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Dick S, MacRae C, McFaul C, Rasul U, Wilson P, Turner SW. Interventions to reduce acute paediatric hospital admissions: a systematic review. Arch Dis Child 2022; 107:234-243. [PMID: 34340984 DOI: 10.1136/archdischild-2021-321884] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 07/19/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Admission rates are rising despite no change to burden of illness, and interventions to reduce unscheduled admission to hospital safely may be justified. OBJECTIVE To systematically examine admission prevention strategies and report long-term follow-up of admission prevention initiatives. DATA SOURCES MEDLINE, Embase, OVID SP, PsychINFO, Science Citation Index Expanded/ISI Web of Science, The Cochrane Library from inception to time of writing. Reference lists were hand searched. STUDY ELIGIBILITY CRITERIA Randomised controlled trials and before-and-after studies. PARTICIPANTS Individuals aged <18 years. STUDY APPRAISAL AND SYNTHESIS METHODS Studies were independently screened by two reviewers with final screening by a third. Data extraction and the Critical Appraisals Skills Programme checklist completion (for risk of bias assessment) were performed by one reviewer and checked by a second. RESULTS Twenty-eight studies were included of whom 24 were before-and-after studies and 4 were studies comparing outcomes between non-randomised groups. Interventions included referral pathways, staff reconfiguration, new healthcare facilities and telemedicine. The strongest evidence for admission prevention was seen in asthma-specific referral pathways (n=6) showing 34% (95% CI 28 to 39) reduction, but with evidence of publication bias. Other pathways showed inconsistent results or were insufficient for wider interpretation. Staffing reconfiguration showed reduced admissions in two studies, and shorter length of stay in one. Short stay admission units reduced admissions in three studies. CONCLUSIONS AND IMPLICATIONS There is little robust evidence to support interventions aimed at preventing paediatric admissions and further research is needed.
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Affiliation(s)
- Smita Dick
- Department of Child Health, University of Aberdeen, Aberdeen, UK
| | - Clare MacRae
- Usher institute, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, Edinburgh, UK
| | - Claire McFaul
- Department of Child Health, University of Aberdeen, Aberdeen, UK
| | - Usman Rasul
- Department of Child Health, University of Aberdeen, Aberdeen, UK
| | - Philip Wilson
- Institute of Health and Wellbeing, University of Aberdeen, Aberdeen, UK
| | - Stephen W Turner
- Department of Child Health, University of Aberdeen, Aberdeen, UK
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2
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Telemedicine applications for pandemic diseases, with a focus on COVID-19. DATA SCIENCE FOR COVID-19 2022. [PMCID: PMC8988874 DOI: 10.1016/b978-0-323-90769-9.00028-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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3
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Turner S, Raja EA. The association between opening a short stay paediatric assessment unit and trends in short stay hospital admissions. BMC Health Serv Res 2021; 21:523. [PMID: 34049553 PMCID: PMC8164232 DOI: 10.1186/s12913-021-06541-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 05/11/2021] [Indexed: 11/10/2022] Open
Abstract
Background Many inpatient facilities in Scotland have opened short stay paediatric assessment units (SSPAU) which are clinical areas separate from the usual inpatient ward area and these are where most short stay (also called zero day) admissions are accommodated. Here we describe the effect of opening short stay paediatric assessment units (SSPAU) on the proportion of zero day admissions relative to all emergency admissions. Methods Details of all emergency medical paediatric admissions to Scottish hospitals between 2000 and 2013 were obtained, including the number of zero day admissions per month and health board (i.e. geographic region). The month and year that an SSPAU opened in each health board was provided by local clinicians. Results SSPAUs opened in 7 health boards, between 2004 and 2012. Health boards with an SSPAU had a slower rise in zero day admissions compared to those without SSPAU (0.6% per month [95% CI 0.04, 0.09]. Across all 7 health boards, opening an SSPAU was associated with a 13% [95% CI 10, 15] increase in the proportion of zero day admissions. When considered individually, zero day admissions rose in four health boards after their SSPAU opened, were unchanged in one and fell in two health boards. Independent of SSPAUs opening, there was an increase in the proportion of all admissions which were zero day admissions (0.1% per month), and this accelerated after SSPAUs opened. Conclusion Opening an SSPAU has heterogeneous outcomes on the proportion of zero day admissions in different settings. Zero day admissions could be reduced in some health boards by understanding differences in clinical referral pathways between health boards with contrasting trends in zero day admissions after their SSPAU opens. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06541-x.
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Affiliation(s)
- Steve Turner
- Child Health, University of Aberdeen, Aberdeen, UK. .,Women and Children Division, NHS Grampian, Aberdeen, AB25 2ZG, UK.
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Korotchikova I, Al Khalaf S, Sheridan E, O'Brien R, Bradley CP, Deasy C. Paediatric attendances of the emergency department in a major Irish tertiary referral centre before and after expansion of free GP care to children under 6: a retrospective observational study. BMJ Paediatr Open 2021; 5:e000862. [PMID: 33665372 PMCID: PMC7893646 DOI: 10.1136/bmjpo-2020-000862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 01/06/2021] [Accepted: 01/28/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To examine the characteristics of paediatric attendances to the emergency department (ED) in Cork University Hospital (CUH) before and after the expansion of free general practitioner (GP) care to children under the age of 6 years. DESIGN This is a retrospective observational study that used a large administrative dataset. SETTING The study was conducted in major Irish tertiary referral centre that serves a total population of over 1.1 million. It is a public hospital, owned and managed by the health service executive. PARTICIPANTS Children aged 0-15 years who attended CUH ED during the study period of 6 years (2012-2018) were included in this study (n=76 831). INTERVENTIONS Free GP care was expanded to all children aged 0-5 years in July 2015. MAIN OUTCOME MEASURES Paediatric attendances to CUH ED were examined before (Time Period 1: July 2012-June 2015) and after (Time Period 2: July 2015-June 2018) the expansion of free GP care to children under 6. Changes in GP referral rates and inpatient hospital admissions were investigated. RESULTS Paediatric presentations to CUH ED increased from 35 819 during the Time Period 1 to 41 012 during the Time Period 2 (14.5%). The proportion of the CUH ED attendances through GP referrals by children under 6 increased by over 8% in the Time Period 2 (from 10 148 to 14 028). Although the number of all children who attended CUH ED and were admitted to hospital increased in Time Period 2 (from 8704 to 9320); the proportion of children in the 0-5 years group who attended the CUH ED through GP referral and were subsequently admitted to hospital, decreased by over 3%. CONCLUSION The expansion of free GP care has upstream health service utilisation implications, such as increased attendances at ED, and should be considered and costed by policy-makers.
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Affiliation(s)
- Irina Korotchikova
- Medical Education Unit, School of Medicine, University College Cork, Cork, Ireland.,Department of Emergency Medicine, Cork University Hospital, Cork, Ireland
| | - Sukainah Al Khalaf
- School of Public Health, University College Cork, Cork, Munster, Ireland.,INFANT Centre, Cork University Hospital, Cork, Ireland
| | - Ewa Sheridan
- Medical Education Unit, School of Medicine, University College Cork, Cork, Ireland
| | - Rory O'Brien
- Department of Emergency Medicine, Cork University Hospital, Cork, Ireland
| | - Colin P Bradley
- Department of General Practice, School of Medicine, University College Cork, Cork, Ireland
| | - Conor Deasy
- Medical Education Unit, School of Medicine, University College Cork, Cork, Ireland.,Department of Emergency Medicine, Cork University Hospital, Cork, Ireland
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5
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Coffey A, Leahy-Warren P, Savage E, Hegarty J, Cornally N, Day MR, Sahm L, O'Connor K, O'Doherty J, Liew A, Sezgin D, O'Caoimh R. Interventions to Promote Early Discharge and Avoid Inappropriate Hospital (Re)Admission: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16142457. [PMID: 31295933 PMCID: PMC6678887 DOI: 10.3390/ijerph16142457] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/29/2019] [Accepted: 07/05/2019] [Indexed: 01/05/2023]
Abstract
Increasing pressure on limited healthcare resources has necessitated the development of measures promoting early discharge and avoiding inappropriate hospital (re)admission. This systematic review examines the evidence for interventions in acute hospitals including (i) hospital-patient discharge to home, community services or other settings, (ii) hospital discharge to another care setting, and (iii) reduction or prevention of inappropriate hospital (re)admissions. Academic electronic databases were searched from 2005 to 2018. In total, ninety-four eligible papers were included. Interventions were categorized into: (1) pre-discharge exclusively delivered in the acute care hospital, (2) pre- and post-discharge delivered by acute care hospital, (3) post-discharge delivered at home and (4) delivered only in a post-acute facility. Mixed results were found regarding the effectiveness of many types of interventions. Interventions exclusively delivered in the acute hospital pre-discharge and those involving education were most common but their effectiveness was limited in avoiding (re)admission. Successful pre- and post-discharge interventions focused on multidisciplinary approaches. Post-discharge interventions exclusively delivered at home reduced hospital stay and contributed to patient satisfaction. Existing systematic reviews on tele-health and long-term care interventions suggest insufficient evidence for admission avoidance. The most effective interventions to avoid inappropriate re-admission to hospital and promote early discharge included integrated systems between hospital and the community care, multidisciplinary service provision, individualization of services, discharge planning initiated in hospital and specialist follow-up.
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Affiliation(s)
- Alice Coffey
- Department of Nursing and Midwifery, Health Sciences Building, University of Limerick, Limerick V94X5K6, Ireland.
| | - Patricia Leahy-Warren
- School of Nursing and Midwifery, University College Cork, Cork City T12AK54, Ireland
| | - Eileen Savage
- Nursing and Vice Dean of Graduate Studies and Inter Professional Learning, College of Medicine and Health, University College Cork, Cork City T12AK54, Ireland
| | - Josephine Hegarty
- School of Nursing and Midwifery, University College Cork, Cork City T12AK54, Ireland
| | - Nicola Cornally
- School of Nursing and Midwifery, University College Cork, Cork City T12AK54, Ireland
| | - Mary Rose Day
- School of Nursing and Midwifery, University College Cork, Cork City T12AK54, Ireland
| | - Laura Sahm
- School of Pharmacy, University College Cork, Cork City T12T656, Ireland
| | - Kieran O'Connor
- Geriatric Medicine, Mercy University Hospital, Cork City T12WE28, Ireland
| | - Jane O'Doherty
- Department of Nursing and Midwifery, Health Sciences Building, University of Limerick, Limerick V94X5K6, Ireland
| | - Aaron Liew
- Clinical Sciences Institute, National University of Ireland, and Portiuncula University Hospital, Ballinasloe Galway H53T971, Ireland
| | - Duygu Sezgin
- Clinical Sciences Institute, National University of Ireland, and Portiuncula University Hospital, Ballinasloe Galway H53T971, Ireland
| | - Rónán O'Caoimh
- Clinical Sciences Institute, National University of Ireland, Galway City, Mercy University Hospital, Grenville Place, Cork City T12WE28, Ireland
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Al-Mahtot M, Barwise-Munro R, Wilson P, Turner S. Changing characteristics of hospital admissions but not the children admitted-a whole population study between 2000 and 2013. Eur J Pediatr 2018; 177:381-388. [PMID: 29260375 PMCID: PMC5816774 DOI: 10.1007/s00431-017-3064-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 11/07/2017] [Accepted: 12/04/2017] [Indexed: 11/28/2022]
Abstract
UNLABELLED There are increasing numbers of emergency medical paediatric admissions. Our hypothesis was that characteristics of children and details of their emergency admissions are also changing over time. Details of emergency admissions in Scotland 2000-2013 were analysed. There were 574,403 emergency admissions, median age 2.3 years. The age distribution, proportion of boys and socioeconomic status of children admitted were essentially unchanged. Emergency admissions rose by 49% from 36/1000 children per annum to 54/1000 between 2000 and 2013. Emergency admissions that were discharged on the same day rose by 186% from 8.6/1000 to 24.6/1000. The mean duration of emergency admission fell from 1.7 to 1.0 days. The odds for an emergency admission with upper respiratory infection, "viral infection", tonsillitis, bronchiolitis and lower respiratory tract infection all rose. In contrast the odds for an emergency admission with asthma and gastroenteritis fell. CONCLUSIONS The demographics of children with emergency admissions have not changed substantially but characteristics of admissions have changed considerably, in particular admissions which are short stay and due to respiratory infection are much more common. The fall in the absolute number of children with some acute medical diagnoses suggests that the rise in admissions is not necessarily inexorable. What is Known: • Emergency admission prevalence is rising in many countries across Europe. What is New: • Our paper is the first to comprehensively analyse emergency medical paediatric admissions by exploring how characteristics of admissions and the children admitted have changed over time for a whole population. • The "take home message" is that whilst characteristics of emergency admissions have changed (e.g. number, duration of stay, readmissions, diagnoses), the characteristics of the children have not changed.
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Affiliation(s)
- Maryam Al-Mahtot
- Child Health, Royal Aberdeen Children’s Hospital, Aberdeen, AB25 2ZG UK
| | | | - Philip Wilson
- Centre for Rural Health, University of Aberdeen, Inverness, UK
| | - Steve Turner
- Child Health, Royal Aberdeen Children's Hospital, Aberdeen, AB25 2ZG, UK.
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Harron K, Gilbert R, Cromwell D, Oddie S, Guttmann A, van der Meulen J. International comparison of emergency hospital use for infants: data linkage cohort study in Canada and England. BMJ Qual Saf 2017; 27:31-39. [PMID: 28607037 PMCID: PMC5750429 DOI: 10.1136/bmjqs-2016-006253] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 04/19/2017] [Accepted: 05/02/2017] [Indexed: 11/25/2022]
Abstract
Objectives To compare emergency hospital use for infants in Ontario (Canada) and England. Methods We conducted a population-based data linkage study in infants born ≥34 weeks’ gestation between 2010 and 2013 in Ontario (n=253 930) and England (n=1 361 128). Outcomes within 12 months of postnatal discharge were captured in hospital records. The primary outcome was all-cause unplanned admissions. Secondary outcomes included emergency department (ED) visits, any unplanned hospital contact (either ED or admission) and mortality. Multivariable regression was used to evaluate risk factors for infant admission. Results The percentage of infants with ≥1 unplanned admission was substantially lower in Ontario (7.9% vs 19.6% in England) while the percentage attending ED but not admitted was higher (39.8% vs 29.9% in England). The percentage of infants with any unplanned hospital contact was similar between countries (42.9% in Ontario, 41.6% in England) as was mortality (0.05% in Ontario, 0.06% in England). Infants attending ED were less likely to be admitted in Ontario (7.3% vs 26.2%), but those who were admitted were more likely to stay for ≥1 night (94.0% vs 55.2%). The strongest risk factors for admission were completed weeks of gestation (adjusted OR for 34–36 weeks vs 39+ weeks: 2.44; 95% CI 2.29 to 2.61 in Ontario and 1.66; 95% CI 1.62 to 1.70 in England) and young maternal age. Conclusions Children attending ED in England were much more likely to be admitted than those in Ontario. The tendency towards more frequent, shorter admissions in England could be due to more pressure to admit within waiting time targets, or less availability of paediatric expertise in ED. Further evaluations should consider where best to focus resources, including in-hospital, primary care and paediatric care in the community.
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Affiliation(s)
- Katie Harron
- London School of Hygiene and Tropical Medicine, London, UK
| | - Ruth Gilbert
- Great Ormond Street Institute of Child Health, London, UK
| | - David Cromwell
- London School of Hygiene and Tropical Medicine, London, UK
| | - Sam Oddie
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Astrid Guttmann
- Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
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8
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Goh GL, Huang P, Kong MCP, Chew SP, Ganapathy S. Unplanned reattendances at the paediatric emergency department within 72 hours: a one-year experience in KKH. Singapore Med J 2017; 57:307-13. [PMID: 27353384 DOI: 10.11622/smedj.2016105] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Unscheduled reattendances at the paediatric emergency department may contribute to overcrowding, which may increase financial burdens. The objectives of this study were to determine the rate of reattendances and characterise factors influencing these reattendances and hospital admission during the return visits. METHODS Medical records of all patients who attended the emergency department at KK Women's and Children's Hospital, Singapore, from 1 June 2013 to 31 May 2014 were retrospectively reviewed. We collected data on patient demographics, attendance data and clinical characteristics. Planned reattendances, recalled cases, reattendances for unrelated complaints and patients who left without being seen were excluded. A multivariate analysis was conducted to determine the odds ratio of variables associated with hospital admission for reattendances. RESULTS Of 162,566 children, 6,968 (4.3%) returned within 72 hours, and 2,925 (42.0% of reattendance group) were admitted on their return visits. Children more likely to reattend were under three years of age, Chinese, triaged as Priority 2 at the first visit, and were initially diagnosed with respiratory or gastrointestinal conditions. However, children more likely to be admitted on their return visits were over 12 years of age, Malay, had a higher triage acuity or were uptriaged, had the presence of a comorbidity, and were diagnosed with gastrointestinal conditions. CONCLUSION We identified certain subgroups in the population who were more likely to be admitted if they reattended. These findings would help in implementing further research and directing strategies to reduce potentially avoidable reattendances and admissions.
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Affiliation(s)
- Guan Lin Goh
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore.,Department of Neonatology, KK Women's and Children's Hospital, Singapore
| | - Peiqi Huang
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore.,Department of Neonatology, KK Women's and Children's Hospital, Singapore
| | | | - So-Phia Chew
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
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Bryant PA, Hopper SM. Alternatives to ward admission from the emergency department. J Paediatr Child Health 2016; 52:237-40. [PMID: 27062630 DOI: 10.1111/jpc.13100] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 11/26/2015] [Accepted: 12/03/2015] [Indexed: 11/28/2022]
Abstract
There is ever-increasing pressure on hospital resources in general and emergency departments (ED) in particular. At the same time, there is increasing recognition that traditional inpatient ward-based care is not necessary for the majority of children presenting to the ED with acute illness, and that there are patient, family and hospital benefits to pursuing other options. Here, we describe alternative pathways for children presenting to the ED, including short stay and observational medicine, hospital-in-the-home and non-admission enhanced care, in other words, additional management practices or pathways for children who are discharged from the ED. We discuss the principles, models and practical considerations involved in each of these.
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Affiliation(s)
- Penelope A Bryant
- Departments of General Medicine and, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,RCH@Home, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Emergency Department, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute.,Department of Paediatrics, University of Melbourne, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Sandy M Hopper
- Emergency Department, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute
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Imison C, Sonola L, Honeyman M, Ross S, Edwards N. Insights from the clinical assurance of service reconfiguration in the NHS: the drivers of reconfiguration and the evidence that underpins it – a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03090] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundOver the life of the NHS, hospital services have been subject to continued reconfiguration. Yet it is rare for the reconfiguration of clinical services to be evaluated, leaving a deficit in the evidence to guide local reconfiguration of services.ObjectivesThe objectives of this research are to determine the current pressures for reconfiguration within the NHS in England and the solutions proposed. We also investigate the quality of evidence used in making the case for change, any key evidence gaps, and the opportunities to strengthen the clinical case for change and how it is made.MethodsWe have drawn on two key sources of evidence. First, we reviewed the reports produced by the National Clinical Advisory Team (NCAT) documenting its reviews of reconfiguration proposals. An in-depth multilevel qualitative analysis was conducted of 123 NCAT reviews published between 2007 and 2012. Second, we carried out a search and synthesis of the literature to identify the key evidence available to support reconfiguration decisions. The findings from this literature search were integrated with the analysis of the reviews to develop a narrative for each specialty and the process of reconfiguration as a whole.ResultsThe evidence from the NCAT reviews shows significant pressure to reconfigure services within the NHS in England. We found that the majority of reconfiguration proposals are driving an increasing concentration of hospital services, with some accompanying decentralisation and, for some specialist services, the development of supporting clinical networks. The primary drivers of reconfiguration have been workforce (in particular the medical workforce) and finance. Improving outcomes and safety issues have been subsidiary drivers, though many make the link between staffing and clinical safety. Policy has also been a notable driver. Access has been notable by its absence as a driver. Despite significant pressures to reconfigure services, many proposals fail to be implemented owing to public and/or clinical opposition. We found strong evidence that some specialist service reconfiguration including vascular surgery and major trauma can significantly improve clinical outcomes. However, there are notable evidence gaps. The most significant is the absence of evidence that service reconfiguration can deliver significant savings. There is also an absence of evidence about safe staffing models and the interplay between staff numbers, skill mix and outcomes. We found that the advice provided by the NCAT reflects the current evidence, but one of the NCAT’s most valuable contributions has been to encourage greater clinical engagement in service change.ConclusionsThe NHS is continuing to concentrate many district general hospital services to resolve financial and workforce pressures. However, many proposals are not implemented owing to public opposition. We also found no evidence to suggest that this will deliver the savings anticipated. There is a significant gap in the evidence about safe staffing models and the appropriate balance of junior and senior medical as well as other clinical staff. There is an urgent need to carry out research that will help to fill the current evidence gap. There is also a need to retain some national clinical expertise to work alongside Clinical Senates in supporting local service reconfiguration.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
| | - Lara Sonola
- Policy Directorate, The King’s Fund, London, UK
| | | | - Shilpa Ross
- Policy Directorate, The King’s Fund, London, UK
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11
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Emergency review clinic: impact on paediatric admissions. Ir J Med Sci 2014; 185:985-987. [PMID: 25370907 DOI: 10.1007/s11845-014-1222-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 10/27/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Inappropriate or unnecessary paediatric inpatient admissions are sometimes unavoidable but are costly and increase pressure on services. Various measures, including paediatric observation units, have been undertaken in an attempt to reduce these admissions. AIMS We established an emergency review clinic to assess whether we could reduce admission rates by giving carefully selected children follow-up ED review appointments. METHODS An emergency review clinic was run in the paediatric room of the Emergency Department by a senior paediatric registrar during the hours 10 a.m. to 12 midday, Monday to Friday inclusive. Patients were booked into this review clinic from ED. Data relating to paediatric admissions in the years prior to and after the institution of the review clinic were analysed. RESULTS A significant reduction (p < 0.0001) was noted in the paediatric inpatient admission rates following establishment of the review clinic. CONCLUSIONS A paediatric emergency review clinic can significantly reduce unnecessary or inappropriate admissions but more research is needed to quantitatively characterise parent/patient satisfaction in this regard.
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12
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Nair M, Yoshida S, Lambrechts T, Boschi-Pinto C, Bose K, Mason EM, Mathai M. Facilitators and barriers to quality of care in maternal, newborn and child health: a global situational analysis through metareview. BMJ Open 2014; 4:e004749. [PMID: 24852300 PMCID: PMC4039842 DOI: 10.1136/bmjopen-2013-004749] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Revised: 04/10/2014] [Accepted: 05/02/2014] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Conduct a global situational analysis to identify the current facilitators and barriers to improving quality of care (QoC) for pregnant women, newborns and children. STUDY DESIGN Metareview of published and unpublished systematic reviews and meta-analyses conducted between January 2000 and March 2013 in any language. Assessment of Multiple Systematic Reviews (AMSTAR) is used to assess the methodological quality of systematic reviews. SETTINGS Health systems of all countries. Study outcome: QoC measured using surrogate indicators--effective, efficient, accessible, acceptable/patient centred, equitable and safe. ANALYSIS Conducted in two phases (1) qualitative synthesis of extracted data to identify and group the facilitators and barriers to improving QoC, for each of the three population groups, into the six domains of WHO's framework and explore new domains and (2) an analysis grid to map the common facilitators and barriers. RESULTS We included 98 systematic reviews with 110 interventions to improve QoC from countries globally. The facilitators and barriers identified fitted the six domains of WHO's framework--information, patient-population engagement, leadership, regulations and standards, organisational capacity and models of care. Two new domains, 'communication' and 'satisfaction', were generated. Facilitators included active and regular interpersonal communication between users and providers; respect, confidentiality, comfort and support during care provision; engaging users in decision-making; continuity of care and effective audit and feedback mechanisms. Key barriers identified were language barriers in information and communication; power difference between users and providers; health systems not accounting for user satisfaction; variable standards of implementation of standard guidelines; shortage of resources in health facilities and lack of studies assessing the role of leadership in improving QoC. These were common across the three population groups. CONCLUSIONS The barriers to good-quality healthcare are common for pregnant women, newborns and children; thus, interventions targeted to address them will have uniform beneficial effects. Adopting the identified facilitators would help countries strengthen their health systems and ensure high-quality care for all.
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Affiliation(s)
- Manisha Nair
- National Perinatal Epidemiology Unit (NPEU), Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
| | - Sachiyo Yoshida
- Department of Maternal, Newborn, Child & Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Thierry Lambrechts
- Department of Maternal, Newborn, Child & Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Cynthia Boschi-Pinto
- Department of Maternal, Newborn, Child & Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Krishna Bose
- Department of Maternal, Newborn, Child & Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Elizabeth Mary Mason
- Department of Maternal, Newborn, Child & Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Matthews Mathai
- Department of Maternal, Newborn, Child & Adolescent Health, World Health Organization, Geneva, Switzerland
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13
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Jensen CS, Jackson K, Kolbæk R, Glasdam S. Children's experiences of acute hospitalisation to a paediatric emergency and assessment unit--a qualitative study. J Child Health Care 2012; 16:263-73. [PMID: 22308539 DOI: 10.1177/1367493511431071] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Short-stay treatment has become a popular form of care as a strategy to cope with increased demands on health care. There is little research that considers children's experiences of acute hospitalisation to a short-stay care facility such as a Paediatric Emergency and Assessment Unit (PEAU). This study explored the experiences of eight children aged 8-10 years. Semi-structured interviews were carried out to investigate the children's own experiences of being hospitalised in a PEAU. Thematic content analyses were used. Three major themes were identified: the children's understanding of disease, treatment and procedures; the children's experiences of health-care personnel and the PEAU and transformation of everyday life into the settings of the hospital. The children identified the hospital stay as an overall positive experience. The children took part in leisure activities as they would at home and enjoyed time together with their parents while in hospital. In their conversations with staff they adapted to professional terms that they did not necessarily understand. They did not differentiate between professionals. Further work should be considered to clarify the consequences of this. This study has provided some limited insight into the child's experiences of acute hospitalisation, which should inform nursing care.
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Relationships between deprivation and duration of children's emergency admissions for breathing difficulty, feverish illness and diarrhoea in North West England: an analysis of hospital episode statistics. BMC Pediatr 2012; 12:22. [PMID: 22401311 PMCID: PMC3311147 DOI: 10.1186/1471-2431-12-22] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Accepted: 03/08/2012] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND In the United Kingdom there has been a long term pattern of increases in children's emergency admissions and a substantial increase in short stay unplanned admissions. The emergency admission rate (EAR) per thousand population for breathing difficulty, feverish illness and diarrhoea varies substantially between children living in different Primary Care Trusts (PCTs). However, there has been no examination of whether disadvantage is associated with short stay unplanned admissions at PCT-level. The aim of this study was to determine whether differences between emergency hospital admission rates for breathing difficulty, feverish illness and diarrhoea are associated with population-level measures of multiple deprivation and child well-being, and whether there is variation by length of stay and age. METHODS Analysis of hospital episode statistics and secondary analysis of Index of Multiple Deprivation (IMD) 2007 and Local Index of Child Well-being (CWI) 2009 in ten adjacent PCTs in North West England. The outcome measure for each PCT was the emergency admission rate to hospital for breathing difficulty, feverish illness and diarrhoea. RESULTS 23,496 children aged 0-14 were discharged following emergency admission for breathing difficulty, feverish illness and/or diarrhoea during 2006/07. The emergency admission rate ranged from 27.9 to 62.7 per thousand. There were no statistically significant relationships between shorter (0 to 3 day) hospitalisations and the IMD or domains of the CWI. The rate for hospitalisations of 4 or more days was associated with the IMD (Kendall's tau(b) = 0.64) and domains of the CWI: Environment (tau(b) = 0.60); Crime (tau(b) = 0.56); Material (tau(b) = 0.51); Education (tau(b) = 0.51); and Children in Need (tau(b) = 0.51). This pattern was also evident in children aged under 1 year, who had the highest emergency admission rates. There were wide variations between the proportions of children discharged on the day of admission at different hospitals. CONCLUSIONS Differences between rates of the more common shorter (0 to 3 day) hospitalisations were not explained by deprivation or well-being measured at PCT-level. Indices of multiple deprivation and child well-being were only associated with rates of children's emergency admission for breathing difficulty, feverish illness and diarrhoea for hospitalisations of 4 or more days.
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Abstract
OBJECTIVE This study aimed to compare the use of outpatient ambulatory care versus admission for intravenous antibiotics in the management of preseptal cellulitis. METHODS This is a retrospective consecutive cohort study of children younger than 16 years presenting to an Inner London Paediatric Emergency Department with signs and symptoms of preseptal cellulitis. RESULTS A total of 94 cases were identified during a 17-month period. Of them, 30 children were prescribed oral antibiotics. One child did not receive treatment. Of the 63 children prescribed with intravenous antibiotics, 42 were managed on an ambulatory basis and 21 were admitted. There was no significant difference in duration of treatment in days between those on ambulatory management and those admitted (2.79 ± 0.8 vs 2.76 ± 1.9, P = 0.94) or in the rate of complications. The net cost saving was $205,924 (£131,065; &OV0556;147,578) overall, equal to $4900 (£3120; &OV0556;3513) per patient. CONCLUSIONS Ambulatory intravenous antibiotics with daily review are a safe and cost-effective alternative to inpatient admission in simple preseptal cellulitis for children in our population who require parenteral antibiotics.
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Abstract
BACKGROUND As more efficient and value-based care models are sought for the US healthcare system, geographically distinct observation units (OUs) may become an integral part of hospital-based care for children. PURPOSE To systematically review the literature and evaluate the structure and function of pediatric OUs in the United States. DATA SOURCES Searches were conducted in Medline, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Care Advisory Board (HCAB), Lexis-Nexis, National Guideline Clearinghouse, and Cochrane Reviews, through February 2009, with review of select bibliographies. STUDY SELECTION English language peer-reviewed publications on pediatric OU care in the United States. DATA EXTRACTION Two authors independently determined study eligibility. Studies were graded using a 5-level quality assessment tool. Data were extracted using a standardized form. DATA SYNTHESIS A total of 21 studies met inclusion criteria: 2 randomized trials, 2 prospective observational, 12 retrospective cohort, 2 before and after, and 3 descriptive studies. Studies present data on more than 22,000 children cared for in OUs, most at large academic centers. This systematic review provides a descriptive overview of the structure and function of pediatric OUs in the United States. Despite seemingly straightforward outcomes for OU care, significant heterogeneity in the reporting of length of stay, admission rates, return visit rates, and costs precluded our ability to conduct meta-analyses. We propose standard outcome measures and future directions for pediatric OU research. CONCLUSIONS Future research using consistent outcome measures will be critical to determining whether OUs can improve the quality and cost of providing care to children requiring observation-length stays.
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Affiliation(s)
- Michelle L Macy
- Division of General Pediatrics, Child Health Evaluation and Research Unit, University of Michigan, Ann Arbor, Michigan 48109-5456, USA.
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Saxena S, Bottle A, Gilbert R, Sharland M. Increasing short-stay unplanned hospital admissions among children in England; time trends analysis '97-'06. PLoS One 2009; 4:e7484. [PMID: 19829695 PMCID: PMC2758998 DOI: 10.1371/journal.pone.0007484] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Accepted: 09/10/2009] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Timely care by general practitioners in the community keeps children out of hospital and provides better continuity of care. Yet in the UK, access to primary care has diminished since 2004 when changes in general practitioners' contracts enabled them to 'opt out' of providing out-of-hours care and since then unplanned pediatric hospital admission rates have escalated, particularly through emergency departments. We hypothesised that any increase in isolated short stay admissions for childhood illness might reflect failure to manage these cases in the community over a 10 year period spanning these changes. METHODS AND FINDINGS We conducted a population based time trends study of major causes of hospital admission in children <10 years using the Hospital Episode Statistics database, which records all admissions to all NHS hospitals in England using ICD10 codes. Outcomes measures were total and isolated short stay unplanned hospital admissions (lasting less than 2 days without readmission within 28 days) from 1997 to 2006. Over the period annual unplanned admission rates in children aged <10 years rose by 22% (from 73.6/1000 to 89.5/1000 child years) with larger increases of 41% in isolated short stay admissions (from 42.7/1000 to 60.2/1000 child years). There was a smaller fall of 12% in admissions with length of stay of >2 days. By 2006, 67.3% of all unplanned admissions were isolated short stays <2 days. The increases in admission rates were greater for common non-infectious than infectious causes of admissions. CONCLUSIONS Short stay unplanned hospital admission rates in young children in England have increased substantially in recent years and are not accounted for by reductions in length of in-hospital stay. The majority are isolated short stay admissions for minor illness episodes that could be better managed by primary care in the community and may be evidence of a failure of primary care services.
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Affiliation(s)
- Sonia Saxena
- Department of Primary Care and Social Medicine, Imperial College London, London, United Kingdom.
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Williams L, Fryer J, Andrew R, Powell C, Pink J, Elwyn G. Setting up a Paediatric Rapid Access Outpatient Unit: views of general practice teams. BMC FAMILY PRACTICE 2008; 9:54. [PMID: 18823553 PMCID: PMC2566556 DOI: 10.1186/1471-2296-9-54] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/28/2008] [Accepted: 09/29/2008] [Indexed: 11/23/2022]
Abstract
Background Rapid Access Outpatient Units (RAOUs) have been suggested as an alternative to hospital inpatient units for the management of some acutely unwell children. These units can provide ambulatory care, delivered close to home, and may prevent unnecessary hospital admission. There are no qualitative data on the views of primary care practitioners regarding these types of facilities. The aim of the study was to explore the opinions of primary care practitioners regarding a newly established RAOU. Methods The RAOU was established locally at a district general hospital when inpatient beds were closed and moved to an inpatient centre, based six miles away at the tertiary teaching hospital. Qualitative, practice based group interviews with primary care practitioners (general practitioners (GPs), nurse practitioners and practice nurses) on their experiences of the RAOU. The data collection consisted of three practice based interviews with 14 participants. The interviews were recorded and transcribed verbatim. Thematic content analysis was used to evaluate the data. Results There was positive feedback regarding ease of telephone access for referral, location, and the value of a service staffed by senior doctors where children could be observed, investigated and discharged quickly. There was confusion regarding the referral criteria for the assessment unit and where to send certain children. A majority of the practitioners felt the utility of the RAOU was restricted by its opening hours. Most participants felt they lacked sufficient information regarding the remit and facilities of the unit and this led to some uneasiness regarding safety and long term sustainability. Conclusion Practitioners considered that the RAOU offered a rapid senior opinion, flexible short term observation, quick access to investigations and was more convenient for patients. There were concerns regarding opening hours, safety of patients and lack of information about the unit's facilities. There was confusion about which children should be sent to the unit. This study raises questions regarding policy in regard to the organisation of paediatric services. It highlights that when establishing alternative services to local inpatient units, continual communication and engagement of primary care is essential if the units are to function effectively.
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Affiliation(s)
- Lisa Williams
- Department of Paediatrics, School of Medicine, Cardiff University, The Children's Hospital for Wales, Heath Park, Cardiff, CF14 4XW, UK.
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Abstract
AIM To review the function of an emergency department paediatric observation unit. METHOD A retrospective observational study reviewing the activity of the observation unit for 12 months RESULTS During 12 months, 4446 children were admitted to the observation unit and 76% were discharged home: usually within 8 hours. The average admission rate was 12 children in 24 hours. The commonest causes for children being admitted to the observation unit were respiratory problems and gastroenteritis or dehydration. CONCLUSION The emergency paediatric observational unit was used to assess and treat children with a variety of conditions. This enabled many children to be managed in the emergency department rather than being admitted to the paediatric wards.
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Affiliation(s)
- I Levett
- New Cross Hospital, Wolverhampton, UK.
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Abstract
100 years of telemedicine
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Affiliation(s)
- E M Strehle
- North Tyneside General Hospital, North Shields, UK.
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Birch S, Glasper EA, Aitken P, Wiltshire M, Cogman G. GP views of nurse-led telephone referral for paediatric assessment. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2005; 14:667, 670-3. [PMID: 16010219 DOI: 10.12968/bjon.2005.14.12.18290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Following the introduction of a new nurse-led telephone referral service to a dedicated paediatric emergency assessment unit (PEAU), a study was conducted to determine the views of general practitioners (GPs) who use the service. The PEAU operates between 10 am and 10 pm on weekdays and between 10 am and 6 pm at weekends. The unit has four beds and treatment and stabilization areas, plus associated services in a dedicated area of a regional child health unit. The design utilized a faxed questionnaire over a 1-month period to all consenting GPs using the PEAU with a postal questionnaire follow-up. Non-parametric Likert scores and qualitative data were used to determine levels of satisfaction with the service and the subsequent management of the referred children. Sixty-nine GPs referred 80 children to the PEAU via the service over a period of 1 month. All consented to participate and were sent a faxed questionnaire, which generated 39 (57%) responses. A follow-up questionnaire sent to the 39 respondents achieved a return of 25 (64%) responses. Thirty-four GPs agreed that referral via the dedicated nurse service was easier than the previous senior house officer referral system. Of the 25 GP respondents to the follow-up postal survey, the majority (17) agreed that the follow-up morning after discharge telephone call to parents by the PEAU nurses was helpful. Four GPs indicated that the 24-hour open access system, offered by the nursing staff, in which a parent may attend PEAU with a discharged child causing concern without a previous appointment, does not always work. This study has shown that a nurse-led telephone referral system to a PEAU for GPs and the subsequent management of the children has been favourably received.
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Affiliation(s)
- S Birch
- St Mary's Hospital, Portsmouth
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