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Cantrell A, Chambers D, Booth A. Interventions to minimise hospital winter pressures related to discharge planning and integrated care: a rapid mapping review of UK evidence. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-116. [PMID: 39267416 DOI: 10.3310/krwh4301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/17/2024]
Abstract
Background Winter pressures are a familiar phenomenon within the National Health Service and represent the most extreme of many regular demands placed on health and social care service provision. This review focuses on a part of the pathway that is particularly problematic: the discharge process from hospital to social care and the community. Although studies of discharge are plentiful, we identified a need to focus on identifying interventions and initiatives that are a specific response to 'winter pressures'. This mapping review focuses on interventions or initiatives in relation to hospital winter pressures in the United Kingdom with either discharge planning to increase smart discharge (both a reduction in patients waiting to be discharged and patients being discharged to the most appropriate place) and/or integrated care. Methods We conducted a mapping review of United Kingdom evidence published 2018-22. Initially, we searched MEDLINE, Health Management Information Consortium, Social Care Online, Social Sciences Citation Index and the King's Fund Library to find relevant interventions in conjunction with winter pressures. From these interventions we created a taxonomy of intervention types and a draft map. A second broader stage of searching was then undertaken for named candidate interventions on Google Scholar (Google Inc., Mountain View, CA, USA). For each taxonomy heading, we produced a table with definitions, findings from research studies, local initiatives and systematic reviews and evidence gaps. Results The taxonomy developed was split into structural, changing staff behaviour, changing community provision, integrated care, targeting carers, modelling and workforce planning. The last two categories were excluded from the scope. Within the different taxonomy sections we generated a total of 41 headings. These headings were further organised into the different stages of the patient pathway: hospital avoidance, alternative delivery site, facilitated discharge and cross-cutting. The evidence for each heading was summarised in tables and evidence gaps were identified. Conclusions Few initiatives identified were specifically identified as a response to winter pressures. Discharge to assess and hospital at home interventions are heavily used and well supported by the evidence but other responses, while also heavily used, were based on limited evidence. There is a lack of studies considering patient, family and provider needs when developing interventions aimed at improving delayed discharge. Additionally, there is a shortage of studies that measure the longer-term impact of interventions. Hospital avoidance and discharge planning are whole-system approaches. Considering the whole health and social care system is imperative to ensure that implementing an initiative in one setting does not just move the problem to another setting. Limitations Time limitations for completing the review constrained the period available for additional searches. This may carry implications for the completeness of the evidence base identified. Future work Further research to consider a realist review that views approaches across the different sectors within a whole system evaluation frame. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130588) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 31. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Anna Cantrell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Duncan Chambers
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Subbe CP, Gebril A, Atkin C, Rahman LR, Komrower VA. Quality metrics for same day emergency care-Consensus of a multi-professional panel of experts using a modified Delphi process. Clin Med (Lond) 2024; 24:100212. [PMID: 38643830 PMCID: PMC11101841 DOI: 10.1016/j.clinme.2024.100212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 02/23/2024] [Indexed: 04/23/2024]
Abstract
Same Day Emergency Care (SDEC) services are at the heart of recovery plans for Emergency Care in the National Health Service. There are no validated metrics for the quality of care in SDEC. The Society for Acute Medicine's Quality Improvement Committee invited to a three-stage modified Delphi process to gather metrics used by clinicians. Proposed metrics were ranked and further explored by 33 participating experts from a broad range of backgrounds including clinicians, data scientists and operational managers. Experts ranked five system-based metrics highest. These focus on optimisation of the proportion of patients receiving same day care in and out of SDEC units. Patient and staff experience metrics were ranked low, possibly due to present lack of viable examples. The paper adds a glossary with the rationale for ranking of metrics and their use for the improvement of quality and safety of clinical care.
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Affiliation(s)
| | | | - Catherine Atkin
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Latif Raiyan Rahman
- Specialist Medicine, University Hospitals Leicester, Leicester, United Kingdom
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McNamara R, van Oppen JD, Conroy SP. Frailty same day emergency care (SDEC): a novel service model or an unhelpful distraction? Age Ageing 2024; 53:afae064. [PMID: 38577965 DOI: 10.1093/ageing/afae064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Indexed: 04/06/2024] Open
Affiliation(s)
- Rosa McNamara
- Emergency Department, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - James D van Oppen
- Centre for Urgent and Emergency Care Research, ScHARR, The University of Sheffield, Sheffield S1 4DA, UK
- College of Life Sciences, George Davies Centre, University of Leicester, Leicester LE1 7HA, UK
| | - Simon P Conroy
- MRC Unit for Lifelong Health and Ageing at UCL, University of Leicester College of Life Sciences, 5th Floor, 1-19 Torrington Place, London WC1E 7HB, UK
- St Pancras Rehabilitation Unit, Central and North West London NHS Foundation Trust, St Pancras Hospital, South Wing 4 St Pancras Way, London NW1 0PE, UK
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Dean S, Barratt J. What is the existing evidence base for adult medical Same Day Emergency Care in UK NHS hospitals? A scoping review. Future Healthc J 2024; 11:100011. [PMID: 38646058 PMCID: PMC11025060 DOI: 10.1016/j.fhj.2024.100011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
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.
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Affiliation(s)
- Sue Dean
- Same Day Emergency Care, Pilgrim Hospital, Boston, United Lincolnshire Hospitals NHS Trust, UK
- School of Health Sciences, Faculty of Medicine and Health Sciences, University of Nottingham, UK
| | - Julian Barratt
- Faculty for Advancing Practice, NHS England Workforce, Training and Education, Midlands, UK
- Centre for Advancing Practice, NHS England Workforce, Training and Education, England, UK
- Faculty of Education, Health and Wellbeing, University of Wolverhampton, UK
- Aston Medical School, Aston University, Birmingham, UK
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Atkin C, Knight T, Cooksley T, Holland M, Subbe C, Kennedy A, Varia R, Gebril A, Lasserson D. Performance of admission pathways within acute medicine services: Analysis from the Society for Acute Medicine Benchmarking Audit 2022 and comparison with performance 2019 - 2021. Eur J Intern Med 2023; 118:89-97. [PMID: 37543498 DOI: 10.1016/j.ejim.2023.07.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 07/17/2023] [Accepted: 07/28/2023] [Indexed: 08/07/2023]
Abstract
Urgent and emergency care services face increasing pressure, impacting patient care. We evaluated the performance of acute medicine services, assessing clinical quality indicators for unplanned medical admissions to acute hospital services. 152 acute UK hospital services accepting unplanned admissions to acute and general internal medicine completed a day-of-care survey incorporating organisational structure questionnaire and patient-level data over a pre-defined 24-hour period in June 2022. Clinical quality indicators were: Early Warning Score (EWS) measurement within 30 min of hospital arrival; clinician assessment within 4 h; assessment by consultant physician within 6 h (daytime) or 14 h (night-time). Results were compared with 2019, 2020, 2021. 7293 sequential patients were included (and compared with 19,817 patients across 2019-2021). In 2022, 69% of patients (95%CI 67.7-69.9%) had an EWS documented within 30 min. 79% of patients (95%CI 77.8-79.7%) were reviewed by a clinical decision maker within 4 h of hospital arrival. Patients assessed in Same Day Emergency Care services were more likely to meet this target than those assessed in Acute Medical Units or Emergency Departments (OR 2.4, 95%CI 2.02-2.87, p<0.001). Overall, 50% of patients received consultant physician review within the target time (3065/6161, 95%CI 48.5-51.0%); performance varied with time of arrival and location of initial assessment. Performance against all three clinical quality indicators was lower than 2019, 2020 and 2021 (p<0.001 for all). Performance against all quality indicators within acute medicine services is deteriorating. However, performance in Same Day Emergency Care Units is greater than in Acute Medical Units or Emergency Departments.
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Affiliation(s)
- Catherine Atkin
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham B15 2GW, UK.
| | - Thomas Knight
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham B15 2GW, UK
| | - Tim Cooksley
- Departments of Acute Medicine, Manchester University NHS Foundation Trust, M23 9LT and The Christie, Manchester M20 4BX, UK
| | - Mark Holland
- Clinical and Biomedical Sciences, Faculty of Health and Wellbeing, University of Bolton, BL3 5AB, UK
| | - Chris Subbe
- School of Medical Sciences, Bangor University & Consultant Acute, Respiratory & Critical Care Medicine, Ysbyty Gwynedd, Bangor LL57 2PW, UK
| | - Adrian Kennedy
- Department of Acute Medicine, Airedale Hospital NHS Foundation Trust, West Yorkshire, Keighley BD20 6TD, UK
| | - Ragit Varia
- Department of Acute Medicine, St Helens and Knowsley Teaching Hospitals NHS Trust, Prescot L35 5DR, UK
| | - Adnan Gebril
- Department of Acute Medicine, Salford Royal, Northern Care Alliance NHS Foundation Trust, Salford, Manchester M6 8HD, UK
| | - Daniel Lasserson
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK; Division of Acute General Medicine, Oxford University Hospitals NHS Foundation Trust, Headington, Oxford OX3 9DU, UK
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Knight T, Atkin C, Kamwa V, Cooksley T, Subbe C, Holland M, Sapey E, Lasserson D. The impact of frailty and geriatric syndromes on metrics of acute care performance: results of a national day of care survey. EClinicalMedicine 2023; 66:102278. [PMID: 38192597 PMCID: PMC10772156 DOI: 10.1016/j.eclinm.2023.102278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 09/24/2023] [Accepted: 10/02/2023] [Indexed: 01/10/2024] Open
Abstract
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.
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Affiliation(s)
- Thomas Knight
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, UK
| | - Catherine Atkin
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, UK
| | - Vicky Kamwa
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, UK
| | - Tim Cooksley
- The Christie NHS Foundation Trust, Manchester, UK
| | - Chris Subbe
- School of Medical and Health Sciences, Bangor University, UK
| | - Mark Holland
- School of Clinical and Biomedical Sciences, University of Bolton, UK
| | - Elizabeth Sapey
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, UK
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Dean S, Barratt J. What is the existing evidence base for adult medical same day emergency care in UK NHS hospitals? A scoping review protocol. BMJ Open 2023; 13:e071890. [PMID: 37793937 PMCID: PMC10551928 DOI: 10.1136/bmjopen-2023-071890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 09/18/2023] [Indexed: 10/06/2023] Open
Abstract
OBJECTIVES Same day emergency care (SDEC) is a new model of care, which has emerged over the past 5 years, building on prior ambulatory care services. The National Health Service (NHS) England National Strategy for SDEC suggests SDEC can meet local health needs by providing alternatives to emergency department attendance or hospital admission, for people with an urgent healthcare need, beyond the limited scope of an urgent treatment centre. This review focuses on acute medical SDEC, as medical patients represent a significant proportion of emergency admissions. The planned scoping review aims to map the existing evidence base. METHODS AND ANALYSIS This is a protocol for a scoping review to be conducted in accordance with the format of the Joanna Briggs Institute (JBI) methodology for scoping reviews. The databases to be searched will include EMBASE, MEDLINE and CINAHL, via EBSCOhost. Sources of unpublished studies, policies and grey literature will include Google Scholar, the Cochrane Library, TRIP database, ProQuest Dissertations and Theses Open, and the Health Management Information Consortium. Papers relating to acute medicine adult patients attending NHS SDEC services in the UK will be included. International papers will be excluded, as will those over 5 years old, and those where full text is not available. The results of the search and study inclusion/exclusion process will be reported and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram. Data will be extracted from papers included in the scoping review by two reviewers, using a JBI data extraction tool. Any differences of opinion will be discussed until consensus is reached. If needed, a third reviewer will be asked to join the review team to achieve consensus. Data and themes extracted will be summarised and presented in tables. A narrative thematic summary will accompany the presented results, describing how the results relate to the review objective. Literature gaps will be identified and recommendations for future research made. ETHICS AND DISSEMINATION There is no requirement for ethical approval for this scoping review. On completion, it will be published in a peer-reviewed academic journal and presented at a conference.
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Affiliation(s)
- Sue Dean
- Same Day Emergency Care, United Lincolnshire Hospitals NHS Trust, Boston, UK
| | - Julian Barratt
- The Centre for Advancing Practice, Health Education England - East Midlands, Nottingham, UK
- The Institute of Health, University of Wolverhampton, Wolverhampton, UK
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Houghton M. Same-day emergency care. Clin Med (Lond) 2023; 23:99. [PMID: 36697020 PMCID: PMC11046541 DOI: 10.7861/clinmed.let.23.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Michael Houghton
- General practitioner (retired), Preston, UK, and GP with special interest in acute medicine (retired), University Hospital Coventry, Coventry, UK
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Atkin C, Gallier S, Wallin E, Reddy-Kolanu V, Sapey E. 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. BMJ Open 2022; 12:e064910. [PMID: 36526319 PMCID: PMC9764605 DOI: 10.1136/bmjopen-2022-064910] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES To assess the performance of the Amb score and Glasgow Admission Prediction Score (GAPS) in identifying acute medical admissions suitable for same day emergency care (SDEC) in a large urban secondary centre. DESIGN Retrospective assessment of routinely collected data from electronic healthcare records. SETTING Single large urban tertiary care centre. PARTICIPANTS All unplanned admissions to general medicine on Monday-Friday, episodes starting 08:00-16:59 hours and lasting up to 48 hours, between 1 April 2019 and 9 March 2020. MAIN OUTCOME MEASURES Sensitivity, specificity, positive and negative predictive value of the Amb score and GAPS in identifying patients discharged within 12 hours of arrival. RESULTS 7365 episodes were assessed. 94.6% of episodes had an Amb score suggesting suitability for SDEC. The positive predictive value of the Amb score in identifying those discharged within 12 hours was 54.5% (95% CI 53.3% to 55.8%). The area under the receiver operating characteristic curve (AUROC) for the Amb score was 0.612 (95% CI 0.599 to 0.625).42.4% of episodes had a GAPS suggesting suitability for SDEC. The positive predictive value of the GAPS in identifying those discharged within 12 hours was 50.5% (95% CI 48.4% to 52.7%). The AUROC for the GAPS was 0.606 (95% CI 0.590 to 0.622).41.4% of the population had both an Amb and GAPS score suggestive of suitability for SDEC and 5.7% of the population had both and Amb and GAPS score suggestive of a lack of suitability for SDEC. CONCLUSIONS The Amb score and GAPS had poor discriminatory ability to identify acute medical admissions suitable for discharge within 12 hours, limiting their utility in selecting patients for assessment within SDEC services within this diverse patient population.
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Affiliation(s)
- Catherine Atkin
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Suzy Gallier
- Department of Health Informatics, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Elizabeth Wallin
- Acute Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Vinay Reddy-Kolanu
- Acute Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Elizabeth Sapey
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- Acute Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Emmanuel A. Health means more than just healthcare. Clin Med (Lond) 2022; 22:94. [PMID: 38589194 DOI: 10.7861/clinmed.ed.22.2.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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