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Local innovation key to ‘reducing avoidable admissions’

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A study investigating how hospitals try to avoid unnecessary emergency admissions has identified a series of tailored innovations that can help to address this pressing problem in different ways

Emergency admission to UK hospitals rose by 47% between 1998 and 2013, but there is evidence that a significant proportion are avoidable, according to researchers from the South West.

“The systems and innovations they put in place were informed by local knowledge and need”

Jonathan Pinkney

They noted that hospitals across the country have introduced a range of initiatives to try to avoid unnecessary admissions but previously there had been no research to investigate how well such measures worked in practice.

The researchers – from Plymouth University, the University of the West of England, Bristol University and Exeter University – investigated how the accident and emergency departments and staff of four major hospitals responded to pressures and the experiences of their patients.

The study, published today in the journal Health Services and Delivery Research, found the likelihood of a decision being made to admit was not determined solely by the diagnosis and perceived risk.

It was also influenced by the seniority and experience of the clinical staff making the decisions, the patient’s social circumstances, access to certain investigations, the proximity of the four-hour target and the availability of time to arrange available alternatives to admission.

However, the approaches taken to reducing unnecessary admissions varied considerably across the hospitals and the researchers said it was evident that the various innovations had been developed to respond to local need.

Some of the more common ones included a hospital-based acute GP service, ambulatory care units, a range of discharge assessment procedures and teams for elderly patients, rapid access outpatient clinics and the use of observation areas where patients were not subject to the four-hour target.

Early patient assessment by senior staff always played a central role in reducing admissions in all four hospitals, but their expertise was deployed in different ways, including in a purely advisory “controller” capacity supporting trainees and other frontline staff.

For medical and nursing staff of all grades, there were concerns around pressure of work, staff retention, but also the use of temporary staff – an observation that emphasised the importance of good local knowledge of alternatives to admission and continuity of care.

Lead researcher Jonathan Pinkney, from Plymouth University Peninsula Schools of Medicine and Dentistry, said: “Hospitals and their staff are under immense pressure to ensure that each and every patient receives the best and most appropriate treatment.

Plymouth University Peninsula Schools of Medicine and Dentistry

Local innovation key to ‘reducing avoidable admissions’

Jonathan Pinkney

“The emergency department is a particular pressure point and we were impressed by how each of the four hospitals in the study addressed the issue of avoiding admitting patients to the ward where it was unnecessary,” he said.

“While there were common themes in how the hospitals approached this issue, the systems and innovations they put in place were informed by local knowledge and need,” said Professor Pinkney.

He added: “The fundamental problem is the high demand for hospital treatment, but the pressure on staff, recruitment difficulties and sometimes reliance on temporary staff also tend to contribute to admissions.

“The four-hour rule expedites treatment decisions – which is a good thing, but it seemed that many decisions about care were made in a rush in the final half hour, which may be why some of the ‘off the clock’ innovations we observed were thought to be successful in avoiding admissions,” he said.

The study authors hoped their findings would inform the ongoing debate about how to cut avoidable admissions and provide policy makers with much-needed evidence on innovations that can improve NHS performance.

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