Innovations to reduce demand and crowding in emergency care; a review study

In 1998, the National Health Service of England instituted NHS Direct, a national advice line for health concerns [6]. This was a nurse led telephone service with a principal aim of providing easier and faster advice for patients. There was also an underlying expectation that it might help reduce or limit the demand on other parts of the NHS, in particular ambulance services, EDs and general practice urgent care services by providing self care advice or suggesting alternative places of care, including a routine visit to the general practitioner (GP). However, an evaluation of the early NHS Direct pilot sites conducted by the University of Sheffield showed the advice line had little impact on ambulance use or ED visits [7] and although the service subsequently became nationwide there is no evidence that it has had any impact on the demand for ED care and visits have continued to rise. More recently, NHS Direct has been replaced by a new, free to use service, NHS 111 [8]. The rationale for this change was that as options for accessing emergency and urgent care were increasing, the public were still confused about how to access services appropriately. Whilst NHS Direct was primarily an “advice and direct” service, NHS 111 is a “direct and advice” service with greater integration between the telephone triage element and other health care services. So, for example, an ambulance can be dispatched, the call transferred for additional clinical assessment or appointments with services made in a single telephone call. Unlike NHS Direct, NHS 111 uses non-clinical call handlers for the initial call assessment. The objectives of NHS 111 were to improve access by having only two telephone numbers – 999 for emergencies and 111 for urgent requests – thereby increasing public satisfaction and confidence and improving efficiency within the emergency and urgent care system by directing callers to the “right place, first time”. An expected benefit was that this would reduce avoidable ambulance journeys, ED attendances as well as emergency admissions [9]. An evaluation of the first 4 pilot sites found there was no significant impact on ED attendances and that, contrary to expectations, there was a significant increase in ambulance responses [9].

In 2005 there was a national renegotiation of the General Practitioner (GP) contract allowing GPs to opt out of care of their patients on holidays, nights and weekends. The gap in service delivery was filled by a surge in the organisation of alternative sites of care and expansion of allied health professional roles. There has been a proliferation of Walk-in centres and Urgent Care Centres, generally nurse-led with some being remotely situated from EDs and others being co-located with the ED. GP-led walk-in centres were established in England in 2009 to increase GP accessibility and to decrease minor case attendance at EDs [10].

Despite the increase in the number of alternative services, studies in the UK show no significant impact of alternative services on ED attendances [11],[12]. One ecological study conducted to determine the effect of walk-in centres in reducing waiting time in other primary health care services found no benefit of such centres in reducing load on other health care services [13]. Similarly, other studies reported limited evidence to support any decrease in the EM load where nurse led walk-in centres were co-located with EDs [14]. However, one study on a single walk-in centre has shown a significant decline in ED attendances as a result of the opening of the walk-in centre [15]. Patient satisfaction with quality of service is also greater in walk–in centres as a result of easy access and much shorter waiting times when compared to primary care [16]. Furthermore, the services are of standard quality and safety [17].

It is difficult to accurately measure the impact of opening a parallel service on the ED because when a new health care service is established, it creates its own demand for health care along with sharing the load of existing emergency services. Patient load on other services may actually increase if more patients are consulting these services for minor and self-limiting illnesses as a result of easy access [18]. This may lead to an increased load on health care services as well as increased referrals through these centres. There are several other reasons why alternative services may not be able to show the desired impact on ED attendances such as lack of awareness amongst the general public, patients’ perceptions about their health problems and lack of encouragement from health care providers to access alternative services [19].

The concept of walk-in centres was introduced in early 80s when the first walk in centre was opened in Canada in 1980 [20]. Canadian walk-in centres are more comparable to UK walk in centres than USA centres. Two features of Canadian centres are similar to the UK walk in centres. First, they are also funded by general taxation. Second, GPs play a gate keeper role for secondary and tertiary healthcare. A third feature which is similar to the UK is that patients are not charged for using the walk in centres which is different to the USA walk in centres [21].

Australia has recently introduced nurse led walk-in centres (2010) as a result of a shortage of GPs [22]. Australian model is based on the UK urgent care services and similar strategies have been implemented. The centres have been co-located with EDs. Consultations are provided by nurse practitioners only who get support from clinical decision support software. The aim is to complement other healthcare services and reduce patient load at other services [23]. Further evaluations need to be conducted in the future to determine the impact of these services on reducing overcrowding at EDs.

Paramedic roles have extended substantially with the development in the UK of the paramedic practitioner and the emergency care practitioner. These individuals are trained to assess patients at home and can provide treatment and also referral onwards to other services when appropriate. Training aims to develop skills in history taking, examination techniques and basic investigations (such as urine testing, ECGs, referral for x-ray), and treatment options ranging from referral or signposting to other services, prescription of analgesia or antibiotics and wound management. The focus has generally been on management of minor illnesses and injury conditions, and is often aimed at the management of the frail elderly [24] and therefore incorporates an element of cognitive evaluation and social assessment. Evaluations have shown benefits to patients in reducing the need for onward journeys to the ED, high levels of patient satisfaction, high quality care with no impact on mortality and morbidity demonstrated, and reduced health service costs [25],[26].

In common with other developed countries, UK health policy is promoting the use of technology as a means of reducing the need for face-to-face contact by health and social care, thereby controlling escalating demands upon services. A new model of health care delivery has been identified which is underpinned by information and communication technologies [27]. Telehealth is one example of such a technology and involves the remote exchange of physiological data such as blood pressure, and other vital signs between the patient and healthcare professionals who are located at a distance [28]. A variety of devices are commercially available which can be used to identify potential deterioration, prevent avoidable hospital admissions and help improve the individual’s quality of life [29]. Cited benefits of Telehealth include enabling clinicians to reprioritise their workloads and assisting people with long- term conditions to self-manage [30]. The second main form of technology, Telecare, is concerned with promoting safety and security through monitoring activity in the home and community and providing alerts when that activity falls outside anticipated parameters [31]. The UK policy push for both Telehealth and Telecare has been accompanied by a large (5830 subjects at 12 sites), randomised controlled trial of both types of technologies, which demonstrated a mixed picture on outcomes. Patients with COPD, CHF and Diabetes who received tele-monitoring (e.g. glucometer, oxygen saturation, weight monitoring) as well as motivational interventions had fewer emergency visits after adjustment for baseline characteristics and predicted risk score (IRR0.85) [32]. Further research in this area is needed to fully understand the possible benefits in terms of cost effectiveness.

Emergency Nurse Practitioners are found among provider staff in most UK emergency departments. Whilst not reducing attendances per se, the evidence has shown that these roles can operate effectively and autonomously in managing a specific workload in the ED mainly relating to minor injury and illness, similar to their roles in many EDs in the USA [33],[34]. However, some UK departments have engaged advanced practice nurses for specific streams of protocol-driven care to which patients are directly referred from their GPs, or immediately assigned on arrival to the ED. These include patients with chest pain requiring a “rule-out”, often with same-day stress testing, and evaluation and treatment for suspected deep vein thrombosis [35]. There is some concerns that these streamlined services result in more GP referrals to the ED to procure this service, but they also reduce ED waiting times, standardise care and allow predictable follow-ups without physician involvement [34].

The involvement of senior physicians early in the patient’s visit to improve flow is increasingly occurring in the UK. The approach was first recommended by England’s Audit Commission in 1999 [36]. Various systems of senior-led initial assessment have been proposed and trialed across the UK already. The 2004 IMPACT study by Terris et al. found that senior physician initial assessment significantly reduced waiting times in the whole department, most especially for ‘minors’ patients but the effect of additional resources was not directly measured [37]. Team triage by Subash et al. also showed reduced waiting times during the intervention periods but no benefit to the ED beyond these times [38]. Other authors have also observed improved efficiency with senior physician initial assessment; however the process is not thought to be sustainable without additional staffing resources [39]-[41].

Most hospitals in the UK now have Medical and Surgical Assessment Units where patients admitted from the ED often go for further assessment by internists or surgeons before being admitted to a specific ward [42]. This decreases the need for extensive testing in the ED, thus reducing ED length of stay and crowding. Increasingly, the Medical Assessment Units (MAU) are staffed by “Acute Physicians,” a growing specialty in the UK. These are senior physicians who have no other responsibilities during their practice day, conduct twice daily patient rounds, and whose primary goal is rapid evaluation of patients. It is expected that more than 50% of patients admitted to the MAU will be evaluated and discharged within 72 hours; those who cannot be discharged are transferred to specialist wards. Because the MAU’s are physically close to the ED’s (usually on the same hospital floor), the acute physicians frequently assess patients in the ED and evaluate patients that are likely to need admission, even before the ED has called them. Finally, these units also accept direct admissions from nursing homes and GPs, allowing patients who clearly need admission and who have already been evaluated by a clinician, to bypass the ED.

A study conducted by the Royal College of Physicians in 2012 demonstrated that when these units were staffed appropriately with physicians dedicated to the units that are able to round at least twice daily, the quality of care was higher in terms of reduced case fatality ratio. In addition, a lower 28 day readmission rate was observed. However, they did not demonstrate a shorter length of hospital stay [43].

MAUs have also been established in Australia and New Zealand to reduce pressure on emergency departments [44]. There are various synonyms used by different units throughout Australia and New Zealand and which may be referred to in this document: Acute Medical Ward (AMW) or Unit (AMU), Acute Assessment Unit (AAU), Acute Medical Assessment and Planning Units (AMAPU), and Admission and Planning Unit (APU) [44].

In 2002, the UK government introduced a four-hour target, target of arrival in the ED to discharge or admission, for its emergency departments. Initially aimed at 90% of attending patients, the target quickly rose to include 98% of attending patients by 2005. A huge amount of resource and attention was poured into achieving the target, which also received a lot of media attention. Critics point out that this is merely a process measure and does little to improve quality of care. There have been further well-publicised criticisms of the standard; that it leads to ‘gaming’ and ‘cheating’ [45]. Other criticisms are that it impairs training and recruitment, reduces professional satisfaction creates an adversarial culture between the emergency department and other inpatient specialties and results in unreliable data. One study found that real-time training opportunities were being lost due to the pressures of the target, and that key skills were not being practiced because they were being referred on to other specialties for management such as complex suturing [46]. However, the pressure that the target brings cannot be convincingly and solely linked to the current recruitment difficulties in emergency medicine [46]. The target was reduced to 95% of patients in June of 2010 after the coalition government was elected. In April of 2011, the target was de-emphasised as it became one of the several indicators in a quality dashboard. Evidence has shown that the target was achievable without compromising on patient care; however, overall performance on the four-hour target has markedly deteriorated since its de-emphasis [31],[46],[47].

Australia has also been one of the few other countries to embrace the four-hour target concept. However, the Australian picture is more positive, with the introduction of the National Emergency Access Target being associated with a substantial decrease in mortality from 1.12% to 0.98% [48]. Similarly, Canada also introduced four-hour emergency department targets in for type V and type VI patients [49].