Delays ‘put safety of patients at risk’

DELAYS in transferring patients from ambulances into hospitals are putting their safety and dignity at risk, inspectors have warned.

Healthcare Inspectorate Wales (HIW) has today published a new report looking specifically at handover delays between the Welsh Ambulance Service and hospital A&E departments and how they are affecting patient care.

Between April 2020 and March 2021 there were approximately 185,000 ambulance handovers to emergency departments throughout Wales. However, less than half of them (79,500) occurred within the target time of 15 minutes.

During that period there were also 32,699 incidents recorded where handover delays were in excess of 60 minutes, with almost half (16,405) involving patients over the age of 65 who are more likely to be vulnerable and at risk of unnecessary harm.

Data published by the Welsh Government highlighted that in December 2020 alone, a total of 11,542 hours were lost by the ambulance service due to handover delays. This figure has been rising sharply and has now reached pre-pandemic levels once again.

Inspectors said these delays have consistently led to multiple ambulances waiting outside A&E departments for excessive amounts of time, unable to respond to emergencies within their communities.

“These delays have serious implications on the ability of the service to provide timely responses to patients requiring urgent and life-threatening care,” the report stated.

“We found handover delays impact on the ability of ambulance crew to provide a positive experience for

patients. It may also increase the risk to patient safety through delays in diagnosis and receiving treatment, as well as to the risk to people awaiting an ambulance in the community, with fewer ambulances available to respond to their needs.”

HIW said that patient handover delays are not directly a problem with the Welsh Ambulance Service, but are a consequence of “wider systemic patient flow issues” throughout NHS healthcare systems and social care services.

“Concerns were also highlighted to us of severe overcrowding within emergency departments which leads to the inability to offload patients from ambulances,” the report added.

While handover processes at emergency departments across Wales were broadly similar, inspectors found “many examples” of them being adapted due to departmental layouts, differences in staff roles and availability of staff.

They also found a minority of A&E workers and ambulance crews were unfamiliar with handover policies.

The report added: “We found dayto-day inconsistencies within the same department and sometimes between clinicians and ED staff, as well as a lack of clarity between the Welsh Ambulance Service and ED staff about responsibility for a patient until transfer to the ED. These types of inconsistencies can introduce risk and have a detrimental impact on patient care and safety and therefore requires attention.

“We found that new roles had been introduced by some health boards aimed at improving handover processes; however, these roles are not in place across all EDs, and we believe that all health boards should consider the benefits that these roles may bring.”

A survey by HIW found 71% of ambulance crews who responded stated they did not feel emergency department staff and the service provided by ambulance crews worked together to provide seamless patient treatment and care.

During 2020-21, the Welsh Ambulance Service recruited more than 100 additional frontline staff to gain a more timely response to the public’s demand. However, inspectors said it was “concerning” to find in response to its survey, only 31% of ambulance workers said there were adequate staff for them to do their job properly.

The report added: “We identified that staff welfare in urban areas is easier to manage than rural areas, since crews are stationed closer to the ED they most often attend with patients and are therefore able to return to their base station during their breaks and sooner at end of shift times.

“In rural areas, we were told that it is not uncommon for shifts to overrun by two to three hours. The impact of delayed handovers is also increased in areas where a high number of tourists arrive during peak holiday times. If ambulance crews are late leaving the ED at the end of their shift whilst awaiting the arrival of a relief crew, at times crews may be delayed by up to a further two hours before they arrive back at their base station.”

Despite the handover problems, HIW said patients were generally positive about their experiences of ambulance staff, particularly in relation to their kindness, communication and management of situations.

Commenting on the report, Alun Jones, interim chief executive of Healthcare Inspectorate Wales, said: “It is clear that the dedication and commitment of WAST and ED staff has continued to result in positive patient experiences despite the challenges of the pandemic.

“There is, however, significant collaborative work needed to resolve the issue of prolonged handover delays which are a symptom of wider patient flow issues throughout the NHS in Wales. It is my expectation that the recommendations that fall from this review are taken forward alongside, and in the context of, other work in this area to achieve the required improvement.”

In response to the report Claire Roche, the Welsh Ambulance Service’s executive director of quality and nursing, said: “Ambulance crews know better than anyone the impact that delayed handover has on a patient’s experience because they spend many hours – sometimes an entire shift – with the same patient on the back of a vehicle.

“It’s as distressing for our crews as it is for the patient and their loved ones, especially when there are other patients in the community who need our help and we can’t get to them.

“The focus of all of us in NHS Wales should be on patient safety, whether that’s patients on the back of an ambulance outside the emergency department or patients in the community where arguably, the risk to their safety is greater because they don’t have an expert clinician by their side.

“Our emergency ambulance service exists to deliver life-saving immediate care and to take patients promptly to hospital for the necessary treatment – being available in the community to respond to people is therefore essential.

“For the Welsh Ambulance Service, this is about getting to the root cause of the issue in order to resolve it, rather than adapting to a situation so that it becomes the new normal.”

A Welsh Government spokeswoman said: “We note the report’s findings and welcome its recognition of the significant amount of work that is already under way to help tackle challenges faced by the entire health and care system.

“We acknowledge the scale of these challenges and the impact on staff and patients. Health boards are responsible for improving ambulance patient handover times and we expect to see them deliver improvement in this area. A broad range of actions are already in place including recruitment of additional ambulance clinicians, creation of urgent primary care centres and a new national programme to support people to return home from hospital when ready. We have also announced £25m in recurrent funding.”