MedicalResearch.com Interview with:
Jonathan Pinkney MD FRCP
Professor of Medicine
Plymouth University and Peninsula Schools of Medicine and Dentistry
Centre for Clinical Trials and Population Studies
Plymouth Science Park Phase 1
Honorary Consultant Physician Diabetes and Endocrinology
University Medicine Derriford Hospital
Plymouth Hospitals NHS Trust
Medical Research: What is the background for this study?
Dr. Pinkney: The background is that the study was funded by the National Institute for Health Research in response to a call for research on the problem of unscheduled emergency admissions to hospitals in the UK. The rates of patient attendance at emergency departments and subsequent acute admissions to hospitals have risen year on year. Rising numbers of admissions have significant knock-on effects for acute hospitals including crowding in emergency departments, pressures on staffing, and disruption of elective treatment because of high rates of bed occupancy. The increase in admissions has been associated largely with increased short stay admissions. As a result, there has been an increasing view that a significant proportion of acute medical admissions may not be necessary, and in this respect may be said to be avoidable. There had been relatively limited research on how hospitals can best reduce these avoidable admissions.
The main aims of the study were to investigate how senior staff in four major acute hospitals in south west England endeavour to avoid unnecessary acute admissions, and to examine a range of different systems in place in different hospitals to avoid unnecessary admissions. We called this project the “3A” or Avoidable Acute Admissions study. The 3A study was a mixed methods study with a strong emphasis on the narrative experience of patients, carers and healthcare professionals in the emergency departments and associated units of these four acute hospitals. The quantitative component of the study was an application of Value Stream Mapping (VSM), a technique from lean theory, and this was used to identify and measure points of delay in the patient journey.
Medical Research: What are the main findings?
Dr. Pinkney: The main results of the study can be viewed as the experience of patients and their carers, the detailed opinions of healthcare professionals, and observations on the contrasting care configurations used to meet the high demand and reduce unnecessary admissions.
· Patients’ experiences of their treatment in these busy emergency units were generally positive. While the pressures in these departments were often visible, patients didn’t tend to express concerns, although carers, friends and relatives were sometimes more vocal. On occasion, the apparent focus on patient “flow” could limit time for basic care and communication.
· The VSM study showed that the time spent by patients being assessed, admitted or discharged was similar in the four hospitals, despite their somewhat contrasting care configurations. However, there were significant differences in waiting times before being seen, for tests, or after admission decisions.
· This study found that the 4-hour target was a key driver affecting the timing of the decision to admit or discharge a patient. So, most of these decisions were made between 3.5 and 4 hours, suggesting that the target may be forcing the decision either way, at least for some patients.
· The senior and experienced medical staff clearly played a major role in delivering frontline care at all hospitals, but interestingly they were deployed in a wide range of quite different ways, and these also related to structural differences in the organisation of care at the four hospitals. Different ways of using hospital ‘space’ were found. In particular, hospital emergency departments with capacity for “Clinical Decision Units” or “Observation Units” could accommodate potentially dischargeable patients with medical and/or social problems ‘off the clock’, so they were no longer subject to a forced decision to discharge or admit simply to avoiding breach of the target. There is the potential for inappropriate admission to result by default simply because the team can’t fully sort out alternative arrangements within 4 hours. Therefore, these units allow essential time for tests, period of observation and time to make safe discharge arrangements. New workforce arrangements also supported admission avoidance: One notable innovation was an Acute GP Service – run from a well resourced unit staffed by experienced GPs, that assessed all GP referrals on an ambulatory car basis, frequently succeeding in treating and discharging without unnecessary admissions. Discharge teams were also prominent in several hospitals, providing multidisciplinary expertise, for example in Elder Care, physiotherapy and occupational therapy, and these teams linked with community services. In the emergency units, senior doctors had a range of roles, selecting and evaluating more complex patients, but also advising and training juniors. One hospital had developed an innovative “controller” system in its emergency department, where one emergency consultant acted in a desk-based purely advisory role – monitoring activity, advising and directing, and teaching and training junior doctors as they managed . This innovation enabled all patients to benefit from early input of an experienced consultant, without compromising the training of juniors.
· The study suggested several additional factors that may be associated with increased likelihood of admission, and these included less experienced staff who may be unable to establish a management plan soon enough within the 4–hour target time, or less able to assess and manage risk, and when there is a high percentage of locum staff who are unfamiliar with local pathways and available alternatives to admission.
Medical Research: What should clinicians and patients take away from your report?
Dr. Pinkney: Clinicians can observe the potential value of a variety of different care configurations and initiatives that can help to reduce the chances of unnecessary admissions. The study suggested that the availability of a variety of alternatives pathways for selected patient groups in emergency departments, or diversion into other types of units, may be important to avoid unnecessary admissions through pressured emergency departments subject to the 4-hour target. Some of these innovations are already in relatively widespread use although the extent of their use, and therefore the capacity of these units varies very considerably. There appeared to be scope to use some of these innovations more widley in some hospitals. In some cases, better use could be made of ambulatory care facilities and clinical decision units. Other innovations appeared relatively unique in the study, such as a hospital based acute GP service and the “controller” system in the emergency department. There was a range of ideas that clinicians could take away from the 3A study.
In general, patients will probably feel reassured that the many patients who were interviewed in this study expressed considerable confidence in the care they received, despite the obvious pressures faced by these emergency departments. All these units, in different ways were clearly trying to respond to patients’ needs and reach decisions to admit or discharge appropriatley.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Pinkney: Future research could benefit by learning from the experience of patients and staff as in this study.
Pinkney J, Rance S, Benger J, Brant H, Joel-Edgar S, Swancutt D, et al.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. Health Serv Deliv Res 2016;4(3)
Jonathan Pinkney MD FRCP (2016). Avoidable Acute Admissions From Emergency Room Driven By Time and Space Pressures MedicalResearch.com