Creating a Real-World Linked Research Platform for Analyzing the Urgent and Emergency Care System

Use of emergency departments by children and young people following telephone triage: a large database study

BACKGROUND

Although one objective of NHS 111 is to ease the strain on urgent and emergency care services, studies suggest the telephone triage service may be contributing to increased demand. Moreover, while parents and caregivers generally find NHS 111 satisfactory, concerns exist about its integration with the healthcare system and the appropriateness of advice. This study aimed to analyse the advice provided in NHS 111 calls, the duration between the call and ED attendance, and the outcomes of such attendances made by children and young people (C&YP).

METHODS

A retrospective cohort study was carried out of C&YP (≤17) attending an ED in the Yorkshire and Humber region of the UK following contact with NHS 111 between 1 April 2016 and 31 March 2017. This linked-data study examined NHS 111 calls and ED outcomes. Lognormal mixture distributions were fit to compare the time taken to attend ED following calls. Logistic mixed effects regression models were used to identify predictors of low-acuity NHS 111-related ED attendances.

RESULTS

Our study of 348 401 NHS 111 calls found they were primarily concerning children aged 0-4 years. Overall, 13.1% of calls were followed by an ED attendance, with a median arrival time of 51 minutes. Of the 34 664 calls advising ED attendance 41% complied, arriving with a median of 38 minutes-27% of which defined as low-acuity. Although most calls advising primary care were not followed by an ED attendance (93%), those seen in an ED generally attended later (median 102 minutes) with 23% defined as low-acuity. Younger age (<1) was a statistically significant predictor of low-acuity ED attendance following all call dispositions apart from home care.

CONCLUSION

More tailored options for unscheduled healthcare may be needed for younger children. Both early low-acuity attendance and late high-acuity attendance following contact with NHS 111 could act as useful entry points for clinical audits of the telephone triage service.

Developing feasible person-centred care alternatives to emergency department responses for adults with epilepsy: a discrete choice analysis mixed-methods study

Background

Calls have been made for paramedics to have some form of care pathway that they could use to safely divert adults with epilepsy away from emergency departments and instigate ambulatory care improvements. Different configurations are possible. To know which to prioritise for implementation/evaluation, there is a need to determine which are acceptable to service users and likely National Health Service-feasible.

Objective(s)

(1) Identify configurations being considered, (2) understand service users' views of them and current provision, (3) identify what sort of care service users want and (4) determine which configuration(s) is considered to achieve optimal balance in meeting users' preference and being National Health Service-feasible.

Design

Service providers were surveyed to address objective 1. Interviews with service users addressed objective 2. Objective 3 was addressed by completing discrete choice experiments. These determined users' care preferences for different seizure scenarios. Objective 4 was addressed by completing 'knowledge exchange' workshops. At these, stakeholders considered the findings on users' stated preferences and judged different pathway configurations against Michie's 'acceptability, practicability, effectiveness, affordability, side-effects and equity' feasibility criteria.

Setting

This project took place in England. The survey recruited representatives from neurology and neuroscience centres and from urgent and emergency care providers. For the interviews, recruitment occurred via third-sector support groups. Recruitment for discrete choice experiments occurred via the North West Ambulance Service NHS Trust and public advert. Workshop participants were recruited from neurology and neuroscience centres, urgent and emergency care providers, support groups and commissioning networks.

Participants

Seventy-two services completed the survey. Interviews were conducted with 25 adults with epilepsy (and 5 relatives) who had emergency service contact in the prior 12 months. Discrete choice experiments were completed by 427 adults with epilepsy (and 167 relatives) who had ambulance service contact in the prior 12 months. Workshops were completed with 27 stakeholders.

Results

The survey identified a range of pathway configurations. They differed in where they would take the patient and their potential to instigate ambulatory care improvements. Users had been rarely consulted in designing them. The discrete choice experiments found that users want a configuration of care markedly different to that offered. Across the seizure scenarios, users wanted their paramedic to have access to their medical records; for an epilepsy specialist (e.g. an epilepsy nurse, neurologist) to be available to advise; for their general practitioner to receive a report; for the incident to generate an appointment with an epilepsy specialist; for the care episode to last < 6 hours; and there was a pattern of preference to avoid conveyance to emergency departments and stay where they were. Stakeholders judged this configuration to be National Health Service-feasible within 5-10 years, with some elements being immediately deployable.

Limitations

The discrete choice experiment sample was broadly representative, but those reporting recent contact with an epilepsy specialist were over-represented.

Conclusions

Users state they want a configuration of care that is markedly different to current provision. The configuration they prefer was, with support and investment, judged to likely be National Health Service-feasible. The preferred configuration should now be developed and evaluated to determine its actual deliverability and efficacy.

Study registration

The study is registered as researchregistry4723.

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: 17/05/62) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 24. See the NIHR Funding and Awards website for further award information.

What impact would reducing low-acuity attendance have on emergency department length of stay? A discrete event simulation modelling study

BACKGROUND

Long waiting times in the ED have been shown to cause negative outcomes for patients. This study aims to assess the effect in reducing length of stay of (1) preventing low-acuity attenders from attending the ED and (2) diverting low-acuity attenders at triage to a colocated general practice (GP) service.

METHODS

Discrete event simulation was used to model a large urban teaching hospital in the UK, as a case study, with a colocated GP service. The Centre for Urgent and Emergency Care research database patient-level database (May 2015-April 2016), secondary literature and expert elicitation were used to inform the model. The model predicted length of stay, the percentage of patients being seen within 4 hours and the incremental cost-effectiveness of the colocated GP service.

RESULTS

The model predicted that diverting low-acuity patients to a colocated GP open 9:00 to 17:00 reduces the average time in the system for higher acuity attenders by 29 min at an estimated additional cost of £6.76 per patient on average. The percentage of higher acuity patients being seen within 4 hours increased from 61% to 67% due to the reduction in the length of stay of those who were in the ED for the longest time. However, the model is sensitive to changes in model inputs and there is uncertainty around ED activity durations, for which further primary data collection would be useful.

CONCLUSION

Reducing the proportion of low-acuity attenders at the ED could have an impact on the time in the ED for higher acuity patients due to their use of shared resources, but is insufficient alone to meet current targets. The simulation model could be adapted for further analyses to understand which other changes would be needed to meet current government targets.

Use of urgent, emergency and acute care by mental health service users: A record-level cohort study

BACKGROUND

People with serious mental illness experience worse physical health and greater mortality than the general population. Crude rates of A&E attendance and acute hospital admission are higher in people with serious mental illness than other hospital users. We aimed to further these findings by undertaking a standardised comparison of urgent and emergency care pathway use among users of mental health services and the general population.

METHODS

Retrospective cohort analysis using routine data from 2013-2016 from the CUREd dataset for urgent and emergency care contacts (NHS 111, ambulance, A&E and acute admissions) and linked mental health trust data for Sheffield, England. We compared annual age- and sex-standardised usage rates for each urgent and emergency care service between users of mental health services and those without a recent history of mental health service use.

RESULTS

We found marked differences in usage rates for all four urgent and emergency care services between the general population and users of mental health services. Usage rates and the proportion of users were 5-6 times and 3-4 times higher in users of mental health services, respectively, for all urgent and emergency care services. Users of mental health services were often more likely to experience the highest or lowest acuity usage characteristics.

CONCLUSIONS

Current users of mental health services were heavily over-represented among urgent and emergency care users, and they made more contacts per-person. Higher service use among users of mental health services could be addressed by improved community care, more integrated physical and mental health support, and more proactive primary care. A complex pattern of service use among users of mental health services suggests this will need careful targeting to reduce avoidable contacts and optimise patient outcomes.

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

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.