NHS Information Authority

Data Standards Programme

Streaming

The practice of streaming involves the separation of cases within A&E Departments to allocate resources effectively. Simple streaming involves the separation of cases into 3 streams. The practice of simple streaming was expected to have been introduced into all A&E Departments in 2002: http://www.doh.gov.uk/emergencycare/streamingguidance.pdf and http://www.doh.gov.uk/emergencycare/reformingemergencycare.pdf .

The practice of full streaming is expected to be in place by 2004 (full streaming will involve the separation of cases into 5 streams).

This DSCN makes necessary changes to the NHS Data Dictionary Version.2, as a result of the streaming of ACCIDENT AND EMERGENCY ATTENDANCES being introduced into all ACCIDENT AND EMERGENCY DEPARTMENTS.

Triage

Other changes have also been made to A&E triage definitions in the NHS Data Dictionary Version.2 as follows:

(a) The attribute A+E INITIAL ASSESSMENT TRIAGE CATEGORY was introduced to support national triage categories by DSCN 25/2001. However this attribute was essentially the same as an existing attribute A+E PATIENT PRIORITY, except that it specified national triage codes, whereas A+E PATIENTPRIORITY specified local codes.

A+E PATIENT PRIORITY has therefore been deleted, and A+E INITIALASSESSMENT TRIAGE CATEGORY has been made mandatory in its place.

Note that this change has no effect on the A&E CDS message, since it does not currently carry the triage category.

(b) The Patient's Charter requirement for A&E stated that patients requiring immediate treatment would be treated immediately, without an initial assessment. This was changed in 'Your Guide to the NHS' to a requirement that all patients should be given an initial assessment within 15 minutes of their arrival in A&E, and told how quickly they would be treated. The attribute and data item note A+E INITIAL ASSESSMENT TIME have been updated to reflect the change in requirement.

(c) The initial assessment/triage requirement relates to A&E first attendances, and unplanned follow-up attendances, but not to planned follow-up attendances. A comment has been added to A+E INITIAL ASSESSMENT TIME and A+E INITIAL ASSESSMENT TRIAGE CATEGORY in the ACCIDENT AND EMERGENCY ATTENDANCE to make this clear. A comment has also been added to A+E INITIAL ASSESSMENT TIME in the Accident and Emergency Attendance CDS type.

(d) In some circumstances an A&E patient may decide to leave the A&E Department before being seen for treatment. The opportunity has been taken to make the attribute A+E TIME SEEN FOR TREATMENT optional to allow for this event.

ACCIDENT AND EMERGENCY ATTENDANCE

An individual visit by one PATIENT to an ACCIDENT AND EMERGENCY DEPARTMENT to receive treatment from the accident and emergency service.

Note that the accident and emergency service may be provided by staff from other SPECIALTIES.

During an ACCIDENT AND EMERGENCY ATTENDANCE the PATIENT may temporarily leave the ACCIDENT AND EMERGENCY DEPARTMENT, e.g. for an X-ray, whilst still under the responsibility of the ACCIDENT AND EMERGENCY DEPARTMENT.

ACCIDENT AND EMERGENCY ATTENDANCES may be as a result of a request from a GENERAL PRACTITIONER for help with diagnosis or treatment.

Attendances at OUT-PATIENT CLINICS run in the ACCIDENT AND EMERGENCY DEPARTMENT should not be recorded as ACCIDENT AND EMERGENCY ATTENDANCES but should be recorded as OUT-PATIENT ATTENDANCE CONSULTANT or CLINIC ATTENDANCE NON-CONSULTANT depending upon the type of OUT-PATIENT CLINIC attended.

Any facility set up to receive and treat emergency cases is regarded as an ACCIDENT AND EMERGENCY DEPARTMENT for this purpose.

ACCIDENT AND EMERGENCY ATTENDANCES include both first and follow-up attendances. A follow-up attendance is any subsequent ACCIDENT AND EMERGENCY ATTENDANCE at the same ACCIDENT AND EMERGENCY DEPARTMENT for the same incident.

Each ACCIDENT AND EMERGENCY ATTENDANCE, which is a first attendance or an unplanned follow-up attendance, should be assigned an A+E STREAM.

This class is also known by these names:

Context	Alias
plural	ACCIDENT AND EMERGENCY ATTENDANCES

ACCIDENT AND EMERGENCY ATTENDANCE

Attributes of this Class are:

K		A+E ATTENDANCE NUMBER
		A+E ARRIVAL MODE
		A+E ATTENDANCE CATEGORY
		A+E ATTENDANCE CONCLUSION TIME
		A+E ATTENDANCE DISPOSAL
		A+E DEPARTURE TIME
	O	A+E INITIAL ASSESSMENT TIME
		first attendances and unplanned follow-up attendances
	O	A+E INITIAL ASSESSMENT TRIAGE CATEGORY
		A+E PATIENT PRIORITY
		first attendances and unplanned follow-up attendances
		A+E STAFF MEMBER CODE
		person principally responsible for care
		A+E TIME SEEN FOR TREATMENT
	O	A+E STREAM
		if first attendance or unplanned follow-up attendance
	O	A+E TIME SEEN FOR TREATMENT
		ARRIVAL DATE
		ARRIVAL TIME

A+E INITIAL ASSESSMENT TIME

The time a PATIENT not needing immediate treatment, is assessed by medical or nursing staff in an ACCIDENT AND EMERGENCY DEPARTMENT to determine priority for treatment. The time a PATIENT is assessed by medical or nursing staff in an ACCIDENT AND EMERGENCY DEPARTMENT to determine priority for treatment. The assessment should be conducted by medical or nursing staff who have received appropriate training in triage.

Patients requiring immediate treatment will be treated immediately; there will be no assessment time recorded. PATIENTS will be assessed within 15 minutes of their arrival in the A&E Department.

This attribute is also known by these names:

Context	Alias
plural	A+E INITIAL ASSESSMENT TIMES

A+E INITIAL ASSESSMENT TRIAGE CATEGORY

The category assigned to a PATIENT as a result of an initial assessment by medical or nursing staff in an ACCIDENT AND EMERGENCY DEPARTMENT. The triage category is used to determine the PATIENT's priority for treatment. The triage category is used to determine the PATIENT's priority for treatment, and to inform the PATIENT of their waiting time.

National Codes:

1.	Immediate resuscitation. Patients in need of immediate treatment for preservation of life.
2.	Very urgent. Seriously ill or injured patients whose lives are not in immediate danger.
3.	Urgent. Patients with serious problems, but apparently stable condition.
4.	Standard. Standard A&E cases without immediate danger or distress.
5.	Non-urgent. Patients whose conditions are not true accidents or emergencies.

References:
Triage and casemix accident and emergency medicine. Marrow, J. European Journal of Emergency Medicine 1998; 5: 53-58

This attribute is also known by these names:

Context	Alias
plural	A+E INITIAL ASSESSMENT TRIAGE CATEGORIES

A+E PATIENT PRIORITY

A+E STREAM

A+E STREAM

This records the streaming classification assigned to an ACCIDENT AND EMERGENCY ATTENDANCE, within an ACCIDENT AND EMERGENCY DEPARTMENT. Streaming is a system whereby PATIENTS are allocated to different flows according to their needs. These flows are individually staffed and continue to function whatever the pressures in other streams. Within any stream, at any one time, there may be PATIENTS with different A+E INITIAL ASSESSMENT TRIAGE CATEGORY. An ACCIDENT AND EMERGENCY DEPARTMENT will have either simple streaming or full streaming in place and will use the appropriate classification.

Classifications:

	Simple streaming
a.	Minor case
b.	Major case
c.	Resuscitation
	Full streaming
d.	Self Care (those patients who attend A&E and do not need investigation or hospital treatment. After a thorough assessment the patients are given appropriate advice on self-care and are discharged. They will also be advised on indications for further contact)
e.	Primary Care (those patients with conditions who could be treated by a primary care team),
f.	Minor Injury and Moderate Illness (Ambulatory care) (patients who need some investigation or treatment for an injury but are unlikely to be admitted),
g.	Clinical Assessment (Majors) (those patients needing a more thorough clinical assessment and may need a series of investigations or observation before definitive treatment can be determined.)
h.	Resuscitation (patients with serious illness or injury that need emergency assessment and care.)

References:
Reforming Emergency Care First Steps to a New Approach:
http://www.doh.gov.uk/emergencycare/reformingemergencycare.pdf
Reforming Emergency Care 2001-2 & 2002-3, Streaming in accident and emergency departments:
http://www.doh.gov.uk/emergencycare/streamingguidance.pdf

This attribute is also known by these names:

Context	Alias
plural	A+E STREAMS

A+E INITIAL ASSESSMENT TIME

Format/length:	n4
HES item:
National Codes:
Default Codes:

Notes:
The assessment may be a formal triage or otherwise.

PATIENTS requiring immediate treatment will be treated immediately; there will be no assessment time recorded. PATIENTS should be assigned a triage category using the national codes.

This data element is also known by these names:

Context	Alias
plural	A+E INITIAL ASSESSMENT TIMES

ACCIDENT AND EMERGENCY ATTENDANCE CDS TYPE

COMMISSIONING DATA SET (CDS)

ACCIDENT AND EMERGENCY ATTENDANCE CDS TYPE

The Accident and Emergency Commissioning Data Set Type carries the data for an Accident and Emergency Attendance Episode. The column headed Opt (Optionality) shows whether the Data item is Mandatory M, Optional O or Must Not Be Used *.
Opt	CDS Data Item	U/A
Person Group (Patient): To carry the personal details of the Patient. One occurrence of this Group is permitted.
M	LOCAL PATIENT IDENTIFIER
M	ORGANISATION CODE (LOCAL PATIENT IDENTIFIER)
M	ORGANISATION CODE TYPE
O	NHS NUMBER
M	BIRTH DATE
O	CARER SUPPORT INDICATOR
*	ETHNIC CATEGORY
*	MARITAL STATUS (psychiatric patients only)
M	NHS NUMBER STATUS INDICATOR
M	SEX
O	NAME FORMAT CODE
O	PATIENT NAME
O	ADDRESS FORMAT CODE
O	PATIENT USUAL ADDRESS
M	POSTCODE OF USUAL ADDRESS
M	ORGANISATION CODE (PCT OF RESIDENCE)
M	ORGANISATION CODE TYPE

Note: For reasons of confidentiality, the patient's preferred name and address (not including POSTCODE OF USUAL ADDRESS) must not be carried where a valid NHS Number is present.

(HCA) GP Registration: To carry the details of the Patient's Registered GMP. One occurrence of this Group is permitted.
M	GMP (CODE OF REGISTERED OR REFERRING GMP)
O	CODE OF GP PRACTICE (REGISTERED GMP)
O	ORGANISATION CODE TYPE
(HCA) Attendance Occurrence Activity Characteristics: To carry the details of the Accident and Emergency attendance.
M	A+E ATTENDANCE NUMBER
M	A+E ARRIVAL MODE
M	A+E ATTENDANCE CATEGORY
M	A+E ATTENDANCE DISPOSAL
M	A+E INCIDENT LOCATION TYPE
M	A+E PATIENT GROUP
M	SOURCE OF REFERRAL FOR A+E
M	ARRIVAL DATE
M	A+E ATTENDANCE CONCLUSION TIME
M	A+E DEPARTURE TIME
M	A+E INITIAL ASSESSMENT TIME
M	A+E INITIAL ASSESSMENT TIME (first and unplanned follow-up attendances only)
M	A+E TIME SEEN FOR TREATMENT
M	ARRIVAL TIME
(HCA) Attendance Occurrence - Service Agreement Details: To carry the details of the Service Agreement for the Accident and Emergency Attendance.
M	COMMISSIONING SERIAL NUMBER
O	NHS SERVICE AGREEMENT LINE NUMBER
O	PROVIDER REFERENCE NUMBER
O	COMMISSIONER REFERENCE NUMBER
M	ORGANISATION CODE (CODE OF PROVIDER)
M	ORGANISATION CODE TYPE
M	ORGANISATION CODE (CODE OF COMMISSIONER)
M	ORGANISATION CODE TYPE
(HCA) Attendance Occurrence Person Group (Consultant): To carry the details of the responsible Clinician. One occurrence of this Group is permitted.
M	A+E STAFF MEMBER CODE
(HCA) Attendance Occurrence - Clinical Information Group (Diagnosis Occurrence): To carry the details of the coded Diagnosis Scheme and the Diagnoses. Up to 2 occurrences of this Group are permitted.
M	DIAGNOSIS SCHEME IN USE
M	ACCIDENT AND EMERGENCY DIAGNOSIS - FIRST
M	ACCIDENT AND EMERGENCY DIAGNOSIS - SECOND
(HCA) Attendance Occurrence - Clinical Information Group (Investigation Occurrence): To carry the details of the coded Investigation Activities undertaken. Up to 2 occurrences of this Group are permitted.
M	INVESTIGATION SCHEME IN USE
M	ACCIDENT AND EMERGENCY INVESTIGATION - FIRST
M	ACCIDENT AND EMERGENCY INVESTIGATION - SECOND
(HCA) Attendance Occurrence - Clinical Information Group (Treatment Occurrence): To carry the details of the coded Treatment Activities undertaken. Up to 2 occurrences of this Group are permitted.
M	PROCEDURE SCHEME IN USE
M	ACCIDENT AND EMERGENCY TREATMENT - FIRST
M	ACCIDENT AND EMERGENCY TREATMENT - SECOND
(HCA) Healthcare Resource Group Activity - Activity Characteristics: To carry the details of the Healthcare Resource Group and will be mandatory from 01/10/2001. Each CDS may contain only a single occurrence of this Group.
M	HEALTHCARE RESOURCE GROUP CODE
M	HEALTHCARE RESOURCE GROUP CODE-VERSION NUMBER

Note: In addition, Accident and Emergency reference costs are mandated and collected via a direct, non-NWCS data flow between Providers and the Department of Health.

(HCA) Healthcare Resource Group Activity - Clinical Activity Group: To carry the details of the HRG Dominant Grouping Variable - Procedure. Note that this will not apply when no operation was carried out. In this case, the segment referring to HRG Dominant Grouping Variable - Procedure should be omitted. Only one Procedure either OPCS or READ may be specified
O	PROCEDURE SCHEME IN USE
O	HRG DOMINANT GROUPING VARIABLE-PROCEDURE

Please address enquiries about this DSCN to:-
Data Standards Team
NHS Information Authority
Aqueous II
Aston Cross
Rocky Lane
Birmingham
B6 5RQ

Tel: 0121 333 0333