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Urgent Care

Patient Safety Commissioner-Initiatives: Improving patient safety at the Emergency Department front door

Riccardo Garavani  | 26th February 2024

The NHS is currently facing a number of unprecedented challenges and one of these is maintaining the safety of patients at the front door of A&E.

Difficulty accessing community and GP care, rising numbers of emergency attendances and an ageing population with complex health needs often result in demand outstripping capacity in Emergency Departments (ED), increasing the challenge of maintaining safety.

When emergency departments are overwhelmed, flow becomes blocked, queues start to back up and long waits occur, leading to increased risk of patient harm.

At the front door of the ED patients can often queue and wait for 1-2 hours for triage. This undifferentiated queue holds considerable risk as the clinical team do not have any visibility of clinical need, who should be treated quickly, and who is safe to wait.

eTriage is an automated self-check in and triage platform developed by NHS emergency clinicians to address this. Walk-in patients check in on a tablet in the ED waiting room, enter their demographic data to validate their identity through the NHS number look up. The system collects Emergency Care Data Set information with a short, focused triage history using a clinical algorithm of over 10,000 questions, with inbuilt flagging managed through a clinical governance process. Patients are automatically categorised into Priority 1-5 acuity criteria and their eTriage pushed instantly into the Hospitals Electronic Patient Record system.

Within six minutes of arrival, patients are checked in and triaged and the clinical team know exactly who and what acuity level is in their waiting room.

Over the last five years just under 900k patients have been safely triaged this way at 11 ED/UTCs and a further 10 sites are going in the next three months.

There are a number of benefits digital check in and triage brings to the EDs:

  • Improved Patient Flow – through earlier identification of unwell patients and highlighting those suitable for early redirection to more appropriate services
  • Improved Patient Safety – elimination of pre-registration queues, clinical visibility of the waiting room within six minutes of arrival, red flagging of individuals with high risk presentations moving them to the top of the triage list as P1, improved time to initial assessment, treatment and analgesia
  • Freeing up resources – through reduced check-in times and triage durations.

eConsult has an internal team of clinicians that work with each ED to help improve front door safety including:

  • redesigning patient triage and assessment pathways
  • training and standardisation of triage process
  • incident reporting and response
  • under/over triages and agreed levels of error
  • a robust and strict clinical governance process
  • pathways that reflect latest clinical guidance, with monthly review of NICE updates and their relevance
  • DCB0129/0160 and regulatory MHRA compliance
  • specific accessibility training to ensure that patients who are not suitable for eTriage do not have their care delayed.

eTriage has picked up serious life-threatening conditions within minutes of arrival, such as Subarachnoid haemorrhage in 24-year-old male, a heart attack in a 63 year old male in the waiting room, a stroke in a 77 year old female patient.

A recent paper published by the lead academic ED consultant at University Hospitals NHS Trust showed sensitivity for prediction of high acuity outcomes was 88.5% for eTriage and 53.8% for nurse Manchester Triage System. The specificity for predicting low risk patients was 88.5% for eTriage and 80.6% for nurse MTS. See

There is currently no standardized acceptable triage accuracy rate, although the American College of Surgeons has suggested an acceptable rate of undertriage (those patients who are triaged incorrectly) for trauma patients of 5% ( eTriage accuracy falls within this level. eTriage delivers a standardisation of accuracy to the triage process.

We are now planning:

1. Virtual Observations to develop technology that can automatically capture a patient’s vital signs along with their triage history, providing a NEWS2 score along with the eTriage priority giving an even more accurate picture of a patient’s presenting complaint.

2. To identify patients suitable for particular treatment pathways such as same day emergency care or early pregnancy assessment to get patients to the right clinician as quickly as possible.

Dr Mark Harmon is an emergency department doctor and the Chief Strategy Officer at eConsult Health.