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Noble AJ, Mason SM, Bonnett LJ, Reuber M, Wright J, Pilbery R, Jacques RM, Simpson RM, Campbell R, Fuller A, Marson AG, Dickson JM. Supporting the ambulance service to safely convey fewer patients to hospital by developing a risk prediction tool: Risk of Adverse Outcomes after a Suspected Seizure (RADOSS)-protocol for the mixed-methods observational RADOSS project. BMJ Open 2022; 12:e069156. [PMID: 36375988 PMCID: PMC9668054 DOI: 10.1136/bmjopen-2022-069156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Ambulances services are asked to further reduce avoidable conveyances to emergency departments (EDs). Risk of Adverse Outcomes after a Suspected Seizure seeks to support this by: (1) clarifying the risks of conveyance and non-conveyance, and (2) developing a risk prediction tool for clinicians to use 'on scene' to estimate the benefits an individual would receive if conveyed to ED and risks if not. METHODS AND ANALYSIS Mixed-methods, multi-work package (WP) project. For WP1 and WP2 we shall use an existing linked data set that tracks urgent and emergency care (UEC) use of persons served by one English regional ambulance service. Risk tools are specific to clinical scenarios. We shall use suspected seizures in adults as an exemplar.WP1: Form a cohort of patients cared for a seizure by the service during 2019/2020. It, and nested Knowledge Exchange workshops with clinicians and service users, will allow us to: determine the proportions following conveyance and non-conveyance that die and/or recontact UEC system within 3 (/30) days; quantify the proportion of conveyed incidents resulting in 'avoidable ED attendances' (AA); optimise risk tool development; and develop statistical models that, using information available 'on scene', predict the risk of death/recontact with the UEC system within 3 (/30) days and the likelihood of an attendance at ED resulting in an AA.WP2: Form a cohort of patients cared for a seizure during 2021/2022 to 'temporally' validate the WP1 predictive models.WP3: Complete the 'next steps' workshops with stakeholders. Using nominal group techniques, finalise plans to develop the risk tool for clinical use and its evaluation. ETHICS AND DISSEMINATION WP1a and WP2 will be conducted under database ethical approval (IRAS 307353) and Confidentiality Advisory Group (22/CAG/0019) approval. WP1b and WP3 have approval from the University of Liverpool Central Research Ethics Committee (11450). We shall engage in proactive dissemination and knowledge mobilisation to share findings with stakeholders and maximise evidence usage.
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Affiliation(s)
- Adam J Noble
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Suzanne M Mason
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Laura J Bonnett
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Markus Reuber
- Academic Neurology Unit, The University of Sheffield, Sheffield, UK
| | | | - Richard Pilbery
- Research and Development Department, Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | - Richard M Jacques
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Rebecca M Simpson
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Richard Campbell
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | | | - Anthony Guy Marson
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK
| | - Jon Mark Dickson
- Academic Unit of Primary Medical Care, The University of Sheffield, Sheffield, UK
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Eggli Y, Halfon P, Piaget-Rossel R, Bischoff T. Measuring medically unjustified hospitalizations in Switzerland. BMC Health Serv Res 2022; 22:158. [PMID: 35130896 PMCID: PMC8822832 DOI: 10.1186/s12913-022-07569-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/24/2022] [Indexed: 11/10/2022] Open
Abstract
Background Inappropriate use of acute hospital beds is a major topic in health politics. We present here a new approach to measure unnecessary hospitalizations in Medicine and Pediatrics. Methods The necessity of a hospital admission was determined using explicit criteria related to the recorded diagnoses. Two indicators (i.e. “unjustified” and “sometimes justified” stays) were applied to more than 800,000 hospital stays and a random sample of 200 of them was analyzed by two clinicians, using routine data available in medical statistics. The validation of the indicators focused on their precision, validity and adjustment, as well as their usefulness (i.e. interest and risk of abuse). Results Rates, adjusted for case mix (i.e. age of patient, admission planned or not), showed statistically significant differences among hospitals. Only 6.5% of false positives were observed for “unjustified stays” and 17% for “sometimes justified stays”. Respectively 7 and 12% of stays had an unknown status, due to a lack of sufficiently precise data. Considering true positives only, almost one third of medical and pediatric stays were classified as not strictly justified from a medical point of view in Switzerland. Among these stays, about one fifth could have probably been avoided without risk. To enable a larger ambulatory shift, recommendations were made to strengthen the ambulatory care, notably regarding post-emergency follow-up, cardiac and pulmonary functions’ monitoring, pain management, falls prevention, and specialized at-home services that should be offered. Conclusion We recommend using “unjustified stays” and “sometimes justified stays” indicators to monitor inappropriate hospitalizations. The latter could help the planning of reinforced ambulatory care measures to pursue the ambulatory shift. Nonetheless, we clearly advise against the use of these two indicators for hospitals financing purposes. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07569-3.
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Affiliation(s)
- Yves Eggli
- Primary Care and Public Health Center (Unisanté), University of Lausanne, Route de la Corniche 10, 1010, Lausanne, Switzerland.
| | - Patricia Halfon
- Primary Care and Public Health Center (Unisanté), University of Lausanne, Route de la Corniche 10, 1010, Lausanne, Switzerland
| | - Romain Piaget-Rossel
- Primary Care and Public Health Center (Unisanté), University of Lausanne, Route de la Corniche 10, 1010, Lausanne, Switzerland
| | - Thomas Bischoff
- Primary Care and Public Health Center (Unisanté), University of Lausanne, Route de la Corniche 10, 1010, Lausanne, Switzerland
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Dixon P, Kallis C, Grainger R, Pearson MG, Tudur-Smith C, Marson AG. Care After Presenting with Seizures (CAPS): An analysis of the impact of a seizure referral pathway and nurse support on neurology referral rates for patients admitted with a seizure. Seizure 2021; 92:18-23. [PMID: 34399397 DOI: 10.1016/j.seizure.2021.07.023] [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: 06/16/2021] [Revised: 07/20/2021] [Accepted: 07/22/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION The National Audit of Seizure Management in Hospitals (NASH) identified low referral rates to neurology and epilepsy services after an emergency department attendance or admission with a seizure. METHODS National Health Service Secondary Users Service (SUS) data were used to assess the impact of a seizure pathway at seven hospitals in Cheshire & Merseyside, which was implemented in 2014. Three of these hospitals also had a nurse employed part-time to support the pathway. Patients admitted with a seizure between 2011 and 2018 inclusive were identified using an algorithm based on ICD-10 codes, and the primary outcome was a neurology referral within 3 months of admission. Regression models were used to assess the impact of age, deprivation and comorbidity on post admission clinic referral rates. RESULTS 13,285 admissions with seizure were included in the analysis. 5,677 had not attended a neurology clinic appointment in the 12 months before the admission. The percentage of whom that were offered an appointment following the admission was: 16.0% before the pathway and 35.9% with the nurse-supported pathway, which was significant in the regression model. 4,700 admissions had attended a neurology clinic appointment in the 12 months before the admission. Of this group, the percentage of whom that were offered an appointment following the admission was: 55.2% before the pathway and 62.4% with the nurse-supported pathway, an increase that was not significant in the regression model. The regression models identified significant health inequalities whereby older patients, those with comorbidities and those living in deprived areas were significantly less likely to be referred. CONCLUSION Neurology out-patient appointment rates following an admission with seizures are low, worryingly so for those with no neurology appointment in the previous 12 months. A nurse-supported pathway can improve appointment rates, but the effect is modest. Further service redesign is required; the impact of which should be rigorously evaluated.
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Affiliation(s)
- Pete Dixon
- Department of Public Health, Policy and Systems, Waterhouse Building, University of Liverpool, L69 3GL, UK.
| | | | - Ruth Grainger
- Department of Data and Systems, Arden and GEM CSU, Chester, UK.
| | - Michael G Pearson
- Department of Health Data Science, University of Liverpool, Liverpool, UK.
| | - Catrin Tudur-Smith
- Department of Health Data Science, University of Liverpool, Liverpool, UK.
| | - Anthony G Marson
- The Walton Centre NHS Foundation Trust, Lower Lane, Liverpool, L9 7LJ, UK; Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK.
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McKinlay A, Morgan M, Noble A, Ridsdale L. Patient views on use of emergency and alternative care services for adult epilepsy: A qualitative study. Seizure 2020; 80:56-62. [PMID: 32540637 PMCID: PMC7443693 DOI: 10.1016/j.seizure.2020.04.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/18/2020] [Accepted: 04/22/2020] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Emergency Department (ED) visits are costly to the health service and alternative care pathways may address this whilst improving outcomes. We aimed to describe decision-making and preferences of people with epilepsy (PWE) during emergency service use, and views of ED alternatives, including use of an Urgent Treatment Centre and telephone-based support from an epilepsy nurse specialist. METHODS We conducted a community-based interview study in South East England, informed by a qualitative framework approach. 25 adults with epilepsy and 5 of their carers took part. RESULTS Participants' choice to attend ED generally corresponded with guidelines, including continuing seizures and injury. Nevertheless, over half reported unwanted or unnecessary ED attendance, mainly due to lack of access to individual patient history, a carer, or seizures occurring in a public place. Participants used proactive strategies to communicate their care needs to others, including 24 -h alarm devices and care plans. Some suggested preventative strategies including referral after ED. Participants highlighted the importance of ambulance staff in providing fast and efficient care that gives reassurance. CONCLUSION Improving communication and access to preventative, proactive services may facilitate better outcomes within existing care pathways. PWE felt ED alternatives were helpful in some circumstances, but Urgent Treatment Centres or epilepsy nurse specialists were not viewed as an ED replacement.
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Affiliation(s)
- Alison McKinlay
- King's College London, Department of Basic and Clinical Neuroscience, London, UK.
| | - Myfanwy Morgan
- King's College London, Institute of Pharmaceutical Science, London, UK.
| | - Adam Noble
- University of Liverpool, Department of Health Services Research, UK.
| | - Leone Ridsdale
- King's College London, Department of Basic and Clinical Neuroscience, London, UK.
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Burrows L, Lennard S, Hudson S, McLean B, Jadav M, Henley W, Sander JW, Shankar R. Exploring epilepsy attendance at the emergency department and interventions which may reduce unnecessary attendances: A scoping review. Seizure 2020; 76:39-46. [PMID: 31999986 DOI: 10.1016/j.seizure.2020.01.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/14/2020] [Accepted: 01/19/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Repeat attendances to emergency departments for seizures, impacts on the individual and burdens health care systems. We conducted a review to identify implementable measures which improve the management of people with epilepsy reducing healthcare costs and their supportive evidence. METHODS A scoping review design using suitable search strategy as outlined by PRISMA-ScR was used to examine seven databases: MEDLINE, EMBASE, CINAHL, AMED, PsychINFO, HMIC and BNI. A manual search of the COCHRANE database and citation searching was also conducted. A thematic analysis was conducted to explore the context and reasons of emergency department attendance for seizures, particularly repeat attendances and the strategies and measures deployed to reduce repeat attendances. RESULTS Twenty-nine reports were included, comprising of a systematic review, a randomised control study, a multi-method study, quantitative studies (n = 17), qualitative studies (n = 6), an audit, a survey and a quality improvement project. Thematic analysis identified four broad areas for reducing repeat attendances. These were developing care pathways, conducting care and treatment reviews, providing educational interventions and role of ambulance staff. CONCLUSION The findings indicate varied reasons for attendance at ED following seizure, including mental health and knowledge of seizure management and lack of education. Implementations of care pathways in ED have been found to reduce admission related costs.
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Affiliation(s)
- Lisa Burrows
- Department of Intellectual Disability Neuropsychiatry, Research Team, Cornwall Partnership NHS Foundation Trust, Truro, TR1 3QB, UK; University of Plymouth, UK
| | - Sarah Lennard
- Department of Intellectual Disability Neuropsychiatry, Research Team, Cornwall Partnership NHS Foundation Trust, Truro, TR1 3QB, UK
| | - Sharon Hudson
- Department of Intellectual Disability Neuropsychiatry, Research Team, Cornwall Partnership NHS Foundation Trust, Truro, TR1 3QB, UK
| | | | - Mark Jadav
- Royal Cornwall Hospital NHS Trust, TR1 3HD, UK
| | - William Henley
- Exeter Medical School, Knowledge Spa, Truro, TR1 3HD, UK
| | - Josemir W Sander
- UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK; Chalfont Centre for Epilepsy, Buckinghamshire, SL9 0RJ, UK; Stichting Epilepsie Instellingen Nederland (SEIN), Achterweg 5, 2103 SW, Heemstede, the Netherlands
| | - Rohit Shankar
- Department of Intellectual Disability Neuropsychiatry, Research Team, Cornwall Partnership NHS Foundation Trust, Truro, TR1 3QB, UK; Exeter Medical School, Knowledge Spa, Truro, TR1 3HD, UK.
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