Abstract
Introduction
Emergency care is a major focus of healthcare systems internationally, both in terms of seeking appropriate treatments for conditions requiring emergency care as well as investigating the most effective and cost-effective ways of organizing services to provide that care. The research reported in this theme is very broad and covers the whole care pathway, including finding better ways of diagnosing acute conditions, such as stroke, and determining the most appropriate treatments for life-threatening conditions. Other studies consider the means by which emergency attendances may be avoided through provision of alternative options as well as the best ways of organizing care to ensure rapid and effective treatment for those who do require emergency treatment. Robust health services research requires good quality data and the final case study demonstrates the innovative utilization of a population-based stroke register to design and evaluate models of care in order to improve services for patients.
Reducing unnecessary attendance at hospital emergency departments by improving care out of hospital
Summary
Care provided to patients by emergency ambulance services is changing nationally and internationally, with the proportion of 999 calls in England resulting in conveyance to hospital falling over time (from 68% to 55% between 2007 and 2012). Research has identified approaches more cost-effective than routine conveyance to emergency departments (EDs) for many patients. Evidence that telephone advice, decision support and referral pathways are safe and effective has reduced unnecessary attendance at EDs and associated costs, without compromising patient experience, safety or quality of care.
Research and impact
Calls to emergency health services continue to rise internationally. In England, there were 9.1 million calls in 2012–2013: 80% more than in 2002–2003. Most calls are neither life-threatening nor serious and a review reported that 40% of calls to emergency health services world-wide did not need an emergency ambulance. 1 This unnecessary workload jeopardizes timely responses to those with urgent needs, causing avoidable morbidity and mortality across the spectrum of need.
A programme of applied research in collaboration with ambulance service providers, policy makers and academics has identified safe and cost-effective alternatives to ambulance dispatch and conveyance to ED. The research has included systematic reviews, cohort studies and randomized trials aimed at improving triage and decision-making in emergency care out of hospital, including new protocols and pathways for referrals to non-emergency healthcare providers. The work has included three internationally relevant themes.
First, observational studies by Swansea University analysed existing UK emergency care practice and outcomes to inform future development. Analysis of outcomes in people aged 65 or over who were left at home by an ambulance crew after a fall showed that current practice is unsafe for patients, with about half making at least one further emergency healthcare contact within 2 weeks, and fivefold increases in risk of emergency admission and of death. 2 These findings were reinforced by reviews and focus-group studies. 3
Second, experimental evaluations identified alternatives to ED conveyance that enable paramedics to leave patients at home with referral to a non-emergency health care provider. A controlled before-and-after study assessed 23 ‘Treat and Refer’ protocols for ambulance crews to assess patients on scene and, when appropriate, use alternative pathways of care to avoid hospital admission. Findings were encouraging but not definitive: the intervention was generally acceptable to 250 intervention patients and crews but the conveyance rate to ED remained unchanged. 4 The Paramedic Practitioner Older People Study was a randomized trial showing that paramedics with extended clinical skills (e.g. suturing) could avoid standard ambulance transfer to ED for patients aged over 60 with acute minor conditions, and improve both subsequent emergency contacts and patient satisfaction.5,6 The SAFER 1 randomized trial evaluated the effect of a computerized clinical decision support tool on the care of older people who had fallen; it found that the new model of care was safe, doubled referrals to community falls services and was potentially cost-effective. 6
Third, experimental evaluations of alternatives to ambulance dispatch at initial telephone contacts with the health service included a randomized trial of computerised decision support for 999 call takers. This showed the safety of telephone assessment and advice in place of sending an ambulance to patients with problems triaged as non-serious, 7 and stimulated reductions in emergency ambulance dispatch rates without increasing risk: 330 of 635 intervention group patients (52%) were triaged as not requiring an emergency ambulance. 8 A further study showed the safety and potential effectiveness of provision of advice to callers to the emergency ambulance service by nurses through National Health Service (NHS) Direct: in only 4 of 1552 cases identified could delay in sending an ambulance have been clinically important. 9
The programme of research, dissemination and service support has provided the scientific foundation for major changes in conveyance to hospital by emergency ambulances. In England, for example, the proportion of emergency calls leading to hospital conveyance has fallen from 68% (4.3 million of 6.3 million in 2007–2008) to 55% (5.0 million of 9.1 million in 2012–2013. Though causal inference in this multifactorial field is difficult, it is estimated that hospital conveyances in 2012–2013 were some 1.2 million fewer than expected if the pattern of 2007–2008 had continued. If the cost of these avoided ambulance journeys alone is calculated, at £20 per journey, the marginal benefit of the journeys avoided is estimated to be £24 million. The reduced attendances at ED may also yield further savings for the NHS.
Ambulance service providers across UK have implemented phone-based advice in accordance with recommendations from the Department of Health in response to this research. For example, NHS Direct nursing staff at several sites now provide advice to Category C emergency callers, the least urgent. In 2012–2013, over 360,000 emergency calls in England were resolved through telephone advice, avoiding ambulance dispatch (NHS Information Centre).
The results of this research have been used during the development of strategies, guidelines and standards issued by governing bodies including the Department of Health, Welsh Government, NHS Scotland and authorities in Victoria, Australia and Alberta, Canada.10–15 Research on the ‘Treat and Refer’ protocols and extended paramedic roles has prompted all UK ambulance services to introduce pathways for ambulance crews to assess patients for alternatives to hospital admission and similar service models are being adopted internationally.
Acknowledgement
Institutions listed as contributors to the research: Swansea University.
References
Re-organisation of ambulance services and increased public awareness of stroke symptoms through the Act FAST campaign have improved outcomes for stroke
Summary
Stroke is a major health burden to patients, carers and the NHS, with estimated UK annual costs of £15.5 billion. Clot-busting agents (thrombolytics) can substantially improve the consequences of ischaemic stroke, but only if administered rapidly. Research that recognized the importance of rapid referral to a stroke unit allowed reconfiguration of ambulance services for direct transport of victims to a specialized centre. It has also validated a test developed for paramedics to recognize the signs of stroke, which was developed as the nationwide Face Arms Speech Time (Act FAST) campaign. Use of thrombolytics has increased eightfold between 2005 and 2012, and there has been a considerable increase in public awareness of FAST.
Research and impact
In the UK alone, over 150,000 people have a stroke annually, 1.1 million people live with stroke and the annual costs of stroke, which include health and informal care costs and loss of productivity, are estimated to be up to £15.5 billion. Treatment exists for ischaemic stroke in the form of clot-busting drugs, called thrombolytics, but these are only effective if administered rapidly as every 10-minute delay results in a further 12 out of every 1000 patients having impaired walking ability at discharge, demonstrating the importance of rapid diagnosis and transfer to a specialist centre. Thrombolytics are most effective if administered within three hours and beyond 4.5 hours the chances that the treatment will help or harm the patients are approximately equal. This highlights the importance of rapid diagnosis and transport to a specialized unit.
Two major contributing factors to the low rate of thrombolytic treatment in England (below 1% in 2005) are lack of public awareness of the emergency nature of a stroke, and failure of services to provide an appropriate integrated emergency response. Research has addressed both challenges by: (1) recognizing that paramedics could diagnose stroke with a high degree of accuracy; (2) testing the theory that re-organizing ambulance services would allow more rapid admission of a patient directly to a stroke unit; and (3) developing a protocol to increase public awareness of stroke as a medical emergency.
Research tested the hypothesis that paramedics could recognize acute stroke using a simple, quick protocol1,2 and direct the patient to the appropriate unit for prompt action. This protocol, named FAST for “Face Arm Speech Time”, was developed from the Cincinnati Prehospital Stroke Scale (CPSS). The FAST test contains three elements of the CPSS which were modified to use assessment of spontaneous speech rather than repetition of a sentence. This allows the test to be performed more quickly, reducing assessment time and enabling a positively identified stroke patient to be transferred to a stroke unit without delay. The FAST test was also developed to complement existing assessments that paramedics were familiar with, such as consciousness level. Research found that paramedics correctly diagnosed stroke in 79% of patients using FAST, 2 and that there was good agreement between paramedic identification of stroke and later confirmation by a specialist. 3
FAST was included in the NICE clinical guideline 68 in 2008: ‘In people with sudden onset of neurological symptoms a validated tool, such as FAST (Face Arm Speech Test [sic]), should be used outside hospital to screen for a diagnosis of stroke or TIA [transient ischemic attack: a mini-stroke]’. 4 The 2012 National Clinical Guideline for stroke 5 states that ‘The FAST is accepted as the tool of choice for prehospital clinicians’. The effectiveness of FAST in paramedic use led to its adoption as a public recognition instrument. The first body to make use of the validated FAST test was the Stroke Association and the work went on to inform the Department of Health’s nationwide Act FAST campaign, to help members of the public recognize the signs of stroke and to act quickly to ensure that thrombolytics are administered within the short window of opportunity. The campaign has seen several waves of activity, and the memorable imagery includes the use of a ‘flaming head’ which has appeared on national TV, posters and bus stops. 6 A National Audit Office report 7 stated that the Act FAST campaign had been seen by 92% of the 2000 people that responded to a survey on its use. The same survey found that public awareness of the symptoms of stroke increased from 15% to 82% after the campaign. The report also states that an audit of one hyper-acute stroke centre saw a 171% increase in the number of patients presenting within three hours of a stroke between 2008 and 2009. Following a renewal of the Act FAST campaign in 2012, there was a 25% rise in stroke-related 999 calls and a 19% increase in stroke sufferers being seen more quickly. 6
In order to improve the speed of access of acute-stroke patients to a dedicated acute stroke unit, a protocol was established in Newcastle in 1997 and assessed after 15 months. 1 The protocol required paramedics to assess patients using the Face Arm Speech Time (FAST) test, with its outcome determining whether patients were admitted directly by the acute stroke unit (ACU), rather than by the EDs. During this time, 123 patients were admitted to the ACU. Admissions increased during the first year from an average of three to 13 patients per month, with diagnostic accuracy above 80%, showing that reorganization of the service allowed acute-stroke patients to be directed appropriately and thus have a greater chance of rapid treatment. As a direct result, stroke services in two cites were reconfigured to provide more rapid access to specialist care (Greater Manchester and North Central London), and this was associated with increases in thrombolytic treatment given. This reconfiguration of stroke care led to NHS London and the Greater Manchester and Cheshire Cardiac and Stroke Network winning the 2009 and 2010 Health Service Journal award for Clinical Service Redesign, respectively. The 2012 National Clinical Guideline for stroke 5 recommends that ‘All patients seen with an acute neurological syndrome suspected to be a stroke should be transferred directly to a specialised hyperacute stroke unit’.
As a result of the re-organization of stroke services and the introduction of the Act FAST campaign, thrombolysis treatment for those stroke patients who will benefit has increased nationwide fivefold between 2006–2007 and 2008–2009. 7 The thrombolysis intervention rate has continued to grow: from less than 1% in 2005 1 , to 8% by late 2011, according to the Stroke Improvement National Audit Programme. 8
Acknowledgement
Institutions listed as contributors to the research: Newcastle University.
References
Influencing emergency healthcare policy and practice
Summary
Research on the use of use of a β-agonist (salbutamol) in acute respiratory distress syndrome (ARDS) has influenced therapeutic recommendations in the International Sepsis Guidelines, reducing the use of a potentially detrimental therapy. Research on cardiac arrest informed the 2010 international guidelines on cardiopulmonary resuscitation (CPR) and prompted new technologies which have led to improved CPR practice and improved patient survival. Finally, major policy changes and redesign of UK emergency healthcare have been based on research evidence, improving cost efficiency, the patient experience and clinical outcomes.
Research and impact
The first strand of the research considered treatment in ARDS, a life-threatening condition which can be caused by severe sepsis. Use of the β2-adrenergic receptor agonist salbutamol had increased internationally following previous trials showing a benefit. However, a subsequent phase III multi-centre, double-blind, randomized controlled trial of intravenous salbutamol in ARDS 1 was stopped early after treatment when salbutamol was found to be poorly tolerated by patients and associated with increased organ failure and mortality (RR 1·47, 95% CI 1·03–2·08), leading to calls to discontinue the routine use of β-agonists in this condition. The impact on reducing drug use was demonstrated in an international point-prevalence survey, performed in 2012, which showed that β-agonist use in patients with ARDS had fallen to 7.9% in the UK and 13.9% in China. This study concluded that, based on the extrapolation of study results, 389 potential deaths per year could be avoided in the UK alone by ceasing usage of β2-agonists for ARDS. 2 The International Surviving Sepsis Guideline group has published guidelines, which ‘recommend against the routine use of beta agonists in ARDS’. 3 The guidelines have been endorsed by 30 organizations, translated into six different languages and are widely implemented around the world.
The second research strand considered cardiac arrest, the final common event prior to death in a wide range of emergency conditions. To improve patient survival, strategies to improve the effectiveness of CPR were evaluated, demonstrating that the quality of CPR was suboptimal during in-hospital CPR due to compression of the underlying mattress during chest compression and that recalibration of a device that provides CPR pressure feedback could overcome this problem. A subsequent systematic review found that such devices could improve CPR quality in a number of settings. 4 The review also found that a commonly used accelerometer-based feedback device failed to differentiate between chest and mattress compression, which led to the development (by a Medical Technology Company – PhysioControl) of the new technology TrueCPR™, which uses magnetic fields to overcome the limitations with accelerometers. TrueCPR™ has been granted CE (Conformité Européenne) mark approval from the EU and approval from the US Food and Drug Administration (USFDA). It is now available for sale in most countries and Laerdal Medical (Norway) has started developing a smart backboard to overcome the limitations highlighted by the research. The research on CPR has also played a central role in the development of the Advanced Life Support Course, which is taught to over 20,000 healthcare professionals each year in the UK, Europe and Australia. It fed into the recommendations of the International Liaison Committee for Resuscitation, adopted by the American Heart Association, European, Asian, South Africa and Australian Resuscitation Councils. 5 Implementation of CPR feedback devices into clinical practice has been associated with improved CPR performance and increased survival (adjusted odds ratio of 2.72 (95% CI 1.15–6.41). 6
The third strand of research consists of a number of studies related to emergency care policy over many years. Specific projects have addressed the causes behind delays in care and the means for reducing delays, such as the introduction of observation wards, 7 and fast-tracking of individuals with minor injuries. It has also demonstrated more efficient and clinically effective utilization of new roles for clinicians, such as the development and introduction of emergency care practitioners 8 and Advanced Clinical Practitioners. Research has also shown how improved facilities such as walk-in centres can change emergency patient flow by reducing AED attendances in specific circumstances and by reducing the patients transported to AED by ambulance. 9 In an evaluation of these changes, a reduction in the number of patients who leave AEDs without being seen and changes in the causes of re-attendance related to initial quality of care and improved access to community services for follow-up care were found. 10
Acknowledgement
Institutions listed as contributors to the research: University of Warwick.
References
The South London Stroke Register: informing innovation in stroke care
Summary
The South London Stroke Register is the world’s longest running, population-based stroke research register, assessing the incidence of stroke; the acute and long-term needs of stroke patients; and the quality of stroke care. The South London Stroke Register provided data and analyses that informed the Parliamentary Public Accounts Committee report on stroke, the National Strategy for Stroke and contributed to two National Audit Office reports on acute and longer-term stroke care. The latter contributed to a major service reconfiguration in London, which has led to lower mortality and more efficient use of health care resources for stroke. The Register provides a platform for designing and evaluating new models of stroke care, including the largest trial of early supported discharge (ESD), a cost-effective intervention which is now provided in 66% of hospitals in England, as well as being rolled out internationally.
Research and impact
The South London Stroke Register collects data for stroke incidence and stroke outcomes (including mortality, morbidity and quality of life) in a well-defined multi-ethnic population and contains detailed information from almost 5000 stroke patients in the Register area, with each patient followed up at three months and annually after stroke, for life.
Research based on the register falls into four key areas all of which have informed the development of appropriate services for stroke. First, research has measured the incidence of stroke and its immediate and long-term consequences for patients, contributing to understanding needs for services. It has reported continually on changing patterns in stroke incidence, 1 with a focus on ethnic variations in risk. 2 It has demonstrated that stroke risk and stroke sub-types vary substantially between ethnic groups, with a large proportion of strokes occurring in people with untreated risk factors including hypertension with limited improvement in detecting these risk factors over time 2 Register data have shown that 20–30% of survivors have a poor range of functional outcomes (e.g. walking ability) up to 10 years after stroke, 3 and other researchers have used the data to demonstrate other long-term impacts of stroke. This has allowed the risk of stroke and needs for long-term care to be quantified and guided interventions to reduce the significantly poor outcomes of stroke survivors. The research has informed national strategy for stroke 4 and guidance for the NHS. 5 Estimates for risk of stroke, long-term outcomes and survival to inform recommendations for stroke care have been utilized by the National Audit Office 6 and informed the Parliamentary Public Accounts Committee report on the need for a step change in stroke care. 7
Second, the first and largest randomized trial to assess the clinical effectiveness of an ESD policy provided evidence that outcomes following ESD were comparable to conventional hospital and community care, while the length of hospital stay was substantially reduced. 8 A meta-analysis showed that appropriately resourced ESD services, provided for selected groups of stroke patients, can reduce long-term dependency and admission to institutional care as well as shortening hospital stays. 9 The cost-effectiveness of ESD has also been examined. 10 The Royal College of Physicians (RCP) National Clinical Guideline for Stroke recommends that ESD should be a component of stroke care and their National Sentinel Stroke Audit recommended that ESD should be available in all districts. 11 ESD is now provided by 66% of English hospitals and has been implemented internationally. 12 The research also informed the 2008 National Institute of Health and Care Excellence (NICE) guidelines on stroke and the 2010 Stroke Quality Standard, the latter recommending ESD as a component of the rehabilitation pathway. 13
Third, collaborative research across the European Union has focused on explaining variations in incidence, 14 quality and costs of stroke care in Europe 15 and outcomes. 16 These studies highlighted the high costs and poor outcomes associated with acute stroke care in the UK, contributing to making the case for more efficient service models that provide higher quality care. They also showed wide variations in quality of stroke care and implementation of evidence-based practice. The studies were the catalyst for research registers being established in other European centres which have enabled on-going comparative research to improve the quality of stroke care. Register data on incidence and patient outcomes were used to develop a Stroke Strategy for London, in particular to estimate the number of people who can be expected to have a stroke and thereby the number of Hyper Acute Stroke Unit (HASU) and Acute Stroke Unit (ASU) beds required in the city, and to develop models of cost-effective configurations of services. 17 The reconfiguration, implemented in 2010, consisted of 8 HASUs and 24 Stroke Units. It has been estimated that this resulted in a 12% reduction in deaths at 90 days, as well as a reduction in the median length of stay, with an estimated cost saving of £811 per patient (2011) in London after the reconfiguration. 18
Finally, researchers have actively engaged with patients and families to identify priorities for research, including the development of a national survey of long-term need that has informed the Stroke Association’s policy on longer term care. 19
Acknowledgement
Institutions listed as contributors to the research: King’s College, London.
References
This Emergency Care themed article is based on the following case studies:
Reducing unnecessary attendance at hospital emergency departments by improving care out of hospital http://results.ref.ac.uk/DownloadFile/ImpactCaseStudy/pdf?caseStudyId=35234 Re-organization of ambulance services and increased public awareness of stroke symptoms http://results.ref.ac.uk/DownloadFile/ImpactCaseStudy/pdf?caseStudyId=21764 Influencing Emergency Healthcare Policy and Practice http://results.ref.ac.uk/DownloadFile/ImpactCaseStudy/pdf?caseStudyId=3067 King’s South London Stroke Register: Informing Innovation in Stroke Care http://results.ref.ac.uk/DownloadFile/ImpactCaseStudy/pdf?caseStudyId=41174