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Author: Nikki Abela / Editor: Charlotte Davies / Codes: SLO11, SLO12, SLO9 / Published: 13/10/2020

Since February 2020, the UK has seen over 145,000 hospital admissions with COVID-19 and over 42,000 deaths. To say this pandemic has reeked havoc on the NHS is an understatement.

But as we enter the second phase of this pandemic, and before it likely enters the more endemic phase, we are presented with an opportunity to stop and reflect on what we have learned, to make our systems better.

The initial phase has given us some experience on how to tackle this problem and if we stop and learn, we may develop some immunity to better fight the second wave and future outbreaks.

Space, Staff and Flow

As soon as social distancing measures were put into place, it became evident that space was a necessity and not a commodity.

The way we utilise that space, in terms of using rooms with doors rather than cubicles with curtains, and dividing the department into lower risk and higher risk areas is important to avoid nosocomial spread and protect staff from contracting the disease.

Crowding kills. We knew this before COVID. Adding a contagious, deadly respiratory disease into the mix can only make crowding more dangerous.

In the first wave most hospitals did not have crowding because of the unprecedented drop in presentations due to other causes. Unfortunately, the second wave, which is coinciding with the advent of winter pressures will not have the luxury of empty hospital beds and corridors.

RCEM have developed guidelines on what to do if your ED is becoming crowded here and should be used far and wide to avoid this issue. A certain amount of innovation is needed to come up with measures to avoid crowded EDs. Examples of solutions include reverse queuing, boarding, virtual clinics, same day emergency care and 111 first.

Unfortunately, if our spaces are crowded, we risk departments becoming hubs of nosocomial infection for patients, relatives and staff and provision of adequate PPE is paramount.


When the pandemic first started some departments were lucky enough to have other specialties re-deployed to the ED, and some departments had inpatient specialities take ownership of their patients from the front door.

This need hasn’t changed with the second wave and there needs to be a trust-wide response to patients being seen by the right person, at the right place and the right time.

This may also mean working with our primary care providers to create direct pathways of care between them and the inpatient specialties and also encourage/support them to see patients in the community, even virtually.


Of course, it’s all well and good to come up with pathways for care, but if the patients or the staff do not know about them, then they will still present to the ED for treatment there. Therefore it is important to teach and update our staff and our patients that there are different ways to access care and the ED may not necessarily be the best place for it.

This can be done for example, through public health messages on social media platforms, working with inpatient teams to create appropriate information leaflets with directions on how to access their help, even outside of normal working hours.

Keeping staff up to date is another issue altogether and the information overload that accompanied COVID definitely had a negative effect on wellbeing and engagement.

With crowded classrooms a thing of the past, we now need to look towards virtual ways of learning and communication. At RCEMLearning, this is not something new to us. Our COVID tab is regularly updated and we have continued to produce our monthly CPD podcasts and created an induction module which was used during the national changeover day in August (if your hospital hasn’t signed up, they can do so here), as well as advising on virtual education methodology, and even planning some teaching for you! We also made some of our relevant learning modules open access for everyone via the COVID tab. RCEM has also created a COVID communication page, journal club, and CPD podcasts.

To keep your finger on the pulse of what is going on, now is the time to set up a twitter account and use your social media time to your benefit. Create your own virtual teams for teaching in handover using programs like Whatsapp, and get used to online teaching through Teams or Zoom.

Be mindful though, that this can mean a 24/7 working day so find time to switch off and engage in a healthy relationship with technology.

Be Kind

Civility saves lives, we know this, but in the midst of a pandemic, being kind has never been so important.

Strive to promote wellness. If you don’t know where to start, try here and here.

This is such a difficult time for everyone. For patients, deprived of relatives from the front door at their most vulnerable time, being treated by staff whose smiles are hidden it must be so difficult. Empathise and be kind. Think about ways to make it less scary like drawing funny faces on masks when dealing with children or using designated tablets for patients to be able to video call families.

For staff and yourself, be mindful that a one size fits all approach does not work. What could be fixed with a yoga session for one person, may need a debrief and vigorous run for another.

Andy Tagg said it best here:


We should not wait for illness to strive for wellness as that is a system that is inherently flawed. Especially at a time rotes are struggling due to quarantine and isolation needs, we really need to look after each other to make our practise sustainable.

However, if recent events have left you feeling broken, please take the time to read these excellent blogs by Liz Crowe.

This is a difficult time for everyone. No one thought this was going to happen this time last year, but we are all in it together and we need to be kind to one another, and to ourselves, to not give COVID a fighting chance.

Further Links and Reading

For more links on COVID please visit our RCEMLearning COVID page or blog, or the RCEM COVID page.

For more links on capacity and flow:
RCEM Crowding after COVID presentation
RCEM Crowding after COVID guidance
RCEM Crowding toolkit
RCEMLearning Crowding podcast
RCEMLearning New Years Quiz about Crowding
RCEMLearning creating flow in the ED
RCEMLearning validating the ICMED
RCEMLearning creating flow in ED & hospital targets
RCEMLearning exit block

NHSImprovement capacity and flow guidelines
The patients you don’t see – a flow video