OUHT emergency department attendances: audit of patients brought in by ambulance

Transcription

1 ED attendances audit report Page 1 of 14 OUHT emergency department attendances: audit of patients brought in by ambulance November, 2013 Members of Working Group: Adam Briggs David Mant Karen Kearley Hywel Jones Paul Brennan James Price Members of the Audit Team: Adam Briggs David Mant Karen Kearley James Price Sudhir Singh Larry Fitton John Black Linda Scott Kirsty Stuart Amar Latif Barbara Batty

2 ED attendances audit report Page 2 of 14 Executive Summary Introduction Following a recent analysis of trends in emergency department (ED) attendances at the Oxford University Hospitals NHS Trust (OUHT), it was recommended that the management of patients arriving by ambulance between April 2012 and March 2013 should be audited to identify patients who could have been managed without attending the ED. Key findings Ten senior healthcare professionals audited 97 ED attendances. The majority of patients were from Oxfordshire, and about half called the ambulance between 8am and 6pm. Without exception, the standard of decision making by ambulance crews was excellent given the choices available to them at the time. In about a third of ED attendances (36%, 95% confidence intervals: 24% to 48%) patient s needs could have been met without ED attendance if alternative care facilities had been available in the community. Most of the potentially avoidable admissions were cases where the patient s condition was stable and the admission was primarily for assessment. Obtaining advice from primary care was repeatedly identified as a barrier to preventing conveyance to ED. This was particularly the case during out-ofhours (OOH) where ambulance crews have to phone through the 111 system to speak to an OOH GP rather than having access via a direct number. For certain patients (such as those in residential care or with chronic conditions, and those receiving end-of-life care) advanced patient care plans could prevent inappropriate ambulance call outs and subsequent ED attendances and hospital admissions. SCAS specific recommendations 1. Provision should be made for direct communication, 24 hours a day and seven days a week, between ambulance crews and GP services for the provision of clinical advice, particularly discussion of non-ed care options, and to allow safety netting. 2. South Central Ambulance Services should re-circulate information to crew members on which patients may be transferred to the Abingdon Emergency Multidisciplinary Unit. 3. Patient care plans, available to SCAS, should be agreed for high-risk patients who may trigger an ambulance call but will not benefit from ED attendance. 4. Plans for direct access to specialist services (such as acute psychiatric care) should be agreed for specific patient groups.

3 ED attendances audit report Page 3 of 14 Further recommendations, also made in the audit of short-term emergency admissions 1 1. OUHT should explore alternative cost-effective organisational solutions for delivering a community assessment and investigative function. Specifically it should consider whether following other Trusts in establishing integrated ambulatory care centres outside the Emergency Department (ED) is likely to reduce breaching, attendances at ED, and emergency admissions for investigation. 2. Cross-sector clinical management policies should be written for key care pathways, as agreed by an expert group with representatives from OUHT, the CCG, SCAS, adult social care, and academia. These policies should stipulate what risk assessment will be made, what investigations will be done to investigate risk, the use of individual patient management plans, and the possibility of direct referral to specialist care. 3. OUHT should seek support from both the Oxford Collaboration in Leadership for Applied Health Research and Care (CLAHRC) and Biomedical Research Centre (BMC) to develop and evaluate the cost-effectiveness of the relevant elements of the existing interface medicine initiative in liaison with the University. This should be alongside the on-going evaluation of the Abingdon Emergency Multidisciplinary Unit. 1 OUHT Emergency Attendances and Admissions Joint Working Group OUHT Emergency Admissions: audit of short-term emergency admissions at ages OUHT and Oxfordshire CCG.

4 ED attendances audit report Page 4 of Introduction Over the past ten years, emergency admissions and emergency department (ED) attendances have been increasing both in the South Central region and across England as a whole In the five years between 2008/9 and 2012/13, emergency admissions to OUHT increased by 16.8% and ED attendances by 10.8%. The majority of the increases in activity are found at the John Radcliffe Hospital (JRH) with only about a third attributable to population change. Following a recent analysis of rising OUHT trends in ED attendances and emergency admissions, 5 several recommendations were made to address the issue. Included in these recommendations was the following: Recommendation 3 To reduce the number of emergency admissions and ED attendances, the reasons for the substantial unexplained increase in ambulance arrivals need to be investigated urgently through auditing JRH ED patient notes and South Central Ambulance Service notes in liaison with the South Central Ambulance Service. Strategies to reduce the number of inappropriate arrivals should be identified. This recommendation is based on the fact that the increase in ED attendances between 2008/9 and 2012/13 was 14.6% at the JRH compared to just 2.3% at the Horton and that 73.4% of the overall increase in ED attendances were due to patients being brought by ambulance. 2 Appelby J Are accident and emergency attendances increasing? The King s Fund. 3 Blunt I, Bardsley M, Dixon J Trends in emergency admissions in England The Nuffield Trust 4 The King s Fund Urgent and Emergency Care. A review for NHS South of England. The King s Fund 5 OUHT Emergency Attendances and Admissions Joint Working Group OUHT Emergency Department Attendances and Emergency Admissions 2008/9 to 2012/13. OUHT and Oxfordshire CCG.

5 ED attendances audit report Page 5 of Methods A random sample was drawn of 217 South Central Ambulance Service (SCAS) records and ED notes of patients attending the JRH ED between 1 st April 2012 and 31 st March 2013 (the patient group of interest, see figure 1 for the number of patients from which those included in the audit were selected). Figure 1. Derivation of sampling frame for selection of patient notes Approximately 23% of notes were unavailable at the time of request due to them not being in the ED department filing system; this is usually due to the notes being in clinical use. Therefore 280 ED attendances were identified in order for 217 sets of notes to be retrieved. The audit was performed over a working day by four senior GPs, four OUHT hospital consultants in either acute medicine or emergency medicine (including the medical director for SCAS), and two senior paramedics from SCAS. The audit team was divided into two groups with a representative from OUHT, primary care, and SCAS in each group. Initially six sets of notes were reviewed by both groups to identify and discuss any inter-group variability when extracting the relevant data (see appendix for a copy of the data extraction form used). Following this validation exercise, the two groups independently reviewed consecutive sets of notes; an hour before lunch and an hour before close were set aside to allow for discussion among the entire audit team of more complicated cases and of any overarching themes. One hundred sets of notes were reviewed and no useful information pertaining to the audit was identified in three cases. Of the remaining 97 ED attendances reviewed, the ED notes were available for all 97 attendances and SCAS notes for 78 (80%).

6 ED attendances audit report Page 6 of 14 The data extraction form (see appendix) was designed to identify the needs of the patient and whether they could feasibly have been met without admission (questions 1 and 2 on the form). Group discussions focused on common themes identified across attendances and on potential mechanisms for addressing the patients needs in alternative settings. Both a quantitative analysis of the data extracted and a qualitative analysis of the main themes raised in discussion are presented here.

7 ED attendances audit report Page 7 of Results 3.1 Quantitative analysis Characteristics of sample Of the 97 attendances with relevant information available, the age range of patients was 0 years to 92 years (interquartile range years, average 49 years), the majority were from Oxfordshire (83/97, 86%), and about half of attendances audited phoned the ambulance between 8am and 6pm (45, 46%). Of the attendances with the number of previous attendances to ED in the past 12 months recorded (85/97), 65% of patients were attending for the first time, 27% had attended 1-2 times, and 8% had attended three or more times in the past 12 months Necessity of attendances Sixty-one per cent of ED attendances (59/97) were thought to be definitely unavoidable (i.e. the audit team could think of no feasible changes that could be made to the current provision of healthcare in Oxfordshire that would have prevented the attendance) with a further single attendance thought to be probably unavoidable. In the case of two attendances the panel was unsure about whether the attendance was avoidable or not. However, 35 (36%, 95% confidence intervals: 24% to 48%) ED attendances were considered definitely or probably avoidable if appropriate changes could be made to existing healthcare provision. Based on these 35 attendances, the most common primary need which panel members felt could have been met without an ED attendance - or if met differently would have avoided ED attendance was for some form of clinical assessment (34 of the 35 attendances, 97%). A secondary need for diagnostics and treatment was identified for 10 (29%) and 9 (26%) attendances respectively. In 18 of the 35 attendances (51%) it was thought that primary care (either in or out of hours) were best placed to have addressed the relevant need in order to avoid an ED attendance; an ambulatory care centre was identified as being the ideal solution in 14 (40%) attendances. Examples of avoidable attendances include: A young infant attending the ED out of hours with signs of a respiratory illness where a GP assessment and reassurance may have been sufficient. A more complex patient in their sixties having a fall in the middle of the day where subsequent assessment and diagnostics could have taken place in an ambulatory centre. An elderly patient attending following a fall at home where either a primary care visit or assessment in an ambulatory care setting may have been more appropriate.

8 ED attendances audit report Page 8 of Qualitative observations Key issues identified 1. The decision making by ambulance crews as to whether to transfer a patient to hospital was entirely appropriate for all cases examined. 2. For the majority of attendances, most were unavoidable and required immediate hospital-level assessment, investigation, and management. 3. Most of the potentially avoidable admissions were cases where the patient s condition was stable and the admission was primarily for assessment. Under these circumstances, it was evident that often the ambulance crew had no alternative option but to take the patient to the ED, whereas a less acute setting may have been more appropriate. 4. Of the attendances where feasible changes to the provision of care could have avoided an ED attendance, difficulties with ambulance crews being able to obtain advice from primary care were identified as a barrier to preventing conveyance to ED. This was particularly the case during out-of-hours (OOH) where ambulance crews phone through to the duty clinician in the 111 call centre to request a 20 minute call back from an OOH GP rather than having access via a direct number. 5. For certain cases, such as those attending from a residential care setting and those with chronic conditions, greater provision of, and access to, advanced patient care plans could prevent inappropriate ambulance call outs and subsequent ED attendances and hospital admissions. 6. The provision of an ambulatory assessment centre either in the community or co-located with the ED could prevent attendances where multidisciplinary assessment and minor investigations and treatment are required (identified in 16 of the 97 attendances audited). Such centres would ideally be staffed 24 hours a day, seven days a week. 7. For some of the patients who could have had their needs addressed outside of the ED, ambulance crews were not aware that the Abingdon Emergency Multidisciplinary Unit (EMU) may have been appropriate for that particular patient. 8. It was unclear how best to manage patients who repeatedly attend the ED with problems such as long standing substance addiction or psychiatric illness. Currently these patients are best managed through the ED however in the future direct access to specialist clinical settings (such as acute psychiatric care in the absence of the requirement for any physical health intervention) may be possible in order to optimise care. It was recognised that this provision of care is unlikely to be feasible in the immediate future.

9 ED attendances audit report Page 9 of For two admissions, the patient need was for end-of-life care. Discussion among the audit team identified that the provision of clear management plans in the community (including advanced do-not-attempt-resuscitation orders when appropriate) is often not adequate, and where appropriate such documentation needs to be agreed in advance and to be accessible across the health system. Such orders should then be reviewed on a regular basis and when a patient s clinical location or clinical condition changes. 10. For many of the ED attendances that were audited, it was felt by the audit team that patient care would be improved with direct access to specialist clinical services rather than the patient having first to be triaged in ED. This would be relevant for patients with clinical conditions that require specialist assessment, investigations, and treatment. To facilitate this there would need to be clear guidelines for ambulance crews and primary care teams of the necessary clinical criteria. Such care pathways thought to be amenable to this include cardiac care, respiratory medicine, end of life care, psychiatric care, and trauma and orthopaedics Management of risk Discussion of cases with members of SCAS highlighted that they are increasingly trying to avoid bringing a patient to the ED unless absolutely necessary with current rates of non-conveyance reported to be between 50% and 54% (up from 42% in March, 2013) 6. Rates of non-conveyance have historically been increasing month by month but more recently they have plateaued. This is due to both the numbers of calls being made to SCAS increasing alongside anecdotal reports of an increase in the acuity of patient illness. More and more, therefore, decisions are being made by ambulance crews at the edge of the threshold for conveyance. In order to do this, they need to have appropriate support including the provision of clinical safety-nets, such as patient care plans and clinical support (e.g. agreement that a GP will reassess after an appropriate period). Having immediate access to highquality clinical opinion (for example from GPs both in and out of hours) is essential to making such knife-edge decisions Alternative locations for assessment and investigation Consistent with results from the audit of emergency admissions, 7 this audit suggests that provision of ambulatory care centres for multidisciplinary assessment, investigation, and minor treatment may represent an appropriate alternative location to the ED for patients brought by ambulance. Trusts elsewhere in the country have introduced such centres as an intermediate destination for ED attenders and as an alternative place of acute referral for primary care practitioners. The feasibility and cost-effectiveness of such centres as an alternative for ambulance and GP referrals warrants further investigation. 6 Unify2 data collection AmbSYS. Ambulance Quality Indicators: System Indicators, Ambulance trusts in England NHS England. 7 OUHT Emergency Attendances and Admissions Joint Working Group OUHT Emergency Admissions: audit of short-term emergency admissions at ages OUHT and Oxfordshire CCG.

10 ED attendances audit report Page 10 of 14 Existing research skills within Oxford and NIHR funding for the Oxford Collaboration in Leadership for Applied Health Research and Care (CLAHRC) and Biomedical Research Centre (BRC) represent opportunities for developing and evaluating the existing interface medicine initiative in liaison with the University (see results of the audit of emergency admissions for more details) The need for an integrated approach This audit adds support to the conclusions of the recent emergency admissions audit suggesting the need for an integrated approach to patient care. 7 Cross-pathway clinical care themes (i.e. end of life care, the management of the frail elderly including falls, psychological support, chronic disease management) could benefit from key organisations and professional groups working together to reduce attendances and admissions. Such organisations include OUHT, SCAS, and GPs, as well as adult social care. Rising trends in secondary care use were identified as a multifactorial and multi-disciplinary problem driven by factors ranging from patients perceiving that they will be seen more quickly by a healthcare professional if they phone an ambulance, to changes to infrastructure required to give GPs and ambulance crews direct access to specialist clinical care.

11 ED attendances audit report Page 11 of Discussion and recommendations 4.1 Main findings This audit suggests that about a third of ED attendances arriving by ambulance could feasibly be avoided were alternative clinically- and costeffective diagnostic and assessment services available in the community. Increased timely OOH access to clinical advice from primary care for ambulance crews has the potential to reduce the number of patients requiring conveyance to hospital. Greater access to, and use of, advanced individual care plans across the health-system could improve this even further. Provision of alternative centres for multidisciplinary assessment and investigation of patients has the potential to address the needs of a significant proportion of ambulance arrivals to ED. Decision making by ambulance crews as to whether to transfer to hospital was entirely appropriate for all cases examined. 4.2 Seeing the wider picture The audit reminded the panel of the overall high standard of care OUHT provides. OUHT ED has a relatively low conversion rate for ED attendances becoming admissions of 16% (compared to a South Central average of 22%), 8 and SCAS similarly performs well with over 40% of incidents in March 2013 managed without need for transport to ED compared to national average of 36%. 9 This is now reported by SCAS to be as high as 50% to 54%. Comparatively Oxfordshire performs well in having a low admission rate for acute conditions not usually requiring admission, and the county has good patient reported access to, and satisfaction with, GPs. 10 OUHT also has a particularly low standardised hospital mortality of 90.9 from conditions amenable to healthcare interventions (derived from the same dataset used to calculate the Summary Hospital Mortality Indicator SHMI). 11 Therefore, any further work and service changes made need to acknowledge that the healthcare providers of Oxfordshire are already providing comparatively good emergency care and although the population served is notably healthier than much of the UK, 12 this would not necessarily explain good performance in terms of conversion and admission rates, and SHMI. 8 The King s Fund Urgent and Emergency Care. A review for NHS South of England. The King s Fund 9 Unify2 data collection AmbSYS. Ambulance Quality Indicators: System Indicators, Ambulance trusts in England NHS England. 10 NHS England Analytical Service Improving General Practice a call to action. Evidence Pack. NHS England. 11 The Information Centre. Data as of Summer, English Public Health Observatories. Oxfordshire Health Profile, Department of Health

12 ED attendances audit report Page 12 of Strengths and limitations The quantitative results of the audit are based on analysis of 97 ED attendances brought by ambulance. They are a random selection from the 28,318 admissions eligible for inclusion and may not be truly representative. Conclusions were limited by the availability of accurate documentation in the patient notes with detailed SCAS notes only being available for 80% of attendances. The subsequent discussions between the audit team are representative only of the opinions of the people present. A strength of this work is that the team assembled were senior healthcare professionals from a range of clinical backgrounds including primary and secondary care, and SCAS, and with significant experience of and interest in acute care within Oxfordshire. 4.4 SCAS specific recommendations 1. Provision should be made for direct communication, 24 hours a day and seven days a week, between ambulance crews and GP services for the provision of clinical advice, particularly discussion of non-ed care options, and to allow safety netting. 2. South Central Ambulance Services should re-circulate information to crew members on which patients may be transferred to the Abingdon Emergency Multidisciplinary Unit. 3. Patient care plans, available to SCAS, should be agreed for high-risk patients who may trigger an ambulance call but will not benefit from ED attendance. 4. Plans for direct access to specialist services (such as acute psychiatric care) should be agreed for specific patient groups.

13 ED attendances audit report Page 13 of Further recommendations, also made in the audit of shortterm emergency admissions OUHT should explore alternative cost-effective organisational solutions for delivering a community assessment and investigative function. Specifically it should consider whether following other Trusts in establishing integrated ambulatory care centres outside the Emergency Department (ED) is likely to reduce breaching, attendances at ED, and emergency admissions for investigation. 2. Cross-sector clinical management policies should be written for key care pathways, as agreed by an expert group with representatives from OUHT, the CCG, SCAS, adult social care, and academia. These policies should stipulate what risk assessment will be made, what investigations will be done to investigate risk, the use of individual patient management plans, and the possibility of direct referral to specialist care. 3. OUHT should seek support from both the Oxford Collaboration in Leadership for Applied Health Research and Care (CLAHRC) and Biomedical Research Centre (BMC) to develop and evaluate the cost-effectiveness of the relevant elements of the existing interface medicine initiative in liaison with the University. This should be alongside the on-going evaluation of the Abingdon Emergency Multidisciplinary Unit. 13 OUHT Emergency Attendances and Admissions Joint Working Group OUHT Emergency Admissions: audit of short-term emergency admissions at ages OUHT and Oxfordshire CCG.

14 ED attendances audit report Page 14 of Appendix data extraction form Audit ID Postcode # ED attendances in past year Available information ED notes SCAS form Other (specify) Ambulance call out time ED arrival time ED departure time Referred for/asked to phone ambulance by: GP 111 Self Other (specify) Unknown Discharged from ED to: Hospital (specify ward) Home Other (specify) 1. Presenting needs (highlight with * the most important) 2. Could we feasibly make changes (within SCAS or in the community) to avoid the needs for this attendance? (circle one) Yes definitely / Yes probably / Not sure / No probably / No Definitely If yes (definitely or probably), 2a. what avoidable factors could have been addressed (*most important)? If not sure, please explain. (i) Assessment (ii) Social/Community Care (iii) Diagnostics (iv) Treatment (v) Other (specify) 2b. who could address these avoidable factors? Community/social care Primary care 111 Ambulance crews OUHT Other 3. Does this case relate to specific clinical pathway that would benefit from evaluation, plus any other comments