The growing evidence on high-intensity hospital care

Despite wide variation in the amount we spend on care, patients’ outcomes are often the same. So clearly, we should just do less. Indeed, given the growing problems of overdiagnosis and overtreatment, less is more | Emergency Medicine Journal

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As emergency physicians, we deliver a fair amount of high-intensity care. Yes, good care can sometimes be as simple as an astute diagnosis or a kind word. But it can also involve cross-sectional imaging, invasive procedures and hospital admission. At the right time and for the right patient, we believe, this care can be the difference between life and death.

And yet this care is coming under increasing scrutiny from payers and policy makers.

While emergency care accounts for a small fraction of direct health system costs, the decision to admit a patient to the hospital is an expensive one indeed. There are many good reasons to send patients home—reducing crowding, avoiding hospital-acquired infections and more. But the driving force behind efforts to reduce admissions today is simple: to reduce costs. As a result, physicians everywhere face increasing pressure to discharge patients to home.

This poses a particular dilemma for emergency physicians. On one hand, the rest of the world seems very certain we should be sending more patients home. On the other, our experience suggests that failures of risk stratification and mistriage to home can have terrible consequences.

Full reference: Obermeyer, Z. (2017) Is less more, or is it less? The growing evidence on high-intensity hospital care. Emergency Medicine Journal. Published Online First: 18 August 2017. 

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Winter pressure in A&E: response to Health Select Committee

The government’s response to the House of Commons Health Select Committee report on winter pressure in accident and emergency departments.

This report responds to each of the 27 conclusions and recommendations in the Health Select Committee’s report, Winter Pressure in A&E Departments . It highlights how the NHS prepares for winter, as part of its year-round operational resilience planning, to ensure the health and social care system in England is fully prepared for the increased pressures at that time of year.

Full document: Government Response to Health Select Committee Report on Winter Pressure in Accident and Emergency Departments

Emergency medicine: what keeps me, what might lose me?

EDs are currently under intense pressure due to increased patient demand. There are major issues with retention of senior personnel, making the specialty a less attractive choice for junior doctors | Emergency Medicine Journal

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This study aims to explore what attracted EM consultants to their career and keeps them there. It is hoped this can inform recruitment strategies to increase the popularity of EM to medical students and junior doctors, many of whom have very limited EM exposure.

Methods: Semistructured interviews were conducted with 10 consultants from Welsh EDs using a narrative approach.

Results: Three main themes emerged that influenced the career choice of the consultants interviewed: (1) early exposure to positive EM role models; (2) non-hierarchical team structure; (3) suitability of EM for flexible working. The main reason for consultants leaving was the pressure of work impacting on patient care.

Conclusion: The study findings suggest that EM consultants in post are positive about their careers despite the high volume of consultant attrition. This study reinforces the need for dedicated undergraduate EM placements to stimulate interest and encourage medical student EM aspirations. Consultants identified that improving the physical working environment, including organisation, would increase their effectiveness and the attractiveness of EM as a long-term career.

Full reference: James, F. & Gerrard, F. (2017) Emergency medicine: what keeps me, what might lose me? A narrative study of consultant views in Wales. Emergency Medicine Journal. 34:436-440

NHS standards and performance: is prioritisation the answer?

The Kings Fund June 2017 quarterly monitoring report (QMR) showed that NHS performance on key access targets over the financial year 2016/17 continued to deteriorate. In this new blog James Thompson asks whether a combination of increased funding, incentives and pressure from the centre will be enough to get A&E waiting time targets back on track.

Patient flow within UK emergency departments

Mohiuddin, S. et al. (2017) BMJ Open. 7:e015007

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Objectives: Overcrowding in the emergency department (ED) is common in the UK as in other countries worldwide. Computer simulation is one approach used for understanding the causes of ED overcrowding and assessing the likely impact of changes to the delivery of emergency care. However, little is known about the usefulness of computer simulation for analysis of ED patient flow. We undertook a systematic review to investigate the different computer simulation methods and their contribution for analysis of patient flow within EDs in the UK.

Conclusions: We found that computer simulation can provide a means to pretest changes to ED care delivery before implementation in a safe and efficient manner. However, the evidence base is small and poorly developed. There are some methodological, data, stakeholder, implementation and reporting issues, which must be addressed by future studies.

Read the full article here

The Impact of Walk-in Centres and GP Co-operatives on Emergency Department Presentations

Crawford, J. et al. International Emergency Nursing | Published online: 18 April 2017

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Image source: Kake – Flickr // CC BY-NC-SA 2.0

Highlights:

  • Workload and resource pressures on EDs require the development of applicable minor illness and injury pathways.
  • Walk-in-centres have the potential to reduce ED workloads but more work is required to substantiate this pathway.
  • GP cooperatives can reduce ED workloads but further evidence is required to be confident of the efficacy of this care pathway.

Read the full abstract here

Patient experience of different regional models of urgent and emergency care

Foley, C. et al. (2017) BMJ Open. 7:e013339

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Objectives: To compare user experiences of 8 regional urgent and emergency care systems in the Republic of Ireland, and explore potential avenues for improvement.

Conclusions: No consistent relationship was found between the type of urgent and emergency care model in different regions and patient experience. Scale-level data may not offer a useful metric for exploring the impact of system-level service change.

Read the full article here