1. Rapid review of the evidence on urgent care and unplanned admissions
July 2013

2. Context

3. Context Review by Chris Ham (2006)
Which initiatives would be most effective for reducing unscheduled admissions and number of unplanned days in hospital?
Explored:
the way care is organised
programmes and methods of care
tools to facilitate more effective care
strategies for involving people in own care
Reviewed impact on:
admissions
readmissions
length of stay

4. Conclusions Unplanned admissions and readmissions Length of stay
Length of subsequent hospital stays
• self-management education,
• self-monitoring,
• group visits to primary care,
• broad managed care programmes,
• integrating social and health care,
• multidisciplinary teams in hospital,
• discharge planning,
• multidisciplinary teams after discharge,
• care from specialist nurses,
• nurse-led clinics,
• telecare,
• telemonitoring.
self-management education,
• home hospitalisation,
• educating professionals.
targeting people at high risk,
• telemonitoring,
• nurse-led clinics and nurse-led follow-up,
• targeted assertive case management,
• home visits.
Ham concluded that some evidence to show that these interventions may be effective.

5. Rapid review of recent evidence
Central Midlands CSU Knowledge Management team requested to review evidence since 2006 report
In interests of time, focused on:
secondary research only – systematic reviews, summaries
english language only
narrower range of sources
Cochrane
Medline
CINAHL
Embase
HMIC
Kings Fund
Nuffield
Health Foundation
NIHR
Also completed a rapid review of key recent evidence on urgent care for a CCG customer

6. A number of significant recent reviews, including:
Avoiding hospital admissions: what does the research evidence say? (Kings Fund, 2010)
Improving patient flow (Health Foundation, 2012)
Models of care – managing emergency department attendances (Evidence Adoption Centre, 2011)
Urgent and emergency care: a review for NHS South of England (Kings Fund, 2013)
Urgent care centres: what works best? (Primary Care Foundation, 2012)
Reducing emergency admissions: what works? (NHS Confederation, 2013)
Interventions to reduce unplanned admissions: a series of systematic reviews (University of Bristol, 2012)
Focused initially on summarising key recent reviews

7. Overview so far Category Strong Evidence Weak / Uncertain Evidence
Primary
NHS Walk-in centres and Out of hours services
Telephone Triage and consultation services
Pharmacists
Quality of primary care
Acute
Early senior clinical involvement e.g. senior clinical engagement at front door
Change in working patterns – consultants / diagnostics
Pull - Specialist visit MAU after morning ward rounds / discharges 'pull' patients from MAU to specialist wards
Pooling junior doctors from A&E, MAU, and medical and surgical specialties
Assessment units / MAU focusing on medical admissions of particular medical specialties e.g. frail elder people
Combine outpatients and emergency patients into a single system of care / Medical assessment Treatment Centre (Ambulatory Care)
Collaborative Care Team (CCT) - integrated care / Multidisciplinary assessment team
Social worker in A&E
Using GPs in Emergency Department
Preventative
Education / self management (COPD / Asthma adults)
Exercise / rehabilitation (COPD and heart failure)
Telemedicine
Specialist clinics (heart failure)
Integrated care (angina and diabetes)
Case management
Finance Schemes
Vaccine programmes
Care pathways
Intermediate Care
Discharge
Discharge Planning
Hospital at Home

8. Primary care interventions

9. Lessons learned from PCT initiatives
‘Urgent Care: a practical guide to transforming same-day care in general practice’ ( ) by The Primary Care Foundation outlines lessons from 5 PCTs:
key recommendation was ensuring there are appointments available for urgent cases
initiatives include:
open access clinics
integrated care / multidisciplinary teams
nurse-led emergency clinics
telephone assessments
duty doctor / home visits
telephone scripts to manage appointments
emergency and urgent care checklist to help select the best pathway of care.

10. Interventions Walk in centres and out of hours services
Evidence Adoption Centre (2011)
cite controlled before and after study by Salisbury et al (2007) which found no evidence of any effect of Walk-in Centres on attendance rates, service cost or long term outcomes of care
lack of evidence to support hypothesis out of hours services help reduce attendances at emergency departments
Primary Care Foundation (2012)
reviewed 15 urgent care centres and found great variation across services
lack of published evidence to support hypothesis that UCCs and walk-in centres will reduce attendances at A&E, and some suggestion that they may increase total burden on the NHS.
Telephone triage and consultation
The Evidence Adoption Centre (2011)
cite 2004 Cochrane review ‘Telephone consultation and triage: effects on health care use and patient satisfaction’
review found telephone consultations can reduce the number of GP surgery contacts and out-of-hours visits, however, may be an increase in repeat visits.
about 50% of the calls could be handled by telephone advice alone
studies had variability in the interventions studied and methodological limitations, therefore the results should be treated with caution.
The effect of out of hours services on emergency department visits was not reported in detail in the literature reviewed so far.

11. Interventions Medication review Kings Fund (2010):
Royal et al (2006) found relatively weak evidence that pharmacist-led medication reviews are effective in reducing admissions
Holland et al (2005) - pharmacist home-based medication review at 2 and 8 weeks after discharge, for patients over 80, associated with significantly higher rate of hospital admission
University of Bristol (2012):
“There was no evidence of an effect on UHA in older people, and on those with heart failure or asthma carried out by clinical, community or research pharmacists. It is important to note that the evidence was limited to two studies for asthma patients."
Quality
Downing et al (2007) and Bottle et al (2008) did not find association between QOF scores and hospital admission for patients with asthma, COPD or coronary heart disease.
Saxena et al (2006) provision of diabetes clinics in primary care significantly associated with reduced admission rates for diabetes, but provision of asthma clinics not associated with a similar reduction in admissions
Griffin and Kinmonth (2006) concluded high standards of diabetes care in primary care do not necessarily lead to reduced hospital admissions.
Royal – systematic review
Holland - RCT

12. Secondary interventions

13. Interventions Early senior clinical involvement Kings Fund (2010):
White et al senior emergency medicine clinician available to review patients in ED shown to reduce inpatient admissions by 12% and specifically reduced admissions to the acute medical assessment unit by 21%
Kings Fund (2013):
implementation of Rapid Assessment and Treatment (RAT) for “majors” patients and early senior review likely to increase number of people able to be managed at home and to prevent adverse outcomes
Health Foundation (2012):
Sheffield Teaching Hospitals NHS Foundation Trust: consultants assess patients 10 to 20 hours sooner than in previous system - increased number discharged on day of admission
Pull - Specialist visit MAU after morning ward rounds / discharges 'pull' patients from MAU to specialist wards
South Warwickshire Foundation NHS Trust – daily visits by senior clinicians to MAU to decide discharge/follow-up outpatient or transfer to specialist ward
White – didn’t include patients sent for emergency medical admission by GP
Health Foundation – 2 case studies

14. Interventions Change in working patterns – consultants / diagnostics
Kings Fund (2013):
“many of the ECIST reports highlighted the impact of reduced diagnostic services on emergency departments during weekends and also over lunchtimes” - concluded 7 day a week services would facilitate discharges and reduce bed days
Health Foundation (2012)
South Warwickshire Foundation NHS Trust –increased same-day blood test results available on ward rounds from <15% to >80%.
Pooling junior doctors from A&E, MAU, and medical and surgical specialties
Health Foundation (2012):
Sheffield Teaching Hospitals NHS Foundation Trust – pooling capacity of junior doctors from A&E, MAUs and medical/surgical specialties help meet peaks in emergency patient demand
Collaborative Care Team - integrated care/multidisciplinary assessment team
Sheffield Teaching Hospitals NHS Foundation Trust - dedicated ‘Front Door Response Team’
NHS Institute for Innovation and Improvement:
Weston Experience - Collaborative Care Team (CCT) providing care in patients’ own homes to avoid emergency admissions and hospital readmissions and to support early discharge.
S Warks - senior clinicians (including cardiologists, geriatric medicine specialists, gastroenterologists and chest physicians

15. Interventions
Assessment units/MAU focusing on medical admissions of particular medical specialties
NHS Confederation (2013):
Cooke et al (2004) – “[...] seem to have advantages over traditional admission to a general hospital ward, including reducing the number of admissions to general wards and the length of stay[...]”
Kings Fund (2010):
refers to Singapore study where 6.4% saving using observation wards
Kings Fund (2013)
AMU consultant on call takes GP referral calls directly, preventing 40% from being admitted
Combine outpatients and emergency patients into a single system of care / Medical assessment Treatment Centre (Ambulatory Care) Health Foundation (2012)
MAU focused on frail older people reduced unnecessary overnight stays for people who were able to return home with support.  
NHS Institute for Innovation and Improvement published 2 case studies:
medical day case unit where patients assessed and treated on the same day
ambulatory care service adjacent to hospital - clinical risk scores used to identify which conditions can be treated in an ambulatory way   
Lateef- Singapore not UK

16. Emergency department interventions
Social worker in A&E
Kings Fund (2010):
international evidence that admissions to hospital could be avoided if seen by a social work in A&E but limited applicability to the UK
McLeod et al (2003) - uncertainty about effectiveness of social workers based in the ED in reducing inappropriate admissions among older people
Using GPs in Emergency Department
Carson et al (2010) - GPs working in ED may result in fewer referrals for admission; although cost benefits may exist, the evidence for this is weak.
Rogers et al (2010) - GP service aimed at patients referred for urgent medical admission by a GP in the community, showed small reduction in admissions to the medical assessment unit.
Evidence Adoption Centre (2011):
Uni Warwick (2008)- “GP working in EDs can reduce the number of referrals for admissions and order less investigations. It can be cost effective but the level of evidence is weak”.
Cochrane Review ‘Primary care professionals providing non-urgent care in hospital emergency departments’ (2012):
not enough evidence to suggest introducing GPs in accident and emergency wards results in cost savings and reductions in overcrowding. 
Carson - By focusing on ‘walk-in’ patients, unlikely to affect admission numbers, as these patients are unlikely to be admitted.
Cochrane - insufficient basis upon which to draw conclusions regarding the effectiveness and safety of care provided by GPs versus emergency physicians for non-urgent patients in the Emergency Departments, and stated further studies are needed to evaluate patient wait-times, length of hospital stay, and adverse effects or mortality.

17. Preventative interventions

18. Interventions Self management and education Uni Bristol (2012):
“Cochrane reviews concluded that education with self-management reduced UHA in adults with asthma, and in COPD patients but not in children with asthma. There is weak evidence for the role of education in reducing UHA in heart failure patients."
Kings Fund (2010):
“Six of the eight studies that did demonstrate a reduction included a self-management action plan, compared with three of the seven that did not, suggesting that a self-management action plan is a useful component”.
Integrated care
concluded integrating primary and secondary care to be effective at reducing unplanned admissions, however the cost effectiveness is less certain.
Curry and Ham (2010) ”There is evidence from The King’s Fund review that integrating primary and secondary care to provide disease management for patients with certain conditions can reduce unplanned admissions.”

19. Interventions Exercise and rehabilitation Specialist clinics
Uni Bristol (2012):
“Cochrane reviews conclude that pulmonary rehabilitation is a highly effective and safe intervention to reduce UHA in patients who have recently suffered an exacerbation of COPD, exercise-based cardiac rehabilitation for coronary heart disease is effective in reducing UHA in shorter term studies, therapy based rehabilitation targeted towards stroke patients living at home did not appear to improve UHA and there were limited data on the effect of fall prevention interventions for at risk older people. The data that were available suggest they did not influence UHA.“
Specialist clinics
"RCTs found by our searches covered heart failure, asthma and older people. Overall specialist clinics for heart failure patients, which included clinic appointments and monitoring over a 12 month period reduced UHA. There was no evidence to suggest that specialist clinics reduced UHA in asthma patients or in older people.“
Vaccine programmes
 Uni Bristol (2012)
“The authors concluded that the available evidence is of poor quality and provides no guidance for outcomes including UHA."   

20. Interventions Telehealthcare Uni Bristol (2012):
“evidence to date has been mixed, but studies have shown particular benefit for people with heart failure in telehealth initiatives (sometimes combined with case management)”
“Telemedicine is implicated in reduced UHA for heart disease, diabetes, hypertension and the older people.“
Care pathways
 Uni Bristol (2012):
"Care pathway systematic reviews have been conducted across conditions as well as for specific diseases such as gastrointestinal surgery, stroke and asthma. Guidelines have been reviewed similarly across conditions. There is no convincing evidence to make any firm conclusions regarding the effect of these approaches on UHA, although it is important to point out that data are limited for most conditions.”
Finance Schemes
 Uni Bristol (2012)
insufficient evidence to make any conclusions on the role of finance schemes, emergency department interventions and continuity of care for the reduction of UHA
Uni Bristol - Whole System Demonstrator (WSD) “Although this study found indications of an impact on emergency admissions and deaths, it did not conclude that there was a reduction in hospital costs due to telehealth”

21. Interventions Case management Uni Bristol (2012):
“case management did not have any effect on UHA although we did find three positive heart failure studies in which the interventions involved specialist care from a cardiologist."
NHS Confederation (2013):
some positive effects in intensive case management with specialist input for people with heart failure
Kings Fund (2010):
assertive case management is beneficial for patients with mental health problems
Intermediate Care
 Kings Fund (2010)
“One previous review has concluded that most available evidence on intermediate care shows no reduction in admissions (Ham 2006). However, one systematic review of nurse-led units in the UK compared with usual inpatient care, for patients over 18 following an acute hospital admission for a physical health condition, found that early re-admissions were reduced by around 50 per cent, but that costs on the nursing-led unit were higher than inpatient stays (Griffiths et al 2007).”.

22. Discharge initiatives

23. Interventions Discharge Planning Kings Fund (2010):
 ”strong evidence [...] that an individualised discharge plan for hospital inpatients is more effective than routine discharge care that was not tailored to the individual. Re-admissions to hospital were significantly reduced by around 15% for patients allocated to structured individualised discharge planning (Shepperd et al 2010)”.
  However the Kings Fund did report that when associated with hospital at home services higher rates of re-admission might be seen
Hospital at Home
NHS Confederation (2013):
hospital at home admission avoidance schemes appear to provide similar outcomes to inpatient care and may generate some savings however schemes to get people home sooner (supported discharge) appear to increase chances of readmission.
echoed in Uni Bristol (2012): “Readmission rates were significantly increased for older people with a mixture of conditions allocated to hospital at home services"

24. Challenges

25. Challenges
admission, readmission, length of stay not always included as an outcome measure
limited systematic reviews
can be difficult to synthesise evidence of interventions across different patient groups – e.g. Differences in self management and education interventions
difficult to measure impact of interventions on admissions, readmissions, length of stay
applicability of research where populations have been very specific/interventions have been specifically targeted

26. Next steps

27. Next steps
Summary to be completed by end July incorporating secondary research retrieved via Cochrane and bibliographic databases.
Also reviewing evidence on the following services and interventions:
Shared decision making
Community services
Disease management
Palliative care
Care homes
Falls prevention
Hospices
Risk prediction

28. Forthcoming research NIHR:
Understanding system characteristics of urgent care affecting avoidable admissions (2014)
Using clinical prediction models in Wales to identify patients at risk of emergency admission (2015)
Evaluating impact of virtual wards in reducing emergency admissions (2013)
Reducing emergency admissions for people over 85 year (2013)
Review of evidence of impact of supported self-care on hospitalisation rates (2013)
Avoidable acute admissions (AAA) decision-making: a mixed-methods study (2014)
Sarah Purdy, Uni Bristol on systems/culture within primary care

29. Contact us Alison Turner Head of Knowledge and Evidence Management
Shiona Aldridge
Evidence Synthesis Manager