Urgent and emergency care: best practice

This CQC report offers practical examples of how leading emergency departments are meeting the challenges of managing capacity and demand, and managing risks to patient safety .

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This report from the Care Quality Commission details the good practice identified following the Commission’s work with consultants, clinical leads, senior nursing staff and managers from leading emergency departments in 17 NHS acute trusts.

This resource identifies:

  • strategies staff use to meet the challenge of increased demand and manage risks to patient safety
  • positive actions to address potential safety risks and to manage increased demand better
  • how working with others can manage patient flow and ensure patients get the care they need
  • that rising demand pressures in emergency departments are an issue for the whole hospital and local health economy.

Full report: Sharing best practice from clinical leaders in emergency departments

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Elevated mortality among weekend hospital admissions is not associated with adoption of seven day clinical standards

Meacock R, Sutton M. Elevated mortality among weekend hospital admissions is not associated with adoption of seven day clinical standards
Emerg Med J Published Online First: 08 November 2017. doi: 10.1136/emermed-2017-206740

Introduction Patients admitted to hospital in an emergency at weekends have been found to experience higher mortality rates than those admitted during the week. The National Health Service (NHS) in England has introduced four priority clinical standards for emergency hospital care with the objective of reducing deaths associated with this ‘weekend effect’. This study aimed to determine whether adoption of these clinical standards is associated with the extent to which weekend mortality is elevated.

Methods We used publicly available data on performance against the four priority clinical standards in 2015 and estimates of Trusts’ weekend effects between 2013/2014 and 2015/2016 for 123 NHS Trusts in England. We examined whether adoption of the priority clinical standards was associated with the extent to which weekend mortality was elevated, and changes over a 3 year period in the extent to which mortality was elevated.

Results Levels of achievement of two of the four clinical standards (ongoing review and access to diagnostic services) had small positive associations with the magnitude of the weekend effect in 2015/2016. Levels of achievement of the remaining two standards (time to first consultant review and access to consultant directed interventions) had small negative associations with the magnitude of the weekend effect in 2015/2016. No association was statistically significant. The same pattern was observed in the associations between achievement of the standards and changes in the magnitudes of the weekend effect between 2013/2014 and 2015/2016.

Discussion
We found no association between Trusts’ performance against any of the four standards and the current magnitude of their weekend effects, or the change in their weekend effects over the past 3 years. These findings cast doubt on whether adoption of seven day clinical standards in the delivery of emergency hospital services will be successful in reducing the weekend effect.

CHOICE: Choosing Health Options In Chronic Care Emergencies

Guthrie E, Afzal C, Blakeley C, Blakemore A, Byford R, Camacho E, et al. CHOICE: Choosing Health Options In Chronic Care Emergencies. Programme Grants Appl Res 2017;5(13)

Over 70% of the health-care budget in England is spent on the care of people with long-term conditions (LTCs), and a major cost component is unscheduled health care. Psychological morbidity is high in people with LTCs and is associated with a range of adverse outcomes, including increased mortality, poorer physical health outcomes, increased health costs and service utilisation.

Objectives
The aim of this programme of research was to examine the relationship between psychological morbidity and use of unscheduled care in people with LTCs, and to develop a psychosocial intervention that would have the potential to reduce unscheduled care use. We focused largely on emergency hospital admissions (EHAs) and attendances at emergency departments (EDs).

Design
A three-phase mixed-methods study. Research methods included systematic reviews; a longitudinal prospective cohort study in primary care to identify people with LTCs at risk of EHA or ED admission; a replication study in primary care using routinely collected data; an exploratory and feasibility cluster randomised controlled trial in primary care; and qualitative studies to identify personal reasons for the use of unscheduled care and factors in routine consultations in primary care that may influence health-care use. People with lived experience of LTCs worked closely with the research team.

Setting
Primary care. Manchester and London.

Participants
People aged ≥ 18 years with at least one of four common LTCs: asthma, coronary heart disease, chronic obstructive pulmonary disease (COPD) and diabetes. Participants also included health-care staff.

Results
Evidence synthesis suggested that depression, but not anxiety, is a predictor of use of unscheduled care in patients with LTCs, and low-intensity complex interventions reduce unscheduled care use in people with asthma and COPD. The results of the prospective study were that depression, not having a partner and life stressors, in addition to prior use of unscheduled care, severity of illness and multimorbidity, were independent predictors of EHA and ED admission. Approximately half of the cost of health care for people with LTCs was accounted for by use of unscheduled care. The results of the replication study, carried out in London, broadly supported our findings for risk of ED attendances, but not EHAs. This was most likely due to low rates of detection of depression in general practitioner (GP) data sets. Qualitative work showed that patients were reluctant to use unscheduled care, deciding to do so when they perceived a serious and urgent need for care, and following previous experience that unscheduled care had successfully and unquestioningly met similar needs in the past. In general, emergency and primary care doctors did not regard unscheduled care as problematic. We found there are missed opportunities to identify and discuss psychosocial issues during routine consultations in primary care due to the ‘overmechanisation’ of routine health-care reviews. The feasibility trial examined two levels of an intervention for people with COPD: we tried to improve the way in which practices manage patients with COPD and developed a targeted psychosocial treatment for patients at risk of using unscheduled care. The former had low acceptability, whereas the latter had high acceptability. Exploratory health economic analyses suggested that the practice-level intervention would be unlikely to be cost-effective, limiting the value of detailed health economic modelling.

Limitations
The findings of this programme may not apply to all people with LTCs. It was conducted in an area of high social deprivation, which may limit the generalisability to more affluent areas. The response rate to the prospective longitudinal study was low. The feasibility trial focused solely on people with COPD.

Conclusions
Prior use of unscheduled care is the most powerful predictor of unscheduled care use in people with LTCs. However, psychosocial factors, particularly depression, are important additional predictors of use of unscheduled care in patients with LTCs, independent of severity and multimorbidity. Patients and health-care practitioners are unaware that psychosocial factors influence health-care use, and such factors are rarely acknowledged or addressed in consultations or discussions about use of unscheduled care. A targeted patient intervention for people with LTCs and comorbid depression has shown high levels of acceptability when delivered in a primary care context. An intervention at the level of the GP practice showed little evidence of acceptability or cost-effectiveness.

Future work
The potential benefits of case-finding for depression in patients with LTCs in primary care need to be evaluated, in addition to further evaluation of the targeted patient intervention.

New ambulance service standards

NHS England has announced a new set of performance targets for the ambulance service which will apply to all 999 calls for the first time.

  • National response targets to apply to every single 999 patient for the first time
  • Faster treatment for those needing it to save 250 lives a year
  • An end to “hidden waits” for millions of patients
  • Up to 750,000 more calls a year to get an immediate response
  • New standards to drive improved care for stroke and heart attack
  • World’s largest clinical ambulance trial updates decades-old system

The new targetsnew targets will save lives and remove “hidden” and long waits suffered by millions of patients, including reducing lengthy waits for the frail and elderly. The new system is backed by the Association of Ambulance Chief Executives, the Royal College of Emergency Medicine, the Stroke Association and the British Heart Foundation amongst others.

Call handlers will change the way they assess cases and will have slightly more time to decide the most appropriate clinical response. As a result cardiac arrest patients can be identified quicker than ever before, with evidence showing this could save up to 250 lives every year.

Full story via NHS England

 

Towards evidence-based emergency medicine

Horner, D. (2017) Emergency Medicine Journal. 34(5) pp. 331-334.

BestBETS

Image source: BEstBETS

Best Evidence Topic reports (BETs) summarise the evidence pertaining to particular clinical questions. They are not systematic reviews, but rather contain the best (highest level) evidence that can be practically obtained by busy practicing clinicians. The search strategies used to find the best evidence are reported in detail to allow clinicians to update searches whenever necessary. Each BET is based on a clinical scenario and ends with a clinical bottom line which indicates, in the light of the evidence found, what the reporting clinician would do if faced with the same scenario again.

The BETs published below were first reported at the Critical Appraisal Journal Club at the Manchester Royal Infirmary or placed on the BestBETs website. Each BET has been constructed in the four stages that have been described elsewhere. The BETs shown here together with those published previously and those currently under construction can be seen at http://www.bestbets.org. Two BETs are included in this issue of the journal.

Read the full abstract here

Retrospective observational study of emergency admission, readmission and the ‘weekend effect’

Shiue I, McMeekin P, Price C. Retrospective observational study of emergency admission, readmission and the ‘weekend effect’. BMJ Open 2017;7:e012493. doi: 10.1136/bmjopen-2016-012493 

Excess mortality following weekend hospital admission has been observed but not explained. As readmissions have greater age, comorbidity and social deprivation, outcomes following emergency index admission and readmission were examined for temporal and demographic associations to confirm whether weekend readmissions contribute towards excess mortality.

Design A retrospective observational study. Individual patient Hospital Episode Statistics were linked and 2 categories created: index admissions (not within 60 days of discharge from an emergency hospitalisation) and readmissions (within 60 days of discharge from an emergency hospitalisation). Logistic regression examined associations between admission category, weekend and weekday mortality, age, gender, season, comorbidity and social deprivation.

Setting A single acute National Health Service (NHS) trust serving a population of 550 000 via 3 emergency departments.

Participants Emergency admissions between 1 January 2010 and 31 March 2015.

Outcome measure All-cause 30-day mortality.

Results Over 5 years there were 128 966 index admissions (74.7% weekday/25.3% weekend) and 20 030 readmissions (74.9% weekday/25.1% weekend). Adjusted 30-day death rates for weekday/weekend admissions were 6.93%/7.04% for index cases and 12.26%/13.27% for readmissions. Weekend readmissions had a higher mortality risk relative to weekday readmissions (OR 1.10 (95% CI 1.01 to 1.20)) without differences in comorbidity or deprivation. Weekend index admissions did not have a significantly increased mortality risk (OR 1.04 (95% CI 0.98 to 1.11)) but deaths which did occur were associated with lower deprivation (OR 1.24 (95% CI 1.11 to 1.38)) and an absence of comorbidities (OR 1.17 (1.02 to 1.34)).

Conclusions Associations with emergency hospitalisation were not identical for index admissions and readmissions. Further research is needed to confirm what factors are responsible for the ‘weekend effect’.