An escalation pathway that exists on paper but staff do not know.
• The response time is not stated, so nobody can tell if it was met.

Questions the surveyor asks

• A named senior clinician is responsible for the department at each time. The surveyor checks the rota for a named senior clinician in every period.
• Each specialist call follows the defined escalation pathway. The surveyor checks each call for the pathway step and the response time.
• The stated response time for specialist review is met. The surveyor checks each call for the time from request to review against the stated time.

How the surveyor verifies this criterion

References

1. Royal College of Emergency Medicine (2016, revised February 2016). The on call role of the Emergency Medicine Consultant.

The decision to admit, transfer or discharge is recorded with its reasons. Handover to the receiving ward or facility is structured. Interfacility transfers are handled under the transfer requirements of this Version 11 set.

Rating: Minimum in humanitarian settings; Medium in transition and fragile settings; Must in standard settings.

Not assessed (N/A) for: ambulatory clinic, aesthetic and procedure clinic, primary health clinic, long-term care, telemedicine, home care, fitness and wellness, dental clinic.

Guidance

Each time a patient leaves the department, the decision is recorded with its reasons on the disposition decision record. The record shows whether the patient is admitted, transferred or discharged.

The handover to the receiving ward, clinician or facility is structured, so the next team knows the diagnosis, the treatment given and what remains to be done.

What good looks like

• A disposition decision record (ED-FRM-002) for every attendance that ends in a decision.
• A structured handover that covers diagnosis, treatment, and what remains to be done.
• Medication list handed over with the patient on transfer or discharge.
• Regular audit of recorded reasons.

Common mistakes

• A discharge recorded with no reason.
• A verbal handover that is not recorded.
• A medication list missing from a transfer.
• The GP not informed of a discharge that needs follow-up.

Questions the surveyor asks

• Each decision to admit, transfer or discharge is recorded with its reason. The surveyor checks each attendance for the decision and the reason recorded.
• Each handover is structured and recorded. The surveyor checks the handover records for the 15 sampled attendances.

How the surveyor verifies this criterion

References

1. WHO (2020). Medication safety in transitions of care. Medication safety in patient transfers and discharge; medication-specific. https://news.gmj.ge/guideline/medication-safety-in-transitions-of-care/
2. World Health Organization (2021). Global Patient Safety Action Plan 2021–2030: Towards Eliminating Avoidable Harm in Health Care. Geneva: WHO. https://www.who.int/publications-detail-redirect/9789240032705

Patients who leave before they are assessed or treated are recorded, and the department makes reasonable attempts to follow them up. The rate and reasons are reviewed.

Rating: Minimum in humanitarian settings; Medium in transition and fragile settings; Must in standard settings.

Not assessed (N/A) for: ambulatory clinic, aesthetic and procedure clinic, primary health clinic, long-term care, telemedicine, home care, fitness and wellness, dental clinic.

Guidance

Some patients leave before they are seen. Each departure is recorded in the register at the time it happens, with the time and the reason if given.

The department makes reasonable attempts to contact each recorded patient, and records the attempts. The rate of departures and the reasons are reviewed at a set interval, and the review leads to action where the rate is high.

What good looks like

• A procedure (ED-SOP-003) for departures before assessment and for follow-up.
• A register (ED-REG-002) kept for each shift.
• Follow-up attempts recorded with their dates.
• Review of the rate and the reasons at a set interval.

Common mistakes

• Departures are not recorded because the register is kept only on busy shifts.
• Follow-up calls not recorded, so it cannot be shown they were made.
• The rate is never reviewed.
• Reasons recorded, but nothing changes as a result.

Questions the surveyor asks

• Each patient who leaves before assessment is recorded. The surveyor checks compare the department attendance log with the register for each shift.
• The department makes reasonable attempts to follow up each recorded patient. The surveyor checks each record for the follow-up attempts and their dates.
• The rate and the reasons are reviewed at a set interval. The surveyor checks the review entries for the rate and the reasons.

How the surveyor verifies this criterion

References

1. No external reference is cited for this criterion. Its requirements are set out in the criterion, the checks and the evidence listed.