ObjectivesRising demand for emergency and urgent care services is well documented, as are the consequences, for example, emergency department (ED) crowding, increased costs, pressure on services, and waiting times. Multiple factors have been suggested to explain why demand is increasing, including an aging population, rising number of people with multiple chronic conditions, and behavioral changes relating to how people choose to access health services. The aim of this systematic mapping review was to bring together published research from urgent and emergency care settings to identify drivers that underpin patient decisions to access urgent and emergency care.MethodsSystematic searches were conducted across Medline (via Ovid SP), EMBASE (via Ovid), The Cochrane Library (via Wiley Online Library), Web of Science (via the Web of Knowledge), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; via EBSCOhost). Peer‐reviewed studies written in English that reported reasons for accessing or choosing emergency or urgent care services and were published between 1995 and 2016 were included. Data were extracted and reasons for choosing emergency and urgent care were identified and mapped. Thematic analysis was used to identify themes and findings were reported qualitatively using framework‐based narrative synthesis.ResultsThirty‐eight studies were identified that met the inclusion criteria. Most studies were set in the United Kingdom (39.4%) or the United States (34.2%) and reported results relating to ED (68.4%). Thirty‐nine percent of studies utilized qualitative or mixed research designs. Our thematic analysis identified six broad themes that summarized reasons why patients chose to access ED or urgent care. These were access to and confidence in primary care; perceived urgency, anxiety, and the value of reassurance from emergency‐based services; views of family, friends, or healthcare professionals; convenience (location, not having to make appointment, and opening hours); individual patient factors (e.g., cost); and perceived need for emergency medical services or hospital care, treatment, or investigations.ConclusionsWe identified six distinct reasons explaining why patients choose to access emergency and urgent care services: limited access to or confidence in primary care; patient perceived urgency; convenience; views of family, friends, or other health professionals; and a belief that their condition required the resources and facilities offered by a particular healthcare provider. There is a need to examine demand from a whole system perspective to gain better understanding of demand for different parts of the emergency and urgent care system and the characteristics of patients within each sector.

BackgroundIn 2013 NHS England set out its strategy for the development of an emergency and urgent care system that is more responsive to patients’ needs, improves outcomes and delivers clinically excellent and safe care. Knowledge about the current evidence base on models for provision of safe and effective urgent care, and the gaps in evidence that need to be addressed, can support this process.ObjectiveThe purpose of the evidence synthesis is to assess the nature and quality of the existing evidence base on delivery of emergency and urgent care services and identify gaps that require further primary research or evidence synthesis.Data sourcesMEDLINE, EMBASE, The Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Web of Science.MethodsWe have conducted a rapid, framework-based, evidence synthesis approach. Five separate reviews linked to themes in the NHS England review were conducted. One general and five theme-specific database searches were conducted for the years 1995–2014. Relevant systematic reviews and additional primary research papers were included and narrative assessment of evidence quality was conducted for each review.ResultsThe review was completed in 6 months. In total, 45 systematic reviews and 102 primary research studies have been included across all five reviews. The key findings for each review are as follows: (1) demand – there is little empirical evidence to explain increases in demand for urgent care; (2) telephone triage – overall, these services provide appropriate and safe decision-making with high patient satisfaction, but the required clinical skill mix and effectiveness in a system is unclear; (3) extended paramedic roles have been implemented in various health settings and appear to be successful at reducing the number of transports to hospital, making safe decisions about the need for transport and delivering acceptable, cost-effective care out of hospital; (4) emergency department (ED) – the evidence on co-location of general practitioner services with EDs indicates that there is potential to improve care. The attempt to summarise the evidence about wider ED operations proved to be too complex and further focused reviews are needed; and (5) there is no empirical evidence to support the design and development of urgent care networks.LimitationsAlthough there is a large body of evidence on relevant interventions, much of it is weak, with only very small numbers of randomised controlled trials identified. Evidence is dominated by single-site studies, many of which were uncontrolled.ConclusionsThe evidence gaps of most relevance to the delivery of services are (1) a requirement for more detailed understanding and mapping of the characteristics of demand to inform service planning; (2) assessment of the current state of urgent care network development and evaluation of the effectiveness of different models; and (3) expanding the current evidence base on existing interventions that are viewed as central to delivery of the NHS England plan by assessing the implications of increasing interventions at scale and measuring costs and system impact. It would be prudent to develop a national picture of existing pilot projects or interventions in development to support decisions about research commissioning.FundingThe National Institute for Health Research Health Services and Delivery Research Programme.

BackgroundPatients taking direct oral anticoagulants (DOACs) commonly undergo CT head imaging after minor head injury, regardless of symptoms or signs. However, the risk of intracranial haemorrhage (ICH) in such patients is unclear, and further research has been recommended by the UK National Institute for Health and Care Excellence head injury guideline group.MethodsAn observational cohort study was performed in the UK South Yorkshire major trauma centre between 26 June and 3 September 2018. Adult patients taking DOACs with minor head injury were prospectively identified, with case ascertainment supplemented by screening of radiology and ED information technology systems. Clinical and outcome data were subsequently collated from patient records. The primary endpoint was adverse outcome within 30 days, comprising: neurosurgery, ICH or death due to head injury. A previously published meta-analysis was updated with the current results and the findings of other recent studies.Results148 patients with minor head injury were included (GCS 15, n=107, 72%; GCS 14, n=41, 28%). Patients were elderly (median 82 years) and most frequently injured from ground level falls (n=142, 96%). Overall risk of adverse outcome was 3.4% (5/148, 95% CI 1.4% to 8.0%). Five patients had ICH, of whom one died within 30 days. One patient was treated with prothrombin complex concentrate but no patient received critical care management or underwent neurosurgical intervention. Updated random effects meta-analysis, including the current results and two further recent studies, showed a weighted overall risk of adverse outcome of 3.2% (n=29/787, 95% CI 2.0% to 4.4%).ConclusionsThe risk of adverse outcome following mild head injury in patients taking DOACs appears low. These findings would support shared patient-clinician decision making, rather than routine imaging, following minor head injury while taking DOACs.

BackgroundAmbulance service quality measures have focused on response times and a small number of emergency conditions, such as cardiac arrest. These quality measures do not reflect the care for the wide range of problems that ambulance services respond to and the Prehospital Outcomes for Evidence Based Evaluation (PhOEBE) programme sought to address this.ObjectivesThe aim was to develop new ways of measuring the impact of ambulance service care by reviewing and synthesising literature on prehospital ambulance outcome measures and using consensus methods to identify measures for further development; creating a data set linking routinely collected ambulance service, hospital and mortality data; and using the linked data to explore the development of case-mix adjustment models to assess differences or changes in processes and outcomes resulting from ambulance service care.DesignA mixed-methods study using a systematic review and synthesis of performance and outcome measures reported in policy and research literature; qualitative interviews with ambulance service users; a three-stage consensus process to identify candidate indicators; the creation of a data set linking ambulance, hospital and mortality data; and statistical modelling of the linked data set to produce novel case-mix adjustment measures of ambulance service quality.SettingEast Midlands and Yorkshire, England.ParticipantsAmbulance services, patients, public, emergency care clinical academics, commissioners and policy-makers between 2011 and 2015.InterventionsNone.Main outcome measuresAmbulance performance and quality measures.Data sourcesAmbulance call-and-dispatch and electronic patient report forms, Hospital Episode Statistics, accident and emergency and inpatient data, and Office for National Statistics mortality data.ResultsSeventy-two candidate measures were generated from systematic reviews in four categories: (1) ambulance service operations (n = 14), (2) clinical management of patients (n = 20), (3) impact of care on patients (n = 9) and (4) time measures (n = 29). The most common operations measures were call triage accuracy; clinical management was adherence to care protocols, and for patient outcome it was survival measures. Excluding time measures, nine measures were highly prioritised by participants taking part in the consensus event, including measures relating to pain, patient experience, accuracy of dispatch decisions and patient safety. Twenty experts participated in two Delphi rounds to refine and prioritise measures and 20 measures scored ≥ 8/9 points, which indicated good consensus. Eighteen patient and public representatives attending a consensus workshop identified six measures as important: time to definitive care, response time, reduction in pain score, calls correctly prioritised to appropriate levels of response, proportion of patients with a specific condition who are treated in accordance with established guidelines, and survival to hospital discharge for treatable emergency conditions. From this we developed six new potential indicators using the linked data set, of which five were constructed using case-mix-adjusted predictive models: (1) mean change in pain score; (2) proportion of serious emergency conditions correctly identified at the time of the 999 call; (3) response time (unadjusted); (4) proportion of decisions to leave a patient at scene that were potentially inappropriate; (5) proportion of patients transported to the emergency department by 999 emergency ambulance who did not require treatment or investigation(s); and (6) proportion of ambulance patients with a serious emergency condition who survive to admission, and to 7 days post admission. Two indicators (pain score and response times) did not need case-mix adjustment. Among the four adjusted indicators, we found that accuracy of call triage was 61%, rate of potentially inappropriate decisions to leave at home was 5–10%, unnecessary transport to hospital was 1.7–19.2% and survival to hospital admission was 89.5–96.4% depending on Clinical Commissioning Group area. We were unable to complete a fourth objective to test the indicators in use because of delays in obtaining data. An economic analysis using indicators (4) and (5) showed that incorrect decisions resulted in higher costs.LimitationsCreation of a linked data set was complex and time-consuming and data quality was variable. Construction of the indicators was also complex and revealed the effects of other services on outcome, which limits comparisons between services.ConclusionsWe identified and prioritised, through consensus processes, a set of potential ambulance service quality measures that reflected preferences of services and users. Together, these encompass a broad range of domains relevant to the population using the emergency ambulance service. The quality measures can be used to compare ambulance services or regions or measure performance over time if there are improvements in mechanisms for linking data across services.Future workThe new measures can be used to assess different dimensions of ambulance service delivery but current data challenges prohibit routine use. There are opportunities to improve data linkage processes and to further develop, validate and simplify these measures.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

Background in high-income countries trauma patients are becoming older, more likely to have comorbidities, and are being injured by low-energy mechanisms. This systematic review investigates the association between higher-level trauma centre care and outcomes of adult patients who were admitted to hospital due to injuries sustained following low-energy trauma. Methods a systematic review was conducted in January 2021. Studies were eligible if they reported outcomes in adults admitted to hospital due to low-energy trauma. In the presence of study heterogeneity, a narrative synthesis was pre-specified. Results three studies were included from 2,898 unique records. The studies’ risk of bias was moderate-to-serious. All studies compared outcomes in trauma centres verified by the American College of Surgeons in the USA. The mean/median ages of patients in the studies were 73.4, 74.5 and 80 years. The studies reported divergent results. One demonstrated improved outcomes in level 3 or 4 trauma centres (Observed: Expected Mortality 0.973, 95% CI: 0.971–0.975), one demonstrated improved outcomes in level 1 trauma centres (Adjusted Odds Ratio 0.71, 95% CI: 0.56–0.91), and one demonstrated no difference between level 1 or 2 and level 3 or 4 trauma centre care (adjusted odds ratio 0.91, 95% CI: 0.80–1.04). Conclusions the few relevant studies identified provided discordant evidence for the value of major trauma centre care following low-energy trauma. The main implication of this review is the paucity of high-quality research into the optimum care of patients injured in low-energy trauma. Further studies into triage, interventions and research methodology are required.