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

Overall aim

To investigate how clinician expertise and models of care in four contrasting hospitals contributed to appropriate decision-making regarding admissions in acute medical care; and to make recommendations about different admission avoidance models and their likely impact on workload management at the hospital front end.

Objectives

1. To investigate influences on decision-making about admissions in acute medical care.

2. To investigate how frontline experience and new models of care contribute to reducing avoidable acute admissions.

Research questions

1. What influences are operating in the acute admissions decision process?

2. This question was considered from the perspective of:

   • patients and relatives or carers

   • medical and other clinical staff responsible for decision-making (the role of early senior input in admission avoidance was specifically considered)

   • organisational factors that may influence decision-making.

3. How is the whole admissions process experienced by patients and practitioners?

4. How are the four models of care similar and different?

   • How does patient experience vary in each setting?

   • How are different ideas and policies and incentives adopted in each setting?

   • How often do the potentially critical components of care (e.g. early senior input) occur for potentially avoidable admissions? How does this vary by diagnostic group?

   • How is each model of care associated with demographically adjusted admission rates?

   • How does the cost of providing care during the unplanned admission process relate to different organisational models, and do such models have different impacts on workload management?

5. How can frontline expertise and new models safely reduce rates of admission?

Growth of emergency admissions

The context for the 3A study was the 2010 Nuffield Trust report,1 describing the rapid growth of emergency admissions in the UK between 2004 and 2009, and local concerns in South West England. In this period, numbers of emergency admissions in England rose by 11.8%, resulting in 1.35 million extra admissions. There was a large rise in short-stay admissions, and one possible explanation was that this might reflect a decline in longer-stay admissions. Alternatively, it was possible that increasing numbers of less severe cases were being admitted, perhaps because the clinical threshold for admissions had been reduced. 1 More recently, the National Audit Office observed that there were 5.3 million emergency admissions to hospital in 2012–13, representing a 47% rise over 15 years. The annual cost to the NHS rose to around £12.5B. Overall, 26% of patients attending EDs were admitted. There was a 124% rise in short-stay admissions, and 850,000 acute bed-days were lost because of delayed discharges. Moreover, 50% of emergency medicine training posts were unfilled in 2011–12. 2

There was also significant variation between NHS trusts in England: in some, emergency admissions declined by a third, while in others they almost doubled. There was also variation between primary care trusts. These data suggested that admission rates are influenced by factors unrelated to medical need. Emergency admission rates were found to be twice as high in the most deprived areas as in the least deprived areas. 1 Research by O’Cathain et al. estimated that 22% of admissions were potentially avoidable, and that there was a threefold variation in potentially avoidable admissions. 3 This finding supported the results of an earlier meta-analysis. 4 However, O’Cathain et al. also linked high avoidable admission rates with unemployment. Furthermore, there was demographic variation in sociocultural expectations of emergency care, with evidence of significantly increased avoidable admission rates in urban compared with rural areas, and for younger compared with older patients. 3 Avoidable admission rates were also higher for hospitals with higher ED attendance rates, higher numbers of acute beds per 1000 population, and higher conversion rates from ED attendance to admission. 5

The Nuffield Trust report1 and the research by O’Cathain et al. 3,5 reinforce the idea that many acute hospital admissions are medically non-essential and therefore probably represent suboptimal use of resources, in addition to exposing people to potential iatrogenic harm. However, neither of these studies specifically sought the patient or ‘user’ perspective on ED attendance. The premise for the present study was that a significant proportion of emergency medical admissions are potentially avoidable for a range of different reasons, and that, if ED experience is better understood from the patient perspective, there may be opportunities to handle some acute admissions more appropriately, with resulting benefits for patients and the NHS.

Quality and efficiency

Since its introduction in 2000, the 4-hour standard has had a major influence on the way in which EDs have responded to rising demand. This target was introduced to improve patient experience and outcomes by ending lengthy ED waits, particularly for patients requiring admission. The target was also seen as an instrument to enhance patient safety, but it was not observed to promote safety and quality of care to the same extent as efficiency. NHS quality indicators were introduced in 2011 to address perverse effects of target compliance. 6 Although the target time for discharge or admission was designed to improve patient flow, co-operative working with other services and departments often presented a challenge. 7 Recent studies have found some indications of variation in the coding of admissions, with patients in some clinical areas coded as admissions while patients’ overnight stays in other clinical areas might not be coded as admissions or breaches. 8

The 4-hour target has been considered a blunt tool to drive quality improvement in emergency care systems. 9 The quality of hospital emergency care has come under new scrutiny, and the Royal College of Emergency Medicine has called for wholesale system redesign, better care integration, greater resourcing of clinical decision and ambulatory care units (ACUs), and improved governance, staffing and skill mixing. 10 Much existing literature focuses on systems and patient flow, in contrast to the lack of research on patient experience. 10

Crowding and waiting times

Crowding is a visible manifestation of high demand. While ED waiting times have attracted considerable attention, the phenomenon of crowding has been little addressed in the UK literature. 11 High demand that outstripped capacity was considered to increase risks of certain types of critical incident. 12 High demand appears not to be explained by frequent attenders; rather, this patient group generally has more urgent needs,13 and makes appropriate use of urgent care services. 14 Crowding and long waiting times may lead to poor user experience, and to safety being compromised: times of overcrowding in one ED were associated with an increased 10-day mortality rate. 15

Crowding occurs when demand outstrips capacity and may arise in the face of both appropriate and inappropriate demand. Higginson et al. suggested ways in which demand and capacity planning could address this problem. 16 Strategies to combat overcrowding were the focus of a report by the Royal College of Emergency Medicine,17 which recognised that a range of hospital and community initiatives were required to tackle the problem. Higginson et al. drew attention to the international recognition of crowding as a significant concern, raising the question of how to address this issue in the UK. 11 The 4-hour target alone has been an inadequate instrument to address complex issues responsible for crowding, long waiting times and quality issues. There has been concern that undue focus on flow may detract from patient-centred care. 9

Practitioner experience

High levels of demand for emergency medical assessment associated with ED crowding placed considerable expectations on staff. An ethnographic study from Australia described how the work of ED staff focused on management of patient flow,18 but the experiences of staff working in EDs have received little attention. Workplace pressures may significantly contribute to recruitment and retention problems in this specialty. 19

Several studies have investigated teamwork in EDs. Recent studies using social network analysis found wide variation in the frequency of communication between ED staff working on different shifts,20 which could influence quality of care. A systematic review found evidence that multidisciplinary teams in EDs probably reduce access block, and that physiotherapists could play a role in this. The need for ED teamwork and communication was also related to safety improvement and reduction of waiting times. 21 Communication at team handover was highlighted as an important factor influencing admit/discharge decisions and quality of care. Jeffcott et al. 22,23 introduced the concept of ‘resilience’ and, using clinical handover as the example, suggested that it could be beneficial to understand and adopt elements associated with good outcomes, rather than solely focusing on problems. Another recent study of clinical handover found that only 1.5–5% of handover conversation content related to patients’ social and psychological needs,24 when these were highly likely to influence outcomes.

Demand, capacity and safety

Significant variations in emergency attendances and admissions by day of the week and time of day are well known. 2 Although there are fewer attendances and admissions at weekends, a recent analysis of 4,317,866 episodes of emergency care in the UK observed 10% higher mortality at weekends. 25 Concern about fluctuations in the quality and safety of care across times and days of the week had led to recommendations for 24/7 staffing for acute service provision in hospitals. 10

Measures to reduce avoidable admissions

Decisions about hospital admission reflect the impact of policies generated both by financial and safety concerns. Influences on decision-making include medical need, social considerations, family and carer expectations, experience and seniority of decision-makers, system factors, policy directives and the availability of alternatives to admission. Efforts have been invested in exploring admission prevention and avoidance through the development of community-based chronic disease models. 26 However, there is more limited research to support the wide variety of initiatives currently being developed at the ‘front door’ of NHS hospitals and examined in this project. Early streaming of urgent and less urgent cases was first tested in the 1980s in order to reduce waiting times and reduce duration time in EDs27 and has since become widely adopted in many countries. However, few patient-centred data were found relating to the avoidability of acute admissions.

Early senior input and managing flow

Several studies supported the idea that early triage by more experienced staff might improve decision-making and patient flow. Early research showed that patients assessed by more experienced doctors were substantially less likely to be admitted or subsequently readmitted than those seen by less experienced doctors. 28 More recent research showed that early physician involvement reduced the time spent by patients in ED beds. 29 Physician screening of less urgent cases, and early initiation of care for more complex patients, were associated with reduced treatment and discharge times. 30

Compared with middle-grade and junior doctors, ED consultants admitted significantly fewer patients, referred fewer patients to clinics and had a faster patient turnaround time. 31 A variation of the ‘senior first’ model was a combined doctor–nurse early triage system that expedited medical assessment and discharge from an ED. 32 An observational study found that inpatient admissions were reduced by 12% and admissions to an acute medical assessment unit were reduced by 21% following early review by a senior clinician. 33

In December 2010, the Royal College of Emergency Medicine introduced a clinical standard relating to consultant review of high-risk patients. 34 This concept was adopted by the UK Department of Health as a key quality indicator for emergency care. 6 The Royal College of Emergency Medicine also highlighted the need for consultant expansion if capacity were to match demand for 24/7 access. 35 The Royal College of Emergency Medicine also argued against ‘gate-keeper’ functions and emphasised that early senior input was essential to control crowding. 17 However, most studies on the involvement of senior staff in emergency medicine have adopted a quantitative approach, have been based on relatively small samples and have not explored the experiences of patients and staff.

Reconfiguring hospital emergency care

The debate about how best to configure emergency medical care, and for which patients hospital admission is appropriate, is part of a wider dilemma between ‘senior/specialist first’ and ‘stepped care’ throughout the NHS. Several care configurations have been explored in attempts to reduce ED congestion. The presence in EDs of general practitioners (GPs) focusing on patients with primary care needs was found to reduce costs of emergency care. 36 A review by Carson et al. 37 found fewer referrals for admissions when GPs worked in EDs than with standard care. In another study, a hospital-based acute GP-led service, designed to provide support to community GPs, was found to modestly reduce numbers of GP admissions to the MAU, although the overall number of GP admissions to hospital wards was not necessarily reduced. 38

There was some evidence that specifically targeted measures might reduce inappropriate admissions of certain patient groups. A recent report highlighted the needs of elderly patients, emphasising better community-based services with rapid access, and improved recognition of problems such as confusion, falls, polypharmacy and safeguarding issues. It was suggested that greater use of care of the elderly liaison services in MAUs might increase the proportion of older people who could be managed in a community setting. The commissioning of evidence-based integrated health and social care was seen as essential. 39 A triage and early treatment system for elderly patients in London appeared to reduce avoidable acute hospital admissions. 40

There was much interest in reconfiguring the management of ambulatory care-sensitive conditions to reduce unnecessary admissions. A group of 19 common conditions, accounting for about one in six of all acute admissions, was considered suitable for medical management outside hospital,41 although it was acknowledged that concomitant social factors also had to be addressed. The related issue of avoiding unnecessary admission of people with chronic conditions was also recognised,42 together with evidence to support various interventions that could reduce unnecessary admissions. 43 Many acute hospitals have prioritised the identification and treatment of ambulatory care-sensitive conditions in order to avoid admission, as recently reported from Plymouth. 44

In summary, the literature pointed to potential advantages in reconfiguring various aspects of emergency care. There were possible disadvantages in terms of deployment costs and loss of training opportunities associated with having experienced practitioners at the front line. Given the lack of evidence in this area, there was a need to understand the benefits and disadvantages of different configurations.

Decision-making in acute medical admissions

Although decision-making is pivotal to admission and discharge planning, much remains to be understood about this process. The diversity of system and clinical practices that underpin decision-making during a patient’s journey through emergency care was noted by Lattimer et al. ,45 who studied this subject from the workforce perspective. The patient journey started with help-seeking in the community and initial contact with a professional either in the community or at the hospital ‘front door’. The scenarios and styles of decision-making were variable, ranging from entirely medical ‘paternalistic’ decision-making – particularly in medical emergency situations46 – through to more complex situations where there could be several options in which decision-making was shared between professionals, or between professionals and patients. Skill mixing involving other types of professionals might also enhance the speed and quality of decision-making in EDs, although Lattimer et al. 45 considered that further research was required on this subject. In support of this idea, however, non-medical emergency care practitioners (ECPs) were found to be able to deliver care to a similar standard to that offered by medical practitioners. 47

A priori, it was expected that decision-making would be broadly influenced by patient, practitioner and organisational factors, and that outcomes would be affected by individual beliefs, attitudes and expectations, personal resources and functioning, specific illnesses and comorbidity. 48 Domestic resources and the wishes and interventions of family members and carers could also be relevant. Research examining patients’ views of hospital admissions found that 70% of patients specified possible alternatives. 49 Professional factors included the experience, attitudes and beliefs of doctors. 50 Hensher et al. 51 examined decisions made about alternatives to hospital care, finding that consultants often chose hospital admission and were more likely than GPs to state that there was no alternative to this. A recent study considered why patients with primary care problems – often with long-term conditions – called for ambulances, and concluded that poor knowledge of alternatives, anxieties of carers and attitudes to risk were some of the factors that channelled people unnecessarily towards secondary care. 52

Organisational factors – including commissioning and monitoring arrangements, the model for admissions pathways and the governance and culture of organisations, as well as the wider health and social care system, including the availability of community-based care – could all contribute to the likelihood of hospital admission. Attention to these factors could also help to ensure provision of timely, appropriate and high-quality care. In summary, greater clarity is needed to understand the variations in, and influences on, decision-making in acute admission settings.

Contribution of the study

The aim of this study was to examine the patient journey, from initial help-seeking through to the consequences of the admission decision, in four hospital settings spanning novel and traditional approaches, focusing on research questions (RQs) informed by the above-mentioned evidence. The decision to admit or not to admit was the focal point of the 3A study. The study aimed not to test one approach against another, but rather to explore models developed in South-West England.

This literature review confirmed a paucity of evidence about the patient journey through the acute admission process, and about organisational and professional factors that contribute to individual decisions to admit or to discharge. A review by Nairn et al. 53 identified a range of patients’ concerns in emergency care including waiting times, communication, cultural aspects of care, treatment of pain and the care environment. However, that review did not examine how these concerns affected decision-making.

During the course of the study, new publications emerged in all the areas discussed above. Clinical practice has been influenced by a combination of ‘top-down’ and ‘bottom-up’ initiatives that aim to manage fluctuating demand in a capacity-limited system, maintain patient flow and ensure safety. As highlighted by the 2013 King’s Fund report on patient-centred leadership,54 in the wake of the 2013 Francis report55 there is a need for the NHS to embrace a primary focus on patient care and experience. The Royal College of Physicians’ report Future Hospital: Caring for Medical Patients56 emphasised many related themes including early specialist care when needed, multidisciplinary evaluation that meets the needs of all patients, including the elderly, and the need for improved communication at the community–hospital interface. However, the patient voice has been largely absent from this literature.

As is apparent from the literature review, the patient voice and the experience of patients and practitioners, have been largely absent from previous research on EDs. However, there is growing acknowledgement of the centrality of patient experience for the NHS, and of the need to consider practitioner experience and system design in planning and policy. We therefore undertook a mixed-methods study of patients’ journeys through emergency medicine departments at four acute hospitals with contrasting models of care. In 3A, journeys are captured from the perspectives of patients, carers and practitioners, and set in the context of the resources available in these emergency medical units. The study interprets decision-making in acute admissions by synthesising these streams of evidence and examining them through the lens of realist evaluation.

Mixed methods

We conducted the VSM and ethnography components separately, although each influenced the other, and both contributed to answering RQs 1–3 (see Chapter 1, Research questions). The ethnography was carried out during the first half of the project and informed the planning of the VSM study. Integration of VSM fieldwork and ethnographic analysis was promoted through regular meetings of both teams, and through researchers’ day-to-day input to an electronically shared file with notes on field observations. Findings from these and other project components were used to generate hypotheses about causation in acute admission decisions during the project and as part of the final synthesis. Initial analysis of the VSM data led to further analysis of the ethnographic data. To provide continuity following the site descriptions (see Chapter 3), the VSM study (see Chapter 4) precedes the ethnographic chapters (see Chapters 5 and 6), which are exploratory in nature. The synthesis of findings (see Chapter 7) makes some tentative hypotheses about how emergency care could best be provided, answering RQ 4 (see Chapter 1, Research questions).

Patients and carers

A PPI group (see Appendices 4 and 5), whose members had experience of acute admissions, worked with the team on the approach to obtaining informed consent, design of research instruments, interpretation of ethnographic data and patient case studies, and construction of value stream maps.

Managers and practitioners

On each study site, a lead practitioner or manager – who changed over time in two sites – was the main link with the project. A cross-site learning set was developed to enable practitioners, managers and researchers to discuss lessons learned about the acute admission process. Findings from both study phases were discussed for each site in the learning sets (see Appendix 6).

In the mid-project stakeholder workshop (January 2014), a total of 29 patients, carers, clinicians, managers and researchers (study team and external invitees) reflected on the initial analyses in relation to their experiences. In the final stakeholder workshop (November 2014), a similarly conformed group of 27 participants contributed to the synthesis by working together to identify mechanisms influencing acute admissions within and across sites.

Ethical and governance arrangements

Ethical permission was granted by National Research Ethics Service Committee South West – Cornwall & Plymouth, on 22 June 2012. The study steering group of nine members (see Appendix 8) was convened on five occasions. Changes to the protocol as agreed with NIHR are detailed in Appendix 9.

Anonymisation and referencing of sites and participants

Study participants recruited at the sites were given unique identifiers for purposes of anonymity and referencing. Each participant included in the study was assigned a unique coded identifier. A simplified version of these identifiers was used to label study participants referred to or quoted in the report; the labels used the site pseudonym and consecutive numbering. Coded identifiers were kept in password-secured files and safe electronic and physical storage.

Clinical panel review used independent numbering systems for patient cases summarised from ethnographic data, in order to guard anonymity of patients and sites. To further protect anonymity, these numbering systems only differentiated between ethnographic patient cases, and did not reference particular sites.

Site maps

Site mapping was used to depict the acute access routes into each of the four sites. Preliminary site maps were constructed during the mid-project workshop, with input from participating clinicians.

Study participants

Data on the patient journey

The direct observation of the process involved:

1. observation of what was happening (or not happening) to the patient at every step

2. assessment of the process from the perspective of the patients and practitioners involved.

The VSM method was adapted for this project to provide additional data for key liaison activities (e.g. nurses discussing patients with doctors or providing treatment, juniors gaining advice from seniors). These data were gained from direct observation of staff and debriefing with key staff.

The details of each journey through acute care were recorded minute by minute, using the iPhone ‘HoursTracker’ application (Cribasoft LLC, Round Rock, TX, USA). The mapping process captured the seniority and number of medical staff involved in care, waiting times and diagnostic tests. The waste categories (such as transportation or looking for staff), and Lean values identified by Ohno,62 were applied by the researchers based on their interactions with patients and practitioners, in which they elicited views on the value of the care provided.

The ‘assessment of process’ was elicited from the principal clinical practitioner, who decided whether the patient would be admitted or discharged. These individuals were asked to consider, using a Likert scale, to what degree their decision had been affected by colleagues, the patient or his/her carer, availability of alternative care pathways, and additional factors.

This approach allowed us to apply the Lean principle of ‘thinking deeply’ about the problem to quantify and examine only those aspects of care processes that helped us to contrast the models of care at different sites.

The VSM study’s raw data therefore comprised detailed timings of stages of care throughout each patient’s journey, together with clinicians’ ratings of value, opinions on alternative care pathways and reflections upon their own decision-making.

Value stream mapping analysis

When conducting this analysis, we followed a methodological protocol to quantitatively describe and compare the acute care admissions pathways in the four NHS trusts (RQ 3), including:

1. patient pathway times overall

2. waste-to-value ratio

3. where in the ED process wastes were occurring

4. contrast among the proportions of patients who were admitted, were seen by different practitioners at different times and had investigations, including:

   • proportion of senior involvement

   • proportion of admitted patients

   • time first seen by a doctor

   • differences in patient hospital pathway

   • categorisation of known waits

   • patient pathway time for differing presenting conditions.

Practitioners and organisation of services

Patient journeys

Analysis of ethnographic data

Approach to the synthesis across component studies

A critical realist approach64,65 provided the framework for integrating knowledge from each of the component studies, the stakeholder workshops, the clinical panels and the learning sets. We aimed to identify mechanisms that could explain how different outcomes arose in complex systems,66 with the goal of producing multifaceted explanations about how frontline expertise and new models can safely reduce admissions. We used the approach of Pawson and Tilley’s57 to identify potential mechanisms that result from the interaction of resource and opportunity with the reasoning of individuals and lead to behavioural change. In order to produce a more fine-grained analysis across the studies, we understood mechanisms as consisting of both reflexive and automatic responses.

Taking a realist perspective

Taking a realist perspective, the admission decision can be seen as a sequence, over time, of beliefs, knowledge and behaviours of the key actors: patients, carers and practitioners. The beliefs and actions of individual patients are affected by their immediate context, which can include both the cultural and structural context of their lives, family and home life, and their current state of physical and cognitive capacity. Patients and carers respond to the opportunities/resources provided (practitioners, acute care environment) with a variety of patterns of reasoning. It is the variety and detail of these patterns that we sought to understand.

Each of the practitioners involved in decision-making also has different beliefs and attitudes, based on previous training and experience that influence behaviours involved in the admission decision, such as further questioning, physical examinations, requesting tests or gathering opinions from other practitioners. Practitioner behaviour is also influenced by the organisational context in which the practitioners work: both structural – the teams, hierarchies, incentives, physical layout – and cultural – the norms and ideals of teamwork and professional conduct. Understanding how the immediate setting and wider hospital and health-care system beyond influence the individual practitioner’s reasoning is an important objective of the 3A study.

Individual practitioners also differ in their patterns of reasoning and capacity and respond differently to the same hospital and team environments, both in the immediate reasoning for the patient before them, and also over time in their acquisition of beliefs and cultural norms. This heterogeneity of practitioner responses may be one of the keys to understanding variations in acute admissions decision-making. In a contrastive way, we were also interested in seeing how practitioners as a group might respond to (1) the common and different resources and opportunities in existence at each of the four sites studied; (2) innovations that have been introduced, such as new types of teams, new diagnostic processes and pathways, or other innovations developed within the acute admissions system.

Integration of findings

We produced a set of analytic statements (see Appendix 13) from each study for presentation and discussion at researcher meetings and at the end-of-project stakeholder workshop. Wherever possible, we expressed these as causal ‘If . . . then’ statements that specified context, mechanism and outcome in relation to patient safety [i.e. appropriate (non-)admission decision]. For example, ‘If there is an acute bed shortage and pressure from management to decrease admissions (context) then clinicians may feel pressurised (mechanism) to discharge inappropriately (outcome)’.

However, in many instances it was necessary for the outcome stated to be a plausible stage on the decision-making route. For example, ‘If there is more than one team involved in the care of a patient (such as a specialist medical team) (context) then there can be confusion between practitioners (mechanism) about who is responsible for the care of the patient (outcome)’. Not all analyses or sources could support these types of causal statement. Where this was the case, we retained statements about context alone, for example, ‘Resource and time constraints may sway doctors towards admission as a safer option’. The statements were shared within and across teams so that an ongoing awareness of findings was cultivated. This also underpinned the development of collaborative working relationships, which in turn facilitated criticism and refinement of the synthesis.

We found that the common language of the ‘If . . . then’ statements helped us to group and look across project component studies. Our integration of findings focused on identifying how practitioners, patients and carers responded to each other, as well as how each responded to the resources and opportunities of the acute care setting.

In summary, the process was:

1. Based on the findings of each project component, ‘If . . . then’ statements (or other analytic statements or scenarios) were developed. A selection of these were further refined at the end-of-project workshop.

2. Refined statements were organised in tables by RQ and grouped by the participants in interactions (e.g. patient–carer–practitioner).

3. Through a process of reflection and discussion based on these refined statements (returning to the original data where necessary to clarify particular issues), we developed explanatory statements that incorporated all of the information in groups of refined statements (documents available on request from the authors). This typically involved the following tasks:

   • reading through to ‘sensitise’ ourselves to the issues

   • ‘sense making’ – asking ‘How can we explain what has been observed here?’ and how we could account for context or rival explanations asking ‘What if?’ questions (i.e. looking for alternative explanations)

   • seeking disconfirming cases.

The statements were then brought together in narrative form within themes based around practice and service design in a narrative form referencing the analytic statement (see Appendix 13). Finally, we undertook an exercise of transforming negative statements into positive ones and setting these out as principles of practice that were likely to achieve particular objectives.

We focused on identifying mechanisms and the ways in which they could operate differently within varying contexts, as distinct from the pattern of events. 66 We endeavoured to recognise heterogeneity of responses as an inherent phenomenon within the system,67 acknowledging that, although social structures and culture have causal powers, people will interact with and respond differently to the same phenomena. 68

Porthaven Hospital

Porthaven is a large university teaching hospital providing secondary and tertiary care services to a population of 450,000. Porthaven opened in 1981 and is situated 5 miles from the city centre. Porthaven serves both a large urban population and a widely dispersed rural population. There is wide socioeconomic variation, with particular pockets of urban deprivation. The hospital trains doctors, nurses and a range of other health-care professionals (HCPs).

Churchtown Hospital

Churchtown is a university teaching hospital with foundation trust status. It serves a population of roughly 350,000 people, including urban and rural areas, and has many summer visitors. The site is 1.3 miles from the city centre and operates a park-and-ride scheme for patients. The site has been occupied for 250 years although the current building was completed during the 1990s.

Underbridge Hospital

Underbridge is a district general hospital close to the city centre. This modern hospital was developed in the 1960s. It is one of two acute hospitals, each with its own ED, run by the same foundation trust. However, 24-hour emergency care is provided only by Underbridge, whereas the partner ED accepts only walk-in patients at night-time, who are treated by ECPs. Underbridge provides care for a large urban and rural area, including districts of both high deprivation and relative affluence.

Waterbury Hospital

Waterbury is a large district general hospital providing care for a large, predominantly rural, population covering four counties with relatively low levels of deprivation and some areas of high affluence. The hospital is located 1.5 miles from the city centre.

Sources of emergency admissions at the four sites

The sources of referrals and admissions at the four sites closely reflected national data, with about 70% of emergency admissions referred through EDs (Figure 2), about 15% by GPs and 15% from other sources. The statistics for Waterbury and Underbridge were similar to national patterns, although Porthaven and Churchtown exhibited relatively higher numbers of GP referrals in relation to admissions through EDs.

FIGURE 2.

Sources of all emergency admissions at the four study sites compared with national data. Data are from HES, 2009–13. Hospital Episode Statistics data were accessed through the Health and Social Care Information Centre (www.hscic.gov.uk/hes) using the Lightfoot signalsfromnoise (SFN) tool (Lightfoot, Bracknell, UK).

Demand and activity at the four sites

The times of arrival of patients in the four EDs of the studied sites were similar and in line with national data (Figure 3). Arrivals reached a nadir at 05.00–06.00 and then rose rapidly to a significant peak around 11.00, before reaching a plateau throughout the afternoon. A small peak was observed around 18.00 followed by a gradual decline throughout the night.

FIGURE 3.

Diurnal variation in patient arrival times at the four sites compared with national statistics. Data are from HES, 2009–13. Hospital Episode Statistics data were accessed through the Health and Social Care Information Centre (www.hscic.gov.uk/hes) using the Lightfoot signalsfromnoise (SFN) tool (Lightfoot, Bracknell, UK).

At these four sites, numbers of ED attendances peaked on Mondays, in line with national data. Numbers were lower from Tuesday to Saturday before a small increase on Sunday. Waterbury and Underbridge exhibited very similar patterns to the national profile, whereas Porthaven and Churchtown also exhibited peaks in attendance on Sundays that equalled the Monday attendances.

Emergency admissions tended to reflect the attendance rate, with a corresponding peak on Mondays, declining somewhat from Tuesday to Friday, followed by a 20–25% reduction on Saturdays and Sundays. Nationally, the decline in emergency admissions is associated with a fall in GP referrals. Waterbury and Underbridge reflected the national pattern, whereas Porthaven and Churchtown also showed some decline in admissions through the EDs at weekends.

Similarly, all sites showed typical daily fluctuations in the number of beds occupied with emergency admissions. Bed occupancy peaked on Mondays and declined through the week to a nadir on Fridays, before climbing over the course of the weekend. The emergency patient bed occupancy varied by 5–6% on average throughout the week. Length of stay was a little lower at the four sites than the national average, and was around 5.0 days at the time this study was conducted.

Uptake rates

Of the 124 patients identified as meeting the inclusion criteria and then approached, 108 consented to the study, giving an uptake rate of 87% (Figure 4). Ten per cent of patients declined to participate, mainly because they were in pain or they were fearful of the emergency situation. Another 3% were excluded by the researchers either because they could not ensure that informed consent had been obtained or because the patient became too unwell to continue with the consent process.

FIGURE 4.

Patient recruitment flow chart for the VSM study.

Overall, of the participants recruited, 48% were discharged and 52% were admitted to hospital. This approximately even split indicated that the criteria of admission ‘uncertainty’ had been applied effectively during the patient selection process.

Participants

The characteristics of the VSM study participants are summarised in Table 5.

There was a broad age range of participants and a balance of male and female participants and of presenting conditions. There was limited ethnic variation, reflecting regional demographics.

Participants were recruited from all acute access routes and from both groups of presenting conditions at each site (Table 6).

Although it was expected that elderly people might make more use of non-emergency acute routes into the hospital, a somewhat greater proportion of this patient group was found to have come through the ED route.

All non-ED patients arrived at hospital following referral from their GP or an outpatient clinic. In contrast, many participants arrived in ED either in response to first seeking advice through another health professional, such as a GP or the 111 service, or following a 999 ambulance call. Table 7 summarises the routes followed before patients arrived in the ED.

Porthaven had the lowest proportion of ED attenders using the 999 service. It also had the highest proportion arriving as a result of GP advice (31%). Churchtown had the highest proportion of patients attending the ED on their own initiative (17%), while Waterbury had a particularly high proportion attending the ED on the advice of a carer or nurse (41%).

Analysis

This study aimed to describe what happens to patients as they traverse acute medical pathways that may result in hospital admission. To do this, admission decision pathways were mapped for each site. Visual representations of these pathways (or ‘value stream maps’) are shown in Appendix 7. It soon transpired that these value stream maps represented an ideal, in which certain process tasks happened in sequence. The observed reality was that multiple factors affected the pathway, so that processes could happen in a different order from that presented by the value stream map, and additional processes were sometimes added and others removed, depending on the needs of the patient and the context in which the patient arrived. Consequently, the patient pathways were analysed by examining the overall picture rather than by abstracting the timings for a specific patient in relation to a generic value stream map.

To understand the patient journeys at each hospital, timing data was used to analyse journey time (known in Lean terminology as ‘lead time’), at what points in the patient pathway waits occurred, and time attributed to either value-adding activity (predominantly contact time with patient) or non-value-adding activity from a patient’s perspective (how long the patient was waiting). The VSM timing data were then used to address three RQs relating to the quantification of patient pathways:

1. How do medical staff and other practitioners contribute to decision-making?

2. How do organisational factors affect decision-making?

3. How are the four models of care similar and different?

Firstly, the VSM analysis examined patient journey time by site. The box-and-whisker plot in Figure 5 shows median journey times, which ranged from 195 to 243 minutes, with a mean of 223 minutes.

FIGURE 5.

Median patient journey time by site. max., maximum; min., minimum.

A wider range in overall patient journey times is clearly evident at the Porthaven site. In contrast, Underbridge, with the smallest range of journey times, also has the lowest median time.

During these journeys, the ratio of value (contact) to waste (predominantly non-contact time and waiting) ranged from 39% to 52%, with an average of 45.5% at each site (Figure 6).

FIGURE 6.

Value-to-waste ratio for each site.

There was no significant difference between the ratios of percentage waste and value times at the four sites. However, total waste time at the four sites differed significantly [one-way analysis of variance (ANOVA); p = 0.007]. Thus, the mean waste time in Underbridge (95 minutes) was significantly less than in Churchtown (128 minutes), Porthaven (138 minutes) and Waterbury (151 minutes). The total value time also differed significantly between the four sites (one-way ANOVA; p = 0.01). Value time was significantly higher at Porthaven (150 minutes) than at Churchtown (82 minutes), Underbridge (93 minutes) and Waterbury (111 minutes).

To understand where wastes (non-value activity when patients were mainly waiting) were occurring, wastes were attributed to key time frames in the patient pathway. The key time points chosen were:

• waits after the patient arrived but before being assessed by a doctor

• waits after assessment by a doctor but before a final admission decision

• waits after a final admission decision but before the patient left the department or was admitted to a ward.

A breakdown of waste stage, by site, is shown in Figure 7. The pie charts indicate a clear variation between sites in the stage at which the greatest proportion of waste occurred. At Underbridge, almost half of the time the patient spent waiting was before the patient was assessed by a clinician. Waste time after assessment but before final decision was in the range of 30–39% for three sites, but lower at Waterbury (20%). This time interval typically represented the wait for diagnostic test results. The wait after the final decision was shortest at Underbridge (23%), and similarly lengthy at both Churchtown and Waterbury (51–54%).

FIGURE 7.

Stage of patient care where waste occurred.

These process points – arrival, assessment, decision and leaving – were used, as they were carried out for every patient and occurred in a specific order, whereas other process points, as shown in Appendix 15, occurred less consistently (in both occurrence and order). Although these process points were chosen because they occurred routinely, there were a few occasions when a final decision had been made at the point when an assessment occurred, and this could influence the results. However, in general, a working decision was made at the point of assessment, and the final decision was made after the diagnostic tests.

Research question 1: how do medical staff and other practitioners contribute to decision-making?

The first RQ addressed by the VSM study related to the role of different medical staff in the decision-making process. The data captured the grade of medical staff who conducted the assessment and who made the final decision. It also captured whether there had been direct senior medical staff involvement in either the assessment or the decision-making, or indirect involvement through liaison with junior medical staff. Figure 8 shows the proportion of patients who were observed to have direct consultant involvement. In comparing consultant involvement and admission rates, it appeared that sites with greater consultant involvement had higher discharge rates. Overall, this fell short of significance (p = 0.06; Fisher’s exact test).

FIGURE 8.

Proportion of consultant involvement and admission rate by site.

In comparing patients who had consultant involvement, we also plotted their overall journey time against patients without direct consultant involvement. The bar chart in Figure 9 suggests that patient journey time on average (median) was little affected by senior involvement.

FIGURE 9.

Median patient journey time and consultant involvement.

The shortest patient journey time, of 195 minutes, occurred at Underbridge. The data show that consultant involvement for that site accounted for only a 1-minute difference, on average, in journey time. In contrast, the longest patient journey time was observed at Porthaven, lasting 259 minutes, where a consultant was involved. This site experienced longer journey times with consultant involvement, but it also regularly used an observation unit for patients who required time-consuming diagnostic tests. During the observation unit stay, the patient remained under the responsibility of the ED staff.

To further investigate the involvement of medical staff in decision–making, we examined the time point when a doctor first saw the patient. Across the four sites, the median times to first review by a doctor ranged from 32 to 66 minutes, but averaged 55 minutes. We observed no significant association between time to first assessment and overall journey time [r = 0.13; p = 0.17 (Table 8)].

We found that time to senior involvement was correlated significantly with overall journey time (r = 0.25; p = 0.03), represented by the scatter plot in Figure 10. This association suggested that earlier senior involvement could expedite decision-making. The connection observed tended to be more marked in cases seen in an ED (and it did not include alternative acute medical decision-making routes), but it did not reach statistical significance in this subgroup (r = 0.20; p = 0.09).

FIGURE 10.

Time to consultant involvement against journey time.

Research question 2: how do organisational factors affect decision-making?

The main organisational factor affecting the time to admission and discharge decisions was the 4-hour target, the impact of which can be seen in Figure 11.

FIGURE 11.

Admission and discharge decisions by time from arrival.

Few, if any, decisions were reached in the first hour, but the number of decisions rose rapidly and peaked at 223 minutes, close to the 4-hour target. A small tail of longer waits was also evident.

In considering the second RQ we also compared the acute care pathways at each site. The box-and-whisker plot in Figure 12 shows the journey time of patients divided by hospital pathway. In general, median journey times through both the ED and alternative pathways at each of the four sites appeared relatively similar.

FIGURE 12.

Patient journey time by hospital pathway for each site. max., maximum; min., minimum.

There may be several reasons for any time differences between medical pathways. Patients entering through the medical referral route had already had GP assessments; senior staff interviews and the clinical panel discussions suggested that these prior assessments were important in expediting decision-making. This factor could have offset the tendency towards slower assessment through the medical route, with consultant review often being based on periodic ‘board rounds’ between formal ward rounds, whereas consultant work patterns in EDs were more geared to continuous availability. However, beyond the ED/medical pathway dichotomy there were other organisational factors that were linked to the different models of care at the four sites, and these were considered separately.

Research question 3: how are the four models of care similar and different?

The third question addressed through the VSM data was that of the similarities and differences between the four sites. The overall patient journey times were similar for all four sites (see Figure 5). Although value-to-waste ratios were also similar at each site (see Figure 6), the stages in the pathways with lengthier waits differed (see Figure 7). Waiting prior to assessment varied significantly across the four sites (one-way ANOVA; p = 0.002). In general, significantly longer waits prior to assessment were observed at Underbridge (mean 45 minutes) and Waterbury (33 minutes) than at Porthaven (27 minutes) and Churchtown (17 minutes). It is possible that the shorter waits were at sites that made more frequent use of alternative entry points for GP-referred patients (i.e. direct to AMU and/or AGPS/ACU at Porthaven, and MTU at Churchtown), whereas sites where single-entry points predominated (Underbridge and Waterbury) appeared to have somewhat longer pre-treatment waits. However, Waterbury differed from Underbridge in accepting GP-referred patients through the ED because of lack of capacity in the medical assessment unit.

Safer and speedier decision-making was facilitated at Porthaven, a site with faster time to assessment, involving a central decision-maker within the ED, where the senior consultant had a designated advisory role, did not see patients directly and was clearly visible to juniors. However, Churchtown was the site with the shortest times to assessment. Churchtown also had a consultant in charge but did not use a controller in exactly the same way as Porthaven. At the sites without a controller, consultants moved around the departments or saw patients in addition. Possibly as a result, junior staff appeared to spend time locating the decision-maker, and this could have been a factor that slowed down decision-making.

Although waiting times after assessment, but prior to final decision, did not differ significantly across the sites (one-way ANOVA; p = 0.13), waiting times tended to be longer at Porthaven (mean 58 minutes). These times did not differ significantly from Churchtown (46 minutes) or Waterbury (30 minutes), but appeared slightly longer than at Underbridge [mean 28 minutes; p = 0.06 (t-test, unequal variance)]. There are several possible explanations for this, including the availability and use of observation units such as the CDU at Porthaven, where patients were ‘off the clock’ (see Chapter 5). Although the underlying explanation cannot be clearly identified, it may be speculated that there was a trade-off between longer waiting times for a decision and management plan that resulted in discharge – and thus less overall time in hospital – and an early decision to admit for observation and to await investigations and results, which resulted in a lengthier hospital stay.

Waits after the final decision also differed significantly between the sites (one-way ANOVA; p = 0.02). There was nearly a fourfold variation in mean wait at this stage. Waits were significantly shorter at Underbridge (mean 22 minutes), compared with 57 minutes at Porthaven (p = 0.02), 65 minutes at Churchtown (p = 0.01) and the longest waits, of 82 minutes, at Waterbury (p < 0.001). The time from the final decision to the time the patient left the assessment area, either admitted or discharged, is shown in Figure 13.

FIGURE 13.

Time from final decision to leaving department. max., maximum; min., minimum.

At all sites, discharged patients left the departments more quickly than those admitted. At Waterbury, the median time to discharge was nearly an hour after the decision, which appeared longer than at the other sites. All sites took nearly 1 hour or more to admit patients to a ward. It seems probable that differences in population dispersal and transportation could influence time to discharge, while in-hospital factors such as bed availability influenced time to admission.

Figure 14 shows a detailed breakdown of the known, observed reasons for waste time (with unknown reasons for waste excluded). Using the Lean definition, the largest source of waste from the patient perspective was in ‘waiting’. We therefore grouped the other categories of Lean waste into one, labelled ‘system wastes’, and explored the known reasons behind the waiting categories more fully. It can be seen from these figures that there appeared to be significant variation. For instance, in both Churchtown and Waterbury about 40% of wait time was attributable to waiting for a bed, compared with 9% at Porthaven and 3% at Underbridge. In Porthaven, 50% of observed wait times were associated with waiting for investigations or results, compared with 22–28% at the other three sites. At Underbridge, 28% of waits were for staff availability, compared with 21% at Porthaven, 12% at Waterbury and 8% at Churchtown.

FIGURE 14.

Types of waste from the patient’s perspective.

However, these figures should be treated with caution because they relate only to known waste. Some sites may have lent themselves more than others to the identification of reasons for waste, be they related to the observer’s location and the physical layout, ease of access to certain staff, or differences in information technology systems. In view of these considerations, no formal statistical comparison was undertaken on the data in Figure 14. Long waits for beds could have reflected high bed occupancy, slower turnaround or poor communication. Waits for tests or their results could have reflected differences in staffing, ability to move patients between different areas, proximity of X-ray departments, laboratory staffing and speed of diagnostic tests, or the information technology systems used to communicate results. The prominence of staff availability as a factor at one site suggests that waste time may have increased with workload, indicating reduced efficiency.

At the time of this study, it was reported that there were significant numbers of locum and agency staff at Underbridge. That may have been associated with decision-making by practitioners who were less well informed about local care pathways, and it also suggested staffing shortfalls.

Overall patient journey times were compared at each site for discharged and admitted patients, and in relation to presenting medical conditions. Figure 15 shows that median journey times were relatively similar for both admitted and discharged patients.

FIGURE 15.

Patient journey time and decisions to admit or discharge. max., maximum; min., minimum.

Similarly, there appeared to be relatively little difference between the journey times of cardiorespiratory and elderly patients at each site, although elderly patients tended to have longer journey times than cardiorespiratory patients at Waterbury. It is possible that this might have reflected differences in services for elderly patients with more complex conditions. Porthaven also included some considerably longer journey times for both patient categories (Figure 16).

FIGURE 16.

Overall patient journey times by category of presenting condition. max., maximum; min., minimum.

Estimates of staff costs at the four sites

We used routine NHS data to estimate the cost of NHS staff time spent on face-to-face interaction with VSM patients and on other observed patient-related activities (see Chapter 2 for method). Table 9 shows that there was an approximately twofold variation in the number of different staff seen by each VSM patient between Porthaven (median 4 staff seen) and Waterbury (median 8.5 staff seen).

There appeared to be differences between two pairs of sites: Porthaven and Churchtown on the one hand, and Underbridge and Waterbury on the other. More than three-quarters of patients in the latter two EDs saw over five different members of staff, compared with three-quarters of patients in Porthaven and Churchtown EDs seeing over three different members of staff. The maximum recorded number of staff was seen in Churchtown (21), illustrating the high number of practitioners that a patient might encounter during the journey through acute care.

The difference across sites in staff cost per patient was rather less marked (Table 10), suggesting that, in those EDs where patients saw more staff, the additional encounters were shorter and/or mainly with lower-grade (less highly paid) staff. Once again, Churchtown stood out from the other sites by having the widest range of staff costs, from £15 minimum to £253 maximum. It is not possible to ascertain the reasons for such variation in cost but it may imply significant variation in the complexity of individual patient journeys.

Table 11 shows a comparison of staff cost between admitted and discharged patients. Porthaven and Churchtown ED patients who were ultimately admitted to hospital had lower staff costs than those discharged. In contrast, the opposite was observed for Underbridge and Waterbury, where discharged patients had higher average staff costs than those admitted.

Although analysis of their data was based on smaller subsamples of patients, Underbridge and Waterbury had higher staff costs for older patients than for those with cardiorespiratory problems, whereas average staff costs for older and cardiorespiratory patients in Porthaven were similar (Table 12).

Although these results should be viewed cautiously because of the low numbers and limited sampling approach, they indicate some interesting differences in staffing arrangements and variation in models of care across sites.

Review of value stream mapping data by clinical panels

The review of selected VSM patient case studies by the clinical panels (see Appendix 2) resulted in rich discussions that also aided the interpretation of the VSM data.

The clinical panels commented on a patient whose VSM data identified a very rapid decision to admit in the face of an element of diagnostic uncertainty, followed by a long wait in the ED for a bed. The panel considered that the admission was probably inappropriate and might well have been avoidable, had the decision by the clinician been delayed, and had more time been spent on identifying a suitable alternative. Alternative options suggested were a dedicated rapid assessment team – had this been available – or placement in a community bed, which was apparently not explored. It was speculated that this was an example of the 4-hour target influencing a clinician to make an early, but ultimately suboptimal, decision. The availability and use of a CDU/observation ward in this case might have allowed more time to make a more appropriate decision for both patient and hospital (case VAP103).

The VSM data of another patient, who the panel considered was probably appropriately admitted, prompted the comment that admissions for observation can occur to avoid breaching the 4-hour target (case VAP121).

A further patient, whose admission was considered understandable but probably avoidable, had a long VSM time, being transferred to a ward 12 hours later. The clinical panel considered that this was a good example of a complex patient, perhaps inappropriately referred to the ED, when he could have received more appropriate and timely care by the relevant specialist team, probably without hospital admission (case VAP101). This case again highlighted the importance of accessible alternatives to admission for some patients; yet there was often difficulty in accessing these alternatives once a patient reached the ED and decision-making was subject to the 4-hour target.

Another patient’s VSM data revealed very rapid assessment and discharge, which was considered entirely appropriate (case VCP108), although the panel considered that such quick turnaround was relatively unusual, and in some contrast to the medical and social complexity of many of the patients commonly seen in EDs and AMUs.

The importance of patient safety and the risk of a wrong decision also arose in the case of another patient (case VDP101), whose admission was considered inevitable on the grounds of potential diagnosis and risk, and therefore it was not appropriate to consider alternatives.

In summary, the clinical panel discussions highlighted some key influences on decision-making in this selection of VSM cases. Whether an admission was avoidable or not depended ultimately on practitioners’, patients’ and carers’ perceptions of the medical and social risk of discharge; but also on practitioners having access to relevant background medical details, information about social circumstances and the availability of alternatives including community options, observation wards and appropriately resourced ambulatory care pathways. The availability of sufficient time appeared to be an overriding requirement in order to make the best decisions in more complex cases.

Research question 1: how do medical staff and other practitioners contribute to decision-making?

Overall, senior clinician input was not significantly associated with admission rates, although there was a weak but significant correlation between early senior involvement and journey time. The site with most consultant involvement also appeared to have the lowest admission rate, while the site with the least consultant involvement had the highest admission rate, suggesting that there might be some relationship between the two.

All four sites had prioritised the ‘senior first’ approach, although this manifested in contrasting ways. While ethnographic analysis can help us to understand how senior clinicians (medical and/or nursing) became involved in patient care and what factors influenced this, it cannot necessarily ascertain how senior clinicians chose to distribute their time between direct involvement in decision-making for medically complex patients, and supervising and advising more junior staff. The VSM findings may question the claim that the ‘senior first’ policy – at least ‘consultant-led senior first’ – is essential for expeditious care and admission avoidance in all cases. Indirect senior input via juniors and nurses or via a ‘controller’, as at Porthaven, could provide alternative or complementary models and could have several advantages in terms of costs of staffing and training. The organisational ethnography (see Chapter 5) suggests that there may also have been differences among sites in the extent of skill-mixing, and the involvement and autonomy of nurse practitioners in decision-making.

Senior clinician input also appeared to exert relatively little influence on the duration of the patient journey. However, this could have been because all sites prioritised senior input (see Chapter 5), making differences less apparent. This finding could also be explained by the patient groups studied: for many of these patients, medical or social uncertainty was high at the outset; alternatively, other undetermined, factors were more influential than senior input. The 4-hour target was clearly a driving force that affected journey times, and senior input may have been a factor in adherence to this target.

It is possible to speculate that senior input may have been a significant factor in deciding whether patients were to be kept in admissions areas for longer or transferred to observation areas (e.g. a CDU such as Porthaven) where they were not subject to the 4-hour target, for observation (including ‘watchful waiting’), treatment and discharge planning. This flexibility could have had the added benefit of reducing peaks in patient movement as the 4-hour benchmark approached, thereby promoting a more even and predictable distribution of resources.

Research question 2: how do organisational factors affect decision-making?

The acute care pathway that patients followed was determined by their route of entry into the system. Patients’ experiences of care included overall journey times to admission or discharge, of which VSM gave a detailed breakdown. There was some suggestion that organisational factors could influence decision-making processes. For example, the AGPS in Porthaven – a feature not present at other sites – had lower admission rates than units for similar patients elsewhere.

However, journey times at other sites were also shorter for patients seen by medical teams than for those seen in the ED (p = 0.04). To access these faster pathways, patients usually had to be referred by their GP. Patients and GPs may have perceived attending the ED as resulting in quicker tests and diagnosis, but this was not necessarily the case. It may be suggested that a better understanding of these systems could favourably influence the way in which patients access health care and GPs make referrals. In turn, this could help to manage demand and influence future service planning. The Royal College of Emergency Medicine has proposed that ‘best practice’ is for all medical patients with GP assessments to be taken directly to the MAU (p. 2, recommendation 2N). 10 Our findings support the view that patients can receive treatment as promptly from medical teams as from the ED.

There was evidence that organisations’ responses to the 4-hour target influenced overall patient journey time, and therefore decision-making. All four sites had similar patient journey times, and admissions and discharges peaked around the 4-hour point. This suggested that the 4-hour target was driving the time point at which a decision was made and the patient was moved from the ED (or department associated with the 4-hour target).

Research question 3: how are the four models of care similar and different?

In addition to similar overall journey times, the amount of time spent waiting at each of the four sites was similar: a little less than half of the total time was spent waiting. This high proportion of waiting time is consistent with previous Lean work conducted in EDs. 69 The wait time may have reflected intrinsic elements of the clinical assessment process, such as the need for time to run tests and obtain results, or attend to personal care (e.g. eating, drinking, toileting), or may have been part of a more complex system of queuing in acute health care. However, the reasons for waiting, and the points in the journey where the longest waits occurred, differed significantly between sites.

One possible reason for differences in waiting times across sites might have been differences in the location and capacity of ACUs, as described in Chapter 3. Moreover, the ways in which these resources were used could also vary. At Porthaven, ED consultants had the option of both a CDU and ACU and referred to both of these, while the ACU was also used by the AGPS and medical assessment unit. At Churchtown, where there was no ED observation unit, the ACU was within the triage area of the medical assessment unit (remote from the ED) and patients were taken mostly via GP referrals. At Underbridge, appropriate patients were directed to the ambulatory emergency unit directly from the ED. At Waterbury, there was an eight-bedded observation unit (situated in the ED) as well as ambulatory care, used by ED and medical staff. Although 3A was not designed to compare the performance of individual pathways formally, it is clearly plausible that greater use of ACUs may reduce waits for assessment, investigation and discharge, while transfer of significant numbers of patients into CDUs may also shorten measured waiting times.

It is also possible that differences in waiting times may result from deliberate planned decisions about resource allocation. One explanation is that this could indicate a lack of sharing of best practice and innovations that could reduce waits. Sharing insights and best practice could reduce waits in different areas for all patients, thereby reducing waiting times and journey times overall, in all hospitals. For example, hospitals with longer waits for assessment or for discharge might benefit from adopting specific practices associated with shorter waits. Sharing of ideas and practice, promoting a best-practice model of care, could reduce waiting and journey times and enhance patient experience.

There were no substantial differences between the sites in the ratio of waste to value, and patients were waiting in the ED for nearly half of the time. Although value-adding activities could have been occurring behind the scenes, during waiting periods, this value ratio may give some indication of patient experience. However, there were significant differences in types of waits at the four sites. The project’s PPI group felt that some waits were more acceptable than others: waiting for triage and assessment could be experienced as less acceptable than subsequent waiting for test results. Waiting for first assessments was more adverse because the patient was not yet in the system and treatment could not commence. In contrast, waiting for test results could be more understandable, and patients were more amenable to waiting at this stage.

Therefore, the points in the patient journey where significant waits occurred could have a significant impact upon patient experience. Figure 7 shows that the waits occurred at different places in the patient journey at the four sites. Presumably, a relatively large proportion of waiting before being seen by an assessing doctor could have a detrimental effect on the patient’s overall experience. Assuming also that journey times and the ratio of waste to value remained similar across the sites (which we found), the model of care for each site could have a significant impact on different waits and therefore patient experience.

The finding of longer patient journey times for admitted than discharged patients was not overly surprising. The decision to admit triggered the quest for a bed in hospitals with uniformly high rates of bed occupancy. However, identifying the exact reasons for this waste time might identify organisational factors that can be improved. Porthaven was an exception to this trend, suggesting that this particular site may have some characteristic that expedites admissions. Similarly, Porthaven did not fit the pattern seen in Figure 16 of journey times in relation to category of presenting medical condition (i.e. older age group or cardiorespiratory). Three of the four sites had somewhat longer journey times for older patients than for cardiorespiratory patients, whereas Porthaven showed little or no difference.

Although the four sites exhibited similar value-to-waste ratios, the economic data suggested that there might be differences in cost per patient between the sites. These data must be treated with caution, in view of the assumptions upon which they are based, the limited sample sizes, and the fact that different models of care are being compared. Waterbury, the site with most staff per patient case, appeared to have the least consultant input and perhaps the highest admission rate. Porthaven and Churchtown, the sites with lower pre-assessment waste, had lower costs for admitted patients than for those discharged. At Underbridge and Waterbury, where costs for discharged patients appeared greater, there was greater post-assessment waste. At Waterbury, the ED staff costs for elderly patients appeared greater than those for cardiorespiratory patients.

In conclusion, the present study has generated some of the first VSM data for acute medical admissions in the UK, and it has used this method to evaluate and compare four sites with contrasting models of care. While this approach provided several unique insights, it also has limitations, which are discussed in Chapter 8. Several potentially significant differences in system performance were found, and these have possible implications for patient experience, organisational of care and running costs. The findings may be used to generate new hypotheses on the relative merits of different approaches to care, and to suggest solutions to challenges currently faced by the NHS.

Effects of the 4-hour target

A parameter of reference for staff with longer experience in the system was the state of EDs before 2000, when the NHS introduced the 4-hour target: ‘Patients were waiting 8–12 hours routinely on hospital trolleys’ (Churchtown practitioner 1). Several practitioners said that they would not wish to return to that situation and, in that sense, the target had been a boon to them and to patients: ‘it isn’t good to have people in trolleys in the emergency department for a long time’ (Waterbury manager 2).

Emergency departments were designed as a route towards other places where a patient’s medical care and social needs could be more fully met: back at home with adequate support, in a community facility or on a hospital ward. There were other units where patients could ‘stop over’ if a diagnosis sufficient to guide further care could not be completed within 4 hours, if lack of beds or community resources impeded transfer or referral, or if there were transport delays. These could be observation, medical assessment, clinical decision or ACUs, or ‘holding bays’ for patients awaiting beds. Trolley waits in corridors still occurred, although these were said to be less frequent than in pre-target times.

There was widespread recognition by staff of the achievements of acute care in reducing waiting times, despite the increase in demand coupled with a diminishing bed base and closure of many community services: ‘It does work well, like even on busy days, I mean I think we try and see everybody promptly’ (Waterbury practitioner 2). Nevertheless, staff found it challenging to keep up with some of the accident and emergency (A&E) clinical quality indicators. 6 They described tensions in their efforts to ensure safety, avert breaches and provide patient-centred care, knowing that failure on any of these counts could generate financial penalties, patient harm and complaints:

I was aware of the time going by. Um, but I was quite late in deciding whether the patient was going to come into hospital or go home. . . . when the vascular surgeon came and had finished him and he said that he was happy for him to go home, then it was quite close to the 4-hour deadline, so then I was able to get his medication sorted . . . , to get him home before, before the 4 hours.

Waterbury practitioner 3

There was little slack in the system to accommodate peaks in demand, and practitioners described ‘constantly battling away against the crisis’ (Churchtown practitioner 2) as a routine state in medical assessment units as well as in EDs.

Tension between emergency departments and medical specialty wards

The drive to avoid admissions was more visible in EDs than in other parts of the system, because of the pressure of continuous arrivals. MAUs also depended on possibilities for onward referral:

Acute medical units are . . . reliant on the wider medical wards. . . . we do everything we can do to speed up our processes . . . , but if beyond the back door [the unit] isn’t working, then we’re not going to work . . . and then that builds up to . . . a pile-up in ED, for want of a better phrase.

Underbridge manager 1

Target breaches officially belonged to trusts, but ED co-ordinators often carried prime responsibility for averting them. Practitioners from within and outside EDs could feel that they were being made individually responsible for delays affecting throughput:

[A specialty consultant] arrives at this point and takes the [patient’s] notes. The [ED manager] points out the time on the clock forcefully to him and reminds him of the breach target. He rather irritatedly says ‘Yes I know’.

Churchtown fieldnotes 4

Emergency department practitioners on all sites made efforts to reduce patients’ duration of hospital stay, even if this meant keeping them in the department for longer periods of observation and testing. Staff expressed concern about patients, especially the elderly, getting lost in the system. When people left the ED, the sense of urgency could be lost on the wards, paperwork became burdensome, and patients could ‘languish in the system’ (Churchtown fieldnotes 4), resulting in iatrogenic illnesses:

if you let people progress beyond [the ED] . . . they get unnecessarily trapped in a diagnostic and therapeutics spiral which takes days, costs hundreds of thousands of pounds, and doesn’t benefit the patient anyway. So I try and sort them out definitively in [the ED] if possible.

Porthaven practitioner 3

Underbridge staff identified their single-point-of-entry model as a system that attempted to avoid the above-mentioned loss of momentum, by enabling management of all patients – both those needing emergency care and those referred for medical assessment – to be initiated in the ED within the 4-hour limit.

Tipping points

Staff spoke of ‘tipping points’ that took them from a calm situation to one that felt unsafe. A nurse described these as regular rather than exceptional, feeling there were ‘just too many’ patients: ‘they overrun us and we couldn’t cope with it’ (Churchtown practitioner 6). Objective situations of bed occupancy blended with subjective limits when they started to feel out of control:

the department goes from a state of kind of normal business where it is flowing, we are meeting the targets, . . . we’ve got our noses above the water, and then suddenly, whether it be a surge in patient numbers or acuity or whatever it is and we tip over to, . . . we need to make people safe now, and the targets are largely irrelevant. But I find the most stressful bit of my work is . . . trying to hold onto the reins while we are tipping into crisis management.

Consultant in learning set 1

Moving patients through the system

Several nurses and some clinicians commented that the managerial drive for efficiency tended towards packaging and moving patients through the system like objects on a production line:

I think as nurses, um, if you forget that you’re dealing with human beings and you start thinking you’re dealing with boxes, which is sometimes how you get made to feel you should do.

Churchtown practitioner 7

Practitioners sometimes gave positive connotations to commodification of flow, which they explained in terms of not only achieving targets but also reducing delays:

we’ve tried to explain that I have 10 expecteds to come in and I’m moving them because it’s the right thing to do, because we shouldn’t have people awaiting beds, we shouldn’t have people awaiting treatment.

Underbridge manager 2

However, staff’s attention to flow meant that time for basic nursing care was reduced:

the human element to me is why I do my job, and it’s vital that we have the time to do that. . . . we get site management phone us and say, ‘This patient is on . . . 3 hours 55, why haven’t they gone to the ward?’ And it’s like, ‘Because they’ve just been incontinent and actually I want to wash them and put them on a clean bed, because I wouldn’t want to be wheeled down the corridor on a bed covered in urine, would you?’ . . . and I understand that that’s their job, to do the boxes: move that box from there within 4 hours, and it just doesn’t always work like that.

Churchtown practitioner 7

Time for patient care and communication

Flow management under pressure left little time for dialogue with patients and relatives, and staff acknowledged that this generated problems:

there’s lots of complaints that are made against the hospital and against the emergency department, most of which are to do with communication.

Porthaven practitioner 2

Senior clinicians tended to focus on ‘hard’ safety outcomes rather than ‘softer’ aspects of quality of care. Some associated spending time on practitioner–patient interaction with other staff roles, levels or ‘styles’ of delivery:

I get around very quickly, I discharge. . . . I don’t get any more complaints. My readmission rate’s no higher than anybody else, my mortality – so it’s not like I’m discharging people willy-nilly without any sort of safety checks in place. . . . some of the others will have some of the softer stuff that’s a bit more educational with the trainees. . . . they may spend a bit more time with the patients than I would. . . . it’s just a style thing really.

Underbridge practitioner 2

Practitioners made decisions by ‘ruling out’ risk factors rather than ‘ruling in’ to acute care (Underbridge practitioner 3), giving an expulsive movement to the service. A clinician in a stakeholder workshop said that the ‘ED is designed to frontload diagnostics, not “care”’. A learning set participant, however, expressed concern about communication with patients:

a quick way that would make a difference to the patient experience is how we manage to improve our communication of what’s happening with the patient, so that we have a policy where the patient knows what’s going on, . . . why they are waiting at all times.

Learning set 2

When staff did not feel pressured, they could show sensitivity in persuading patients to agree to a move that they considered appropriate. This was apparent in the case of a Churchtown specialist geriatrician who took time to visit the ED with the care of the elderly team, in search of patients they might help to discharge:

What do you think about that? Would you be happy with that?

You’re the doctor, you tell me what to do [laughing]. . . .

What do you think? Does that sound okay? [laughing]

Yeah. If Mum’s happy – if you’re happy for her to go home and you’ve obviously done a lot of tests and whatever and that’s fine.

Churchtown practitioner 8

Some practitioners linked being ‘busy and manic’ (Underbridge manager 2) with a default to admit patients. This state could generate a hyper-efficient, but confusing, mode of delivery, observed in MAUs as well as EDs, that unwittingly obstructed two-way communication:

Sorry about that. . . . such efficiency. . . . If you’re in in the morning, the doctors do a ward round. They usually finish by about 12 o’clock but you’re more than welcome to ring and see how she’s got on, but they might say, ‘We can’t give you any new information until the consultant has seen you’. All right? Any other questions that I can answer for you?

No that’s –

Are you going to go home and put your feet up and have a sleep? Are you going to be all right to drive home? As long as you – do you want to call a taxi? Do you want to use our phone here? Do you know a taxi number that you’d like to use?

No.

Guys, does anybody know a taxi number?

Churchtown practitioner 9

In observation and ambulatory facilities at Churchtown and other sites, the less pressured model of care gave opportunities for more relaxed and frequent communication with patients:

[The nursing assistant] takes it as part of her responsibility to check with patients while they are in the ambulatory area . . . if they have had fluids and foods.

[The staff nurse] comes in to ask [a patient] about her drugs and discusses the dosage . . . before she goes. . . .

Doctors are not based in ambulatory care but keep up with [patients’] progress via Patient First, and go in to see them as needed.

A junior doctor comes to speak to a patient who is waiting to go home. . . .

The junior doctor [says to another patient], ‘You can go home now. [We] will send the letter to the GP in the post. You can take ibuprofen. [I] suspect things will settle down in time. If it doesn’t, you can see your doctor’.

The nursing assistant says to a patient: ‘Sorry for the wait’ [for transport].

Churchtown fieldnotes 5

Effects of pressure on staff

Staff experienced strain between delivering patient-centred care and guarding acute beds:

family members think we’re holding our opinions more important and we’re thinking about resources. . . . an acute bed is a very special thing nowadays . . . so therefore we have to ring-fence them even more . . . everyone should be happy to try and not have you in one, as opposed to the other side that’s always been that a hospital is always there, it’s always safe, it’s always open, it’s always got beds, and that now just doesn’t exist any more.

Waterbury practitioner 6

A staff member described the effects of pressure on a cohort of senior nurses who left one ED:

we were getting more pressure to hit targets, and as senior nurses they were just saying . . . I don’t need this. . . . Roughly at the time . . . we all kind of went, hmm . . . we’ll just take a side-step. . . . [The ED has] lost a lot of nurses, . . . and the new nurses that we’ve recruited have had to be taught the skills to work in A&E, . . . we had to frantically put a lot of them through the triage training. . . . there’s 10 nurse posts out to advert at the moment for A&E here.

Churchtown practitioner 7

Balancing risk and ensuring safety

Across the four sites decision-making was a dynamic process of evaluating the consequences of practitioner decision-making for three principal actors: for the patient, in terms of their safety and well-being; for the practitioner in terms of their reputation and feelings of self-worth; and for the hospital system in terms of resource implications and liabilities. Practitioners sometimes described decision-making as a rational process based on clinical judgement and knowledge of ‘statistics and success rates’ (Porthaven fieldnotes 4). At other moments they said that ‘You have to go with your gut feeling . . . within a reasonably safe parameter’ (Waterbury practitioner 8):

it’s like a sixth sense, it’s like a feeling of . . . failing the end-of-bed-o-gram, . . . and I think even consultants will still admit that feeling that there’s something that they’re not happy with but there’s no physiological complete signs for it, but if something’s not quite right the safest thing to do is . . . to admit them.

Porthaven practitioner 4

Although the attraction of working in ED was partly linked to making rapid decisions, this could also be experienced as the most stressful aspect of the job. Practitioners were acutely aware of the consequences of an inappropriate discharge decision:

I know colleagues who have been harmed by [the fact that] they missed a subarachnoid haemorrhage [or] they missed an aortic dissection and a young person went home and died, . . . and they suffer from that bias from the patient they’ve seen last. I think it’s then difficult to step back and actually go, ‘Just because I had a bad experience it’s not fair to inflict the negatives of over-testing on all the other patients I’ve seen’.

Porthaven practitioner 3

Practitioners often said that concern for patient safety outweighed all other factors (including targets) as an indicator for admission. This concept included the patient’s ability to live independently with or without support, to have their pain adequately managed, and to care for their emotional state or mental health. In responding to this spectrum of needs, acute care often acted as a substitute for social care:

we would obviously never discharge anyone that’s unsafe medically . . . ; and then there’s socially safe. Can somebody look after themselves? Are they going to be all right waiting for their carers that we can’t set up until the next day? . . . and the anxiety-related safe. Are they going to get home and become so anxious they phone an ambulance, in which case that’s not ideal either.

Waterbury practitioner 9

Practitioners characterised patient cases as ‘complex’ according to the combination of medical conditions present together with disability or social care needs. To manage such cases (see Appendix 12), acute care staff gathered information and criteria from various sources including other clinical specialties and, where available, specialist discharge teams. In other cases – typically of younger patients – there was less medical and social complexity, but commonly a level of anxiety that influenced their decision to seek acute care, sometimes out of general practice opening hours. Such patients were sometimes referred to by practitioners as the ‘worried well’ (Porthaven practitioner 4). Nevertheless, researchers observed several instances in which patients who had been described as anxious were assessed case by case to exclude serious conditions.

System contingencies and out of hours

Clinical need was not always the primary consideration in decision-making. Resource constraints, and system contingencies could sway practitioners towards admission. These factors were particularly compounded by the timing of the patient’s presentation at hospital. Practitioners stressed that their decision-making out of hours was influenced by lack of availability of diagnostics and specialist teams within the hospital and a perceived difficulty in setting up community-based support:

if we know that the family situation is breaking down, that the frail little old lady care package isn’t adequate and it can’t be changed, there isn’t a community system that’s responsible enough, um, to make that happen quickly, then I usually find I admit patients – and that’s frequently out of hours, so weekends, evenings – um, because you’re just going to make a difficult situation worse, on the whole, even though the patient may not necessarily be acutely unwell enough to require admission.

Underbridge practitioner 4

Although [the patient] looks clinically well and I think this could potentially be managed in the community hospital . . . I discussed it with [the medical consultant] and she sort of agreed that . . . now [the patient] is here she could come in under us.

Underbridge practitioner 4

Decision-making with limited time and information carried risks including readmission:

I think to myself: ‘What if I missed something? How would it look? But if we keep readmitting . . . it’s not helpful. If at any time anything happens, [the patient] can come back to A&E.

Waterbury practitioner 9

Emergency consultants described their hallmarks as having the confidence to bear risk and an eye for probability:

Admitting people is the easy option actually. Taking the risk and the responsibility to send somebody home is [a] more difficult decision sometimes.

Porthaven practitioner 4

I think it’s the confidence to be able to let them go home with the proviso that they can always come back as well.

Underbridge practitioner 2

Some senior clinicians, especially when occupying the central decision-maker or ‘controller’ role in Porthaven, concentrated on departmental management and reviewed cases by liaising with other practitioners without necessarily seeing patients. Other clinicians emphasised the importance of ‘eyeballing’ the patient (Underbridge practitioner 5) and basing their judgement on the patient’s appearance and a first-hand conversation.

Target compliance

Target compliance was a basic factor influencing the moment at which ED decisions were made:

I would say 9 times out of 10 that decision-making is done because the pressure that’s felt to move those patients out of the emergency department, either ’cos, you know, the general feeling that it’s unsafe or simply because, you know, the clock is ticking and we’re getting to that 4 hours.

Waterbury manager 2

Admissions were observed to occur where there was uncertainty about admission or discharge and a breach time approached, in order to ‘buy time’ for making assessments of an evolving condition:

a lot of the time we admit patients that don’t need to be admitted, they just need a bit longer, so either they need a blood test to be taken for example, 6 hours after a bit of chest pain, and . . . if we want that we potentially have to admit them to wait for that blood test.

Porthaven practitioner 5

The decisions of ED practitioners were often tempered by the threat of sanctions governed by audits. Tension was created between risk aversion and a culture of admission avoidance within a strict time frame:

I think a lot of the junior doctors who haven’t chosen the specialty find that taking risk is very stressful . . . because we do get blamed if we’re . . . I’m not convinced that we’re adequately supported in that and I think if there was better support for backing up risk, as it were, then people would be more willing to take the chance of sending a patient home.

Waterbury practitioner 1

Pressure from patients’ relatives

Practitioners reported that the need to ‘give the relatives the option’ about admission for elderly patients (Churchtown practitioner 7) acted as a pressure in the course of decision-making:

Sometimes [relatives] can really have an impact if they say, ‘Actually, you know, we can’t manage at home, you know, we’ve tried to do this, we’ve tried to do that and actually we want somebody to sort this out’ . . . the wards will say, ‘Well actually [relatives] said can [the patient] stay in another night because they have got to do something and then they’ll come and collect them tomorrow?’ and you think, ‘Really?’ . . . but just by the same token some people will say, ‘No they’re not staying, and I’m taking them home.’

Churchtown manager 2

Defensive practice

Practitioners balanced the risk that might be posed to a patient by admission or discharge, or by investigations that might be requested. They were also influenced by what was safest for the hospital, other patients, the community at large, and practitioners themselves: ‘you could potentially be putting them at risk and subsequently yourself at risk from a defensive perspective’ (Waterbury practitioner 10). Practitioners were concerned that their professional reputation was often at stake in the rapid decisions required of them:

staff are not going to put their jobs on the line by reducing the threshold to discharge patients when it’s not their issue. If you’re left to look after a patient and to medically look after the patient and that’s what you’re there for they’re not going to worry that patients are not getting in through the door, because that’s people’s reputation on the line isn’t it and that patient’s experience of sending them home – all that’ll happen is they’ll just go home and come back in again.

Waterbury practitioner 12

Practitioners said that admission was more likely if a time-consuming process was needed for discharge, where there were staff shortages, and if there were a high number of acutely ill patients:

if you’ve gone down from 9, 10, 11 doctors, to 4 doctors, and the acuity of the patients has gone up – the numbers of new attendances [is] slightly lower at two in the morning than two in the afternoon, but the acuity will be worse – . . . [then] the doctors will be very pressurised in terms of decision-making and much more likely . . . to opt for the path of least resistance and get a patient admitted, rather than try and initiate a whole series of things that are going to be very hard to try and undertake at two o’clock in the morning.

Underbridge practitioner 4

Access to general practitioner notes

Background information about patients was considered important for safe decision-making. This could come from the patient or carer, from referral letters or from GP notes if available. However, it was emphasised that access to primary care information was impossible if patients attended out of hours:

If you’ve got a complex patient who is not the best of historians . . . then trying to piece together . . . enough of the picture to make the decision can be very challenging. . . . if you go out of hours and the GP is no longer open . . . you’re working with far less information and then you have to veer on the side of safety . . . and because you’re going to be more cautious, . . . then you will admit more.

Underbridge practitioner 5

Access to GP notes varied across sites. The AGPS at Porthaven had direct electronic access, and Waterbury ED was piloting a system of electronic access to notes from selected GP practices:

we have access to [notes from] a significant number . . . , probably about half of GP systems at the moment, and that’s going to increase, which has been dramatically helpful in deciding.

Waterbury practitioner 4

However, for one patient in Waterbury ED, access was attempted but was observed to be unsuccessful:

[The consultant] suggested that they utilise a new system whereby they are able to access GP notes, with the patient’s permission. Unfortunately this proved unsuccessful, although the consultant [said] that the new initiative had made decision-making easier when they were able to view GP assessments of patients.

Waterbury fieldnotes 5

On sites without access to GP notes, clinicians could decide to call the GP, although this was rarely observed in our patient case studies. Instead, ED practitioners generally preferred to rely on the accounts of patients and relatives.

Dealing with multiple roles

Drawing on their authority, knowledge and local experience, consultants integrated what they called ‘predictive and proactive management’ into their multiple activities:

trying to maintain an awareness of . . . the whole department and managing . . . the clinical resource, so both nursing and medical . . . but also managing the clinical risk and safety for each patient . . . so within that I might have um, influences in terms of, you know, how busy is the department . . . how busy is the rest of the hospital, how busy are my specialty colleagues, . . . what’s happening outside in the pre-hospital environment, . . . what’s the likely scenario that’s going to happen over the next hour?

Waterbury practitioner 11

Multitasking was a visible feature of the work dynamic of senior managers and clinicians: ‘I remember one patient looked at me and said, “Do you know you’ve had 30 conversations in 15 minutes?”’ (Underbridge practitioner 6). ED seniors generally had limited opportunities to plan their workload, since they responded to all in the department. Consultants’ decision-making expertise was acknowledged, but less recognition was given to their ability to oversee the department, support juniors and maintain flow, and simultaneously attend to their own caseload: ‘that’s often one of the biggest challenges, is trying to do both of those roles at the same time’ (Underbridge practitioner 11). Porthaven used a different model whereby consultants took turns acting as managerial lead without seeing patients, reportedly with several benefits:

when we started to put in lots of consultants on the shop floor, the problem we discovered very rapidly was there were lots of chiefs. . . . so we have what’s called a Fat Controller . . . whose job is not to see patients but . . . to sit and run the department. So they liaise with the senior nurse, they liaise with the specialties, . . . with people like radiology, and they . . . make sure that patients are all seen appropriately, [that] flow is maintained . . . Fat Controller should know a bit about every patient in the department. . . . you’re the focal point for junior doctors to discuss patients with. So it means the other consultants . . . can get on with seeing patients . . . we think it works very well.

Porthaven practitioner 2

Cherry-picking

Some seniors selected cases where they felt they could give most value by diagnosing or discharging them in less time than junior doctors could do:

Sometimes I’ll cherry-pick things that I think I might sort out more quickly or be more likely to send home than other people. So if I see someone that I think is potentially dischargeable then I might see them myself.

Waterbury practitioner 1

An alternative version of ‘cherry-picking’ was choosing to see frequently attending patients, nicknamed ‘frequent flyers’, to avoid junior doctors getting drawn into unnecessary admissions:

if I see someone who is, let’s say, er, a well-known patient, say, who has a problem so like alcoholic, so someone who keeps coming in and complaining of a problem which has been ruled out repeatedly in the past, . . . I’ll go see them because I’ll be able to make the decision much faster than a junior doctor.

Porthaven practitioner 2

Fixing, not delegating

Emergency department consultants described how, if they wanted something done, they just did it, whether that was taking a blood test, arranging for an admission or securing a clinic appointment, particularly when their knowledge of the system allowed them to take shortcuts:

maybe apart from anaesthesia you would struggle to find a consultant doing blood tests, yet here, if I see a patient and they need bloods done I’ll do them.

Porthaven practitioner 2

. . . before going to see [the patient] I was expecting I was going to try and do things for this afternoon . . . a CT [computerised tomography] scan, making sure I’d seen his ECG [electrocardiogram], and have blood tests done. . . . I wanted to [get the patient seen by a] TIA [transient ischaemic attack] clinic which runs Monday to Friday . . . but not at weekends. . . . knowing the system and the seniority allowed me to do those things more quickly.

Underbridge practitioner 7

Seniors could have the confidence to reverse a decision on the basis of further observation and test results, also considering pressure on beds:

if he was pain free and we’d had a CT and it’s normal, and he still hasn’t . . . got a bed on the ward, then we could potentially review things at that point, couldn’t we? . . . reverse the decisions.

Churchtown practitioner 4

Staff acknowledged the speed with which seniors could operate and their ability to take responsibility for discharge:

a consultant was brought in on the weekend and he discharged 16 patients. Now if you’ve got a junior, they won’t do that . . . there is this thing about having a senior person around to say, actually, you can go home, you don’t need to come here.

Underbridge manager 3

In combining multitasking with a hands-on approach, consultants tended to ‘make it happen’ rather than delegate tasks, although they were sometimes observed to delegate to senior nurse co-ordinators. Some ED consultants spoke more of doctors and nurses working ‘together as a team’ in a different way from ward culture, which was said to be ‘more them and us’ (Porthaven practitioner 1). The culture of joint working between doctors and nurses was not however, shared across all sites, and in some departments tensions were reported.

Seniors could facilitate consultations across departments and requests for speedy testing, in ways that were not generally accessible to juniors:

if one of the acute physicians was in the department and I see them, . . . with their specialist interest in a particular area, I might run something by them. Radiologists I’ll phone up if I’m uncertain about a scan or an X-ray. . . . I feel completely comfortable to phone anybody in the hospital if I wanted advice from them and generally they’re very happy to give it. . . . also consultant status means everyone’s nice to you. [Laughs] The junior doctors may not have such an easy time asking for advice or favours or ‘Could you just fit this one in?’ or ‘Could I just have that scanned?’

Waterbury practitioner 1

Training junior doctors and other staff

While making increasing demands for rapid decision-making, the hospital emergency system allowed little time for seniors to train staff in this skill, in triage and in the network of services for referral. Pressure on consultants’ time meant that they sometimes ‘fixed’ issues rather than talking juniors through the process: ‘I’ll just make the decision’ (Underbridge practitioner 3). A Waterbury co-ordinator pointed out one potential disadvantage of the ‘senior first’ model:

if someone senior has already seen [the patient] and said [to a junior doctor], ‘You need to do this, this and this, and this is what the outcome’s likely to be’, then it takes away that kind of decision-making process . . . and [juniors] become a more admin type.

Waterbury practitioner 4

One ED consultant considered that it was characteristic of emergency medicine to have a ‘very high hit rate’ of juniors requesting decision-making support from seniors: ‘It’s hard for you to have your own clinical workload’ (Waterbury practitioner 11). Some consultants acknowledged that taking time to teach was an intrinsic part of their work and beneficial to all. Modes of support varied across sites: Porthaven seniors slotting in micro teaching sessions; Churchtown consultants discussing reasoning processes in decision-making with juniors; Underbridge seniors, from both emergency and medical departments, balancing teaching with safe cover in the department; and Waterbury being known as a site where seniors felt themselves to be particularly accessible. Despite this advantage, new intakes of junior doctors took time to develop their own decision-making skills:

we’re very visible in our department, there’s always somebody [juniors] can ask 24 hours a day and most people are very approachable . . . sometimes you find you’ve got a queue of three people constantly, you know, for 8 hours at a time waiting to ask you to make their decisions for them.

Waterbury practitioner 1

In their early training stages, juniors were said to compound busyness. They underwent rapid training, acquired experience on the job, and moved on:

when we’re quieter the junior doctors will get more support . . . you get your new doctors, you get a really busy department, you just go, well, we’ve just got to survive, we’ve just got to get through this period.

Churchtown practitioner 7

Senior nurse managers as well as consultants monitored and supported junior doctors: ‘Some juniors can be very good, it’s an individual thing . . . they’re sort of safety-netted by our senior team so [as] to reduce risk of bad management’ (Porthaven practitioner 1).

Emergency department pressures were said to leave insufficient time for training staff in decision-making:

undertrained staff . . . are not confident to make a decision and therefore defer this decision to others, which often [means] admitting until someone can review the decision. It is not these individuals who are at fault . . . they do not receive adequate training and support.

Underbridge practitioner 8

On some sites, the decision-making role of ANPs was said to be inadequately supported:

they’re actually very nervous of making those sort of decisions without getting another senior review . . . I think generally it’s about having senior people within the department. If you’ve got emergency nurse practitioners . . . who will . . . look at the X-ray and say, ‘You can go home’ – it’s about training, skill, competence, seniority, I suppose, as opposed to more formal systems.

Underbridge manager 3

This was reflected in one ANP’s comments regarding her limited role in decision-making, which she linked with a deficit in authority, and possibly also in clinical knowledge:

none of us are able to . . . we don’t have that, the authority to say this patient’s going home . . . when you’ve seen the patient . . . we’re not clinical decision-makers in that I couldn’t discharge someone solely off my own back.

Waterbury practitioner 9

Middle-grade doctors who had developed skills and knowledge of the local system over years were observed to bring considerable benefits to teams. Some staff commented that waiting for senior review could cause greater delays to patients than decision-making by capable middle-grades. It was important for safety that they could judge whether or not it was necessary to seek the opinion of a senior:

if I’m fairly happy with what I’m doing then I don’t need to discuss everything with somebody senior. . . . I’ve kind of gone with my . . . gut instinct and I manage him. . . . I know that he’s going to [medical assessment] . . . so I think he’ll be relatively safe.

Porthaven practitioner 5

Trainees’ skill in decision-making was said to be favoured not only by their expanding knowledge and local experience, but also by having a temperament that was neither overly risk averse nor excessively bold:

it’s down to the individual, there are certain docs you are – have got on your radar, . . . the ones that tend to be just a little bit too reckless and also the ones that tend to be too cautious.

Underbridge practitioner 3

Acute medical specialists

Some practitioners considered that input from medical specialists early in decision-making could reduce admissions to acute wards, particularly for the type of patients with uncertain medical diagnoses on which this study focused:

a lot of our doctors are GP trainees, and they’re not necessarily A&E or they’re not necessarily medical . . . they’re not specialised in medicine or . . . surgery, so therefore they’ll admit most people. Whereas if we had a specialty doctor in the department – so if we had a medical doctor specifically – they could say, actually, you don’t need to be admitted. Like we’ve got one of our consultants from medicine down here, at the moment, having a look at one of our patients to decide whether they actually need to go to the ward or not.

Churchtown practitioner 11

Medical physicians sometimes came to assess ‘medical and uncertain’ patients and attempted to achieve their discharge, where appropriate, directly from the ED, thus preventing potential waits for beds to become available in MAUs. This was routine practice in Underbridge, because of the single-point-of-access model in which medical and emergency physicians worked together in the ED. It was also the default practice in Waterbury, where the high occupancy rates of MAU beds rendered it expedient for on-call medical physicians to make admission or discharge decisions directly from the ED. On both sites, the transfer of patients was facilitated by the close proximity of the ED and the MAU.

Even where the geographical distance between units was greater, the working relationship between emergency and medical physicians was emphasised as productive for admission avoidance. A Churchtown medical consultant made occasional, unplanned visits to ED:

had we [the medical team] got to the gentleman in time who has since gone to the ward, we’d have thrown him straight out. . . . this lady here is going to go straight home . . . because we don’t think she needs the blood test that ED want to do. . . . we have a greater confidence because we have greater experience of medical patients.

Churchtown practitioner 2

Initiatives from the ground up

Given manifestations of overload on the front line, EDs were observed and reported to run with remarkable efficiency for much of the time. System improvements operated partly in response to policy mandates, but organisational resilience was fundamentally achieved through a strategy of teams pulling together in EDs and other acute care units in multiple efforts to avoid inappropriate admissions. Practitioners on each site mentioned at least 15 concurrent initiatives that they associated with admission avoidance, including acute GP units, ambulatory care, attendance-avoidance phone advice, care of the elderly teams, CDUs, discharge teams, ‘hot’ clinics, nurse practitioner roles, observation units, physiotherapy within 24 hours of admission, rapid assessment on arrival, short-stay units and urgent care groups. Additionally, clinical protocols to reduce the likelihood of admission had been established for conditions such as cellulitis and pulmonary embolism (PE), and for chest pain investigation (Triple Marker system). Informal initiatives included interpersonal strategies such as ‘begging and chatting people up’ for extra CT-scan slots (Waterbury practitioner 12).

Some initiatives were short-lived pilots, such as an eight-bedded trolley area run by nurse practitioners within a medical assessment unit: ‘We trialled it twice but . . . it lasted about 24 hours before it was filled with inpatients and therefore we sort of adapted our role to now go to the patient wherever they arrive in the hospital’ (Waterbury practitioner 9). Initiatives were constantly adapted in response to changes in site configuration, staff availability, seasonal demand and policy mandates. An AGPS was disbanded at Churchtown shortly before our data collection commenced, and during the course of this study an ACU was opened at Underbridge.

The plethora of initiatives did not depend on formal oversight and seemed to have a motivating effect on teams working towards a common goal:

we’ve launched [AEC] . . . and we’ve got . . . the Go In team, who . . . look at people at the front door rather than admit them straight away. . . . we have got mental health support . . . We have a paediatric assessment unit, . . . It’s kind of like a [CDU] . . . we do have a couple of emergency clinics . . . that we’re able to admit directly into.

Underbridge manager 9

Observation areas ‘off the clock’

In the context of financial penalties for breaches, target workaround allowed patients who required longer periods of observation to be taken ‘off the clock’ and moved from trolleys to beds or into holding bays, observation or short-stay units. Porthaven and Waterbury had observation or decision-making units where patients were under ED care but no longer ‘on the clock’. In Waterbury’s bedded observation ward these patients were regarded as ‘admitted’, although most were awaiting investigation results and formal decisions. On the other sites, where this facility did not exist, or where such areas were for seated patients only, some practitioners believed that a bedded short-term observation area would provide a solution to the problem of patients holding space in the ED, and an alternative to longer-term admission to a ward: ‘We could observe them and send them home from there without them touching the surgeons’ (Churchtown practitioner 4):

we don’t have a CDU where they can wait for things like ultrasounds or CT scans, but all of those types of things cause huge delays, . . . because we can’t get these patients out and there’s no beds. . . . We’ll look at some and we’ll say, ‘Actually, you don’t need to be seen here,’ and we’ll put them directly into [a ward] somewhere so they can be seen by the specialty. . . . They are just a GP admission that has gone to a ward to avoid queuing in a corridor.

Underbridge manager 4

At Churchtown, ED patients were kept within the department for observation:

there’s three cubicles that we call ‘AFO’, Admit For Observation. . . . We don’t AFO them so they don’t breach, because we’re not allowed to do that, you know, we AFO them for genuine reasons. . . . they come off the [clock] . . . so they’re in a cubicle and they go onto a bed. . . . as long as they stay in that cubicle that’s fine . . . it’s like being an inpatient because you’re not on a trolley.

Churchtown manager 3

Patients marked as AFO on the ED whiteboard were counted by managers as a type of admission prior to ‘actual’ admission to a ward:

they’re not on the 4-hour clock any more, but there are very, very strict criteria that we’re allowed to admit for observation . . . people that are awaiting bloods, for example . . . so we can monitor them for the 6 hours and then decide either that they’re OK and they can go home or actually that they need admitting.

Churchtown manager 2

However, some ED consultants had a more nuanced understanding of the term ‘admitted’:

I suppose . . . technically, they’re put on a hospital bed, they’re in an area where they can be kept overnight, so I guess that, you know, that’s an admission . . . I don’t personally see it as an admission really, . . . mainly because . . . it’s within our nine major cubicles as it were, and because those are used flexibly, . . . I wouldn’t see it so much as an admission. Particularly as often it’s used as a period of observation with an expectation that the patient’s going to be discharged home. . . . It’s a way to carry on managing those patients outside the 4-hour target, essentially.

Churchtown practitioner 1

Practitioners across all sites tended to favour the introduction of short-stay units where patients could be monitored without being subject to the 4-hour target. They appreciated observation time as providing a third option in decision-making, beyond the binary concept of admit to a ward/discharge:

it would be better for patients though as well . . . if we could just park them somewhere for a short while. I know that happens on [the acute care unit] but we almost need another area where we can do that. . . . and you haven’t got that pressure then of the 4-hour target, ‘cos you’ve . . . just moved them sideways for an hour or so.

Underbridge manager 3

However, researchers observed that the use of such units sometimes led to a loss of momentum in decision-making and, particularly on bedded units, to patients’ expectation that they would subsequently be admitted.

Ambulatory care and avoiding admission expectations

Ambulatory care was used on all sites, with reported benefits in reducing admissions by allowing patients to be seen, treated and observed, generally by small teams and in seated areas, without the expectation that they would stay overnight. Ambulatory areas across sites showed variations in staffing, consultant input, processes of referral to these units and whether or not patient pathways were subject to the 4-hour target. Porthaven, Waterbury and Churchtown ambulatory units were under MAU management, and they typically received medically expected patients from medical triage, although Porthaven also worked closely with the AGPS. At Porthaven and Churchtown, patients from pathways allowing next-day outpatient appointments were not on a 4-hour target time, as it was expected that they would be investigated and treated, and then return home. Other patients referred by GPs, or occasionally by the ED, were seen on the same day and within a 4-hour limit, as investigation could indicate the need for admission, although the patients were not sufficiently unwell to be in a bed:

our aim is to avoid admissions . . . that’s what we have our ambulatory area for, it’s kind of like the walking wounded . . . so anybody that doesn’t actually need to be within this area on a trolley, or somebody who we feel could come back potentially the next day, or is suitable. . . . so we’ve got the cellulitis pathway, we’ve got the PE pathway and a couple of others as well.

Churchtown practitioner 12

Policy mandates and financial incentives supported the setting up of such units:

we were given an incentive so the tariff was increased to make sure we had more zero-length-stay patients. . . . patients are less at risk of acquiring hospital-acquired infections, patient experience is supposed to be better. . . . and obviously reducing beds as well . . . you get very frustrated about seeing a patient who possibly didn’t need to come in . . . and once they get into the system of the hospital it’s an extended length of stay. That’s why we’re trying to set up the short-stay ward as well.

Porthaven manager 1

The recently established ambulatory area at Underbridge was led by the ED and acted as an alternative pathway for patients who required an assessment that might exceed 4 hours, but who were likely to be discharged. The difficulty for practitioners lay in defining what was ‘ambulatory’:

Obviously, your classic, you know, ‘20-something’ that walks in is clearly ambulatory. . . . But what about your, um, little old lady that mobilises two steps at home with her Zimmer frame because that’s her normal – is that ambulatory or not? I’d say yes, it is . . . They’re not walking but they are ambulatory.

Underbridge practitioner 10

Irregular use of admission avoidance initiatives

Where ambulatory care was effectively signposted and used, it could result in admission avoidance. However, there were indications that ambulatory care and other alternative pathways were not used consistently. This was partly because of confusion about the patient types that could be referred to these units, and partly because the units did not always come to mind when practitioners weighed up alternatives to admission:

If at all possible, I’d like to get you out today.

To where she should have been in the first place: to ambulatory care.

A completely avoidable admission. She is not that unwell. We have an ambulatory care set-up where she should have been.

Porthaven practitioner 7

. . . there is no reason why a patient like her couldn’t have come to ambulatory care, sat, and had everything done for her in there. But because she came in with chest pain, which is what we get hyped up about . . . – so the only reason she’s in MAU is because of the ED 4-hour wait thing, so I guess with that in mind she’s probably more an avoided admission, rather than somebody who’s actually admitted and discharged the same day.

Waterbury practitioner 13

Where ambulatory units were led by the medical team, they were not generally accessed directly from the ED, even though ED practitioners believed this could be beneficial:

I think having well-established . . . pathways for investigating some things that could be done on an outpatient basis is important, and we’ve already got things like that, like . . . ambulatory care pathways . . . They’re helping – having well-established links with those. Sometimes they’d perhaps be better co-ordinated and more available directly from the emergency department.

Churchtown practitioner 1

The somewhat haphazard ensemble of initiatives gave rise to some duplication and irregular use of both formally established and newly created pathways:

I think the ADU [sic] – I’m still confused as to whether I should be calling it MDU, ADU, AEC [laugh] and I have to admit I haven’t quite got my head round what the different acronyms do in terms of which patients I can send where – . . . the service has been in one location and then it’s in a different location and now it’s called this and then it’s called that, I don’t think the department has worked out when to use it and when not to use it.

Underbridge practitioner 5

New intakes of junior doctors were often unaware of the pathways available:

Hi [name], [ACE] team. Anything for the [name of team] geriatricians?

Oh maybe, yes, that might be good. Dunno . . .

70-year-old collapse?

Yeah, that sounds right up your street.

Churchtown practitioners 8 and 13

This junior doctor’s inclination to admit was reversed when the care-of-the-elderly consultant secured agreement for discharge from the patient and her daughter, and arranged an outpatient appointment for the next day. The junior’s reflection illustrated how initiatives involving specialist teams could work in a serendipitous way, even though they had not been integrated by all practitioners as regular pathways:

what happened with that lady is how the system should work, but I think certainly it’s quite a variable . . . [the care of the elderly team] happened to be here and therefore it worked really well, and that’s great.

Churchtown practitioner 13

Reluctance to go to hospital

Rather than a drive to overuse emergency services, our data indicated a clear preference among patients on all sites for using community-based services and avoiding hospital visits:

the pain started again today, and I ignored it around 12 o’clock, because I’ve got two children I don’t want to stress myself. . . . it kept on and I took co-codamol. But it just could not go, then she [GP] said to come here [to the ED].

Waterbury patient 1

A 51-year-old woman from Waterbury had attempted to consult her GP about chest pain. The practice was closed, so she called 111, whereupon she was advised to attend the ED by ambulance:

I just kept saying to people on the phone this morning that I was quite happy to – I just thought they’d send me down to [X community hospital], [X] would give me some painkillers or something and sort of ship me off home again. And I was quite happy to do that. I even said ‘I’m going to see the [GP]’, didn’t I?

Waterbury patient 2

The wish to avoid hospital was especially common among members of the older generation, who tended to associate emergency services with dire situations and also felt the need to justify their use of such services to others. A 69-year-old woman with a pre-existing heart condition attended Porthaven ED after a ‘funny turn’. She was admitted to the medical assessment ward for cardiac and neurological investigations:

Perhaps it’s the way you’re brought up. . . . that you just get on with things. . . . I daren’t tell a couple [of] people that I’ve come in, God. . . . I just feel so embarrassed about it. . . . it’s as though you’re going in for something trivial just because you’re not feeling well.

Porthaven patient 1

Concern for the system

Patients on all sites expressed concern about the appropriate use of emergency services in the context of generalised public support for the NHS and awareness of pressures on its staff and resources. The patient cited above had learned as a carer that ambulance services were not to be overused:

I looked after my husband a lot when he was ill so I know . . . when you should and when you shouldn’t call [an ambulance].

Porthaven patient 1

Some people come in and want to be seen like that [snaps fingers]. Not me. I wouldn’t even call an ambulance. I’d get myself here. I don’t want to waste their time.

Porthaven carer 1

A man accompanying his 82-year-old mother to the ED in an ambulance after a fall echoed practitioners’ comments about the department’s ‘take-all’ model, inappropriate use, and alternative pathways for accessing urgent care:

A&E . . . pick up everything don’t they? There would be a lot of people who don’t need to come here. . . . who could go to the GP or . . . they’ve got a . . . drop-in GP service here.

Porthaven carer 2

Lack of confidence in community services

Despite many patients’ preference for using primary care, past experiences could undermine their confidence in using the community system for urgent care. There were several references to long waits for outpatient appointments and a shortfall in out-of-hours services. Some patients reported delays in receiving test results, and these delays could generate complaints:

We know that the NHS is stretched. We know it’s tremendously stretched. But he had an echocardiogram and we’ve never had the results. And this was months ago, wasn’t it? . . . you’ve written a –

Got the letter there somewhere.

Porthaven patient 2

Some patients expressed doubts about the speed and effectiveness of GP response to their concerns:

I think they [GPs] would have referred me in a few days hence. . . . and I was very concerned . . . this is the first time that the pain had become really violent. . . . I’ve always felt pressure with the heart thing before. So I was rather alarmed and more felt that I needed to see someone . . . as quickly as possible.

Porthaven patient 2

Desire for quick resolution

The VSM study (see Chapter 4) found that only 5 of the 72 patients attending EDs across the four sites had done so on their own initiative. The ethnography, too, found relatively few reports of ED attendance that had been decided by individual patients. Some of these patients had chronic conditions and knowledge of associated risks, such as a 73-year-old Waterbury woman with a recent heart attack and triple bypass who called an ambulance herself:

I’d been in extreme pain for 3 days. . . . because I’ve had operations, and because I’ve had known blockages in my arteries, I wonder whether I had another blockage in my left side. . . .

. . . what made you decide to come here rather than seek some other place for your care?

Well, I wanted a resolution fairly quickly.

Waterbury patient 3

A 24-year-old woman attended Underbridge ED on her own initiative with a recurrence of symptoms that she described as a TIA:

when I first had anything like this happen and I went to the doctor’s, they didn’t do anything . . . when I had a TIA . . . again my GP wouldn’t look into it. . . . last week when I phoned the 111 number . . . thinking, well maybe I should go to the emergency doctors or something, but they said, no, you need to go to A&E. . . . so this week rather than phoning [111] first, we just thought, right, let’s just come [to the ED].

Underbridge patient 1

This account indicates possible communication problems between the patient, who may have self-diagnosed a TIA, and the GP, who may have disagreed but did not make this clear to the patient.

Assessing the seriousness of symptoms

Deciding whether or not symptoms were serious could be confusing, and some patients found it hard to accept that their condition could warrant a hospital visit. A 66-year-old woman with cancer was suffering from chest pain and her GP advised her to attend Waterbury ED:

That surprised me, I must say, that he [GP] did take it more seriously than I did. I just wanted the painkillers or something, you know. So it was just an annoyance, actually, rather than a concern.

Waterbury patient 4

Two patients interviewed in Churchtown’s ambulatory care area had attended GP appointments and, to their surprise, been advised to make their own way to hospital for assessment. One of these patients was a 67-year-old man experiencing breathlessness following recent heart surgery. He was pleased to be discharged after being diagnosed with a routine postsurgical complication that would self-resolve (Churchtown patient 1). The second patient was a 31-year-old man who sought GP advice about a headache and was referred for medical assessment, a move he felt was unfounded:

It’s just a headache really as far as I’m concerned. . . . [the GP] said that my blood pressure was a bit low and she couldn’t get a clear view of my eye or something. . . . I came here and there’s . . . nothing wrong with my blood pressure and they can see clearly in my eye, so it makes you wonder. . . . it was a locum GP so I’m not sure.

Churchtown patient 2

This patient’s mistrust of the GP’s advice may have been exacerbated by poor communication. However, the acute medicine doctor explained to the patient that she wished to exclude life-threatening conditions (subarachnoid haemorrhage, meningitis or raised intracranial pressure). Following negative results from a CT scan and lumbar puncture, the patient was discharged with pain relief.

Once patients had acknowledged that their condition might be serious, they were keen to seek hospital care and ‘get to the bottom’ of the problem (Underbridge patient 2):

We expect that someone will say to us if all is all right, if it is something serious or not, what’s going on, basically.

Waterbury patient 5

A 55-year-old woman with cancer was advised by her oncologist to attend Waterbury ED, and she too considered that her symptoms required urgent attention:

I had lots of shivers, and sweats as well, last night. And I’ve had quite a lot of other symptoms as well, but it’s mainly achy and flu-ey, which is a strong indicator, with a temperature, that you’ve got an infection beginning.

Waterbury patient 6

Patients’ ranking of need

Patients’ desires not to be in the category of serious cases could lead them to compare their situation with that of others, who might be more in need of emergency care. A 60-year-old woman living in a rural area, who had a recurrence of TIA symptoms after a recent suspected mini-stroke, felt ‘shaken up’ when her GP fast-tracked her to the ED by ambulance: ‘I don’t need an ambulance, you know? I thought it’s taking it from somebody who probably needed one’ (Porthaven patient 4). Older patients tended to combine such arguments with their preference for care at home:

Well, I would rather be at home than in a nursing home actually . . .

Or in hospital.

Well, certainly not in hospital.

Why not?

Well . . . I just think I’m clogging a hospital bed, aren’t I, really, when I don’t need to . . . possibly.

Porthaven patient 3 and carer 2

Patients’ concepts of ranking need also included more straightforward doubts about the legitimacy of their place in the system. A 69-year-old woman from Porthaven felt as though she was ‘making a fuss’ or that she was in the ED ‘under false pretences’ when she arrived in an ambulance after a ‘funny turn’ that could have been due to her heart condition or a mini-stroke (Porthaven patient 4). A 65-year-old woman from Underbridge who had collapsed at home said she ‘felt a bit of a . . . a con, ’cos, you know, I don’t feel ill but I’m not right’ (Underbridge patient 3).

Patients sometimes felt caught between nervousness about attending the ED unnecessarily – ‘you just don’t want to bother them’ (Waterbury patient 6) – and fear of being at fault if they failed to attend and ultimately caused more trouble for themselves and the system. A 74-year-old man who had experienced a fainting episode was given a choice by an Underbridge ambulance crew whether or not to attend hospital: ‘I didn’t want to come, but I was going to look like a fool if I had gone home and collapsed there’ (Underbridge patient 4). A Porthaven patient blamed herself for not attending in time to prevent the worsening of a chest infection that led to her admission in the medical assessment unit: ‘I didn’t feel well enough to go out . . . so I stayed put, which was silly . . . and of course I ended up in here’ (Porthaven patient 5).

A sense of fairness regarding service delivery and use

Patients could find it confusing that some who were waiting might be seen before others. In Waterbury and Underbridge, all patients, whether referred by a GP or self-referring, were assessed in the ED under the ‘single point of entry’ system. They were generally unaware of the difference between their status as either medical or emergency patients. Patients in Waterbury, especially, did not necessarily know that patients referred by GPs to the medical team could wait longer for doctors to come and see them in the ED. Patients were often unaware of the 4-hour target that applied to all patients seen in the ED.

Patients commonly acknowledged that other cases could be more urgent than theirs. However, if they perceived that resources were being allocated to ‘undeserving’ cases, they could feel justified in seeking attention for their own needs:

I rang up NHS Direct and they were harping on about chest pain and because I’ve got a little bit of an upper respiratory tract infection . . . I have got a little bit of pain up here. . . . It was like, ‘I’m not worried about that’. . . . I was thinking ‘Oh my God, [the hospital is] wasting resources’ and stuff like that, but then on the other hand I think, well, the amount of people that I’ve seen in hospital that really don’t need to be in here.

Underbridge patient 3

A 40-year-old man attending the ED with pain from a kidney stone, who was frustrated about lack of communication from staff, expressed his view about the right to access urgent care when needed:

Well I pay my taxes don’t I? [laughs] I live in this country that affords us these privileges, and we pay for the right to fitness as well? I see no reason why I shouldn’t be here if the need arises.

Churchtown patient 3

Desire to avoid admission

Other patients alluded to their right not to be admitted and to the inconvenience of unnecessary admissions when their voices were not heard. An 86-year-old man with diabetes, who lived independently with his wife, suffered symptoms that were taken to be suggestive of a heart attack. He felt that there was nothing wrong and that he was being admitted unnecessarily because his knowledge about his condition was not being listened to: ‘I can’t get it through to people, that always happens if I get hungry. . . . because I have got a bad hernia there’ (Waterbury patient 7).

One ethnographic case study concerned a 66-year-old woman presenting with chest pain who resisted admission because she and her husband disliked hospital and had experienced lengthy delays in the past. The patient, who was receiving treatment for bowel cancer, had called the chemotherapy nurse, who advised a GP visit. The GP referred her to the AMU with a possible PE. The patient was seen by a senior house officer (SHO), who wanted to admit her to help ‘speed things up’ (Waterbury fieldnotes 1). Her case was reviewed by a consultant, who discussed it with an oncologist and offered a compromise: she could return the next day for a scan and ambulatory care review. In this case the patient’s wish to avoid admission was taken on board and she effectively influenced decision-making.

Patients putting their interests first

Consideration for the emergency system was often emphasised in patients’ narratives, unless they were in severe pain or in a state of anxiety, when they put their own needs first. A few patients declared the influence of their own pragmatic interests in the way they used the emergency system:

[The patient] had been advised to attend on Friday but had waited until [Monday] as it was more convenient to her.

Underbridge fieldnotes 1

I’m going to New Zealand . . . in a few weeks’ time and I didn’t want none of this, that’s why I didn’t want to come in, . . . I thought, ‘Oh God, we’re going on holiday, I don’t want a blip!’ you know because I suppose I will have to ring up my travel insurance to tell them that I’ve been in A&E now won’t I?

Porthaven patient 6

The relative speed of emergency investigations could act as a ‘pull’ factor for patients:

I feel well cared for, you know, and investigated and they haven’t said, ‘Well, you’ve got to wait until Wednesday week before we can tell you all that’, you know.

Porthaven patient 7

One ethnographic case study focused on a 23-year-old woman who had made 21 visits to Porthaven hospital with various complaints since the age of 7 years. This visit was prompted by a call to her GP:

I told him about the symptoms and said I had a pain in my chest. He said, ‘Go to hospital, we can’t take any chances’.

Waterbury patient 8

Certain elements in the patient’s narrative suggested that she had made pragmatic use of the service, starting with her self-awareness about her definition of the presenting symptom – severe chest pain – which prompted a series of tests, and her estimate of the time needed for results, which would allow her to return home by the evening:

How was the patient journey for you?

A lot quicker this time. It was the symptom, they prioritise that.

How long do you expect to be here?

An hour and a half . . . a rough estimate. ’Cos obviously, they want to get you in and out as quickly as possible. . . . By seven? It gives them an adequate amount of time.

Why seven?

I’d give them an hour [for the tests] and add a bit.

Waterbury patient 8

The tests showed negative results and the doctor gave indications for discharge. In expressing satisfaction with the care received, the patient acknowledged the worry that had led to her seeking urgent care: ‘Two relatives have had atrial fibrillation, a heart condition. My uncle had it when he was my age. He never went to the doctor – and it was too late’ (Waterbury patient 8). She also mentioned travel plans that she felt free to undertake having been reassured that her heart function was good (Waterbury fieldnotes 2).

The 3A PPI group reflected that this patient’s self-interest, as well as concern about her family medical history, might have motivated her use of the emergency system on this occasion to obtain rapid tests and diagnosis. They queried the GP’s role in referring her, and the junior doctor’s role in running tests without consulting a senior. At the same time, they acknowledged that the patient had been assessed on a case-by-case basis without prejudice about her being a ‘serial’ ED attender.

Observing and informing about a patient’s condition and treatment

Carers had a primary role in alerting staff to symptoms that might be indicative of a serious condition:

Because I was actually sitting next to his mother when she had her stroke so . . . as soon as I saw him having trouble speaking I basically started to engage him and ask him questions . . .

So something clearly wasn’t right.

Yeah. You still are struggling with your ‘R’s.

Yeah a little bit, yeah.

Yeah, I can see the way you’re talking there.

Underbridge carer 1

When accompanying their relatives during hospital visits, carers often contributed to filling gaps in a patient’s medical history, especially when they arrived without referral letters and when GP notes were not available. Some could have detailed conversations with clinicians about symptoms, tests and results:

So have they checked the urine? Was there anything?

Yeah, the urines came back clear, didn’t they, ’cos they sent some off? [checking with patient’s wife] I mean, it has been an ongoing problem with Dad that unfortunately he has high infection markers . . .

OK. Right.

And he was tried on a number of antibiotics. They started testing spinal fluid and everything because nothing appeared to work. And then suddenly after a while he gets better [laughs].

That’s the thing with inflammatory markers, . . . they can’t show us urine infection. They don’t really tell us where . . .

No, I mean, he’s also [had] problems with gout in the past.

Churchtown carer 1

Carers could aspire to being partners in decision-making, especially when they had background clinical knowledge or when they had researched treatment options. Some were aware of their importance as information-givers, but they described being valued in this capacity as an exceptional experience:

. . . what’s been good is that the doctors have actually listened to what we’ve said . . . with his previous brain injuries they would have thought he would have needed . . . scans . . . but we, from our previous experience as a family, think it’s more related to some sort of infection. . . .

. . . it was a positive thing that they were prepared to listen and take that on board because we were giving him some history on [patient] that he wasn’t aware of.

Churchtown carers 1 and 2

. . . she [GP] was marvellous! Because right from the beginning when I asked, with [patient]’s permission, could I go in with him, he needed me to help him, and she treated me with every bit of respect, and that was amazing! I can’t tell you, through [patient]’s years of being ill, often I have not even been looked at, let alone acknowledged.

Waterbury carer 1

Some practitioners’ apparent disregard for relatives’ contributions may have been linked to their wish to keep the patient as an active participant in the centre of the discussion:

I remember a case recently where a young man had come in with his wife and his wife was telling me all about his abdominal pain and I was like, I want to hear it from him, not the wife. Erm, but in elderly patients who do suffer with cognitive impairment I think carers can often be very useful at telling us . . . what they are like at baseline.

Underbridge practitioner 1

Avoiding unnecessary admissions

Carers who were knowledgeable about emergency services could make efforts to prevent their relatives from being admitted unnecessarily, but they did not always feel supported by the existing system:

There’s no form that can be filled in for the family to say, ‘Look, he’s a frequent faller, . . . don’t bring him in!’ . . . Last week [the carer’s father] fell in the garden and bumped his head . . . the ambulance crew really wanted to bring him in and I said, ‘He’s absolutely fine. It’s just a little graze. Pick him up and put him in his chair.’ I said, ‘I’ll stay with him’. . . . but if I had been at work, they would have brought him in.

Porthaven carer 3

A participant in a PPI workshop was the carer for his wife, who had complex care needs following a subarachnoid haemorrhage and a diagnosis of dementia. After efforts that lasted for several months, he obtained a GP letter that the family could show to emergency services, if the need arose, to avoid unwanted admissions:

Mr [X] would prefer to avoid acute admissions in the future. We suggest that if [patient’s] mobility deteriorates . . . when the surgery is closed, she should be assessed by [out-of-hours doctors] and, if no acute medical problem is diagnosed necessitating admission, then a short-term increased package of care should be organised. . . . rapid response is another route to go down if the former proves unsuccessful.

GP letter shared by carer in PPI workshop

This carer and others in the PPI workshop reflected that their knowledge was often discounted and that there was a cost to the system of not listening to relatives who wished to avoid acute admissions.

Seeking hospital stays for elderly relatives

Whereas some carers made efforts to avoid unnecessary admissions, others tried to persuade staff of the need to admit patients, fundamentally because of difficulties with home care. Practitioners gathered information about the availability of family support for transport and other needs, but sometimes they made inferences that were rectified by patients:

And then you’ll get, ‘You can’t phone my daughter to pick me up, you know, she’s busy, she’s got a busy life! Can’t I have an ambulance?’

Porthaven practitioner 1

It was frequently reported and observed that relatives sought hospital stays on behalf of elderly patients whom they had difficulty caring for at home – known by staff as ‘boarding’ – whether or not the clinical need was evident. A Porthaven carer was concerned about his mother’s deteriorating condition and the prognosis for her degenerative spinal disease, which did not allow her to adequately care for herself in her sheltered accommodation:

is she going to need to stay in hospital . . . that would be a good idea, as she needs to rest and a bit of TLC [tender loving care], which is very difficult for us to give her. . . . My wife and I both work, you know . . . I’d just like to keep her in overnight and just, you know, just keep an eye on her. . . . at the moment it’s safer in hospital, especially if she’s got to take more morphine and stuff like that. . . . And er, being quite frail anyway, I think it’s not a bad thing.

Porthaven carer 2

. . . she’s a bit wobbly and stuff, so it’s probably best that . . . she stays here. . . . both myself and my brother . . . we haven’t room to sort of have her staying with us and we both work full time and got young families, so that’s quite difficult.

Porthaven carer 4

Carers’ requests for boarding could feel somewhat taboo to voice to staff, since they implicitly breached two moral codes: families’ duty of mutual support and citizens’ responsibility to use hospital services appropriately:

Can you not keep her in for a week?

Pardon?

Can you not keep her in for a week?

Not in this hospital but it depends – because this is an acute hospital, if your partner couldn’t manage at home following this assessment we’d look at what options there are –

That was supposed to be a joke!

Oh was it? [Laughs] I took it very seriously. That’s fine. Well some people do – you know want to stay in the hospital but it’s not always the best place for their care so –

But it’s going to be difficult for her to move about at home.

Well, that’s what we’re going to assess now, so . . . are you at home all the time together?

Yeah.

. . . if your mobility is good enough for you to go home [Mrs X], would you accept having some carers in on a short-term basis? . . .

Carers in? Well I think . . . oh . . . [makes a negative face].

Churchtown carer 3 and patient 4

Conflict was sometimes observed between the desire for admission avoidance, which elderly patients shared with practitioners, and relatives’ wish for hospital stays:

I was saying, Mum, that, if need be, it would be a good idea for you to have a couple of days in, to be looked after, get a bit of TLC –

Mmmm. [Laughter from those present] I would still like to get home, I really would, but if I – if I agree to more help, I should think I should go home actually.

It depends what you’ve done, doesn’t it?

Yes, oh of course it does, because what I’ve done –

It’s very, very difficult for me to get her to agree to more help.

Porthaven patient 8 and carer 2

Use of chairs, beds and trolleys

On some sites there were both seated and bedded areas for patients waiting for investigations and decisions or, after a decision, awaiting discharge and transport. Ambulatory units across sites were largely seated, or with reclining chairs, sometimes with one or two beds for patients who were considered to be less mobile. The use of chairs, beds and trolleys was observed to influence patients’ expectations of admission or discharge. In seated areas, patients tended to move around, they often voiced their desire to go home and they accepted a wait, as they felt comfortable:

[The patient] is not concerned that he has had to wait to see a doctor for initial assessment, as he finds the seated waiting area quiet and comfortable and he has access to drinks and food. He also values the fact that he is kept informed about why he is waiting.

Churchtown fieldnotes 1

Some practitioners believed that putting a patient into a bed increased their expectation of an admission:

if ED feel that that patient [is going to need] admission, . . . then they’ll say this patient is for admission so they automatically go into a bed, which, one, raises patient expectation; two, the relatives go home because they think the patient’s in a bed so they’re staying in hospital; and [it] also builds in a huge delay. So if they were to come to ambulatory care, they’d be seen first-hand by a consultant, . . . they’d still have their clothes on, . . . so there’s not the expectation, not the sheets . . . and the thing. Relatives [are] still there because they’re waiting to see what’s going to happen. . . . the consultant sees the patient and makes an immediate decision, you’re fine, you’re not going to need to come in, we’re going to do this, this, this and this. . . . to avoid admission from here is so much easier than . . . from a bed. Once you get into a bed you go through another junior doctor clerking, another layer, which builds in on average about 4 to 8 hours’ delay.

Porthaven practitioner 2

Where there were only bedded areas for investigations and waiting, patients who did not feel unwell could be frustrated by being put into a bed:

the patient . . . had been referred to the ambulatory care unit by her GP for a scan but they had no space so she was sent to ED. The lady was not impressed at having to go through the ED system, and after being asked to undress she then sat in the chair. . . . the nurse then asked the patient to get onto to the trolley, which the patient did reluctantly for an ECG. . . . when the nurse had finished, the patient got off the trolley and sat back in the chair, as she told [the researcher] this was more comfortable. Later the patient was sent for an X-ray, and again she was instructed to get back onto the trolley so that the porter could push her round. After a review by the medical team, the decision was made that she did not require admission and she was discharged.

Waterbury fieldnotes 3

In another example from the same site, a 99-year-old woman was put into the bedded observation ward awaiting discharge and transport. The patient was surprised to have the sides of the bed raised, and she found it distressing when she wished to use the toilet, attempting to climb out of the bed around the cot sides. When she returned from the toilet, the nurse again put her into bed, although she was destined to go home (Waterbury fieldnotes 4).

Consideration for individual needs

Patients and relatives sometimes alluded to the diminished status of individuals in a crowded system:

We never anticipated all this; we thought we would be in and out in half an hour.

Did you? [To partner] Ah, what did you think?

No. Well you don’t just go in and out of hospital, you know, because there are hundreds of other people before you always.

Churchtown patient 4 and carer 3

Patients’ and carers’ sensitivity about competing with the needs of others was reinforced by practitioners’ allusions to the volume of demand:

I wish they would just come and say, I am sorry there is [sic] delays, and I had to ask the young nurse there, excuse me what is happening? And she said there is [sic] an awful lot of sick people here, so . . . I don’t expect to jump the queue, I don’t.

Waterbury patient 9

When practitioners’ time was short, they could sometimes miss attention to communication and other needs of patients or carers with disabilities that were not immediately apparent:

[The patient] had been identified as suitable [for inclusion in the study] by one of the nursing staff although she warned me that the husband did not seem very happy at all. I [researcher] went to speak to the patient and she was very keen to participate and although I could see her husband was less keen I then realised that this was due to his inability to understand fully what was happening as he was deaf. Once I had approached him with this in mind, he was very happy to participate.

Waterbury fieldnotes 1

Even in cases of ‘social admissions’ that some staff might have considered inappropriate, patients frequently acknowledged that their needs had been taken into account, and many expressed appreciation for the care received:

. . . did you want to stay in hospital or – ?

Well, I had no choice, love, did I really? I had no choice. They just said, ‘We would like to keep you’. . . . I was grateful to be kept. . . . You see if I had somebody at home, I could have . . . but it was really offered to stay. And I was grateful.

And why did you want to stay? . . .

Because I have no one to go home to. That’s why.

Porthaven patient 9

Patients who were known to staff as ‘frequent flyers’ because of their recurrent attendance also reported positive experiences of care, with safe as well as satisfactory outcomes when their levels of risk were considered case by case:

I have always had very happy . . . I mean I have had several trips in here and it has been brilliant. . . . it has always been for my stomach, and they have been absolutely fantastic. Well enough that I have been recognised and they are all saying hello!

Porthaven patient 10

I’m happy! They’ve done a lot of tests today. I’m happy, but with a precaution, to see the GP.

Waterbury patient 8

Self-rationing and system expediency

There were exceptions to these positive accounts. A 41-year-old woman attended the Waterbury ED as a result of a 111 ambulance call for an acute episode of chronic neck pain, apparently associated with a spinal lesion. She had attended the ED on three previous occasions for this problem, and on her last visit, 2 days earlier, she had been admitted to the observation ward for pain relief. Her condition improved and she was discharged soon afterwards in the middle of the night:

they sort of morphined me, given me diazepam, and then dismissed me at two o’clock in the morning, which was a bit dramatic . . . they sent me home in a taxi, and like, high as a kite on drugs. I was crawling up my stairs to get to bed. I don’t think really that should have happened. They did know I was on my own as well. . . . But anyway, I know they’ve got limits to . . . who they can keep in and stuff like that. . . . I said, ‘That’s fine,’ you know. ‘Give me the tablets and let’s go,’ sort of thing. . . . I knew it wouldn’t take the problem away. But I thought, ‘Oh, it might bring it back down to a level where I can cope at home, until I was due to see the pain clinic . . . and hopefully this [neurological] appointment. But obviously I ended up back here, which is just a bit frustrating.’

Waterbury patient 10

In this example of self-rationing, the patient demonstrated a reduced expectation of consideration for her needs. She showed willingness to make allowances for the system under pressure, even though she reported an unpleasant experience and a subsequent need to return to the ED.

As unsatisfactory discharge also occurred in the case of the 60-year-old rural woman who was ‘fast-tracked’ by her GP to Porthaven ED in an ambulance after she consulted about stroke-like symptoms. This patient experienced her whole process of care as troublesome. Having been informed that it had been a mistake to send her in via the ED, she expressed confusion about what was happening:

the doctor told me they’re doing four different things, and I don’t know what they are. One’s taking blood, doing an ECG, that might have been two, I don’t know, and to bring an overnight bag in case I had to stay overnight.

Porthaven patient 3

The patient experienced delay with long waits for a CT scan, and she was eventually discharged with an outpatient appointment for the next day. Since she was considered ‘not unwell’, she was not provided with transport. She was unhappy about travelling home alone on two buses late in the evening and having to return in the morning, and the instruction to bring an overnight bag had added to her expectation that she might stay in hospital. In this case too, discharge and travel arrangements were expedient for the system but were not felt by the patient to be in her best interests. Her experience was negatively affected by miscommunication and lack of consideration for her travel difficulties. The junior doctor was unaware of transport issues and considered this to be part of the nurses’ role (Porthaven patient 3).

Arrangements for safe discharge

Specialist teams could assist with decision-making, provide outpatient alternatives and enable community support to be included in the package of care. Patients were not always aware that this was happening or which staff were members of these specialist teams. At Churchtown, a 70-year-old woman who attended after a fainting episode was hoping not to be admitted, although her daughters were concerned about the possibility of her injuring herself at home. Although a junior doctor had planned to admit the patient for further testing, a senior geriatrician from the ACE team showed tact and skill in giving her the option of going home with a prompt outpatient appointment, to the satisfaction of both patient and family (Churchtown patient 5).

Patients’ safe referral into the community could be facilitated by discharge teams, which had different acronyms across the four sites. However, community resource constraints could limit the impact of such teams. An elderly Churchtown patient with dementia had been considered suitable for a community bed, but lack of availability meant that she stayed for over 3 weeks in an acute ward. The hospital was some distance from her home and her partner had difficulty visiting, which added to her distress (Churchtown fieldnotes 2).

Involvement in decision-making

Whereas practitioners tended to refer to the ‘influence’ or ‘impact’ of patients and carers on decision-making, patients themselves often demonstrated their capacity for active involvement in decisions about treatment and admission or discharge. One case where this was observed concerned an 82-year-old woman who had been admitted to Porthaven medical assessment unit following a fall some days earlier. She had a history of two strokes, and she lived at home alone with no carers. Her relatives, who visited her daily, were worried about her breathing, although the doctor examining her had found no problem there. The patient had pain on her right side, but she reported feeling quite well in herself. An X-ray showed no fractures. A MAU consultant on a ward round with a junior doctor visited the patient, who described her fall and symptoms in detail. Although her relatives had noted problems with her speech, perhaps fearing a stroke, the patient was lucid and communicative. The consultant took time to converse with her, involved her in treatment decisions, and gave instructions to facilitate her discharge:

What was the problem yesterday? Why did they [family] call the ambulance?

I don’t know.

[The junior doctor and consultant both laugh.]

They said, ‘Mum, you’re talking funny.’ I said, ‘I’m not talking funny, I’m talking natural!’

[Everyone laughs. The consultant examines her.]

Well done. The ambulance crew were a bit bothered because the oxygen levels were a bit lower than we would like.

They’ve been taking my temperature all night.

[Consultant asks about medication the patient is supposed to have been taking.]

I can’t get to the toilet in time. Not being personal . . . [I have] accidents. So [I’m only taking] it once every 2 or 3 days.

Take it every day but in a slightly lesser dose: 20 mg instead of 40 mg. Each day. A little bit of benefit without the problems.

If you like, I’ll take a whole tablet every day.

We’ll try and get you a bit more mobile. [To junior doctor] Get the rapid response team. [To patient] If the physio thinks you’ll be OK, I’d be happy to get you home.

When I’m at home, I’ve got a walking frame. I’m OK.

I’ll try and get you home this afternoon. If you behave! [To junior doctor] Medications. GP to keep an eye on.

Porthaven fieldnotes 5

There could be intrinsic constraints to patient involvement when patients had significant cognitive impairment. In such situations, carers could supplant the role of patients in communicating with practitioners, and patients could be vulnerable to a failure to detect their needs in a timely way:

He’s a very good patient.

Yeah, and very, I know. Very nice.

He doesn’t, he doesn’t complain about anything, he, he doesn’t tell you anything. He doesn’t ring the bell.

Yeah.

He’s the best and worst patient, isn’t he?

[Laughter]

He’s quiet but before you know it, he’s on the floor.

Yeah, yeah. That’s not always, not a great thing.

[Laughter]

Churchtown carers 1 and 2 and practitioner 14

Efficiency and care

Just as practitioners gave positive value to the speedy movement of patient flow, patients too expressed appreciation for efficiency as well as ‘customer-aware’ care in a system that was acknowledged to be chronically busy:

Can you tell me something about now when you went to X-ray, what it was like? . . .

Very efficient, very fast. Um . . . about a 2-minute wait, if that. Wheeled straight in. The, um, the staff was [sic] very, she was very polite, very friendly, eye contact, all the things that you would expect a professional to do.

Waterbury patient 3

When staff did make time for the ‘softer’ aspects of care, patients regarded such an approach as exceptional, given the pressures on their time:

They’re very efficient. You can tell everyone’s very busy but they make time for you. And certainly the paramedic was just – couldn’t do enough, you know. . . . Made you feel at ease, which was helpful.

Porthaven patient 11

So what’s your impression so far of the care that you’ve had here?

Oh it’s fantastic. I really appreciate it, from the time I entered until now, the nurses are just running everywhere, they’re helping. And I actually saw the doctor as well.

Waterbury patient 1

The patient’s use of ‘actually’ here could imply that time with doctors was valued as a scarcer resource, or one for which longer waits were expected. Patients could be confused about how decisions were made, as the process was not always visible to them. They could be happy to wait for test results or decisions if they were kept informed of the reason for delays:

I expect it, that I’ll wait at a hospital. Everyone’s been polite and courteous and told me they’re just waiting for a doctor to look at my case, so. It would have been different if I’d just been sat here and no one had said anything to me. I would have been a bit annoyed.

Churchtown patient 2

Sometimes ED practitioners’ focus on speedy throughput could detract from their attention to the symptom that had brought the patient into the department. One patient who disliked hospitals was pleased to be going home but felt that her reason for presenting had not been resolved:

So what are you hoping and expecting?

Well, I’m hoping . . . you know, I wanted someone to take the pain away, and, um, I’ve had a couple of paracetamols and the pain’s, okay, it comes and goes, but nobody’s actually dealt with the pain.

Waterbury patient 4

Timely communication

Just as practitioners reached ‘tipping points’ when they felt a loss of control over the dynamic of maintaining patient flow and providing safe care, patients and carers too experienced moments that took them over the limit of tolerance within the overstretched system, and made them feel dissatisfied with the level of care they were receiving. This feeling could be exacerbated when patients believed that cases less deserving than their own were being given priority or when they were experiencing high levels of pain. The most frequently expressed reason for patient dissatisfaction was the lack of information and updates on their status within the system. This was particularly noted when patients were waiting for test results and admission or discharge decisions. All sites formally emphasised the need for patients to be able to identify a lead or named nurse in charge of their care. However, there was significant variation in how far the lead nurse was involved with a patient’s treatment, and whether or not the patient knew who this individual was.

The VSM study (see Chapter 4) found variation across sites in the stages of patient journeys at which the longest waits occurred. At Churchtown, a large proportion of waits occurred after the final admission or discharge decision. This was reflected in the experience of a 40-year-old patient: the decision had been made to admit him to a ward 1 hour after his arrival in the ED, but he then waited 5 more hours for a bed. During this time, he was not sure what he was waiting for. Whereas at Porthaven there was clear identification of the main decision-maker in charge of a patient’s care, at Churchtown patients were sometimes uncertain about whom they could ask for updates:

. . . it wasn’t until after the CT scan that I started getting worried. So up till then . . .

And what do you mean by worried?

Just no communication.

Yeah. And how could that have been improved, do you think?

Someone just to say, ‘Hi, I’m in charge of you at the moment, umm, while you’re in this ward if there’s anything you need to know talk to me and I’ll tell you everything you need to know.’ I’d just like some formal, like, ‘I’m in charge of your case. There will be 15 other people you’ll see and that’s normal but if you have anything come to me.’

Churchtown patient 3

Patients could understand that staff were busy, and they could also accept that they might be discharged without a clear diagnosis of their presenting condition: ‘I would rather go . . . if there’s nothing wrong, if there’s nothing they can do, “Fine, let’s go home”’ (Waterbury patient 2). However, patients could express annoyance when information about their status was not forthcoming:

I want to see somebody now, to say that I’d be going home. . . . usually they’re very quick at sending you home. . . .

And can you just take me through what happened?

I, um . . . got woken by a doctor and then I got moved to the ward, got me tablet, then woken again for the [inaudible], then woken again to go down for an X-ray at half past three in the morning.

Porthaven patient 12

This patient was aware of pressure on beds, and she hoped to receive a prompt decision with a view to discharge. Her admission experience was negatively affected by the repeated disturbance of moves and procedures during the night, and, it appears, by the sense that she was passively undergoing an instrumental form of processing through the system with insufficient regard for her felt needs:

Have you had any updates at all?

No. I don’t know when, it’s as and when I think, you can’t get one, but I don’t want to stop in here another night, that’s why I’m [annoyed at myself] for coming in . . . I’m getting right frustrated now.

I guess it’s just not knowing um, what’s going to happen in the next 6 hours.

Well, I think they should be able to contact somebody, you know, bleep them or something, and just say I need discharging . . . I think that’s what they could do, I mean if they were short of a bed they would.

Porthaven patient 12

This patient’s initially supportive attitude to the service changed to discontent when she perceived that staff actions such as moving her to a ward, dispensing treatment, organising tests and facilitating discharge were dispensed ‘as and when’ convenient for the hospital rather than primarily with her personal well-being in mind. She experienced not only frustration at the lack of information, but also disillusionment on sensing that her being left ‘in limbo’ was because system needs were prioritised over patients.

Patients approaching breach time could generate concern among staff, and this was often observed to be focused on target compliance, or on investigations that were key to an admission decision, rather than the patient’s comfort or communication needs:

[The patient] seemed irritated by the doctor’s questioning and remarked that he kept having tests on his heart but that no one was telling him why or if there was a problem. . . . [The patient] was frustrated by having to wait for the results of his tests as he was hoping to go home. . . . the co-ordinator and [the consultant] were concerned about the slow progress of [the patient], who had now been in the department for 3.38 hours. . . . [The consultant] went to speak to the patient, who, at this point, looked very uncomfortable, as he had slipped down the bed, resulting in him hanging off the end and having to look up in order to speak . . . but no-one addressed this.

Underbridge fieldnotes 2

In such situations, it was also observed that patients and carers self-rationed their communication with staff about basic care needs when they perceived that practitioners were busy:

For the past half-hour [the patient] has been mentioning that the back of the bed is uncomfortable – not a good neck position. . . . I suggest [the daughter] might ask the nurse in charge of her mother. She looks out for him in the nursing area and we see him moving quickly about between patients. She says ‘He looks a bit busy’ and does not pursue this. The patient remains with an arm behind her head, trying to prop herself up.

Churchtown fieldnotes 2

Offer of fluids and food

The cultures within different acute care units (anonymised in this section) significantly affected patient experience. Where food and drink were provided, or clinicians encouraged access to them, patients appeared to feel less anxious about waiting. One site introduced a ‘discharge lounge’ from the single point of entry ED where patients awaiting final medication, paperwork and transport could wait and also help themselves to food and drink. Another site designated a similar area, available to MAU, triage and ambulatory patients, where ward routines of meal times and the offer of fluids were built into practice.

In EDs, these routines were less evident, and some patients were observed to go for long periods without being offered food and drink. A senior nurse in an observation area suggested: ‘I don’t know that [ED staff] are as good as us at asking the patients, because they’ve got so many, and they’ve got lots of other things to do’ (site X practitioner 8). In one ED, relatives were observed to seek advice from staff when they or the patient were hungry or thirsty, but they were unclear about whom to ask and expressed concern about disrupting practitioners whom they perceived to be busy. Patients’ requests in this area were sometimes not attended to in a timely way:

The patient says ‘Can I have a drink now?’ [Support staff] tell the [PFC] that the patient would like a drink. [The PFC] mentions this to nurse [X]. The nurse is carrying out a procedure with another patient and does not respond to this request at the time I am observing.

Site X fieldnotes 1

So aren’t I supposed to be on fluids and stuff like that?

Well, fluids aren’t critical if you are managing to drink.

Well, I’m not.

Because they haven’t brought you anything or because you’re not thirsty?

Because they haven’t brought me anything. . . .

Right. Do you want something to eat and drink now?

Am I allowed to eat?

Yes!

Oh thank God! Yes please!

Let’s see what we can find.

Site X patient 1

Doctors at this site voiced their concern that staff retention difficulties and pressure on nurses to complete administrative tasks meant that their attention to patient care could be compromised:

the other thing is the nursing staff, . . . having enough nurses to kind of deal with the jobs, the procedures . . . how do you prioritise the . . . jobs for those patients, because then that delays getting a patient ready for the ward and all the rest of it.

Site X practitioner 1

This issue was observed to be a particular problem where patients were elderly, had disabilities, had impaired cognitive functioning or were in too much pain to express their needs, including their capacity to report on their intake of fluids and foods as they were moved between hospital departments. On the same site, an 86-year-old woman with dementia had fallen in the night and had not eaten or drunk for many hours by the time she was transferred to the MAU. The patient herself only asked for a cup of tea after what was reported by her carer to be some 20 hours without food (site X fieldnotes 2).

Risk and decision-making

Practitioners’ interactions

Acute care was ‘pressurised’ in terms of workload, patient acuity and targets, and this could lead to suboptimal interaction between patients, carers and practitioners.

Acute care system

Patients travelled through a sometimes disjointed community and hospital system that aimed to provide safe, efficient and patient-centred care. This journey was facilitated or constrained by the actions of practitioners (including GPs, the 111 service, acute care doctors and nurses, and social care practitioners) and the decisions that they made regarding patient care and referrals.

Responses to the 4-hour target

The 4-hour target acted as an overarching context for decision-making in acute care, driving a need to process patients and keep up the flow.

While practitioners perceived this target as having achieved positive effects as a collective goal for service delivery (no. 73; no. 78), in the context of resource constraints it was also perceived as driving inappropriate admissions (no. 40; no. 102). This was a particular problem for patients who required ‘watchful waiting’ on account of diagnostic uncertainty (no. 72), who needed their mobility or home care conditions assessed (no. 44) or who had complex health and social issues that could nevertheless be resolved without hospital admission (no. 41; no. 73).

Patients were often observed to act less as ‘customers’ of a service and more as collaborators in managing limited resources. Patients often demonstrated self-care and acted in a way that optimised practitioners’ time and the use of available acute beds (no. 4). Patients ‘rationed’ their own care by not making requests to practitioners they perceived to be busy, or to those who were attending to patients whose needs they judged to be greater than their own (no. 5).

The timely availability of hospital beds (no. 20), hospital transport (no. 86) or home care services (no. 9) routinely impinged on decision-making (no. 71). Waiting times for these services significantly increased staff costs within EDs (no. 105). The peak in admissions that occurred shortly before the 4-hour target indicated that avoidable admissions were occurring as a result of efforts to comply with the 4-hour standard.

Practitioner interactions

The experience and engagement of patients and carers/families may be optimised by:

• demonstrating understanding about the patient’s discomfort, distress and predicament

• eliciting his/her goals and preferences as well as information about the patient’s condition and valuing patient and carer knowledge

• making the decision-making process explicit and giving viable choices

• ensuring they feel they can ask questions and make suggestions

• providing information about progress through the system even if it is only to inform people about uncertainty

• practitioners taking over decision-making for those who are the most confused or unwell

• establishing a routine practice of attending to care needs while in acute care – communication, allaying fears and concerns, provision of food and drink, attending to toileting needs, etc.

Patient expectations about being admitted may be managed by:

• GPs and paramedics stressing the possibility or likelihood that patients will go home, when making referrals

• making initial assessments at a desk with patients clothed (more like a GP or outpatient clinic)

• providing an ‘ambulatory space’ when patients are waiting for results or being observed, which allows individuals to be seated and clothed and access food and drinks themselves.

Patients’ and carers’ (sometimes different) anxieties about illness being managed at home may be addressed by:

• eliciting and giving value to concerns

• talking through the risks to create understanding about drawbacks and benefits of care in hospital versus the community

• negotiating compromises

• providing safety net advice about what to do if discharged

• involving senior practitioners when needed to check and support decisions.

The ability of junior doctors to make good decisions may be enhanced by:

• pathways to specialist teams and diagnostics being clear, known, easy and reliable, but sufficiently focused so that all patients are not routinely referred

• ensuring availability of senior doctors

• encouraging senior nurses to provide supportive advice

• being respected by doctors from specialty teams.

Junior doctors’ learning may be enhanced by:

• seniors expecting that juniors may seek advice about a preferred plan rather than wait to be told what to do

• receiving ‘micro’ training in relation to difficult cases.

Seniors may deploy their clinical expertise regarding individual patients in a variety of ways, by:

• selecting cases they may discharge or admit much more rapidly than juniors

• selecting cases with clinical complexity and uncertainty, or anxiety

• advising juniors on decisions without seeing the patient

• advising juniors on decisions by reviewing the patient briefly and advising on tests and referral pathways.

System factors: using resources to manage flow within and out of acute care settings

During the pre-hospital phase, patients may be directed to the appropriate place/team by:

• GPs making themselves available and trusted by patients at risk of admission

• GPs referring patients to specialist teams, where clinically appropriate, rather than signposting to the ED

• hospitals providing referral systems involving clinician–clinician conversations (such as Porthaven AGPS) to differentiate and direct GP referrals to the correct hospital or community team

• ambulance staff liaising with GPs or the admission avoidance team prior to the decision to transfer to the ED.

Overall flow and capacity within EDs may be managed by:

• having a senior doctor and nurse oversee all patients within a unit while others care for individuals

• having information systems in place that allow capacity and flow in the ED and the whole hospital to be visible

• having patient areas visible from central positions, while also guarding privacy

• having easy access to the AMU, radiology and other acute care spaces

• having easy access to past clinical records from hospital and primary care systems.

Relations between specialty teams and practitioners in EDs may be enhanced by:

• ensuring an understanding of each team’s remit and contact details

• making space to work together collaboratively.

Rushed decisions to admit as the 4-hour deadline approaches may be avoided by:

• identifying and managing patients who are likely to need a more prolonged decision-making time period soon after arrival

• involving teams specialising in discharge at an early stage in the pathway

• utilising ambulatory units or CDUs that are ‘off the clock’ for those needing time-consuming investigations or ‘watchful waiting’.

Discharges may be made more safely by:

• liaising with GPs about concerns and plans*

• arranging for GPs to follow up patients the next day*

• having specialist ‘hot’ clinics or diagnostics (plus follow-up) available within days

• support from community teams able to provide social care and/or treatment at home*

• transfers to nursing homes with the facility to monitor and provide rehabilitation*

• encouraging juniors to consider the discharge option, though also checking with a middle-grade or senior doctor

• involving hospital teams specialising in discharge

• providing clear information to patient, family and community teams on safety netting.

The specific components above are more likely to be successful when incorporated into systems where:

• the culture is positive, engendering learning and flexibility

• risk is ‘named’ but managed positively

• teams are stable with minimal use of locums (optimising local knowledge of context and how to get things done efficiently).

Although the ED environment may be stressful, we have indicated several measures that may be employed to mitigate this pressure, and specific features of the clinical environment and communication with patients that could enhance the safety of patients and optimise their experience. The different elements of the acute care system, both in the community and in secondary care, need to collaborate more closely and generate joined-up pathways though a blend of flexibility and management of flow.

Reasoning of patients and carers

The reasoning of patients and carers begins with concerns that prompt the decision to seek urgent care. For patients in our study, the principal value of hospital EDs was rapid access to assessment and treatment that was not available elsewhere. However, the use of emergency services was influenced by the way in which individuals were directed to use them. GPs or out-of-hours services, community nurses or the 111 service could quickly escalate to ambulance call-out, even if this was not necessarily what the patient wanted. This finding adds a further dimension to the results of a study that considered why patients with primary care problems called for ambulances, which concluded that poor knowledge of alternatives, anxieties of carers and attitudes to risk were important. 52

While higher rates of avoidable admissions have been reported in urban areas with greater deprivation,3 the site in our study with the lowest admission rate had the largest and most deprived urban population, suggesting that the multiple initiatives there could be effective in avoiding admissions.

Reasoning of practitioners

Senior practitioners held the view that EDs operated in a ‘take all’ fashion, and that the absence of alternative options, or inability to access them, resulted in unnecessary hospital referral and admission. Higher hospital referral rates are a significant problem in themselves because they are associated with higher rates of conversion to admission. 8 This could be because appropriate decision-making may quickly diminish in overstretched departments under 4-hour target pressure. At times of high pressure, faced with the competing demands of a safe decision for a complex patient – often with limited background information – and maintaining patient flow, the default decision was to admit. While the 3A study observed this phenomenon frequently, cases where junior ED doctors actively considered and tried to set up community-based care were far less common.

Practitioners were aware of the potential clinical risks as well as the social risks arising from the decisions they made. More senior and experienced practitioners was observed to be more tolerant of uncertainty and risk; ED seniors show great understanding of medical risk, and GP involvement both before and after arrival at hospital may provide additional understanding of community capacity. 51

This 3A study has provided insight into the role played in admission avoidance by experience and seniority. More experienced practitioners demonstrated better insights into the risks associated with different decisions. Our findings support the idea that early ‘senior first’ involvement in decisions results in reduced likelihood of admission. 28,31–33 However, ‘senior first’ involvement was not associated with a shorter overall patient journey; this may be because seniors became concurrently involved in more complex cases. Other studies have found that early involvement of physicians in screening reduces time spent in the ED29 and time to treatment and discharge30 but, owing to multiple modes of involvement and small numbers, the results of our study did not show that this was the case. Senior staff expressed the view that the impact of senior input was related to experience, a good knowledge of local services and alternatives, and individual attitudes to uncertainty and risk.

Communication between practitioners

The importance of effective communication between primary and secondary care was repeatedly voiced. A patient who arrived expeditiously with no clinical information was much harder to manage than one whose pathway had been negotiated with the patient’s own GP and who arrived with an informative letter and copy of key clinical information. The Porthaven AGPS’s low admission rate was perhaps unsurprising. Underbridge and Waterbury had some provision to access primary care records from ED, although in our study it was too early to assess the impact of these innovations. However, our observations suggest that systems that incorporated pre-hospital review, facilitated information sharing and employed service models such as the AGPS and ACUs that allow more ‘planned’ care for selected patients, as opposed to unscheduled emergency care, were more likely to find alternatives to admission.

The impact of the 4-hour target on practitioner behaviour

While the 4-hour standard was intended to improve patient experience and outcomes by ending lengthy waits, the 3A study captured the effects of this target from the perspective of appropriate decision-making. The majority of admissions and discharge occurred around the 4-hour target, suggesting that this target may have considerably influenced decision-making. This raised the question of whether or not a quick decision was necessarily the best, even if it maintained flow. These findings support the views of Cooke, who considered that the 4-hour target was a crude tool to drive quality improvement in emergency care and that it could detract from patient-centred care. 9 We found that involvement in decision-making was valued by patients, and that viable alternatives to hospital admission were often preferred. In showing how patients’ preferences could be unvoiced or unheard, while priority was given to avoiding breaches, the 3A study presents a counterperspective to the premise that fastest is necessarily best.

What does patient-centred care mean in emergency medicine?

One definition of patient-centred care is ‘to put the patient first in everything that is done’,56 and this may be said to hold in the context of emergency medicine. The 3A study may help to inform the optimal shape of patient-centred care in emergency medicine:

• practitioners communicating clearly and in a timely fashion with patients and carers

• better information exchange, allowing greater patient and carer participation in decision-making at all stages of the patient journey

• not imposing unrealistic restrictions on time for more complex decision-making

• improving knowledge of, and access to, alternatives to admission at all levels of the system.

We contend that all of the above would increase the likelihood of avoiding unnecessary admissions as well as improving patient experience.

Implications for service design

While the plethora of new initiatives was, at times, confusing for researchers as well as practitioners, we concluded that both new spaces and new teams, as well as ‘differentiation’, could be part of the solution to the problem of escalating admissions:

• The availability of clinical decision/observation units with sufficient capacity at busy periods may allow time for safe decision-making, thereby reducing admission rates and decreasing the risk of inappropriate discharge.

• If patients with complex needs (who may not be the most unwell) are identified and managed early in their journey, by specialist teams where these exist, there is a better chance of avoiding admission.

• ACUs supported by a ‘discharge team’ may be well placed to set up care in the community.

• Sharing clinical information between primary care, secondary care and social care may enhance decision-making.

• Specialist pathways for certain patient groups (e.g. stroke, chest pain) may reduce time in the unscheduled care department and avoid unnecessary admissions.

• Given the predominance of admissions not preceded by GP contact, there may be scope for active liaison between the ED and both GPs and emerging community-based acute care teams in the planning of treatment and care, as a means of avoiding admissions.

In summary, a flexible acute admissions pathway with multiple entry points and subsequent pathways may be better able to meet the needs and expectations of patients and carers. Whether this model is constructed under the overarching umbrella of the ED or is run as separate pathways may be a secondary consideration.

New ways of working

The observation that approximately 50% of training posts in emergency medicine are unfilled poses a significant challenge to aspirations for 24/7 senior-led emergency medicine services. 2 Therefore, creative ways of working that optimise the deployment and flexibility of the whole workforce are needed.

Consultants in EDs, rather than being ‘protocolised’ to see all unwell patients early, need time to take on a range of roles:

• ‘Cherry picking’ cases where their skills, experience and authority will have most benefit – i.e. patients with complexity or anxiety or who may be rapidly ‘shipped on’.

• Adoption of the ‘controller’ system of Porthaven, in which a senior physician is consulted by other staff, including junior and middle-grade medical staff, triage nurses and nurse practitioners, and other professionals. This role of ‘training in action’ may be a feasible way of having senior and specialist advice suggested at the hospital front door. 70

• Involvement in system redesign. We were impressed by the dedication, patient-centred focus, thoughtfulness and energy of seniors in the acute care setting. These attributes were often put to use in devising and modelling new ways of solving the admissions problem.

While our study focused more on the medical role, a potentially important innovation was the nurse practitioner-led emergency care unit, as developed at Underbridge. However, the findings of 3A support the view that whole-system redesign is appropriate to develop new ways of working, better integrate medical and social care, and improve pathways and alternatives to the ED. 10,69

In conclusion, the 3A study has generated a rich narrative description of the acute admission decision-making process and the reasoning behind it, based on observation and accounts of a substantial sample of patients and practitioners. The VSM method was applied in a novel way to examine value, waste and system bottlenecks at four sites with contrasting models of care. The findings, interpreted through a critical realist lens, give considerable insight into why and how patients find themselves being admitted to hospital. These findings may signpost features of care models and service design that are required to safely reduce avoidable acute admissions.

Panel composition

Two clinical panels were assembled, one in the two northern sites and one in the southern sites. The clinical panels comprised four experienced clinicians working in emergency medicine and two patient representatives recruited through the local Collaboration for Leadership in Applied Health Research and Care. The northern panel comprised three ED consultants, a senior trainee in emergency medicine who had completed her training, a nurse practitioner in emergency care and the two patient representatives. The southern panel comprised one ED consultant, one AMU consultant, a senior trainee in acute medicine, a senior nurse/ward manager in the AMU and a GP representing an AGPS and ambulatory care pathway.

Stage 1: case review and selection

Stage 1 of the panel process was undertaken as set out in the terms of reference document. Briefly, batches of ethnographic and VSM case studies were specially prepared for the clinical panels by the research team. Batches of cases were emailed in advance to panel members, who then scored to what extent the admit/discharge decision appeared appropriate, and further described the principal grounds for their opinion. The research team selected from these cases those for which there appeared some difference of opinion between scorers about the likely appropriateness of the decision, or cases considered by the scorers as interesting and representative, to discuss in stage 2. The cases reviewed by the northern panel at both stage 1 and stage 2 were from the southern sites, and vice versa for the southern panel.

Stage 2: consensus discussion

In stage 2, both panels were convened and facilitated in the same way by one of the principal investigators (JP). The northern panel was convened at Underbridge hospital on 6 November 2014, and the southern panel at Porthaven hospital on 9 December 2014. Ten selected cases including ethnographic and VSM studies were discussed in depth by each clinical panel. The discussions were tape-recorded and transcribed.

Summary

• The clinical panel exercise confirmed that most of the cases reviewed were considered typical of patients referred to ED and associated emergency medical units. Most of the clinical decisions for the patients reviewed were deemed appropriate and understandable by these clinicians and patients.

• In stage 1, most reviewers were consistent in their independent responses, but would often express caveats relating to circumstances and availability of alternative management options.

• In stage 2, the principal area of potential disagreement and debate centred on the extent to which the admissions could have been avoided, and these discussions highlighted the extent to which it is possible to identify the optimal solutions to medical and social complexity, especially when faced with a 4-hour target.

• A considerable degree of mutual understanding of the patient and professional perspectives, and systems factors constraining decision-making, was apparent in the stage 2 panel meetings, generating consensus.

• There were no instances where there was strong disagreement about the admit/discharge decisions; rather the different voices on the panels graphically illustrated the challenges of avoiding hospital admission, even when it was not always the most appropriate course of action and admission might have been avoided.

• The discussions highlighted the extent to which admit decisions are constrained by organisational and structural differences in emergency care pathways. The ED unit not infrequently appeared to be the wrong place for the patient’s health-care needs to be assessed and optimal decisions made, whereas alternative pathways, both in the community and within secondary care (including AMU, ACU or CDU), can be more appropriate.

• The professional composition of the two review panels, as well as the site-specific models of care adopted by their hospitals, may have had an effect on the suggestions made by the panels for alternative pathways to admission for the cases reviewed. The panel reviewers from the north site were exclusively from emergency medicine, whereas the southern site reviewers included medical specialists and a GP. Southern panel reviewers particularly emphasised the potential merits of the ambulatory care pathway and AGPS as an alternative to medical admissions in the cases reviewed; those services are available at one of the hospitals.

How the data have been used

The results of the clinical panels have been used to interpret several other streams of data in the project, including practitioner and patient ethnography and the VSM study. The data were also used as source material for the realist synthesis.

FIGURE 18.

Avoidable Acute Admissions clinical panel admission decision score sheet.

Case summary

Summary of clinical panel review of case 1 (AA)

In the scoring of decision-making on the Likert scale (stage 1), there was significant disagreement between reviewers about this patient’s admission. Reviewer 1 thought this was likely to be an appropriate admission, whereas reviewer 2 thought it was an inappropriate admission, believing that a community solution would have been more beneficial for AA: preferably a bed in a community hospital.

During stage 2 discussion, the reviewers pointed out that there was insufficient medical information on which to make a sound decision, since investigations were not carried out in the ED. The implication was that the responsibility of ED is to follow through on as many investigations as possible and achieve a diagnosis before making a decision:

But the thing that struck me really about this was it doesn’t seem clear why they’re medically admitting him, so there’s, you know, a lot of greyness and uncertainty, as you said [CP4].

Why has this guy been admitted to an acute medical bed, what’s the reason for him coming in, is it because he needs care, nursing care, or is it he needs medical treatment?

Lack of information about previous care was also seen as a barrier to making a confident discharge decision, and even though a specialist team had been instrumental in discovering the reluctance of the care home to take AA back that day, which was thought to be ‘a bit of a decision-maker, swayer for the middle-grade doctor’ (CP4), no significant medical or care history had been investigated.

But, you know, as you said, it’s very difficult because actually he’s in a care home and they will have lots of information about him, but we’re not very good at getting that information from care environment to hospital.

CP3

Picking up on AA’s relatives comments, that they needed a booklet to explain his history, a PPI member pointed out that the burden often falls on patients themselves to carry their own medical history, believing that ‘it becomes a responsibility of a patient to be able to give doctors information that they need’ (PPI1). Her practical suggestion was that ‘in a care home or nursing home situation I would think that that information should be in a booklet in his room or where he stays, that if he leaves that just goes with him wherever he goes’ (PPI1).

However, the reviewers were also pragmatic in their assessment of the case, realising that the ideal does not often exist in their working environment, and that system factors of time and limitations of community resources weigh heavily on decision making:

They didn’t quite manage to get to that within the 4 hours that he was in the emergency department.

So you’re feeling it was probably appropriate on . . .

On what they managed to achieve in the time. I guess if, in an ideal world if they had achieved a diagnosis and treated something, and they felt happy that they sort of knew why he was confused, he could potentially, if the local area was set up for that, got him to a community hospital bed rather than an acute medical bed in an acute hospital. But that would have depended on them being confident medically that there wasn’t something else they needed to treat or investigate. We don’t know whether he’s fallen [again?], bumped his head, and it was in a context of his recent, um . . . injuries.

Reviewers found this case typical of many presentations to their ED department and summed up the view that system factors are most likely to determine whether or not this type of patient is admitted.

Case summary

Summary of clinical panel review of case 11 (BC)

At stage 1 of the clinical panel the clinician reviewers both judged this to be an appropriate decision (1 on the Likert scale), although one reviewer commented that from the patient’s viewpoint BC’s primary symptom, her pain, had not been addressed. PPI review suggested that from a patient experience perspective this case was worthy of fuller discussion at stage 2.

During stage 2 discussion, the reviewers suggested a number of ways in which, while it was an appropriate decision to discharge the patient with an outpatient appointment for the next day in ambulatory care, the patient experience could have been better.

The clinician discussion centred around the risk stratification protocols for diagnosis of chest pain and whether this process serves the patient well in such a case as BC’s, where the presence of low levels of cardiac enzyme in the blood and presentation of pain may indicate an admission, but where her medical history and preference for discharge are mediating factors:

We can risk-stratify them [. . .] to whether it’s safe for a patient to go home with a query pulmonary embolism, but a lot of the time it comes down to patient choice. Some patients just don’t want to stay in hospital, and they’re willing, when given the risks and benefits of waiting an investigation or going home, they choose to go home.

But occasionally there’s a patient who does have a raised troponin who you say, ‘Hang on a minute, I was going to send you home, but you’ve got a raised troponin and the pathway says that I should admit you to hospital.’ And sometimes the patient says, ‘I don’t want to come in’, in which case I say, ‘Well . . .’ [indicates that he would go with patient wishes].

The medical physicians discuss that this comes down to the doctor’s individual levels of risk aversion. CP4 (medical registrar) commented: ‘it’s a high-cost strategy for a relatively low risk, but I think because in our patient population [hard to hear] tend to be young, the adverse outcome is massive, so I tend to be relatively risk averse.’

The panel were in agreement that an ambulatory pathway was beneficial for BC, but believed that her route to this decision could have been more direct had a different service been available at the hospital:

I just wondered what CP1 [AGPS] thought about the pathway of this poor patient ringing the oncology nurse [. . .] round the whole hospital and then told to go to your GP?

I mean we would probably get the oncology nurse ringing us actually [. . .] we would never say, ‘Go and see your GP’ for a pulmonary embolism. But I guess if that pathway doesn’t exist in this establishment [. . .] the best way to get them into hospital was probably through their GP.

The panel also pointed out there was an element to BC’s care which was suboptimal and which is commonly experienced by patients in ED:

I think that’s something we’re really bad at, because we . . . admit people to ambulatory care or to our clinical decision unit and it’s normally us that go round and review all the investigations and say to the patient at the end of their, er . . . their visit, ‘So, all good news, everything’s normal, you can go home, it’s all fine,’ and they go ‘Can you give me some painkillers? No one gave me any painkillers, I’ve been here 6 hours.’ ‘Oh, well we were ruling out heart attack.’ ‘Well I haven’t had a heart attack, [hard to hear] some painkillers!’

There was reflection from a PPI member that failure to address patient comfort could have been due to handover between different professionals, a fact that was acknowledged as something that ‘we still can’t get 100% right at the moment’ (CP3, senior nurse ambulatory care) given the strain on the system from numbers coming through ED: ‘I think mistakes happen and things get, don’t get communicated as well as they should be’ (CP3).