How can frontline expertise and new models of care best contribute to safely reducing avoidable acute admissions? A mixed-methods study of four acute hospitals

Project report


Pinkney, Jonathan, Rance, S., Benger, Jonathan, Brant, Heather, Joel-Edgar, Sian, Swancutt, Dawn, Westlake, Debra, Pearson, Mark, Thomas, Daniel, Holme, Ingrid, Endacott, Ruth, Anderson, Rob, Allen, Michael, Purdy, Sarah, Campbell, John, Sheaff, Rod and Byng, Richard 2016. How can frontline expertise and new models of care best contribute to safely reducing avoidable acute admissions? A mixed-methods study of four acute hospitals. National Institute for Health Research Journals Library.
AuthorsPinkney, Jonathan, Rance, S., Benger, Jonathan, Brant, Heather, Joel-Edgar, Sian, Swancutt, Dawn, Westlake, Debra, Pearson, Mark, Thomas, Daniel, Holme, Ingrid, Endacott, Ruth, Anderson, Rob, Allen, Michael, Purdy, Sarah, Campbell, John, Sheaff, Rod and Byng, Richard
TypeProject report
Abstract

Background

Hospital emergency admissions have risen annually, exacerbating pressures on emergency departments (EDs) and acute medical units. These pressures have an adverse impact on patient experience and potentially lead to suboptimal clinical decision-making. In response, a variety of innovations have been developed, but whether or not these reduce inappropriate admissions or improve patient and clinician experience is largely unknown.
Aims

To investigate the interplay of service factors influencing decision-making about emergency admissions, and to understand how the medical assessment process is experienced by patients, carers and practitioners.
Methods

The project used a multiple case study design for a mixed-methods analysis of decision-making about admissions in four acute hospitals. The primary research comprised two parts: value stream mapping to measure time spent by practitioners on key activities in 108 patient pathways, including an embedded study of cost; and an ethnographic study incorporating data from 65 patients, 30 carers and 282 practitioners of different specialties and levels. Additional data were collected through a clinical panel, learning sets, stakeholder workshops, reading groups and review of site data and documentation. We used a realist synthesis approach to integrate findings from all sources.
Findings

Patients’ experiences of emergency care were positive and they often did not raise concerns, whereas carers were more vocal. Staff’s focus on patient flow sometimes limited time for basic care, optimal communication and shared decision-making. Practitioners admitted or discharged few patients during the first hour, but decision-making increased rapidly towards the 4-hour target. Overall, patients’ journey times were similar, although waiting before being seen, for tests or after admission decisions, varied considerably. The meaning of what constituted an ‘admission’ varied across sites and sometimes within a site. Medical and social complexity, targets and ‘bed pressure’, patient safety and risk, each influenced admission/discharge decision-making. Each site responded to these pressures with different initiatives designed to expedite appropriate decision-making. New ways of using hospital ‘space’ were identified. Clinical decision units and observation wards allow potentially dischargeable patients with medical and/or social complexity to be ‘off the clock’, allowing time for tests, observation or safe discharge. New teams supported admission avoidance: an acute general practitioner service filtered patients prior to arrival; discharge teams linked with community services; specialist teams for the elderly facilitated outpatient treatment. Senior doctors had a range of roles: evaluating complex patients, advising and training juniors, and overseeing ED activity.
Conclusions

This research shows how hospitals under pressure manage complexity, safety and risk in emergency care by developing ‘ground-up’ initiatives that facilitate timely, appropriate and safe decision-making, and alternative care pathways for lower-risk, ambulatory patients. New teams and ‘off the clock’ spaces contribute to safely reducing avoidable admissions; frontline expertise brings value not only by placing senior experienced practitioners at the front door of EDs, but also by using seniors in advisory roles. Although the principal limitation of this research is its observational design, so that causation cannot be inferred, its strength is hypothesis generation. Further research should test whether or not the service and care innovations identified here can improve patient experience of acute care and safely reduce avoidable admissions.

Year2016
PublisherNational Institute for Health Research Journals Library
ISSN2050-4357
2050-4349
Web address (URL)http://dx.doi.org/10.3310/hsdr04030
http://www.journalslibrary.nihr.ac.uk/hsdr
FunderNational Institute for Health Research, Health Services and Delivery Research programme
National Institute for Health Research
Publication dates
PrintJan 2016
Publication process dates
Deposited03 Feb 2016
AcceptedAug 2015
Copyright information© Queen’s Printer and Controller of HMSO 2016. This work was produced by Pinkney et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
Additional information

This research report and scientific summary were published in Health Services and Delivery Research, 2016, 4(3).

Series Health Services and Delivery Research
JournalHealth Services and Delivery Research
Journal citation4 (3), pp. 1-202
Publisher's version
License
CC BY-NC
Publisher's version
License
CC BY-NC
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