Performance of scoring systems in selecting short stay medical admissions suitable for assessment in same day emergency care: an analysis of diagnostic accuracy in a UK hospital setting

Strategies to identify medical patients suitable for management through same-day emergency care services: A systematic review

Same-day emergency care (SDEC) in unplanned and emergency care is an NHS England (NHSE) priority. Optimal use of these services requires rapid identification of suitable patients. NHSE suggests the use of one tool for this purpose. This systematic review compares studies that evaluate the performance of selection tools for SDEC pathways. Nine studies met the inclusion criteria. Three scores were evaluated: the Amb score (seven studies), Glasgow Admission Prediction Score (GAPS) (six studies) and Sydney Triage to Admission Risk Tool (START) (two studies). There was heterogeneity in the populations assessed, exclusion criteria used and definitions used for SDEC suitability, with proportions of patients deemed 'suitable' for SDEC ranging from 20 to 80%. Reported score sensitivity and specificity ranged between 18-99% and 10-89%. Score performance could not be compared due to heterogeneity between studies. No studies assessed clinical implementation. The current evidence to support the use of a specific tool for SDEC is limited and requires further evaluation.

What is the existing evidence base for adult medical Same Day Emergency Care in UK NHS hospitals? A scoping review

Introduction

This scoping review focuses on acute medical Same Day Emergency Care (SDEC), as medical patients represent a significant proportion of emergency admissions in the NHS.

Methods

This scoping review has been conducted in accordance with the JBI methodology and as detailed in the published scoping review protocol.

Results

Identified papers included two observational cohort studies, four audits, four review articles, two opinion pieces, a paper on potential future developments, three policy documents, one strategy paper and a position statement. Key themes were extrapolated and discussed in a narrative.

Conclusions

The scarcity of literature in relation to the quality, safety, and effectiveness of SDEC highlights the need for further study. Therefore, there is a pressing need for SDEC specific research within the UK.

The impact of frailty and geriatric syndromes on metrics of acute care performance: results of a national day of care survey

Background

Frailty is associated with a range of adverse clinical outcomes in the acute hospital setting. We sought to determine whether frailty and related factors affected clinical processes such as time to assessment during emergency hospital admission within the National Health Service (NHS) in the UK.

Methods

The Society for Acute Medicine Benchmarking Audit (SAMBA) is an annual cross-sectional day of care survey. SAMBA 2022 was conducted on Thursday 23rd June 2022. We assessed whether the Clinical Frailty Scale (CFS) and presence of a geriatric syndrome affected performance against nationally recognised clinical quality indicators based on time to initial assessment and time to consultant review. CFS was graded into robust (CFS1-3), mild (CFS 4-5), moderate (CFS 6), severe (CFS7-8) and terminal illness (CFS 9). Plausible values were created for missing variables using multi-level multiple imputation. The association was described using mixed effect generalised linear models adjusting for initial National Early Warning Score 2 (NEWS2) and time of arrival.

Findings

A total of 152 hospitals provided patient level data relating to 7248 emergency medical admissions. Patients with mild, moderate and severe frailty were less likely to be assessed within 4 h of arrival (adjusted OR, mild 0.79, 95% CI 0.68-0.96, moderate 0.67 95% CI 0.53-0.84, severe, 0.75 95% CI 0.58-0.96, terminally ill 0.59 95% CI 0.23-1.43) and less likely to be achieve the clinical quality indicator for consultant review (adjusted OR, mild 0.69 95% CI 0.58-0.83, moderate 0.55 95% CI 0.44-0.70, severe 0.54 95% CI 0.41-0.69, terminally ill 0.76 95% CI 0.42-1.5). Patients with geriatric syndromes were also less likely to be assessed within 4 h of arrival (adjusted OR 0.66 95% CI 0.56-0.76) or by a consultant within the recommended time frame (adjusted OR 0.45 95% CI 0.39-0.51). The difference was partially explained by differential use of SDEC pathways. Sub-group analysis of 5148 patients assessed outside of SDEC areas demonstrated patients with geriatric syndromes (adjusted OR 0.71, 95% CI 0.60-0.83), but not frailty defined by CFS were less likely to be assessed within 4 h of arrival. Moderate and severe frailty and the presence of a geriatric syndrome were associated with a decreased likelihood of achieving the consultant review standard (moderate, adjusted OR 0.75, 95% CI 0.59-0.94, severe adjusted OR 0.75 95% CI 0.58-0.96, geriatric syndrome adjusted OR 0.59, 95% CI 0.50-0.69).

Interpretation

Frailty is associated with delayed clinical assessment. This association may suggest a systemic issue with clinical prioritisation, with important implications for acute care policy.

Funding

The database for SAMBA is funded by the Society for Acute Medicine.