Nowhere else to turn: exploring high intensity use of accident and emergency services,

Nowhere else to turn: exploring high intensity use of accident and emergency services
Red Cross November 2021

• People who frequently attend accident and emergency (A&E) make up less than 1 per cent of the population, but account for a significant proportion of all A&E attendances, ambulance journeys and hospital admissions. It is estimated they cost the NHS at least £2.5 billion per year. 
• This report explores the profile and experiences of people who frequently attend A&E and considers what needs to be done to ensure that more people can be supported in the community, before they reach a crisis that leads to the door of the emergency department. It shows the clear link between high intensity use and wider inequalities.

Comparison of the impact of two national health and social care integration programmes on emergency hospital admissions

Comparison of the impact of two national health and social care integration programmes on emergency hospital admissions.
BMC Health Serv Res. 2021 Jul 12;21(1):687. doi: 10.1186/s12913-021-06692-x.

• An evaluation of the impact on emergency hospital admissions of two large nationally-initiated service integration programmes in England: the Pioneer (November 2013 to March 2018) and Vanguard (January 2015 to March 2018) programmes found that health and social care integration programmes can mitigate but not prevent rises in emergency admissions over the longer-term.

Abstract

Changes in weekend and weekday care quality of emergency medical admissions during implementation of the 7-day services national health policy

Changes in weekend and weekday care quality of emergency medical admissions to 20 hospitals in England during implementation of the 7-day services national health policy
BMJ Quality & Safety 2021;30:536-546.
(Full text available through NHS OpenAthens: Register here https://openathens.nice.org.uk/ )

• The aim of this study was to determine whether the quality of care of emergency medical admissions is worse at weekends, and whether this has changed during implementation of 7-day services introduced in 2013 to improve care quality and outcomes for weekend emergency admissions. Reviews of patients (n=4000 ) admitted to 20 acute hospitals Trusts as emergencies at weekends and on weekdays between financial years 2012–2013 and 2016–2017.
• Errors, adverse events and care quality were not significantly different between weekend and weekday admissions, but all improved significantly between epochs, Preadmission processes in the community were suboptimal at weekends and deteriorated between epochs (fewer family doctor referrals, more patients with chronic disease or palliative care designation).

Exploring the potential for social prescribing in pre-hospital emergency and urgent care: A qualitative study.

Exploring the potential for social prescribing inpre-hospital emergency and urgent care: A qualitative study.
Health Soc Care Community. 2021; 29: 654– 663. https://doi.org/10.1111/hsc.13337

• This study aims to develop a better understanding of the role that social prescribing can play in pre-hospital emergency and urgent care services, in order to deliver care to relevant patient cohorts.

Rebuilding the NHS Improving medical pathways for acute care

Rebuilding the NHS Improving medical pathways for acute care
Royal College of Emergency Medicine, Royal College of General Practitioners, Royal College of Physicians, and the Society for Acute Medicine 13 July 2020

• A call for transformation of the urgent and emergency care pathway in light of the COVID-19 pandemic based on the key principle is that patients and carers should only have to attend hospital when it is essential or the added clinical value outweighs the risk

Frequent attendances at emergency departments in England

Frequent attendances at emergency departments in England
Emergency Medicine Journal 16 April 2020. doi: 10.1136/emermed-2018-208189

• Analysis of attendances at all major EDs across England in the financial year 2016–2017. 
• 73.5% of ED attenders attended once and accounted for 49.8% of the total ED attendances. 
• 9.5% of ED attenders attended three times or more and accounted for 27.1% of ED attendances. 
• 1.2% attended six times or more, accounted for 7.6% of total ED attendances. 

Abstract

Why force GP streaming on NHS emergency departments?

Why force GP streaming on NHS emergency departments?
BMJ 2020;368:m992, 18 March 2020 doi: https://doi.org/10.1136/bmj.m992

• The evidence around GP streaming in A&E, and need to tailor solutions to local circumstances.

Is streaming patients in emergency departments to primary care services effective and safe?

Is streaming patients in emergency departments to primary care services effective and safe?
BMJ 2020;368:m462 25 February 2020 doi: https://doi.org/10.1136/bmj.m462

• A discussion of the evidence and its uncertainty.

What matters to people using A&E

What matters to people using A&E
HealthWatch 20 February 2020

• To inform NHS England's Clinical Review of Standards national polling and interviews have been conducted with patients in A&E which indicate that while the length of someone’s visit is important, people are more interested in the overall quality of care on offer at their local hospital.
• Quality of experience is shaped by diverse factors including communication, staff attitude, the speed of initial assessment, the facilities within A&E departments and whether people feel other parts of the NHS are working together with the A&E department to provide joined-up care.

The four-hour NHS waiting time target saves lives - government should think carefully about changes

The four-hour NHS waiting time target saves lives - government should think carefully about changes
IFS 17 January 2020

• "All of this suggests that the four-hour target has played an important role in improving A&E care. Waiting times have fallen, and while costs have increased, this has been accompanied by large reductions in mortality among high-severity patients. On this basis, the current target appears to be working well for patients – at least when hospitals are broadly meeting the standard."

British Social Attitudes Survey - attitudes towards emergency care

British Social Attitudes Survey - attitudes towards emergency care
The National Centre for Social Research 14 August 2019

• The first ever large-scale research into attitudes towards emergency care from the most recent British Social Attitudes Survey reveals significant differences in perspectives by a range of socio-demographic factors, such as area deprivation, age, young children in the household and gender.
• People living in deprived areas are more likely to prefer A&E departments over their GP to get tests done quickly, find it more difficult to get an appointment with their GP and think A&E doctors are more knowledgeable than GPs.
• Parents with children under 5 are most likely to have used an A&E in the last year, to think it is hard to get an appointment with their GP, less likely to trust their GP but are also more likely to use the internet to try to decide what the problem might be.
• Men are less knowledgeable about how to contact a GP out of office hours and less likely to use the internet to research a health problem.
• Those aged 18-24 are twice as likely to both research a health problem online (62%) and to use the internet to decide what to do (47%), compared with those aged 75+.

Emergency readmissions: What's changed one year on?

Emergency readmissions: What's changed one year on?
HealthWatch 14 November 2018

• New research indicates that emergency readmissions to hospital grew by 9% over the last year. The increase for emergency readmissions where someone has returned to hospital within just one day of discharge has increased by 15% year on year. 
• New data shows no correlation between DToC reductions and rising emergency readmissions.

GP and emergency departments (GPED)—efficient models of care: a mixed-methods study protocol

General practitioners and emergency departments (GPED)—efficient models of care: a mixed-methods study protocol
BMJ Open 2018;8:e024012. doi: 10.1136/bmjopen-2018-024012

• This is a protocol for a study which aims to evaluate the impact of GPED on patient care, the primary care and acute hospital team and the wider urgent care system.
• The study will be divided into three work packages (WPs). 
• WP-A; Mapping and Taxonomy: mapping, description and classification of current models of GPED in all emergency departments in England and interviews with key informants to examine the hypotheses that underpin GPED. 
• WP-B; Quantitative Analysis of National Data: measurement of the effectiveness, costs and consequences of the GPED models identified in WP-A, compared with a no-GPED model, using retrospective analysis of Hospital Episode Statistics Data. 
• WP-C; Case Studies: detailed case studies of different GPED models using a mixture of qualitative and quantitative methods including: non-participant observation of clinical care, semistructured interviews with staff, patients and carers; workforce surveys with emergency department staff and analysis of available local routinely collected hospital data.
• See the Project site here.(Includes links to related research)

Getting It Right In Emergency Care advice pack

Getting It Right In Emergency Care advice pack
GIRFT, Emergency Care Intensive Support Team (ECIST.) August 2018

• The advice pack aims to encourage the implementation of existing good practice, but setting out examples of interventions that NHS trusts can adopt to improve patient flow and help to manage the pressures that occur in Emergency Care.

Reducing emergency admissions: unlocking the potential of people to better manage their long-term conditions

Reducing emergency admissions: unlocking the potential of people to better manage their long-term conditions
Health Foundation August 2018

This briefing summarises research that explores the link between how well patients feel able to manage their long-term conditions such as asthma, diabetes and depression and their use of health care. Analysis using the Patient Activation Measure (PAM) and healthcare utilisation across a whole health economy found that self-management capability is associated with lower healthcare utilisation and less wasteful use across primary and secondary care.

Summary of
Self-management capability in patients with long-term conditions is associated with reduced healthcare utilisation across a whole health economy: cross-sectional analysis of electronic health records 

BMJ Qual Saf Published Online First: 23 August 2018. doi: 10.1136/bmjqs-2017-007635

Abstract

Health Based Place of Safety and Emergency Department Rotational Nursing Programme

Health Based Place of Safety and Emergency Department Rotational Nursing Programme: End of pilot report
Healthy London, July 2018

• This report outlines the development and initiation of a rotational nursing programme to support individuals detained under s136, between Health Based Place of Safety (HBPoS) sites and four Emergency Departments (EDs) in London.

Approaches to community services integration and consequences for emergency hospital activity

Horizontal or vertical: which way to integrate? Approaches to community services integration and consequences for emergency hospital activity
The Strategy Unit June 2018

• The Transforming Community Services policy required primary care trusts to decide how they organised the community health services they delivered; vertically integrate with an acute trust, horizontally integrate with a mental health trust, or set up a stand-alone community trust or Community Interest Company. 
• This report explores the impact this choice had on the level and growth in emergency hospital use in older people and considers the wider implications for the NHS as it develops new models of care and integrated care systems.

Emergency and acute medical care in over 16s: service delivery and organisation. [NG94]

Emergency and acute medical care in over 16s: service delivery and organisation. [Guideline NG94]
NICE March 2018

• This guideline makes recommendations around organisation and delivery of emergency and acute medical care for people aged over 16 in the community and in hospital. It aims to reduce the need for hospital admissions by giving advanced training to paramedics and providing community alternatives to hospital care. 
• The Guideline makes a series of recommendations and is accompanied by a number of reviews of the evidence including 
• 02. Non-emergency telephone access and call handlers 
• 05. GP extended hours / 06. GP-led home visits / 07. GP access to laboratory investigations / 08. GP access to radiology 
• 10. Community-based pharmacists 
• 12. Alternatives to hospital care 
• 13. Community rehabilitation / 14. Community palliative care 
• 15. Advance care planning 
• 17. GPs within or on the same site as emergency departments 
• 18. Minor injury unit, urgent care centre or walk-in centre 
• 20. Physician extenders ( Advanced Nurse Practitioners, Physician Associates and Advanced Clinical Practitioners) 
• 23. Liaison psychiatry 
• 25. Admission through elderly care assessment units 
• 35. Discharge planning / 36. Standardised discharge criteria / 37. Post-discharge early follow-up clinics 
• 38. Integrated care 
• 39. Bed occupancy

Variations in mortality across the week following emergency admission to hospital

Variations in mortality across the week following emergency admission to hospital: linked retrospective observational analyses of hospital episode data in England, 2004/5 to 2013/14
Health Services and Delivery Research November 2017, 5(30)

• Retrospective observational analyses of hospital episode data in England, using both national data and data from a single, large acute NHS trust. 
• Nationally excess mortality out of hours was largely explained by a sicker population of patients being selected for admission. However, mortality rates were still elevated on Sunday daytimes after severity of patient illness was accounted for. Mortality rates are also elevated for patients admitted during night-time periods. 
• The estimated cost of implementing 7-day services exceeds the maximum amount that the NICE would recommend the NHS should spend on eradicating excess mortality at weekends.

Health and housing: building the evidence base

Health and housing: building the evidence base
Housing LIN, 3 April 2017

• This evidence review suggests that closer working between the NHS and the housing sector can help reduce hospital admissions and emergency department visits, speed up the discharge of older patients and maintain the independence of older people.