Emergency admissions to hospitals have risen annually, exacerbating pressures on emergency departments (EDs) and acute medical admission units (MAUs). These pressures can adversely impact patient experience through overcrowding and potentially suboptimal clinical decision-making. Solutions proposed to meet demands for emergency care include: development of new units linked to emergency departments, earlier senior input, and hospital-based teams to support discharge. However, the cumulative effect of these alternative care models, on patient and clinician experience, has not been fully investigated.

The NIHR HS&DR funded the Avoidable Acute Admissions project (2012-14) to investigate how clinician expertise and decision-making in four hospitals in south-west England contributed to safely reducing acute admissions.

The project used a mixed-methods case study design for a comparative analysis of decision-making about admissions in four acute hospitals in south-west England. The primary research comprised two parts: value stream mapping (VSM) to measure time spent by practitioners on key activities in 108 patient pathways, including an embedded study of cost; and an ethnographic study incorporating data from 65 patients, 30 carers, and 282 practitioners of different specialties and levels.

Additional data was collected through a clinical panel, learning sets, stakeholder workshops, reading groups and review of site data and documentation. We used a realist synthesis approach to integrate findings from all sources.

This project is supported by the NIHR ARC South West Peninsula (PenARC).

Project aims
The study aimed to investigate the interplay of factors influencing decision-making about emergency admissions, and to understand how the medical assessment process is experienced by patients, carers and practitioners.
Current activity
This project is now completed. 
Conference proceedings
  • D Thomas, D Swancutt, S Joel-Edgar, H Brant, R Byng, J Pinkney. Emergency or ambulatory? GP hospital referral routes for acute patients. Society for Academic Primary Care. Feb 2015, Birmingham
  • S Rance, J Pinkney, H Brant, D Westlake, D Swancutt, I Holme, S Sharkey, R Byng. Time for care? Patients’ and emergency practitioners’ voices. Emergency Admissions Conference, Dec 2014, London
  • S Rance, H Brant, D Westlake, D Swancutt, I Holme, S Sharkey, M Pearson, J Pinkney & R Byng. Embedding ethnography within critical realism: methodological challenges in a study of hospital emergency care. The 1st International Conference on Realist Approaches to Evaluation and Synthesis (CARES) Oct 2014, Liverpool
  • S Rance, J Benger, H Brant, D Swancutt, D Westlake, D Thomas, I Holme, S Sharkey, A Gibson, J Pinkney, R Byng. Emergency department practitioners’ voices on workplace pressures. Dilemmas for Human Services. 17th annual international research conference. Sept 2014, London.