The first few days in hospital are critical to patients’ outcomes and experiences, and we know we can do better. Too many people – 1.7 million in 2024 – are spending 12 hours or more in our emergency departments before or instead of being transferred to more appropriate settings.
When people are admitted, too many are not receiving the timely assessments and treatment they need, or the continuity of care they should be able to rely on from teams working seamlessly together.
As a result, people often end up staying longer in hospital than they would have done had their initial period of care been optimised. The average length of stay is now around 10% longer than it was before the pandemic.
The pathway
In partnership with the Royal College of Physicians, the Society for Acute Medicine and the British Geriatrics Society, we have therefore developed standards for the first 72 hours of hospital care.
The standards are grounded in the real-life experience of our colleagues who are caring for very sick patients every day. These colleagues have a clear understanding of the barriers to delivering the standard of care they strive for and have helped us to describe the actions needed to make meaningful improvement. The key themes of the standards are:
- early senior decision making, with patient and carer involvement
- continuity and coordination of care
- care in the right place at the right time
- 7-day working
- accurate capture of decisions and activity
These standards build on long-standing, evidence-based recommendations that remain the right thing to do. However, progress has stalled or reversed in some hospitals. We have strengthened expectations where more clarity or ambition is now required. The standards set out the timeframes within which patients should expect to have a full assessment, receive a specialty review and be transferred to a ward bed.
If fully implemented, these standards will:
- reduce the time patients are spending in emergency departments
- reduce 12-hour waits and corridor care
- improve quality, safety and patient experience
- reduce anxiety and stress for carers and family members by improving information sharing and involvement in care planning
- ensure greater clarity, ownership and oversight of care
- help reduce unnecessary long stays in hospital and help people return to their homes more quickly
Application and implementation
These standards apply from the moment a patient arrives at hospital but are aimed at what happens after the emergency department has completed their care. They are specifically focused on acute receiving areas (including acute medical units, medical and surgical assessment units, and specialty-specific areas).
While we are not yet counting the amount of time people spend in emergency departments as part of the first 72 hours in hospital, we expect teams to take a common-sense, patient-oriented approach to the application of the standards.
Recognising the considerable variation across services, we are asking hospital teams, led by medical and nursing directors, to determine how to deliver these standards locally, rather than setting this at a national level.
Providers should use the self-assessment tool to evaluate their baseline and identify areas for improvement. The outcome of this self-assessment and associated action plan should be reviewed and endorsed at trust board annually, with progress considered by a sub-committee every 6 months, using local metrics to track progress.
A suite of published resources is mapped to each standard to support local implementation. Nationally, we will begin reporting data on the proportion of patients discharged in the first 72 hours, and on the teams who care for them, to draw attention to this critical period of care.
The standards
Early clinical decision-making
Standard 1: initial and expert assessment
All patients should have a full assessment by a competent clinical decision-maker within 1 hour of referral from the emergency department (ED) or of arrival on the acute receiving area.
Any time-critical medications should be identified and prescribed with a plan for a pharmacy review within 24 hours of admission. This should complement, not duplicate, any previous assessment.
EDs and acute receiving teams should work together to deliver and document a streamlined assessment that builds on a shared clinical narrative.
All admitted patients should be assessed by an expert clinical decision-maker, normally a consultant, within a maximum of 6 hours during the day and 14 hours overnight.
Acute trusts should resource and plan the expert decision-maker workforce to maximise the day’s work by modelling cover for peak times.
Resources
- Six to help fix: acute medicine guidance for improving hospital flow (GIRFT, SAM, NHS IMPACT, July 2023)
- A national audit of acute medical care in the UK (SAMBA, 2024) (SAM, July 2024)
- Seven day services standards (NHS England, February 2022)
- Emergency and acute medical care in over 16s QS174 (NICE, 2018)
- Emergency and acute medical care in over 16s: service delivery and organisation NG94 (NICE, 2018)
- Safety flash: time critical medication (RCEM, November 2023)
Standard 2: additional requirements for specific patient cohorts
Older people with frailty
- Patients aged over 65 presenting to hospital as an emergency should be assessed by a competent clinical decision-maker within 30 minutes of arrival using the Clinical Frailty Scale (CFS) and the 4AT tool for delirium.
- Acute trusts should ensure that older people with frailty (CFS 5+) have access to a senior clinical decision-maker with skills in managing frailty and multiple long-term conditions within 1 hour of referral during the day, or before 10am the next day if overnight.
- All older people with frailty (CFS 5+) should be assessed by an expert clinical decision-maker in managing frailty, normally a consultant, within a maximum of 6 hours during the day and 14 hours overnight.
Patients with long-term conditions
Specialty and/or specialist palliative care teams should be consulted when known patients present to ED with an exacerbation of a long-term condition, where appropriate. Advice should be sought on alternatives to admission including options for accessing support in the community.
Patients receivingpalliative care and end-of-life care
- Acute trusts should ensure patients who are receiving palliative care and end-of-life care or who have advance care plans can be identified to ensure their preferences and wishes are supported.
- A mechanism should also be in place to identify patients who are likely to be in the last phase of life but whose needs are not yet recognised, with referral to their specialty team and/or specialist palliative care where appropriate.
Resources
- FRAIL strategy (NHS England, February 2024)
- Joining the dots: blueprint for preventing and managing frailty in older people (BGS, March 2023)
- Front door frailty: Advice on setting up services (BGS, November 2023)
- Frailty: a framework of core capabilities (Skills for Health, NHS, 2021)
- High Impact Change Model: Improving the timely and effective discharge of people with dementia and delirium into the community
- GIRFT diabetes management
- End of life care in the acute setting (RCP, SAM, 2021)
- Identifying adults who may be approaching the end of their life (NICE guideline – see NG142) (NICE, 2019)
- Uncertain recovery communication guide (RCP, September 2024)
Care navigation
Care on the acute receiving area and continuity of care
Standard 6: continuity of care
Expert clinical decision-makers in acute receiving areas with accountability for individual patients should be job planned and rostered to ensure continuity of care across the first 72 hours and reduce multiple consultant episodes.
This may require annualised job planning across specialties, reconfiguring other commitments and considering part-time and job share arrangements.
Resources
Standard 7: ward rounds and board rounds
After an initial board round, a targeted, consultant-led and multidisciplinary team (MDT)-supported ward round should take place every day for all patients on an acute receiving area, including at weekends and bank holidays.
An additional action-focused MDT meeting/huddle should take place at the end of the ward round.
There should be a second board round and, where clinically indicated, a consultant face-to-face review of high risk/priority patients every day: for example, in enhanced care areas or where this will confirm discharge decisions.
The same principles should apply to patients outlying acute receiving areas within the first 72 hours of admitted care, including in the ED.
Resources
- Modern ward rounds: good practice for multidisciplinary inpatient review (RCP, 2021)
- Six to help fix: acute medicine guidance for improving hospital flow (GIRFT, SAM, NHS IMPACT, July 2023)
- Acute care toolkit 4: delivering a 12-hour, 7-day consultant presence on the acute medical unit (RCP, 2012)
- The benefits of consultant delivered care – 2021 (AMRC, 2021)
Standard 8: clinical huddles and handovers
Clinical huddles and shift handovers must be led by an appropriate senior clinical decision-maker and take place at a designated time and place, with MDT participation from the relevant incoming and outgoing shifts.
Handovers should be consistent and standardised and include the identification of high risk/priority patients and assessment of operational conditions.
Standard 9: specialty response times
Where a patient requires urgent specialty opinion for acuity, clinical decision-making or discharge planning, the specialty senior clinical decision-maker should respond within a maximum of 2 hours of the request.
Patients referred to another specialty by the admitting team should be assessed by a senior clinical decision-maker (with access to an expert clinical decision-maker) within 4 hours during the extended day (as determined by demand and capacity modelling) or before 10am the next day if overnight.
Face-to-face assessment is usually appropriate for patients in hospital.
Standard 10: bed transfers
Patients requiring downstream specialty beds should be transferred within 12 hours of a bed request. If no bed is available, the specialty team should ensure daily review on the acute receiving area.
Specialty teams should know how many patients are waiting for a base ward bed at all times and work to deliver transfer within 12 hours of referral.
Patients should not move from downstream wards or ICU/ITU to acute receiving areas (reverse flow), except where areas support enhanced care or where this is locally agreed policy.
Standard 11: Length of Stay on Acute Receiving Areas
Any individual patient’s length of stay on an acute receiving area should not exceed 72 hours unless sanctioned by the responsible consultant and senior nurse in charge.
Acute receiving area length of stay is expected to be 24–48 hours and should be routinely measured, split by those who are discharged and those who are transferred to downstream wards.
Support services and 7-day working
Standard 12: availability of support services
To ensure equity of provision of care and maximise discharge opportunities, all support services, including therapies, pharmacy and social services, should be available to acute receiving areas during extended-day working hours (for example, 8am to 8pm), 7 days a week.
Input in other areas should be prioritised for patients with an anticipated length of stay of less than 72 hours.
All areas providing acute and emergency non-elective care in the first 72 hours must have the same access to diagnostics, including imaging, in terms of availability and turnaround times, to support decision-making and prevent unnecessary admission.
These services should align to demand across the 7 days. Processes should be in place to prioritise patients who are acutely unwell or for whom discharge is investigation dependent.
Resources
Data recording and metrics
Standard 13: accurate recording of patient care
Patients’ care should be accurately attributed and recorded to the team delivering it.
For example, patients who are referred for care under acute medicine should have Treatment Function Code (TFC) 326 applied regardless of where they are physically located.
If a patient is transferred from an acute receiving area to a specialty ward, the TFC should be changed to reflect the patient’s responsible consultant.
This will enable better understanding of activity, support capacity planning and improve visibility via national reporting, reducing the need to rely on local (ward-based) reporting.
Resources
Our patients, families and carers
Standard 14: patient and carer experience
All patients and carers must be:
- treated with dignity, have their basic needs met – in terms of hydration, access to toilet facilities and food – and be offered adequate pain control when needed
- fully involved in decisions about their care
- kept regularly informed about waiting times and delays to their care
- clear about what they need to achieve to get home, when they should expect to go home and who to contact when they are at home
Board assurance
Standard 15: compliance and governance
The site-level detail of all standards should be reflected in a written internal professional standards document developed following discussion and agreement between hospital teams and owned at executive level.
Acute trusts must assure their board of compliance with the standards. This should be regularly reviewed and robust plans, owned at executive level, put in place to achieve compliance where necessary.
Resources
- Example of internal professional standards: emergency and urgent care pathways (University Hospitals Dorset NHS Foundation Trust, 2022)
- Winter improvement collaborative: urgent and emergency care improvement guide to specialty support to the UEC pathway/internal professional standards (NHS England, April 2023)
Definitions
Acute receiving area
Acute receiving areas are the first point of entry for patients referred to hospital as an acute medical or surgical emergency by primary and community care and those requiring admission from the ED. They are inpatient facilities that are open 24 hours a day, 7 days a week.
This definition of acute receiving areas includes acute medical units, medical and surgical assessment units and any other specialty-based facility that takes patients directly from the community and the ED.
Acute receiving areas provide rapid definitive assessment, investigation and treatment for patients.
Tiers of clinician
All members of the MDT who are patient facing:
- Tier 1: competent clinical decision-makers: clinicians who can perform an initial assessment and treatment of a patient.
- Tier 2: senior clinical decision-makers: clinicians who can collate relevant patient information, make a diagnosis and determine a management plan that includes specific investigations and treatment, usually working at medical registrar level.
- Tier 3: expert clinical decision-makers: clinicians who can develop a comprehensive management plan, have overall responsibility for patient care and have extensive experience in managing acute patients within their specialty; usually a consultant doctor but can include specialist and SAS doctors.
Publication reference: PRN02076