Relationship of the safety of A & E Departments to Size

The following summary reflects a broad consensus view of the relationship of the size and organisation of Accident and Emergency Departments in NHS hospitals to safety, based on interviews with a Senior A & E Consultant who has contributed to standard setting for A & E departments on behalf of the British Association for Accident and Emergency Medicine (BAEM).

Incident to door time

The Committee recommends that maximum Ambulance transfer time from the site of an accident or life-threatening illness to an A & E department should not exceed 20-30 minutes.  It recognises that this may be difficult to achieve in rural areas.  If a department staffed by A & E consultants is not available within this time, the patient should be taken to a casualty or admissions unit where resuscitation and stabilisation facilities are available.  This implies the availability of doctors with these skills.  They may be physicians, G.P.’s or Senior Nursing staff with A & E skills.  Minor injuries units staffed only by nursing staff cannot fulfil this role.

A small minority of A & E attendances with life-threatening illnesses require rapid access to A & E departments.  About 2% of all attendances fall into this category, the majority with acute medical emergencies.  These include acute myocardial infection, severe/life-threatening asthma, meningitis in children, paracetamol overdose, and coma of uncertain aetiology where life support is essential.  About 0.5% of all admissions to A & E departments result from major life-threatening trauma which may require advanced life support.  The proximity of resuscitation and stabilisation facilities (including these provided by trained ambulance paramedics en route) within 20-30 minutes of transfer from incident to hospital is of paramount importance in these situations.

Optimum “safe” size of A & E units in NHS Hospitals

Consensus evidence indicates that the clinical outcomes of A & E patients treated in a department with about 50,000 attendances per annum from a catchment population of 200-250,000 are not significantly different from outcomes in a large A & E department with a catchment population of about 500,000.  For smaller populations, admission or casualty units staffed by doctors, as noted above, permit stabilisation and resuscitation, triage, and the rapid transfer of seriously ill patients with major trauma through managed clinical networks to specialised centres (e.g. for major neurosurgical problems such as severe head injuries).  There is no well founded evidence that very large A & E departments with six or more A & E consultants have significantly better clinical outcomes for the 98% of patients who can be managed within A & E departments of moderate size. The latter comprise the great majority of A & E departments in NHS hospitals in the U.K.

Conclusion

The ‘safety’ argument being used to advocate two large A & E departments for GGHB hospitals is not supported by evidence of clinical outcomes in well-run moderate-sized A & E units which are the U.K. norm.  There are also significant risks in reducing hospital A & E services to nurse-led minor injuries units in hospitals in GGHB and Scotland which are unable to provide immediate resuscitation and stabilisation for the small minority (about 2%) of patients with life-threatening medical and surgical emergencies.  Their establishment will place many areas of Scotland (and GGHB’s catchment area) outwith the 20-30 minute incident to door standard recommended by the BAEM for major emergencies, particularly at times of peak traffic flow in urban areas.

Please click on the below link to see the Standards for Accident & Emergency Departments:

BAEM Audit Standards for Emergency Medicine