Factors associated with longer wait times, admission and reattendances in older patients attending emergency departments: an analysis of linked healthcare data

Why it matters

Healthcare policy in England uses emergency department (ED) wait times to monitor and evaluate the performance of urgent care services, and to set standards for service improvement.

However, wait times alone don’t provide a complete picture of service quality and the outcomes for patients. This is because ED attendance is just one part of the urgent care pathway, which also includes services used by patients before they arrive at the ED (things like ambulances and NHS 111).

Indicators such as hospital admission and re-attendance at the ED also reflect the quality of urgent care services, from the perspective of both patients and systems. However, few studies take account of these important aspects of care delivery, and little research has been done to identify which patient, pathway, and service provider characteristics have the strongest impact upon urgent care outcomes.

Gaining a fuller picture of the factors that affect what happens to patients attending EDs may help us to identify the patients most at risk of poor outcomes and provide better urgent care provision for older patients.

Approach

The team looked at past data relating to patient care, services and outcomes, using the CUREd Research Database – a resource that links together data from a range of healthcare systems in the Yorkshire and Humber region. They studied the records of patients aged over 75 who attended 18 type 1 EDs (major emergency departments) in the region between April 2012 and March 2017.

They measured three service outcomes relating to the quality of care that patients received:

• Waits of longer than four hours.
• Hospital admission.
• Reattendance.

They made sure that the study was robust by considering things like patient characteristics, calls to emergency services and use of ambulance services before their ED attendance, the time and day of attendance, and the size and staffing levels – all of which could affect the measures above.

What the study found

The team identified three characteristics that were strongly associated with all three outcomes:

• Older age
• Previous attendance at the ED
• Attending ED out of hours (on weekends, public holidays and overnight).

Compared with people who hadn’t visited an ED in the previous year, for example, people who had attended three or more times in the previous year were more likely to spend more than four hours in the ED, to be admitted to hospital and to reattend the ED within 30 days.

The correlations were less evident when patients arrived at hospital by ambulance. Emergency call handler designation (the level of priority given to emergency calls) was the single strongest predictor of long ED waits and hospital admission when compared with people who didn’t arrive at the hospital by ambulance. Patients who had been described as having urgent, emergency, or life-threatening conditions were more likely to be admitted than those described as less urgent.

Because of this, it is possible that emergency call handler designation could be used in the future to help urgent care services identify patients who are at the highest risk of experiencing poor urgent care outcomes, and plan their services accordingly.

In addition, the three key outcomes – long waiting times, hospital admission and ED reattendance – could be used together as a more effective way to measure quality of care than just waiting times when assessing urgent care provision for older people.