If you have worked an ED shift over the last year, you will almost certainly have faced this dilemma: an ambulance crew arrives with an elderly, frail, confused patient who needs a Majors space. But with no room available, and increasing pressure to release the crew, a trade-off becomes inevitable. What happens next currently defines the quality and safety landscape of emergency care – and reveals the tussle between strategic and tactical priorities when the system is overwhelmed.
NHS England’s latest corridor care guidance (published 11 December 2025) provides a timely update. Replacing previous recommendations, it drops the euphemistic “temporary escalation space” terminology for plain “corridor care”, and commits to “total eradication” as a “clinical and moral imperative.”
This guideline’s release aligns with existing work to eradicate ambulance ramping. It has real implications for urgent and emergency care (UEC) practice, escalation and accountability. I read the full document carefully to write this post, but would recommend you do the same in case I missed something important. As I wrote from an UEC perspective, I have not included an inpatient perspective.
🔗 Principles for providing patient care in corridors. NHS England; 2025 Dec 11.
What this guidance gets right
Honest problem recognition: the guidance explicitly acknowledges that corridor care produces worse clinical outcomes and poorer patient experiences. It specifically references evidence calling for corridor care eradication from the Royal College of Nursing, Royal College of Emergency Medicine and Royal College of Physicians.
Clear exclusions: no fewer than ten patient types are described as “never acceptable” for the corridor. These are children, anyone with NEWS2 >5, severely frail patients (presumably Clinical Frailty Scale >6), those with confusion/ delirium/ dementia, mental health patients, those with learning disabilities/ neurodivergence/ autism, those with physical disabilities, infectious patients, pregnant/ breastfeeding patients, and end of life patients.
The list is described as “not exhaustive” and requires individual equality impact assessment. The guidance goes on to describe further considerations and requirements which essentially closes the safety, care and dignity gap between designated care spaces and corridor spaces. It is worth having a look at the detail.
In essence, these ten exclusions and further considerations draw firm red lines, providing legitimate clinical grounds to refuse inappropriate corridor placements. This matters when an ambulance crew arrives with an elderly, frail, confused patient who needs a Majors space: the corridor can no longer be the default when the crew must be released.
Board-level accountability: in a significant shift, guidance now explicitly requires “active involvement” from trust boards and quality committees – not passive oversight. It requires that executive leadership be “visible and actively support decisions,” recommends daily situation reports, and warns of potential Care Quality Commission (CQC) registration breaches.
This matters because corridor care is widely recognised as the result of strategic rather than tactical failure: inadequate capacity, poor discharge pathways, insufficient system coordination, etc. These are system-level problems that require system-level solutions.
System-wide approach: the guidance also requires “all healthcare partners” to work collaboratively. Although this may seem a given, ongoing corridor care suggests this is harder than it ought to be. The guidance asks systems to adopt risk-sharing approaches through escalation, de-escalation and dynamic risk assessment. It references the Emergency Care Improvement Support Team‘s frameworks “to support decision-making that balances patient and organisational risk across a system in extremis.”
The Operational Pressures Escalation Levels (OPEL) framework, an underutilised tool referenced in the guidance, is probably best suited to dynamically define “extremis” – specifically the Acute OPEL framework (see example below). Updated in real-time, its simple Black/ Red/ Amber/ Green ratings reveal bottlenecks as these present in the system. This framework should probably be accessible to senior stakeholders, including executives, as a bare minimum.
Can you identify the bottlenecks in the example below?
Infection Prevention and Control (IPC): the guidance asks that IPC be embedded throughout as a critical safety consideration, acknowledging corridor care “limits ability to adhere to fundamental IPC practices.” This can be a real challenge as most corridors don’t come with sinks. We commonly observe poor hand hygiene between corridor patients on CQC inspections.
Staff protection: for staff, the guidance acknowledges the moral and physical challenges associated with crowding. It requires Freedom to Speak Up pathways, debrief opportunities and protection from routine corridor shift allocation. For our nursing readers, it is worth having a look at the additional detail.
Where this guidance falls short
Although the publication introduces the strictest corridor guidance to date, some challenges remain.
A fundamental contradiction: while declaring corridor care unacceptable, the guidance goes on to provide about 10 pages of detailed operational guidance. It stops short of crucial implementation definitions, leaving these up to individual systems. For example, occasional extremis is inevitable given the unpredictable nature of UEC. But what is occasional? A day, a week, a month? And is there a difference between a 15-minute corridor pause (for an imminent admission), and hours and hours of protracted corridor care? Leaving all this for each system to decide risks obscuring what the guidance aims to eliminate.
The maths is conditional: the listed exclusions apply to a substantial portion of patients in crowded EDs. But the guidance doesn’t provide a clear framework for what happens when excluded patients present, appropriate spaces are unavailable, and ambulances continue to arrive. This all-too-common situation places the onus entirely on a variable escalation and strategic response, risking flow being directed back to the ambulance ramp.
Missing accountability mechanisms: although the guidance requires the board’s “active involvement”, it defines no consequences for failure, no triggers for mandatory strategic response, and no thresholds where boards are expected to intervene. Boards can satisfy requirements through compliance theatre: the board notes this month’s corridor update, without driving actual change. This is a pattern I have repeatedly observed in my CQC inspection role.
The harm reporting paradox: the guidance requires harm measurement through incident reports. But in (often understaffed) EDs, staff will have little time to complete submissions. Harm is likely underreported precisely because of the conditions creating it – a fundamental flaw in the measurement framework. There is also a very real risk that reported harm is seen and treated as a tactical rather than a strategic failure (blame shifting)
It seems logical that when corridor care happens persistently, it should probably appear on the corporate risk register as strategic risk, rather than the ED risk register as tactical risk. But this is not explicitly stated.
The unacknowledged resource gap: perhaps the most significant limitation is what the guidance doesn’t say. It commits to ‘total eradication’ of corridor care while committing no additional resources to achieve this. The capacity deficit that creates corridor care (inadequate UEC footprint, insufficient inpatient beds, delayed discharges and social care crisis) is barely acknowledged. Without investment in these areas, the guidance essentially asks organisations to solve a resource problem through better governance alone.
Good governance can optimise existing resources, but it cannot create capacity that doesn’t exist.
The HSSIB investigation (published 8 January 2026) confirms these gaps, finding limited reported patient safety incidents where temporary care environments (corridor care) were recorded as factors, inconsistent data collection, and variation in how trusts define and report corridor care use. The investigation’s Safety Observation calls for NHS regional and national organisations to enhance understanding through agreed definitions and better data collection – the infrastructure this guidance does not provide.
What this means for practice
The challenge this guidance presents is the same as what it aims to resolve: in a crowded system, where do patients go if not into the corridor? The last thing anyone wants is for patients to end up back on the ambulance ramp. There is a very real risk that this guidance can result in just that.
Exclusions as leverage: tactically, when an excluded patient arrives and there is no appropriate space, decision-making should rest with a senior ED decision-maker (doctor and/or nurse). Exclusions provide senior ED decision-makers with nationally recognised criteria to negotiate safer, patient-centred placement.
This probably means wider adoption of a front door Rapid Assessment and Treatment (RAT) model. A separately resourced and ringfenced RAT area can support early opportunity for frontloading treatment and streaming safely to areas other than Majors or the corridor. To better identify exclusions, EDs should probably get better at early recording of the Clinical Frailty Scale and 4 A’s test for delirium screening too.
Revisit strategic escalation: the guidance is clear that strategic, board-level engagement is essential. Good escalation design probably needs to be iterative, with regular review cycles (I’d say at least weekly) and include all stakeholders – this framework only works if relationships exist before a crisis. During CQC inspections, I often encounter senior ED clinical and nursing leads, as well as ambulance service leads, reporting exclusion from escalation design.
Simplify real-time data: data don’t have to be complicated. The %Majors and Resus Occupancy metric from the Acute OPEL framework example above is exactly what it says. A 150% occupancy means ED is operating over its designated Majors and Resus capacity, in other words: in the corridor. Sadly some trusts game this figure by including ED corridor spaces, along with Majors and Resus spaces, in the denominator (artificially reducing their OPEL score). Although implied, the guidance does not explicitly reject this practice.
We’re currently trialling the Emergency Department Work Index (EDWIn) at my local ED. A simple but validated tool that can provide an objective ED crowding status. Similar to the Acute OPEL framework, its Red/ Amber/ Green ratings reveal bottlenecks in ED in real-time. An ED OPEL framework so to speak. We’ve adapted it slightly by designating a Black rating when a negative EDWIn score results from more Admitted patients in beds than Staffed ED beds – arguably a very severe risk, especially in the corridor.
Can you identify the bottlenecks in the example below?
Strategic governance: as already mentioned, incident reporting will substantially under-report harm when systems are most pressured. Similarly, corridor definitions and effective ways to record it will vary widely among acute sites. There are better and simpler metrics, that are already consistently collected, largely unaffected by variation, and do not depend on overwhelmed staff to complete incident forms.
I tend to look at the following two metrics prior to a CQC inspection. These rarely fail to predict what I’ll find in the ED’s corridors:
- Delay Related Harm (DRH): DRH is a calculated metric utilising the established link between longer ED stays and higher 30-day mortality. The GIRFT calculation is 1 in 72 ED patients delayed >8 hours for the last year. Use of the ED corridor becomes very likely once DRH >50, as this translates to >10 patients delayed daily for the last year (=50×72÷365). As a mortality metric, it also reflects very strongly on an acute site’s responsiveness to serious harm.
- Census at midnight versus midday: census as in the total number of patients in ED at a set time. Comparing midnight (when census should be lower) and midday (when census should be higher) provide a reflection of an acute site’s strategic tolerance to ED crowding. Essentially, if census at midnight is the same, or higher than at midday, strategic boarding overnight in ED (including the corridor) is a given.
Summary
This guidance represents meaningful progress. It names corridor care clearly as unacceptable, draws firm red lines protecting vulnerable patients, and explicitly assigns accountability to boards rather than allowing it to rest with frontline staff. The OPEL framework integration and requirement for system-wide risk-sharing recognise this as a strategic problem requiring a strategic solution.
The practical tools this creates – exclusion criteria as leverage, requirement for strategic escalation, focus on meaningful metrics like OPEL, EDWIn, DRH and census – give front-door clinicians, nurses, and middle managers frameworks to push back. They can demand appropriate governance and challenge normalisation of corridor care.
However, the guidance’s most significant gap is what it doesn’t address. Eradicating corridor care requires investment in UEC capacity, inpatient beds, discharge pathways and social care. The guidance asks organisations to solve resource deficits through governance alone – an impossible task that risks shifting patients from corridors back to ambulance ramps.
Whether the guidance achieves its aims depends on board engagement, system maturity and honest acknowledgement that good governance optimises existing capacity but cannot create capacity that doesn’t exist.
Use the tools this guidance provides to create leverage. Build the relationships, protocols and measurement frameworks your system needs. Advocate clearly for the investment required to actually eliminate corridor care, not just better manage its harms.
The guidance is imperfect, but it is progress. Work with what it provides while pushing for what we truly need: adequate capacity to deliver safer, dignified care without impossible trade-offs.
How should active involvement from your board actually look like? How should your trust measure corridor care when definitions vary so widely? And how should your trust define the threshold between “extremis” and normalisation of corridor care? Tell us in the comments.
