Janette Turner

The relationship between distance to hospital and patient mortality in emergencies: an observational study

Objectives: Reconfiguration of emergency services could lead to patients with life-threatening conditions travelling longer distances to hospital. Concerns have been raised that this could increase the risk of death. We aimed to determine whether distance to hospital was associated with mortality in patients with life-threatening emergencies. Methods: We undertook an observational cohort study of 10 315 cases transported with a potentially life-threatening condition (excluding cardiac arrests) by four English ambulance services to associated acute hospitals, to determine whether distance to hospital was associated with mortality, after adjustment for age, sex, clinical category and illness severity. Results: Straight-line ambulance journey distances ranged from 0 to 58 km with a median of 5 km, and 644 patients died (6.2%). Increased distance was associated with increased risk of death (odds ratio 1.02 per kilometre; 95% CI 1.01 to 1.03; p<0.001). This association was not changed by adjustment for confounding by age, sex, clinical category or illness severity. Patients with respiratory emergencies showed the greatest association between distance and mortality. Conclusion: Increased journey distance to hospital appears to be associated with increased risk of mortality. Our data suggest that a 10-km increase in straight-line distance is associated with around a 1% absolute increase in mortality.

Prediction of mortality among emergency medical admissions

Background: The Rapid Acute Physiology Score (RAPS) and Rapid Emergency Medicine Score (REMS) are risk adjustment methods for emergency medical admissions developed for use in audit, research, and clinical practice. Each predicts in hospital mortality using four (RAPS) or six (REMS) variables that can be easily recorded at presentation. We aimed to evaluate the predictive value of REMS, RAPS, and their constituent variables. Methods: Age, heart rate, respiratory rate, blood pressure, Glasgow Coma Score (GCS) and oxygen saturation were recorded for 5583 patients who were transported by emergency ambulance, admitted to hospital and then followed up to determine in hospital mortality. The discriminant power of each variable, RAPS, and REMS were compared using the area under the receiver operator characteristic curve (AROCC). Multivariate analysis was used to identify which variables were independent predictors of mortality. Results: REMS (AROCC 0.74; 95% CI 0.70 to 0.78) was superior to RAPS (AROCC 0.64; 95% CI 0.59 to 0.69) as a predictor of in hospital mortality. Although all the variables, except blood pressure, were associated with mortality, multivariate analysis showed that only age (odds ratio 1.74, p<0.001), GCS (2.10, p<0.001), and oxygen saturation (OR 1.36, p = 0.01) were independent predictors. A combination of age, oxygen saturation, and GCS (AROCC 0.80, 95% CI 0.77 to 0.83) was superior to REMS in our population. Conclusion: REMS is a better predictor of mortality in emergency medical admissions than RAPS. Age, GCS, and oxygen saturation appear to be the most useful predictor variables. Inclusion of other variables in risk adjustment scores, particularly blood pressure, may reduce their value.

Role of ambulance response times in the survival of patients with out-of-hospital cardiac arrest

Objectives To evaluate the role of ambulance response times in improving survival for out-of-hospital cardiac arrest (OHCA). Methods OHCAs were identified by sampling consecutive life-threatening category A emergency ambulance calls on an annual basis for the 5 years 1996/7–2000/1 from four ambulance services in England. From these, all calls where an ambulance arrived at the scene and treated or transported a patient were included in the study. These cohorts of patients were followed up to discharge from hospital. Results Overall, 30 (2.6%) of the 1161 patients with cardiac arrest survived to hospital discharge. If the patient arrested while the paramedics were on scene, survival to hospital discharge was 14%. The most important predictive factors for survival were response time, initial presenting heart rhythm in ventricular fibrillation and whether the arrest was witnessed. The estimated effect of a 1 min reduction in response time was to improve the odds of survival by 24% (95% CI 4% to 48%). The costs of reducing response times across the board by 1 min at the time of this study were estimated at around £54 million. Conclusions The arrival of a crew prior to OHCA means that the chance of surviving the arrest increases sevenfold. Overall it is possible that rapid response to patients in immediate risk of arrest may be at least as beneficial as rapid response to those who have arrested. Concentrating resources on reducing response times across the board to improve survival for those patients already in arrest is unlikely to be a cost-effective option to the UK National Health Service.

What are the highest priorities for research in emergency prehospital care

The recent UK Department of Health publication “ Taking Healthcare to the Patient: Transforming NHS Ambulance Services ”1 recommended that the Department of Health should commission a programme of work to build the evidence base for the delivery of emergency and unscheduled prehospital care. As a starting point, the Department of Health commissioned the 999 EMS Research Forum to review the evidence base for the delivery of emergency prehospital care; to identify gaps in the evidence base; and to prioritise topics for future research. The 999 EMS Research Forum is a partnership of academics, clinicians and prehospital care practitioners and managers formed in 1999, whose aim is to encourage, promote and disseminate research and evidence-based policy and practice in 999 health care. Prioritisation of research topics is a key part of the process of commissioning of research, although methods may differ.2 3 The desirability of including a wide range of stakeholders in a structured approach has been stressed, in order to achieve a credible result that may be more likely to produce research that informs policy and practice.4–6 This emergency prehospital care research prioritisation exercise included …

The appropriateness of, and compliance with, telephone triage decisions: a systematic review and narrative synthesis

AIM This paper is a report of the synthesis of evidence on the appropriateness of, and compliance with, telephone triage decisions. BACKGROUND Telephone triage plays an important role in managing demand for health care. Important questions are whether triage decisions are appropriate and patients comply with them. DATA SOURCES CINAHL, Cochrane Clinical Trials Database, Medline, Embase, Web of Science, and Psyc Info were searched between 1980-June 2010. DESIGN LITERATURE REVIEW Rapid Evidence Synthesis. REVIEW METHODS The principles of rapid evidence assessment were followed. RESULTS We identified 54 relevant papers: 26 papers reported appropriateness of triage decision, 26 papers reported compliance with triage decision, and 2 papers reported both. Nurses triaged calls in most of the studies (n=49). Triage decisions rated as appropriate varied between 44-98% and compliance ranged from 56-98%. Variation could not be explained by type of service or method of assessing appropriateness. However, inconsistent definitions of appropriateness may explain some variation. Triage decisions to contact primary care may have lower compliance than decisions to contact emergency services or self care. CONCLUSION Telephone triage services can offer appropriate decisions and decisions that callers comply with. However, the association between the appropriateness of a decision and subsequent compliance requires further investigation and further consideration needs to be given to the minority of calls which are inappropriately managed. We suggest that a definition of appropriateness incorporating both accuracy and adequacy of triage decision should be encouraged.

A system-wide approach to explaining variation in potentially avoidable emergency admissions: national ecological study

Background Some emergency admissions can be avoided if acute exacerbations of health problems are managed by the range of health services providing emergency and urgent care. Aim To identify system-wide factors explaining variation in age sex adjusted admission rates for conditions rich in avoidable admissions. Design National ecological study. Setting 152 emergency and urgent care systems in England. Methods Hospital Episode Statistics data on emergency admissions were used to calculate an age sex adjusted admission rate for conditions rich in avoidable admissions for each emergency and urgent care system in England for 2008–2011. Results There were 3 273 395 relevant admissions in 2008–2011, accounting for 22% of all emergency admissions. The mean age sex adjusted admission rate was 2258 per year per 100 000 population, with a 3.4-fold variation between systems (1268 and 4359). Factors beyond the control of health services explained the majority of variation: unemployment rates explained 72%, with urban/rural status explaining further variation (R2=75%). Factors related to emergency departments, hospitals, emergency ambulance services and general practice explained further variation (R2=85%): the attendance rate at emergency departments, percentage of emergency department attendances converted to admissions, percentage of emergency admissions staying less than a day, percentage of emergency ambulance calls not transported to hospital and perceived access to general practice within 48 h. Conclusions Interventions to reduce avoidable admissions should be targeted at deprived communities. Better use of emergency departments, ambulance services and primary care could further reduce avoidable emergency admissions.

Impact of the urgent care telephone service NHS 111 pilot sites: a controlled before and after study

Objectives To measure the impact of the urgent care telephone service NHS 111 on the emergency and urgent care system. Design Controlled before and after study using routine data. Setting Four pilot sites and three control sites covering a total population of 3.6 million in England, UK. Participants and data Routine data on 36 months of use of emergency ambulance service calls and incidents, emergency department attendances, urgent care contacts (general practice (GP) out of hours, walk in and urgent care centres) and calls to the telephone triage service NHS direct. Intervention NHS 111, a new 24 h 7 day a week telephone service for non-emergency health problems, operated by trained non-clinical call handlers with clinical support from nurse advisors, using NHS Pathways software to triage calls to different services and home care. Main outcomes Changes in use of emergency and urgent care services. Results NHS 111 triaged 277 163 calls in the first year of operation for a population of 1.8 million. There was no change overall in emergency ambulance calls, emergency department attendances or urgent care use. There was a 19.3% reduction in calls to NHS Direct (95% CI −24.6% to −14.0%) and a 2.9% increase in emergency ambulance incidents (95% CI 1.0% to 4.8%). There was an increase in activity overall in the emergency and urgent care system in each site ranging 4.7–12%/month and this remained when assuming that NHS 111 will eventually take all NHS Direct and GP out of hours calls. Conclusions In its first year of operation in four pilot sites NHS 111 did not deliver the expected system benefits of reducing calls to the 999 ambulance service or shifting patients to urgent rather than emergency care. There is potential that this type of service increases overall demand for urgent care.

A qualitative study of systemic influences on paramedic decision making: care transitions and patient safety

Objectives Paramedics routinely make critical decisions about the most appropriate care to deliver in a complex system characterized by significant variation in patient case-mix, care pathways and linked service providers. There has been little research carried out in the ambulance service to identify areas of risk associated with decisions about patient care. The aim of this study was to explore systemic influences on decision making by paramedics relating to care transitions to identify potential risk factors. Methods An exploratory multi-method qualitative study was conducted in three English National Health Service (NHS) Ambulance Service Trusts, focusing on decision making by paramedic and specialist paramedic staff. Researchers observed 57 staff across 34 shifts. Ten staff completed digital diaries and three focus groups were conducted with 21 staff. Results Nine types of decision were identified, ranging from emergency department conveyance and specialist emergency pathways to non-conveyance. Seven overarching systemic influences and risk factors potentially influencing decision making were identified: demand; performance priorities; access to care options; risk tolerance; training and development; communication and feedback and resources. Conclusions Use of multiple methods provided a consistent picture of key systemic influences and potential risk factors. The study highlighted the increased complexity of paramedic decisions and multi-level system influences that may exacerbate risk. The findings have implications at the level of individual NHS Ambulance Service Trusts (e.g. ensuring an appropriately skilled workforce to manage diverse patient needs and reduce emergency department conveyance) and at the wider prehospital emergency care system level (e.g. ensuring access to appropriate patient care options as alternatives to the emergency department).

Hospital characteristics affecting potentially avoidable emergency admissions: National ecological study

Some emergency admissions can be avoided if acute exacerbations of health problems are managed by emergency and urgent care services without resorting to admission to a hospital bed. In England, these services include hospitals, emergency ambulance, and a range of primary and community services. The aim was to identify whether characteristics of hospitals affect potentially avoidable emergency admission rates. An age-sex adjusted rate of admission for 14 conditions rich in avoidable emergency admissions was calculated for 129 hospitals in England for 2008–2011. Twenty-two per cent (3,273,395/14,998,773) of emergency admissions were classed as potentially avoidable, with threefold variation between hospitals. Explanatory factors of this variation included those which hospital managers could not control (demand for hospital emergency departments) and those which they could control (supply in terms of numbers of acute beds in the hospital, and management of non-emergency and emergency patients within the hospital). Avoidable admission rates were higher for hospitals with higher emergency department attendance rates, higher numbers of acute beds per 1000 catchment population and higher conversion rates from emergency department attendance to admission. Hospital managers may be able to reduce avoidable emergency admissions by reducing supply of acute beds and conversion rates from emergency department attendance.

Reassurance as a key outcome valued by emergency ambulance service users: a qualitative interview study

There is an increasing need to assess the performance of emergency ambulance services using measures other than the time taken for an ambulance to arrive on scene. In line with government policy, patients and carers can help to shape new measures of ambulance service performance.