Patient safety
investigation found that there were internal processes that hospitals can improve to support functions that assist timely discharge so that inpatient beds are available if patients need to be admitted via the ED. These included having good relationships between nurses, doctors, medical specialties, mental health Trusts, cleaning teams, pharmacy, speech and language therapists, dietetics, occupational therapy and physiotherapists. Every team, function and specialty played an important role in supporting flow and the use of temporary care environments. For example, good relationships between nursing and cleaning teams meant that a cubicle could be prioritised for cleaning so that a patient could be moved into that space in a timely manner, potentially minimising the use of a temporary care environment. Another hospital said it was beneficial having a dedicated pharmacist for their department, so that patients had their medications, expediting their discharge from hospital.
Impact on patients and staff The HSSIB investigation spoke to patients who were being treated in temporary care environments, and many of them said they were
grateful they were now on a trolley or bed – describing it as “better being here [on a trolley in a corridor] than sitting in a chair in the waiting room”. Patients said that despite privacy and dignity concerns they “felt safe” and “well looked after” in temporary care environments. This was echoed by many doctors and nurses, who told HSSIB that using temporary care environments was the “best worse” option, compared to the alternatives of leaving people at home, in ambulances or unseen in waiting rooms.
Local-level learning prompts
HSSIB has identified the following local-level learning prompts for acute hospitals: l Does your organisation have a policy that governs the use of temporary care environments, which includes potential risk mitigation strategies? Do these policies consider the severity of patients’ health conditions, the appropriateness of patients who can be assigned to a temporary care environment and what exclusion criteria may apply in assigning patients to temporary care environments?
l Does your organisation use a multidisciplinary team to assist risk-based decisions on where to situate temporary care environments and make decisions on which patients are appropriate to be placed in them?
l Does your organisation consider the staffing ratios needed to manage temporary care environments, including numbers, skill mix, experience and competencies?
l Has your organisation nominated and assigned an individual healthcare professional to oversee temporary care environments, who is responsible for managing the completion of regular patient observations, escalating concerns, and
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standing back and providing leadership and supervision without being involved in direct care?
l Does your organisation have aligned processes across different departments, including the availability of specialty services to help facilitate the movement of patients to the right place of care as soon as possible?
l Has your organisation made adaptations to temporary care environment spaces that include having essential equipment nearby? For example, emergency call bells, communication systems, personal call bells, spaces for personal care and invasive treatments.
l Does your organisation have a means of tracking individual patients who are in a temporary care environment to support their clinical observations, understanding their needs and a process by which they document the length of time they have been in the temporary care environment?
l Does your organisation have a way of displaying clinical information and observations of patients in a temporary care environment to all relevant staff, so that trends or deterioration in a patient’s condition can be identified?
l Does your organisation provide information to patients about the use of temporary care environments and to inform them that any patient may be placed in one if there is a clinical need to provide a space for other patients?
l Does your organisation gather information about the use of temporary care environments including: l the patient cohorts using temporary care environments
l a description of the temporary care environment
l how long patients have been in a temporary care environment incidents that have happened to patients while in a temporary care environment
l the immediate and long-term impact on patient safety and patient outcomes actions taken to reduce patient safety risks?
l Does your organisation ensure that patients in temporary care environments are regularly engaged with to ensure that they have food, water, are comfortable, understand what is happening to them and what the plan is going forward?
However, it was evident from speaking with patients, staff and national organisations that the use of temporary care environments causes challenges around privacy and dignity. This can result in distress to both patients and staff. Several patients who were in temporary care environments in EDs told the investigation that they had challenges with personal care, such as washing and toileting, or having to be given invasive treatments such as insertion of cannulas or drips. Patients understood that there had been a compromise with being in that environment or being somewhere else less safe. Patients said that despite the privacy and dignity concerns they “felt safe” and “well looked after”. Staff described feelings of moral injury (negative emotions that arise because they cannot provide the level of care they would like) caused by having to care for patients in temporary care environments and the resulting compromise in patients’ experience. The investigation was told by staff, at all
levels, that staff were experiencing fatigue and burnout because of the number of people that had to be cared for in temporary care environments. The Royal College of Nursing (RCN) also reported staff burnout and fatigue, higher levels of stress, and people being more
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