The effects of unexpected changes in demand on the performance of emergency departments

Experiences of individuals presenting to the emergency department for mental health reasons: A systematic mixed studies review

OBJECTIVE

Emergency departments the world over have seen substantial increases in the number of individuals presenting for mental health reasons. However, we have a limited understanding of their experiences of care. The aim of this review was to systematically examine and synthesise literature relating to the experiences of individuals presenting to emergency department for mental health reasons.

METHODS

We followed Pluye and Hong's seven-step approach to conducting a systematic mixed studies review. Studies were included if they investigated adult mental health experiences in emergency department from the users' perspective. Studies describing proxy, carer/family or care provider experiences were excluded.

RESULTS

Sixteen studies were included. Thematic synthesis identified three themes and associated subthemes. Theme 1 - ED staff can make-or-break and ED experience - comprised: Feeling understood and heard; Engaging in judgement-free interactions; Receiving therapeutic support; Being actively and passively invalidated for presenting to the ED; and Once a psych patient, always a psych patient. Theme 2 - Being in the ED environment is counter-therapeutic - comprised: Waiting for an 'extremely' long time; and Lacking privacy. Theme 3 was Having nowhere else to go.

CONCLUSIONS

The experiences described by individuals presenting to emergency department for mental health reasons were mostly poor. The results illustrate a need for increased mental health education and training for all emergency department staff. Employment of specialist and lived experience workers should also be prioritised to support more therapeutic relationships and emergency department environments. In addition, greater investment in mental health systems is required to manage the current crisis and ensure future sustainability.

Free-for-all: Does crowding impact outcomes because hospital emergency departments do not prioritise effectively?

Unexpected peaks in volumes of attendances at hospital emergency departments (EDs) have been found to affect waiting times, intensity of care and outcomes. We ask whether these effects of ED crowding on patients are caused by poor clinical prioritisation or a quality-quantity trade-off generated by a binding capacity constraint. We study the effects of crowding created by lower-severity patients on the outcomes of approximately 13 million higher-severity patients attending the 140 public EDs in England between April 2016 and March 2017. Our identification approach relies on high-dimensional fixed effects to account for planned capacity. Unexpected demand from low-severity patients has very limited effects on the care provided to higher-severity patients throughout their entire pathway in ED. Detrimental effects of crowding caused by low-severity patients materialise only at very high levels of unexpected demand, suggesting that binding resource constraints impact patient care only when demand greatly exceeds the ED's expectations. These effects are smaller than those caused by crowding induced by higher-severity patients, suggesting an efficient prioritisation of incoming patients in EDs.

Outcomes for university students following emergency care presentation for deliberate self-harm: a retrospective observational study of emergency departments in England for 2017/2018

OBJECTIVES

Identify university-aged students and contrast their healthcare provision and outcomes with other patients in the same age group attending emergency departments for deliberate self-harm.

DESIGN

Retrospective cross-sectional observational study.

SETTING

Patients visiting 129 public hospital emergency departments across England between April 2017 and March 2018.

PARTICIPANTS

14 074 patients aged 18-23 visiting emergency departments for conditions linked to deliberate self-harm, 1016 of which were identified as university-aged students.

OUTCOME MEASURES

We study various outcomes across the entire patient pathway in the emergency department: waiting time to initial assessment on arrival at the emergency department, count of investigations delivered, discharge destination (patients refusing treatment or leave before being seen, referred to another provider or admitted to inpatient care, discharged with no follow-up) and unplanned follow-up visit within 7 days.

RESULTS

We find a statistically significant difference of 0.262 (-0.491 to -0.0327) less investigations delivered to students compared with non-students (about 8% compared with the baseline number of investigations for non-students). Stratified analyses reveal that this difference is concentrated among students visiting the emergency department outside of regular working hours (-0.485 (-0.850 to -0.120)) and students visiting for repeated deliberate self-harm episodes (-0.881 (-1.510 to -0.252)). Unplanned reattendance within 7 days is lower among students visiting emergency departments during out of hours (-0.0306 (-0.0576 to -0.00363)), while students arriving by ambulance are less likely to be referred to another provider (-0.0708 (-0.140 to -0.00182)) compared with non-students.

CONCLUSIONS

We find evidence of less-intense investigations being delivered to patients aged 18-23 identified as students compared with non-students visiting emergency departments after an episode of deliberate self-harm. Given the high risk of suicide attempts after episodes of deliberate self-harm among students, our findings may highlight the need for more focused interventions on this group of patients.

Does the opening of an emergency department influence hospital admissions? Evidence from French private hospitals

Although operating an emergency department (ED) can influence general admission activity of hospitals, most articles that analyze hospital care ignore the potential spillover of emergency activity. In this paper, we examine the consequences of a French reform that encouraged the creation of EDs within private-for-profit (PFP) hospitals in order to decrease congestion in EDs. We use administrative panel data on 365 French PFP hospitals observed between 2002 and 2012. Specifications including hospital fixed-effects are estimated to examine the impact of an ED opening on private hospitals' admission activity, namely inpatient and day-care admissions (ED visits are excluded, but patients admitted following an ED visit are included). We control for shocks that can impact demand for care in hospitals, and we estimate yearly changes before and after the opening. We find that an ED opening is followed by an increase in the number and proportion of inpatient admissions, and by an increase in the length of inpatient stays. A transitory increase in the bed occupancy rate is also observed. In many countries, public and private hospitals compete to some extent. The former provide a public service, while the latter are profit-maximizers that are allowed to specialize in profitable activities. They generally focus on day-care admissions. We provide empirical evidence that private hospitals experience a significant change in the composition of their admissions when they start providing emergency care. Opening an ED creates a new non-selective entryway to private hospitals, resulting in admissions of inpatients with health problems that are more severe. Hence, involving PFP hospitals in the provision of emergency care is likely to make the structure of admissions of private hospitals closer to that of public hospitals.

Evaluation of an established oncology triage hotline in a model of emergency department avoidance: assessing the UKONS triage tool and call outcomes

PURPOSE

In response to a demonstrable need for 24/7, specialist oncology advice for patients undergoing systemic anti-cancer therapy, many healthcare institutions have adopted a telephone triage (TT) service. This is true of the Clatterbridge Cancer Centre which uses the UKONS framework to guide its decisions. This study aims to investigate the utilisation and outcomes of this TT service, with a focus on the most unwell call outcomes and factors leading to referrals to accident and emergency departments that could be mitigated with service development and modifications.

METHODS

A retrospective evaluation study was conducted of calls occurring between 1st September 2021 and 31st August 2022. A descriptive analysis of call UKONS grading, triage outcome and primary complaint was performed.

RESULTS

The TT hotline received 23,766 calls of which only 9066 were for clinical advice. Of the clinical calls, 45.2% were UKONS red. The majority of red calls 53.3% were directed to AED. The proportion of red calls going to AED changed drastically depending on the timing of call and the corresponding services available at those times, with 38.3% of reds being sent to AED in hours but 72.3% out of hours. The profile of complaints also showed significant differences in hours versus out of hours.

CONCLUSION

Significant use of the hotline supports a genuine demand for oncology TT services. In order to reduce referrals to AED, this study supports the creation of alternative destinations of emergency care, especially out of hours.

Big data evidence of the impact of COVID-19 hospitalizations on mortality rates of non-COVID-19 critically ill patients

The COVID-19 virus caused a global pandemic leading to a swift policy response. While this response was designed to prevent the spread of the virus and support those with COVID-19, there is growing evidence regarding measurable impacts on non-COVID-19 patients. The paper uses a large dataset from administrative records of the Brazilian public health system (SUS) to estimate pandemic spillover effects in critically ill health care delivery, i.e. the additional mortality risk that COVID-19 ICU hospitalizations generate on non-COVID-19 patients receiving intensive care. The data contain the universe of ICU hospitalizations in SUS from February 26, 2020 to December 31, 2021. Spillover estimates are obtained from high-dimensional fixed effects regression models that control for a number of unobservable confounders. Our findings indicate that, on average, the pandemic increased the mortality risk of non-COVID-19 ICU patients by 1.296 percentage points, 95% CI 1.145-1.448. The spillover mortality risk is larger for non-COVID patients receiving intensive care due to diseases of the respiratory system, diseases of the skin and subcutaneous tissue, and infectious and parasitic diseases. As of July 2023, the WHO reports more than 6.9 million global deaths due to COVID-19 infection. However, our estimates of spillover effects suggest that the pandemic's total death toll is much higher.

Factors associated with longer wait times, admission and reattendances in older patients attending emergency departments: an analysis of linked healthcare data

BACKGROUND AND OBJECTIVE

Care for older patients in the ED is an increasingly important issue with the ageing society. To better assess the quality of care in this patient group, we assessed predictors for three outcomes related to ED care: being seen and discharged within 4 hours of ED arrival; being admitted from ED to hospital and reattending the ED within 30 days. We also used these outcomes to identify better-performing EDs.

METHODS

The CUREd Research Database was used for a retrospective observational study of all 1 039 251 attendances by 368 754 patients aged 75+ years in 18 type 1 EDs in the Yorkshire and the Humber region of England between April 2012 and March 2017. We estimated multilevel logit models, accounting for patients' characteristics and contact with emergency services prior to ED arrival, time variables and the ED itself.

RESULTS

Patients in the oldest category (95+ years vs 75-80 years) were more likely to have a long ED wait (OR=1.13 (95% CI=1.10 to 1.15)), hospital admission (OR=1.26 (95% CI=1.23 to 1.29)) and ED reattendance (OR=1.09 (95% CI=1.06 to 1.12)). Those who had previously attended (3+ vs 0 previous attendances) were more likely to have long wait (OR=1.07 (95% CI=1.06 to 1.08)), hospital admission (OR=1.10 (95% CI=1.09 to 1.12)) and ED attendance (OR=3.13 (95% CI=3.09 to 3.17)). Those who attended out of hours (vs not out of hours) were more likely to have a long ED wait (OR=1.33 (95% CI=1.32 to 1.34)), be admitted to hospital (OR=1.19 (95% CI=1.18 to 1.21)) and have ED reattendance (OR=1.07 (95% CI=1.05 to 1.08)). Those living in less deprived decile (vs most deprived decile) were less likely to have any of these three outcomes: OR=0.93 (95% CI=0.92 to 0.95), 0.92 (95% CI=0.90 to 0.94), 0.86 (95% CI=0.84 to 0.88). These characteristics were not strongly associated with long waits for those who arrived by ambulance. Emergency call handler designation was the strongest predictor of long ED waits and hospital admission: compared with those who did not arrive by ambulance; ORs for these outcomes were 1.18 (95% CI=1.16 to 1.20) and 1.85 (95% CI=1.81 to 1.89) for those designated less urgent; 1.37 (95% CI=1.33 to 1.40) and 2.13 (95% CI=2.07 to 2.18) for urgent attendees; 1.26 (95% CI=1.23 to 1.28) and 2.40 (95% CI=2.36 to 2.45) for emergency attendees; and 1.37 (95% CI=1.28 to 1.45) and 2.42 (95% CI=2.26 to 2.59) for those with life-threatening conditions. We identified two EDs whose patients were less likely to have a long ED, hospital admission or ED reattendance than other EDs in the region.

CONCLUSIONS

Age, previous attendance and attending out of hours were all associated with an increased likelihood of exceeding 4 hours in the ED, hospital admission and reattendance among patients over 75 years. These differences were less pronounced among those arriving by ambulance. Emergency call handler designation could be used to identify those at the highest risk of long ED waits, hospital admission and ED reattendance.

Emergency department outcomes for patients experiencing homelessness in England: retrospective cross-sectional study

BACKGROUND

Emergency departments (EDs) are an important point of access to health care for people experiencing homelessness. Evidence suggests that ED attendances by homeless people are more likely to result in leaving the ED without treatment, or dying in the ED. We investigate which diagnoses and patterns of health care use are associated with these (and other) discharge destinations and re-attendance within 7 days among homeless patients.

METHODS

We used national hospital data to analyze attendances of all 109 254 people experiencing homelessness who presented at any Type 1 ED in England over 2013-18. We used logistic regression to estimate the association of each outcome with primary diagnosis and patterns of healthcare use.

RESULTS

Compared with patients with no past ED use, patients with a high frequency of past ED use were more likely to leave without treatment and re-attend within 7 days. Patients not registered at a general practice were likelier to leave without treatment or die in the ED and had lower odds of unplanned re-attendance. A primary diagnosis of 'social problems' was associated with being discharged without follow-up. Patients with a psychiatric primary diagnosis were disproportionately likely to be referred to another health care professional/provider or an outpatient clinic.

CONCLUSIONS

Further research is needed to understand why some homeless patients leave the ED without treatment and whether their healthcare needs are being met. Some patients may be attending the ED frequently due to poor access to other services, such as primary care and social welfare.

The health cost of reducing hospital bed capacity

In the past two decades, most high-income countries have reduced their hospital bed capacity. This could be a sign of increased efficiency but could also reflect a degradation in quality of care. In this paper, we use repeated cross-sections on mortality and staffed hospital beds per capita in all 21 Swedish regions to estimate the potential death toll from reduced bed capacity. Between 2001 and 2019, mortality and beds decreased across all regions, but regions making smaller bed reductions experienced on average greater decreases in mortality, equivalent to one less death per three beds retained. This estimate is stable to a wide range of specifications and to adjustment for potential confounders, which supports a causal interpretation. Our results imply that by providing one more bed, Swedish health care could produce about three quality-adjusted life years (QALYs) at a cost of SEK 400,000 (∼US$40,000) per QALY. These findings could be informative about the marginal productivity of health care and support the credibility of empirical work attempting to estimate the opportunity cost of funding new healthcare interventions subject to a constrained budget.

Socioeconomic inequality in access to timely and appropriate care in emergency departments

In publicly-funded healthcare systems, waiting times for care should be based on need rather than ability to pay. Studies have shown that individuals with lower socioeconomic status face longer waits for planned inpatient care, but there is little evidence on inequalities in waiting times for emergency care. We study waiting times in emergency departments (EDs) following arrival by ambulance, where health consequences of extended waits may be severe. Using data from all major EDs in England during the 2016/17 financial year, we find patients from more deprived areas face longer waits during some parts of the ED care pathway. Inequalities in waits are small, but more deprived individuals also receive less complex ED care, are less likely to be admitted for inpatient care, and are more likely to re-attend ED or die shortly after attendance. Patient-physician interactions and unconscious bias towards more deprived patients may be important sources of inequalities.

Spikes in demand for hospital transfusion services

INTRODUCTION

Spikes in the demand for blood components represent a substantial challenge to transfusion services. Simple metrics for characterizing volatility in blood components within the hospital transfusion service have not been established.

METHODS

We measured the volatility of demand for blood services at a large academic urban general hospital over a 6-month period from July 2019 to December 2019 prior to the SARS-CoV2 pandemic.

RESULTS

Among 4416 consecutive hours assessed, there were 693 h (16%) with spikes in demand for blood components with a mean (sd) of 3.8 (2.7) spikes/day. Spikes in demand were frequently clustered. The median number of hours between spikes differed by shift (6 h for days; 3 h for evenings; 3 h for nights). The percentage of shift hours with demand spikes also differed (9% day; 19% evening; 18% night). During the study, 32,447 components were distributed to 19,431 patients. Of these, 11,819 components (36%) were distributed during hours of peak demand. Hours with a simultaneous spike in both component demand and patient demand occurred in 5% of hours or approximately once each day.

CONCLUSION

Demand for transfusion services was highly volatile in an unpredictable fashion. We provide an approach that could be used to benchmark spikes in demand for blood services at hospitals. Consideration of the frequency, unpredictability, and magnitude of spikes in demand may be relevant for hemovigilance programs and for strategies to determine the laboratory staffing needed for good patient care.