1502 Geospatial visualisation of emergency department attendance rates and their associations with deprivation and non-urgent attendances

Aims, Objectives and Background

Attendances at emergency departments in England continue to increase above the capacity of the urgent and emergency care system. There is significant variability in the rates of attendance at emergency departments across different localities. The aim of this study is to model the association of deprivation and non-urgent attendances with locality-based emergency department attendance rates. The secondary aim is to create an interactive data visualisation tool to engage stakeholders, clinicians, and the public with the research.

Method and Design

We undertook a retrospective, observational study using routinely collected emergency department attendance data from Yorkshire and the Humber (population 5.4 million) between January 2013 and March 2017. We calculated average annual age and sex standardised attendance rates at emergency departments for small localities known as lower layer super output areas.

The association between emergency department attendance rates, deprivation and non-urgent attendances was examined using multivariable linear and logistic regression models, which were adjusted for travel time to the nearest emergency department.

The data was visualised to create an interactive choropleth map using R.

Abstract 1502 Figure 1

Screenshot of interactive data visualisation tool showing age and sex standardised annual emergency department attendance rates in Yorkshire and the Humber

Results and Conclusion

The analytical sample included 6,389,383 attendances across 2,880 localities, with a median age and sex standardised annual emergency department attendance rate of 308 per 1000 population (interquartile range 130).

The fully adjusted linear regression model was significant (Adjusted R2 = 0.648, F (7, 2872)=757, p<0.001 ). Higher locality-based emergency department attendance rates were significantly predicted by each increasing decile of deprivation (β =14.8, p=0.002), each minute less of travel time to the emergency department (β = 7.86, p<0.001) and each percent greater proportion of low acuity attendances (β = 8.61, p<0.001).

A large proportion of the variability in emergency department attendance rates in different geographical areas can be explained by deprivation levels and proportion of non-urgent attendances. This provides an opportunity for targeted interventions to reduce emergency department attendances.

Patient compliance with NHS 111 advice: Analysis of adult call and ED attendance data 2013-2017

The NHS 111 telephone advice and triage service is a vital part of the management of urgent and emergency care (UEC) services in England. Demand for NHS 111 advice has increased since its introduction in 2013, and the service is of particular importance in light of the current pandemic and resulting increased demand for emergency care. Currently, little is known about the effectiveness of NHS 111 in terms of the appropriateness of the advice given, or about the compliance of patients with that advice. We aimed to address this issue by analysing a large linked routine dataset of all NHS 111 calls (n = 3,631,069) and subsequent emergency department (ED) attendances made in the Yorkshire & Humber region from March 2013-March 2017. We found that many patients do not comply with advice, with 11% (n = 289,748) of patients attending ED when they are advised to self-care or seek primary care. We also found that a considerable number of these patients are further classed as urgent (88%, n = 255,931) and a substantial minority (37%, 106,207) are subsequently admitted to hospital. Further, many patients who are sent an ambulance or told to attend ED are classed as non-urgent upon attending ED (9%, n = 42,372). This research suggests that the level at which NHS 111 is currently triaging results in many hundreds of thousands of mis-triaged cases annually. Additionally, patients frequently do not comply with the advice they receive. This has implications for understanding the accuracy and efficiency of triaging systems.

027 The utilisation of urgent emergency care services by older care home residents in the UK and the subsequent impact on emergency departments

Background

Urgent and Emergency Care Services (UECS) in the UK are under increasing pressure. Although accounting for a small proportion of Emergency Department (ED) attendances, there is a continually rising demand for the care of older people. Currently, there is limited data surrounding older care home (CH) residents and their use of UECS, thus this study aims to investigate the characteristics of older CH resident UECS utilisation and factors that influence ED transfer.

Method and results

Interviews were undertaken with healthcare and CH staff to elicit views around: the characteristics of ED attendances; demand placed upon UECS; alternative services; and interventions to reduce demand. Routine administrative data was collected for 21583 patients aged ≥75 from one large, urban type 1 ED in Yorkshire and Humber (Y&H) between April 2016 and March 2017. CH residents were identified to characterise attendances.

Conclusions

CH residents were more likely to arrive by ambulance, OR of 3.810 (95% CI: 3.316–4.378, p<0.001); breach the four-hour target, OR of 1.321 (95% CI: 1.223–1.427, p<0.001); have an investigation, OR of 1.196 (95% CI: 1.035–1.381, p=0.015); receive resuscitation treatment, OR of 1.559 (95% CI: 1.409–1.725, p<0.001); and have a long inpatient admission (>2 days), OR of 2.083 (95% CI: 1.933–2.245, p<0.001) compared with non-care home residents (NCH) reflecting greater demand upon UECS. Interviews revealed ED transfer decisions were complex and reliant upon communication with the wider healthcare system and the risk averse attitudes of CH staff. Increased training of CH staff, advanced care planning and integrating healthcare services into the CH were suggestions to reduce the demands CH residents place upon UECS.

This study reflects the demand CH residents place on UECS compared with NCH residents and highlights the importance of investigating factors influencing ED transfer. This will help to create targeted interventions to improve resident care and reduce UECS demand.

What evidence is there for a relationship between organisational features and patient outcomes in congenital heart disease services? A rapid review

Background

The purpose of this rapid evidence synthesis is to support the current NHS England service review on organisation of services for congenital heart disease (CHD). The evidence synthesis team was asked to examine the evidence on relationships between organisational features and patient outcomes in CHD services and, specifically, any relationship between (1) volume of cases and patient outcomes and (2) proximity of colocated services and patient outcomes. A systematic review published in 2009 had confirmed the existence of this relationship, but cautioned this was not sufficient to make recommendations on the size of units needed.

Objectives

To identify and synthesise the evidence on the relationship between organisational features and patient outcomes for adults and children with CHD.

Data sources

A systematic search of medical- and health-related databases [MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), The Cochrane Library and Web of Science] was undertaken for 2009–14 together with citation searching, reference list checking and stakeholder recommendations of evidence from 2003 to 2014.

Review methods

This was a rapid review and, therefore, the application of the inclusion and exclusion criteria to retrieved records was undertaken by one reviewer, with 10% checked by a second reviewer. Five reviewers extracted data from included studies using a bespoke data extraction form which was subsequently used for evidence synthesis. No formal quality assessment was undertaken, but the usefulness of the evidence was assessed together with limitations identified by study authors.

Results

Thirty-nine papers were included in the review. No UK-based studies were identified and 36 out of 39 (92%) studies included only outcomes for paediatric patients. Thirty-two (82%) studies investigated the relationship between volume and mortality and seven (18%) investigated other service factors or outcomes. Ninety per cent were from the USA, 92% were multicentre studies and all were retrospective observational studies. Twenty-five studies (64%) included all CHD conditions and 14 (36%) included single conditions or procedures. Although the evidence does demonstrate a relationship between volume and outcome in the majority of studies, this relationship is not consistent. The relationship was stronger for single-complex conditions or procedures. A mixed picture emerged revealing a range of factors as well as volume that influence outcome, including condition severity, individual centre and surgeon effects and clinical advances over time. We found limited (seven studies) evidence about the impact of proximity and colocation of services on outcomes, and about volume on non-mortality outcomes.

Limitations

This was a rapid review that followed standard methods to ensure transparency and reproducibility. The main limitations of the included studies were the retrospective nature, reliance on routine data sets, completeness, selection bias and lack of data on key clinical and service-related processes.

Conclusions

This review identified a substantial number of studies reporting a positive relationship between volume and outcome, but the complexity of the evidence requires careful interpretation. The heterogeneity of findings from observational studies suggests that, while a relationship between volume and outcome exists, this is unlikely to be a simple, independent and directly causal relationship. The effect of volume on outcome relative to the effect of other as yet undetermined health system factors remains a complex and unresolved research question.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

An evaluation of foundation doctor training: a mixed-methods study of the impact on workforce well-being and patient care [the Evaluating the Impact of Doctors in Training (EDiT) study]

Background

A major reform of junior doctor training was undertaken in 2004–5, with the introduction of foundation training (FT) to address perceived problems with work structure, conditions and training opportunities for postgraduate doctors. The well-being and motivation of junior doctors within the context of this change to training (and other changes such as restrictions in working hours of junior doctors and increasing demand for health care) and the consequent impact upon the quality of care provided is not well understood.

Objectives

This study aimed to evaluate the well-being of foundation year 2 (F2) doctors in training. Phase 1 describes the aims of delivering foundation training with a focus on the role of training in supporting the well-being of F2 doctors and assesses how FT is implemented on a regional basis, particularly in emergency medicine (EM). Phase 2 identifies how F2 doctor well-being and motivation are influenced over F2 and specifically in relation to EM placements and quality of care provided to patients.

Methods

Phase 1 used semistructured interviews and focus groups with postgraduate deanery leads, training leads (TLs) and F2 doctors to explore the strategic aims and implementation of FT, focusing on the specialty of EM. Phase 2 was a 12-month online longitudinal study of F2 doctors measuring levels of and changes in well-being and motivation. In a range of specialties, one of which was EM, data from measures of well-being, motivation, intention to quit, confidence and competence and job-related characteristics (e.g. work demands, task feedback, role clarity) were collected at four time points. In addition, we examined F2 doctor well-being in relation to quality of care by reviewing clinical records (criterion-based and holistic reviews) during the emergency department (ED) placement relating to head injury and chronic obstructive pulmonary disease (COPD).

Results

Phase 1 of the study found that variation exists in how successfully FT is implemented locally; F2 lacks a clearly defined end point; there is a minimal focus on the well-being of F2 doctors (only on the few already shown to be ‘in difficulty’); the ED presented a challenging but worthwhile learning environment requiring a significant amount of support from senior ED staff; and disagreement existed about the performance and confidence levels of F2 doctors. A total of 30 EDs in nine postgraduate medical deaneries participated in phase 2 with 217 foundation doctors completing the longitudinal study. F2 doctors reported significantly increased confidence in managing common acute conditions and undertaking practical procedures over their second foundation year, with the biggest increase in confidence and competence associated with their ED placement. F2 doctors had levels of job satisfaction and anxiety/depression that were comparable to or better than those of other NHS workers, and adequate quality and safety of care are being provided for head injury and COPD.

Conclusions

There are ongoing challenges in delivering high-quality FT at the local level, especially in time-pressured specialties such as EM. There are also challenges in how FT detects and manages doctors who are struggling with their work. The survey was the first to document the well-being of foundation doctors over the course of their second year, and average scores compared well with those of other doctors and health-care workers. F2 doctors are benefiting from the training provided as we found improvements in perceived confidence and competence over the year, with the ED placement being of most value to F2 doctors in this respect. Although adequate quality of care was demonstrated, we found no significant relationships between well-being of foundation doctors and the quality of care they provided to patients, suggesting the need for further work in this area.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.