IT EMERGENCY ADMISSIONS
Emergency admissions are on the rise and GPs and their commissioning groups have been asked to work together to reduce them. JULIA DENNISON finds out how using data can really help and the whos, whats, whens and whys that contribute to A&E attendance
A
&E is under more pressure than ever. Over 20 million patients visit it each year and this number is growing steadily by three per
cent every year, with no sign of declining. These acute services are also expensive – so not the kind of stat you want to see on the up and up. With the Nicholson Challenge to save £20bn breathing down the neck of CCGs, cutting back on expensive emergency hospital visits could be a winning card. The fastest and easiest way to go about doing this across your locality is by gathering evidence.
Accident and emergency departments,
minor injury units and walk-in centres are required to collect a standard set of details on individual attendances. This ‘commissioning dataset’ has been collated by the Information Centre for Health and Social Care and made available on a national basis through the Hospital Episode Statistics (HES) system. However, this doesn’t always help. A recent Foundation Trust Network (FTN) benchmarking report said the diagnostic information collected as part of the national A&E Commissioning Data Set still demonstrates ‘poor coverage, quality and limited relevance’ to clinicians and policy-makers. A significant percentage of attendances are not given an A&E CDS diagnostic code, for example, and even the diagnostic categories that do exist are not detailed enough to inform improvement, the FTN believes. To help with this, the College of Emergency Medicine has begun development of a Unified Diagnostic Dataset, which will hopefully allow for better data to analyse in future. In the meantime, GPs can do a lot
to help CCGs analyse patient data and working with the data they have can answer a lot of commissioners’ questions.
For example, Stillmoor House Medical Practice in Bodmin, Cornwall reviewed its A&E attendances in a bid to help its CCG with commissioning. From the review of 138 patients, 26% related to out-of-hours care and 16.6% were via the minor injuries unit (MIU). Only six patients could have been seen by a GP but chose to go to A&E instead. For two out of these six, it would have been better for them to see the GP. The conclusions were that while attendances were generally felt to be appropriate, MIU staff could be better trained to handle more cases; an acute care-at-home service would help reduce a number of criteria and increased nursing cover and advanced care planning could be done more, particularly in relation to falls/dementia/nursing residential home patients.
While these conclusions may not have been surprising,the practice felt it was important that information was shared throughout the locality to help everyone make progress. “Overall the process went well although there were some inaccuracies with the discharge data which perhaps affected the overall results,” says Michelle Pratley, of the practice’s support team. Overall, she felt the exercise was worthwhile, as it gave a clearer picture of the source of admissions and produced some possible alternative care pathways which could be applied to future commissioning plans. When analysing data, it’s important to know what you’re looking for. There are a number of different data sets that CCGs can track in order to help reduce emergency attendances that result in admission. Matt Murphy, MD of EMIS IQ, the software firm’s intelligence division, recommends considering things like whether patients who live closest to A&E are the highest users, or maybe it is more likely to be patients with multiple comorbidities with poor
access to care. Also, look at disease groups to identify areas of poor management in the community. Perhaps A&E attendance also shows that patients need better education about the services available to them as an alternative to A&E. Besides benchmarking member practices, Murphy suggests CCGs consider using risk modelling tools to predict which patients are at the highest risk of hospitalisation and focus resource and multidisciplinary team planning around the effective provision of care for these patients. A good IT and data system can help. “CCGs should look for a data system, which allows them to pull on a number of different data sources and run searches and reports across primary and secondary care data as a minimum,” he says. “They should be able to analyse data at different levels – patient identifiable, anonymised, pseudo- anonymised in order to support agendas such as public health, i.e. development of the JSNA [Joint Strategic Needs Assessment], epidemiology [health needs], Primary Care Quality Improvement, commissioning cycle etc. This data should be interrogated by experienced analysts with a good working knowledge of clinical codes.”
WHO AND WHAT? There are certain demographics that are important to consider. Patients aged 75 years and older account for over 12% of all A&E, attendances and nearly half of these end in admission, according to a recent benchmarking report by the FTN. These are a high-need and high-cost group due to the complexity of their clinical conditions. Chronic repeat attenders to A&E account for up to eight per cent of all A&E attendances. According to the FTN, trusts are taking action to segment and understand their patient population and put specific plans in place to reduce these repeat attendances. Around the country, a significant focus has been put on implementing support services, like community alcohol teams and Rapid Assessment, Interface and Discharge (RAID) services for those with mental health needs.
WHEN?
Another matrix to watch through data is time. South Warwickshire NHS Foundation Trust had identified two spikes
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