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
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 innovation...
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| Format: | Article |
| Language: | English |
| Published: |
National Institute for Health Research
2016-01-01
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| Series: | Health Services and Delivery Research |
| Subjects: | |
| Online Access: | https://doi.org/10.3310/hsdr04030 |
| _version_ | 1818127224213078016 |
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| author | Jonathan Pinkney Susanna Rance Jonathan Benger Heather Brant Sian Joel-Edgar Dawn Swancutt Debra Westlake Mark Pearson Daniel Thomas Ingrid Holme Ruth Endacott Rob Anderson Michael Allen Sarah Purdy John Campbell Rod Sheaff Richard Byng |
| author_facet | Jonathan Pinkney Susanna Rance Jonathan Benger Heather Brant Sian Joel-Edgar Dawn Swancutt Debra Westlake Mark Pearson Daniel Thomas Ingrid Holme Ruth Endacott Rob Anderson Michael Allen Sarah Purdy John Campbell Rod Sheaff Richard Byng |
| author_sort | Jonathan Pinkney |
| collection | DOAJ |
| description | 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. Funding: The National Institute for Health Research (NIHR) Health Services and Delivery Research programme (project number 10/1010/06). This research was supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula. |
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| format | Article |
| id | doaj.art-9298e882e3e1403db0b2ae2b6c87d200 |
| institution | Directory Open Access Journal |
| issn | 2050-4349 2050-4357 |
| language | English |
| last_indexed | 2024-12-11T07:13:57Z |
| publishDate | 2016-01-01 |
| publisher | National Institute for Health Research |
| record_format | Article |
| series | Health Services and Delivery Research |
| spelling | doaj.art-9298e882e3e1403db0b2ae2b6c87d2002022-12-22T01:16:17ZengNational Institute for Health ResearchHealth Services and Delivery Research2050-43492050-43572016-01-014310.3310/hsdr0403010/1010/06How can frontline expertise and new models of care best contribute to safely reducing avoidable acute admissions? A mixed-methods study of four acute hospitalsJonathan Pinkney0Susanna Rance1Jonathan Benger2Heather Brant3Sian Joel-Edgar4Dawn Swancutt5Debra Westlake6Mark Pearson7Daniel Thomas8Ingrid Holme9Ruth Endacott10Rob Anderson11Michael Allen12Sarah Purdy13John Campbell14Rod Sheaff15Richard Byng16Centre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UKCentre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UKDepartment of Nursing and Midwifery, University of the West of England, Bristol, UKSchool of Social and Community Medicine, University of Bristol, Bristol, UKUniversity of Exeter Business School, Exeter, UKCentre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UKCentre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UKUniversity of Exeter Medical School, Exeter, UKCentre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UKFaculty of Social Sciences, University of Ulster, Londonderry, UKFaculty of Health and Human Sciences, Plymouth University, Plymouth, UKUniversity of Exeter Medical School, Exeter, UKUniversity of Exeter Medical School, Exeter, UKSchool of Social and Community Medicine, University of Bristol, Bristol, UKUniversity of Exeter Medical School, Exeter, UKSchool of Government, Faculty of Business, Plymouth University, Plymouth, UKCentre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UKBackground: 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. Funding: The National Institute for Health Research (NIHR) Health Services and Delivery Research programme (project number 10/1010/06). This research was supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.https://doi.org/10.3310/hsdr04030avoidable acute admissionsemergency departmentpatient public involvementmixed methodsorganisational ethnographyvalue stream mappingrealist synthesis |
| spellingShingle | Jonathan Pinkney Susanna Rance Jonathan Benger Heather Brant Sian Joel-Edgar Dawn Swancutt Debra Westlake Mark Pearson Daniel Thomas Ingrid Holme Ruth Endacott Rob Anderson Michael Allen Sarah Purdy John Campbell Rod Sheaff Richard Byng 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 Services and Delivery Research avoidable acute admissions emergency department patient public involvement mixed methods organisational ethnography value stream mapping realist synthesis |
| title | 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 |
| title_full | 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 |
| title_fullStr | 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 |
| title_full_unstemmed | 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 |
| title_short | 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 |
| title_sort | 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 |
| topic | avoidable acute admissions emergency department patient public involvement mixed methods organisational ethnography value stream mapping realist synthesis |
| url | https://doi.org/10.3310/hsdr04030 |
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