It is 02:00. ED has 22 patients waiting for medical beds, 6 breaching the 12-hour standard. The site manager is asking you to make decisions. How do you approach this?

Question

You are the sole medical registrar on a 600-bed DGH. ED has 22 medical referrals waiting, 6 patients have breached 12 hours, two are sitting in the corridor. The site manager wants to know who can be moved, discharged or boarded. The on-call consultant is at home.

Accepted Answer

I would frame this using **SPIES**.

**Seek information** — I would ask the ED registrar for a structured SBAR on every waiting patient: NEWS2, working diagnosis, outstanding investigations, and any deteriorating trend. I would walk the department personally to lay eyes on the sickest patients rather than rely solely on the list.

**Patient safety** — my priority is identifying patients at imminent risk: NEWS2 ≥7, suspected sepsis within the one-hour bundle, ACS awaiting troponin, acute stroke, upper GI bleed. These are seen, stabilised and admitted to monitored areas first, even if it means using an escalation bay.

**Initiative** — I would run a rapid board round with the bed manager and night nurse coordinators: identify criteria-led discharges (TTOs, transport), patients suitable for SDEC pathways in the morning, and outliers who can safely move to non-medical wards with a clear medical plan.

**Escalate** — this is a hospital-wide safety issue, not a single-registrar problem. I would phone the on-call medical consultant to share situational awareness, contact the executive on-call via the site manager, and consider activating OPEL escalation. I would not accept an unsafe workload silently.

**Support** — I would brief the junior team clearly, allocate tasks (clerking versus reviews), and ensure the F1/F2 know they can interrupt me for any deteriorating patient. I would document the escalation, risk assessment and decisions contemporaneously, and complete a **Datix** the next morning for the system failure.

Overnight bed crisis — packed ED, no beds, you are the medical registrar

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