OP5 Closing emergency departments in england (CLOSED): the impact on ambulance services

2019 ◽  
Vol 36 (10) ◽  
pp. e4.1-e4
Author(s):  
Emma Knowles ◽  
Neil Shephard ◽  
Tony Stone ◽  
Lindsey Bishop-Edwards ◽  
Enid Hirst ◽  
...  
Keyword(s):  
Emergency Departments ◽  
Control Area ◽  
Ambulance Service ◽  
Urgent Care ◽  
Computer Assisted ◽  
Care Providers ◽  
Interrupted Time Series Analysis ◽  
Additional Increase ◽  
Emergency Ambulance ◽  
The Impact

BackgroundIn recent years a number of Emergency Departments (EDs) in England have closed, or been replaced by a lower acuity facility such as an Urgent Care Centre. With further re-organisation of EDs expected, the ‘closED’ study aimed to provide research evidence to inform the public, NHS, and policymakers when considering future closures. Our aim was to understand the impact of ED closure on populations and emergency care providers, the first study to do so in England. In this session I will focus on the impact on the ambulance service.MethodsWe undertook a controlled interrupted time series analysis assessing changes in ambulance service activity, following the closure of Type 1 EDs in England. Data was sourced data from Ambulance service computer-assisted dispatch (CAD) records. The resident catchment populations of five EDs, closed between 2009 and 2011, were selected for analysis. Five control areas were also selected. The primary ambulance outcome measures were: ambulance service incident volumes and mean ‘call to destination’ time.ResultsThere was some evidence of a large increase of 13.9% [95% confidence interval (CI) 3.5% to 24.4%] in the total number of emergency ambulance incidents compared with the control areas. There was an increase of 3.9 minutes (95% CI 2.2 to 5.6 minutes) in the meantime taken from a 999 ‘red’ call being answered to a patient arriving at hospital.ConclusionsGiven such major reorganisation of emergency and urgent care we might expect some changes in emergency and urgency care activity. Our study found some changes in the ambulance service measures. The increase in emergency ambulance incidents, over and above the increase in the control area, suggests that the closure of the EDs in our study may have contributed to an additional increase in workload within the ambulance services in these areas.

scholarly journals Closing five Emergency Departments in England between 2009 and 2011: the closED controlled interrupted time-series analysis

2018 ◽  
Vol 6 (27) ◽  
pp. 1-234 ◽  
Author(s):  
Emma Knowles ◽  
Neil Shephard ◽  
Tony Stone ◽  
Lindsey Bishop-Edwards ◽  
Enid Hirst ◽  
...  
Keyword(s):  
Time Series ◽  
Outcome Measures ◽  
Emergency Care ◽  
Hospital Admissions ◽  
Interrupted Time Series ◽  
Ambulance Service ◽  
Urgent Care ◽  
Care Providers ◽  
Reliable Evidence ◽  
The Impact

BackgroundIn recent years, a number of emergency departments (EDs) have closed or have been replaced by another facility such as an urgent care centre. With further reorganisation of EDs expected, this study aimed to provide research evidence to inform the public, the NHS and policy-makers when considering local closures.ObjectiveTo understand the impact of ED closures/downgrades on populations and emergency care providers.DesignA controlled interrupted time series of monthly data to assess changes in the patterns of mortality in local populations and changes in local emergency care service activity and performance, following the closure of type 1 EDs.SettingThe populations of interest were in the resident catchment areas of five EDs that closed between 2009 and 2011 (in Newark, Hemel Hempstead, Bishop Auckland, Hartlepool and Rochdale) and of five control areas.Main outcome measuresThe primary outcome measures were ambulance service incident volumes and times, the number of emergency and urgent care attendances at EDs, the number of emergency hospital admissions, mortality, and case fatality ratios.Data sourcesData were sourced from the Office for National Statistics, Hospital Episode Statistics (HES) accident and emergency, HES admitted patient care and ambulance service computer-aided dispatch records.ResultsThere was significant heterogeneity among sites in the results for most of the outcome measures, but the overall findings were as follows: there is evidence of an increase, on average, in the total number of incidents attended by an ambulance following 999 calls, and those categorised as potentially serious emergency incidents; there is no statistically reliable evidence of changes in the number of attendances at emergency or urgent care services or emergency hospital admissions; there is no statistically reliable evidence of any change in the number of deaths from a set of emergency conditions following the ED closure in any site, although, on average, there was a small increase in an indicator of the ‘risk of death’ in the closure areas compared with the control areas.LimitationsUnavailable or unreliable data hindered some of the analysis regarding ED and ambulance service performance.ConclusionsOverall, across the five areas studied, there was no statistically reliable evidence that the reorganisation of emergency care was associated with an increase in population mortality. This suggests that any negative effects caused by increased journey time to the ED can be offset by other factors; for example, if other new services are introduced and care becomes more effective than it used to be, or if the care received at the now-nearest hospital is more effective than that provided at the hospital where the ED closed. However, there may be implications of reorganisation for NHS emergency care providers, with ambulance services appearing to experience a greater burden.Future workUnderstanding why effects vary between sites is necessary. It is also necessary to understand the impact on patient experience. Economic evaluation to understand the cost implications of such reorganisation is also desirable.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Management of non-traumatic epistaxis in adults in the emergency department

2021 ◽  
pp. 1-6
Author(s):  
Ashley Reed ◽  
Martyn Barnes ◽  
Caroline Howard
Keyword(s):  
Emergency Department ◽  
Hospital Admissions ◽  
Interrupted Time Series ◽  
University Teaching ◽  
Attendance Rate ◽  
Interrupted Time Series Analysis ◽  
Current Management ◽  
Emergency Ambulance ◽  
Bed Days ◽  
The Impact

Background/aims Despite epistaxis being a common presentation to emergency departments there is a lack of guidelines, both nationally and internationally, for its management. The authors reviewed the current management of epistaxis and then introduced a new pathway for management to see if care could be improved. The aims were to evaluate the impact of the pathway on reduction of emergency department breaches, emergency ambulance transfers and hospital admissions. Methods The study was an interrupted time series analysis over 29 months and included 903 participants. A pathway for the management of adults with non-traumatic epistaxis was designed and implemented in a university teaching hospital with an emergency department annual attendance rate of 105 495 in 2019–20. Results The pathway led to a 14-minute longer stay in the emergency department, a 5% increase in emergency department breaches, an 8.2% reduction in admissions, a 3.6% reduction in emergency ambulance transfers, a 14.1% increase in nasal cautery and a 3.2% reduction in nasal packing. Conclusions The authors calculate that these results equate to roughly 56 hospital bed days saved, providing better care closer to home for patients, in addition to beneficial knock-on effects for other emergency department and admitted patients.

scholarly journals The impact on patient flow after the integration of nurse practitioners and physician assistants in 6 Ontario emergency departments

CJEM ◽  
2009 ◽  
Vol 11 (05) ◽  
pp. 455-461 ◽  
Author(s):  
James Ducharme ◽  
Robert J. Alder ◽  
Cindy Pelletier ◽  
Don Murray ◽  
Joshua Tepper
Keyword(s):  
Health Care ◽  
Nurse Practitioners ◽  
Emergency Departments ◽  
Patient Flow ◽  
Physician Assistants ◽  
Wait Times ◽  
Care Providers ◽  
Lengths Of Stay ◽  
Left Without Being Seen ◽  
The Impact

ABSTRACT Objective: We sought to assess the impact of the integration of the new roles of primary health care nurse practitioners (NPs) and physician assistants (PAs) on patient flow, wait times and proportions of patients who left without being seen in 6 Ontario emergency departments (EDs). Methods: We performed a retrospective review of health records data on patient arrival time, time of initial assessment by a physician, time of discharge from the ED and discharge status. Results: Whether a PA or NP was directly involved in the care of patients or indirectly involved by being on duty, the wait times, lengths of stay and proportion of patients who left without being seen were significantly reduced. When a PA or NP were directly involved in patients' care, patients were 1.6 (95% confidence interval [CI] 1.3–2.1, p < 0.05) and 2.1 (95% CI 1.6–2.8, p < 0.05) times more likely to be seen within the wait time benchmarks, respectively. Lengths of stay were 30.3% (95% CI 21.6%–39.0%, p < 0.01) and 48.8% (95% CI 35.0%–62.7%, p < 0.01) lower when PAs and NPs, respectively, were involved. When PAs and NPs were not on duty, the proportion of patients who left without being seen were 44% (95% CI 31%–63%, p < 0.01) and 71% (95% CI 53%–96%, p < 0.05), respectively. Conclusion: The addition of PAs or NPs to the ED team can improve patient flow in medium-sized community hospital EDs. Given the ongoing shortage of physicians, use of alternative health care providers should be considered. These results require validation, as their generalizability to other locations or types of EDs is not known.

scholarly journals General practitioners and emergency departments (GPED)—efficient models of care: a mixed-methods study protocol

BMJ Open ◽  
2018 ◽  
Vol 8 (10) ◽  
pp. e024012
Author(s):  
Katherine Morton ◽  
Sarah Voss ◽  
Joy Adamson ◽  
Helen Baxter ◽  
Karen Bloor ◽  
...  
Keyword(s):  
Emergency Department ◽  
Case Studies ◽  
General Practitioners ◽  
Emergency Departments ◽  
Quantitative Methods ◽  
Public Involvement ◽  
Clinical Care ◽  
Urgent Care ◽  
The Uk ◽  
The Impact

IntroductionPressure continues to grow on emergency departments in the UK and throughout the world, with declining performance and adverse effects on patient outcome, safety and experience. One proposed solution is to locate general practitioners to work in or alongside the emergency department (GPED). Several GPED models have been introduced, however, evidence of effectiveness is weak. This study aims to evaluate the impact of GPED on patient care, the primary care and acute hospital team and the wider urgent care system.Methods and analysisThe 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. Prospective case study sites will be identified by completing telephone interviews with sites awarded capital funding by the UK government to implement GPED initiatives. The study has a strong patient and public involvement group that has contributed to study design and materials, and which will be closely involved in data interpretation and dissemination.Ethics and disseminationThe study has been approved by the National Health Service East Midlands—Leicester South Research Ethics Committee: 17/EM/0312. The results of the study will be disseminated through peer-reviewed journals, conferences and a planned programme of knowledge mobilisation.Trial registration numberISRCTN51780222.

scholarly journals The impact of closing emergency departments on mortality in emergencies: an observational study

2019 ◽  
Vol 36 (11) ◽  
pp. 645-651 ◽  
Author(s):  
Emma Knowles ◽  
Neil Shephard ◽  
Tony Stone ◽  
Suzanne M Mason ◽  
Jon Nicholl
Keyword(s):  
Emergency Care ◽  
Emergency Departments ◽  
Hospital Admissions ◽  
Geographical Area ◽  
Case Fatality ◽  
Urgent Care ◽  
Mortality Data ◽  
Risk Of Death ◽  
Population Mortality ◽  
The Impact

BackgroundIn England the demand for emergency care is increasing, while there is also a staffing shortage. This has implications for quality of care and patient safety. One solution may be to concentrate resources on fewer sites by closing or downgrading emergency departments (EDs). Our aim was to quantify the impact of such reorganisation on population mortality.MethodsWe undertook a controlled interrupted time series analysis to detect the impact of closing or downgrading five EDs, which occurred due to concerns regarding sustainability. We obtained mortality data from 2007 to 2014 using national databases. To establish ED resident catchment populations, estimated journey times by road were supplied by the Department for Transport. Other major changes in the emergency and urgent care system were determined by analysis of annual NHS Trust reports in each geographical area studied. Our main outcome measures were mortality and case fatality for a set of 16 serious emergency conditions.ResultsFor residents in the areas affected by closure, journey time to the nearest ED increased (median change 9 min, range 0–25 min). We found no statistically reliable evidence of a change in overall mortality following reorganisation of ED care in any of the five areas or overall (+2.5% more deaths per month on average; 95% CI −5.2% to +10.2%; p=0.52). There was some evidence to suggest that, on average across the five areas, there was a small increase in case fatality, an indicator of the ‘risk of death’ (+2.3%, 95% CI +0.9% to+3.6%; p<0.001), but this may have arisen due to changes in hospital admissions.ConclusionsWe found no evidence that reorganisation of emergency care was associated with a change in population mortality in the five areas studied. Further research should establish the economic consequences and impact on patient experience and neighbouring hospitals.

scholarly journals The Impact of COVID-19 on the Treatment of Craniomaxillofacial Trauma and Head and Neck Infections

2020 ◽  
Vol 06 (04) ◽  
pp. e171-e174
Author(s):  
Heather A. Levites ◽  
Nathaniel L. Quinley ◽  
David B. Powers
Keyword(s):  
Head And Neck ◽  
Health Care Providers ◽  
Peritonsillar Abscess ◽  
Urgent Care ◽  
Care Providers ◽  
Odontogenic Infections ◽  
Craniomaxillofacial Trauma ◽  
Novel Coronavirus ◽  
The Impact ◽  
Head And Neck Infections

AbstractThere is no shortage of news, information, and guidelines with regards to novel coronavirus (COVID-19). However, there is none yet that is specific to the treatment of patients who have sustained trauma or active head and neck infections—frequently encountered from oropharyngeal sources such as peritonsillar abscess or odontogenic infections. The COVID outbreak has not diminished the incidence of these conditions, and in fact has exacerbated access to care by the closing of urgent care treatment centers as well as private dental offices. The purpose of this article is to outline a protocol to protect health care providers in the provision of this care for at-risk patient populations.

scholarly journals Using deterministic record linkage to link ambulance and emergency department data: is it possible without patient identifiers?

2019 ◽  
Vol 4 (1) ◽  
Author(s):  
Sophie Jane Clark ◽  
Mary Halter ◽  
Alison Porter ◽  
Holly Christina Smith ◽  
Martin Brand ◽  
...  
Keyword(s):  
Emergency Department ◽  
Record Linkage ◽  
Emergency Departments ◽  
Data Linkage ◽  
Care Delivery ◽  
Ambulance Service ◽  
Emergency Department Data ◽  
Match Rate ◽  
Emergency Ambulance ◽  
The Uk

IntroductionRoutine linkage of emergency ambulance records with those from the emergency department is uncommon in the UK. Our study, known as the Pre-Hospital Emergency Department Data Linking Project (PHED Data), aimed to link records of all patients conveyed by a single emergency ambulance service to thirteen emergency departments in the UK from 2012-2016. Objectives We aimed to examine the feasibility and resource requirements of collecting de-identified emergency department patient record data and, using a deterministic matching algorithm, linking it to ambulance service data. Methods We used a learning log to record contacts and activities undertaken by the research team to achieve data linkage. We also conducted semi-structured interviews with information management/governance staff involved in the process. Results We found that five steps were required for successful data linkage for each hospital trust. The total time taken to achieve linkage was a mean of 65 weeks. A total of 958,057 emergency department records were obtained and, of these, 81% were linked to a corresponding ambulance record. The match rate varied between hospital trusts (50%-94%). Staff expressed strong enthusiasm for data linkage. Barriers to successful linkage were mainly due to inconsistencies between and within acute trusts in the recording of two ambulance event identifiers (CAD and call sign). Further data cleaning was required on emergency department fields before full analysis could be conducted. Ensuring the data was not re-identifiable limited validation of the matching method. Conclusion We conclude that deterministic record linkage based on the combination of two event identifiers (CAD and call sign) is possible. There is an appetite for data linkage in healthcare organisations but it is a slow process. Developments in standardising the recording of emergency department data are likely to improve the quality of the resultant linked dataset. This would further increase its value for providing evidence to support improvements in health care delivery. Highlights Ambulance records are rarely linked to other datasets; this study looks at the feasibility and resource requirement to use deterministic matching to link ambulance and emergency department data for patients conveyed by ambulance to the emergency department. It is possible to link these data, with an average match rate of 81% across 13 emergency departments and one large ambulance trust. All trusts approached provided match-able data and there was an appetite for data linkage; however, it was a long process taking an average of 65 weeks. We conclude that deterministic matching using no patient identifiers can be used in this setting.

Impact of an electronic best-practice advisory in combination with prescriber education on antibiotic prescribing for ambulatory adults with acute, uncomplicated bronchitis within a large integrated health system

2019 ◽  
Vol 40 (12) ◽  
pp. 1348-1355 ◽  
Author(s):  
Courtney M. Pagels ◽  
Thomas J. Dilworth ◽  
Lynne Fehrenbacher ◽  
Maharaj Singh ◽  
Charles F. Brummitt
Keyword(s):  
Health System ◽  
Emergency Departments ◽  
Best Practice ◽  
Acute Bronchitis ◽  
Primary Diagnosis ◽  
Urgent Care ◽  
Absolute Difference ◽  
Antibiotic Prescribing ◽  
Practice Advisory ◽  
The Impact

AbstractObjective:To determine the impact of a passive, prescriber-directed, electronic best-practice advisory coupled with prescriber education on the rate of antibiotic prescribing for acute, uncomplicated bronchitis in ambulatory adults across a large health system.Design:This study was a quasi-experiment examining antibiotic prescribing for ambulatory adults with acute bronchitis from January 1, 2016 through December 31, 2018. The intervention was implemented in December 2016 for emergency departments and urgent care clinics followed by ambulatory clinics in September 2017.Setting:Outpatient settings across a health system, including 15 emergency departments, >30 urgent care clinics, and >150 ambulatory clinics.Participants:All adults with a primary diagnosis of acute bronchitis who were seen and discharged from a study site were included.Interventions:A passive, prescriber-directed, best-practice advisory for treatment of acute bronchitis in the electronic health record and an optional, online education module regarding acute bronchitis.Results:The study included 81,975 ambulatory adults with a primary diagnosis of acute bronchitis during the preintervention period (19.8% >65 years of age; 61.9% female) and 89,571 ambulatory adults during the postintervention period (16.5% >65 years of age; 61.1% female). Antibiotic prescribing rates decreased from 60.8% (49,877 of 81,975 patients) preintervention to 51.4% (46,018 of 89,571 patients) postintervention (absolute difference, 9.4%; P < .001). The largest reduction occurred in the emergency departments.Conclusions:An electronic best practice advisory combined with prescriber education was associated with a statistically significant reduction in antibiotic prescribing for adults with acute bronchitis. Future studies should incorporate patient education and address prescriber-reported barriers to appropriate antibiotic prescribing.

scholarly journals Reducing repeat paediatric emergency department attendance for non-urgent care: a systematic review of the effectiveness of interventions

2019 ◽  
pp. emermed-2018-207536 ◽  
Author(s):  
Brenda Agyeiwaa Poku ◽  
Pippa Hemingway
Keyword(s):  
Systematic Review ◽  
Meta Analysis ◽  
Experimental Studies ◽  
Primary Care Providers ◽  
Urgent Care ◽  
Care Providers ◽  
Quasi Experimental ◽  
The Usa ◽  
The Impact

ObjectiveNon-urgent paediatric ED (PED) visits appear to contribute a large portion to the growing use of EDs globally. Several interventions have tried to curb repeated non-urgent attendances, but no systematic review of their effectiveness exists. This review examines the effectiveness of interventions designed to reduce subsequent non-urgent PED visits after a non-urgent attendance.MethodA systematic review design. A systematic search of four databases and key journals was conducted from their inception to November 2018. Experimental studies, involving children aged 0–18 years presenting to an ED for non-urgent care, which assessed the effectiveness of interventions on subsequent non-urgent attendance were considered.Results2120 studies were identified. Six studies, including four randomised controlled trials (RCTs) and two quasi-experimental, were included. Studies were of moderate quality methodologically. All studies originated from the USA and involved informational and/or follow-up support interventions. Only two RCTs demonstrated the longest duration of intervention effects on reducing subsequent non-urgent PED attendance. These studies identified participants retrospectively after ED evaluation. The RCT with the largest number of participants involved follow-up support by primary physicians. Meta-analysis was impractical due to wide heterogeneity of the interventions.ConclusionsThere is inconclusive evidence to support any intervention aimed at reducing subsequent non-urgent PED visits following a non-urgent attendance. The long-term impact of interventions is limited, although the effect may be maximised if delivered by primary care providers in children identified after their ED attendance. However, further research is required to evaluate the impact of any such strategies in settings outside the USA.

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