What is the existing evidence base for adult medical Same Day Emergency Care in UK NHS hospitals? A scoping review protocol

INTRODUCTION

Ambulatory care is an umbrella term used in the UK to describe acute hospital care that is distinct from outpatient, accident and emergency, urgent treatment centres, or inpatient

care, and is sometimes referred to as ambulatory emergency care (AEC) (1). In other countries, particularly in Northern America, Europe and Australia, the term ambulatory care is generally

used to describe primary care services, rather than hospital care provision, although countries such as Australia are starting to adopt the UK model (2). The diverse nature and format of ambulatory care services, both nationally and internationally, means that comparisons between services are difficult.

AEC developed over the last decade or so, mainly being promoted by emergency departments and acute medicine, and initially focussing on specific conditions, often termed ambulatory care

sensitive conditions (1). The British Association for Ambulatory Emergency Care was founded in 2011 to promote the development, adoption and expansion of the specialty of AEC across the NHS in the UK, and continues to promote the expansion of SDEC principles and practice today (3). Whilst the NHS England Urgent and Emergency Care Review Team issued guidance recommending that all NHS Trusts should implement AEC in 2015 (4), historically, there was no generic model; such services were heterogeneous and varied widely in their organisation

and service provision (1, 5). AEC tended to be provided in a clinic style setting, or

within acute medical units, aiming to avoid admission and facilitate early

discharge, but a variety of models were used, with some NHS Trusts embracing

AEC, whereas others continued to operate more traditional models of admitting

patients for assessment (6). In fact the Kings Fund demonstrated large variations in

the rate of admission for ambulatory care sensitive conditions, when considered

by local authority area, after adjusting for differences in age, gender and

deprivation within local populations (7). However, by 2018 some 95% of UK

hospitals had some form of ambulatory provision, according to a recent national

audit (8).

Building on the previous work undertaken within AEC, to support non-admitted emergency care pathways, as part of urgent and emergency care transformation, Same Day Emergency Care (SDEC) is a new model of care that has been developed within the NHS (1), and was mandated by the NHS Long Term Plan (9). The National Strategy for SDEC was released in 2021 (10). This review will focus on the UK only, given that this SDEC model, is unique to the UK.

The model suggests that SDEC can meet local health needs by providing an alternative to emergency department (ED) attendance or hospital admission. It is intended for people with an urgent or emergency health care need, requiring hospital level care and diagnostics,

beyond the scope of an urgent treatment centre, and takes referrals from general practice, urgent treatment centres, ambulance services, the 111 service, as well as the ED. SDEC services are considered essential to the future provision of acute care, in an aging society with limited health care resources, and are endorsed by both the Royal College of Emergency Medicine,

and the Society for Acute Medicine (11).

However, as with AEC, considerable svice variation still exists within the SDEC model. Some organisations offer a broad range of specialties within their SDEC services, in addition to acute

medicine: paediatrics; frailty; gynaecology; surgery; and oncology. Whereas

other organisations focus their SDEC model predominantly on acute medicine.

Further, within acute medicine, some SDEC services focus on specific pathways,

for patients presenting with particular conditions, such as low risk chest

pain, cellulitis, low risk pulmonary embolism etc. and exclude patients who do

not fit a specific pathway (5). Some use a risk stratification tool such as the ‘AMB’ Score, a simple seven element scoring tool for ambulatory care (12-14), whereas others rely only on the National Early Warning Score, based on physiological observations (15), or other risk assessment tools (16, 17). Others take a more inclusive approach, taking all medical referrals, as long as clinically stable (18), this is often termed a process driven approach (19).

There is also variation in the staffing models for SDEC nationally, with some being consultant led, whereas other are led by advanced clinical practitioners (ACPs). Over the last decade

or more, across the NHS, shortages of medical staff led to service

transformation and a realisation that workforce development was required. This,

in part, led to development opportunities for other registered clinicians, such

as nurses and allied health professionals, into advanced practice roles.

Advanced clinical practice is designed to enable the safe and effective

development of skills, across traditional professional boundaries. ACPs are

educated to Master’s degree level or equivalent, with knowledge and skills that

permit an expanded scope of practice, and undertake roles and responsibilities

historically seen as being within the jurisdiction of medical staff (20). Advanced clinical practice was recognised in the NHS Long Term Plan (9) as being central to transforming

service delivery and meeting local health needs as a key part of contemporary

workforce planning. There is a growing evidence base to support the safety and

effectiveness of, and patient satisfaction with, ACP roles; whilst recognising

that there is ambiguity and variability within ACP roles nationally (21), progress is being made towards role standardisation and accreditation (20). ACPs are ideally placed to support the

development of SDEC services, given current medical workforce challenges.

This planned scoping review will focus on acute medical SDEC, as medical patients represent a significant proportion of emergency admissions in the NHS. Typically, up to 30% of these

patients are discharged within 24-hours of arrival, suggesting that admission

avoidance, through the use of SDEC services, would meet that need and reduce

pressure on inpatient beds (22), as recommended in The NHS Long Term Plan (9). Where necessary, SDEC patients can attend again on subsequent days, for further investigation or review, rather than being admitted, but there is limited data on the patient experience of

SDEC, and on the impact on patients of the requirement for repeated or multiple

visits. Some services are developing this further, through the use of Virtual

Wards and Hospital at Home (5, 23), but these services are beyond the scope of this review,

as they are distinct from SDEC.

An emerging evidence base suggests that ambulatory services in the UK may improve patient experience and reduce hospital admissions, reduce infection risk and deconditioning, and offer

cost savings (24). However, ambulatory care provision has been heterogeneous, whereas SDEC now has a national strategy, with core requirements (10), although local variations remain significant, in terms of speciality coverage; and some ambulatory care services have simply been rebranded as SDEC. Embedding the SDEC national strategy should guide future service development in a more cohesive manner, leading to a more homogenous service across the seven NHS regions. This in turn will support future research, as comparisons between services will be less subject to confounding.

Given that the SDEC model has been operational for a relatively short period of time, a review of the evidence base is indicated to establish what research underpins the model. It

is not uncommon for new healthcare policies and initiatives to be rolled out,

based on small pilot studies, in a top-down approach from the Department of

Health, as political agendas often drive cost-savings and efficiency, rather

than substantive workforce transformation priorities, given the ever-increasing

demand on the NHS (25-27). It remains to be seen whether medium- and long-term costs

savings are produced by SDEC services, given the requirement for additional

pathways, estate and staffing, or whether this approach simply delays admission

and/or increases severity of illness at presentation, particularly in the

older, frail population. Economic analysis and speciality SDEC such as frailty

SDECs are not considered further, as the focus of this review is on acute

medicine.

Establishing existing evidence underpinning the SDEC model will identify gaps that require investigation through further research. Initial searches suggest that there is little

published literature to date, so a scoping review was chosen as the appropriate

type of literature review to map emerging evidence (28-31). The Joanna Briggs Institute (JBI) methodology for scoping reviews (32) was chosen to provide structure to the

review, and to support the development of a comprehensive overview of the

available evidence in relation to adult medical SDEC in the NHS.

A preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews, JBI Evidence Synthesisand PROSPERO was undertaken to ascertain if this topic had been investigated

previously, and no current, or in progress, systematic reviews or scoping

reviews on the topic were identified.

What is the existing evidence base for adult medical Same Day Emergency Care in UK NHS

hospitals?

Objective

To determine the existing evidence base in relation to medical Same Day Emergency Care, in the NHS, in the UK.

Keywords for searching g

Ambulatory Emergency Care; AEC; Same Day Emergency Care; SDEC.

Eligibility Criteria

Participants - Adult patients (over 18).

Concept - Same Day Emergency Care model of care delivery, acute medicine specialty, excluding all

other specialty SDECs.

Context t - NHS hospitals in the UK only.

Types of Sources –

This scoping review will consider all study designs, including randomised controlled

trials, non-randomised controlled trials, before and after studies and

interrupted time-series studies. Observational studies including prospective

and retrospective cohort studies, case-control studies and cross-sectional

studies will be considered for inclusion. This review will also consider

descriptive observational study designs including case series, individual case

reports and descriptive cross-sectional studies for inclusion (32).

Qualitative studies will also be considered that focus on qualitative data including, but not limited to,

designs such as phenomenology, grounded theory, ethnography, qualitative

description, action research and feminist research. Text and opinion papers,

including policy papers and grey literature, will also be considered for

inclusion (32).

A variety of evidence synthesis methodologies are available, including a range of different types of review, including systematic reviews, mixed methods reviews, realist synthesis etc.,

all aiming to inform policy, practice and/or further research, through

rigorous, explicit and systematic methods (33). If answers to clinically meaningful

questions or to produce practice guidance are required a systematic review is

likely to be the preferred option, whereas to identify the types of evidence

available in a particular area, to identify key characteristics or factors, and

to identify and analyse knowledge gaps, a scoping review is likely to be more

suitable (30). A scoping review offers an initial evaluation of the possible volume and range of existing research literature. Its primary goal is to recognize the nature and breadth of research evidence, often encompassing ongoing studies as well. Whilst in contrast a systematic

review involves a thorough and methodical search for, evaluation, and

integration of research evidence, typically following the guidelines set by the

Cochrane Collaboration for conducting systematic reviews. However, in contrast

to systematic reviews, scoping reviews are not typically considered a

conclusive outcome on their own due to their inherent limitations in rigor and

duration, making them more susceptible to bias. One noted drawback of scoping

reviews is the lack of a quality assessment process, which means that

conclusions may be based more on the quantity of studies rather than their

actual intrinsic quality. Consequently, the findings from scoping reviews

cannot be relied upon to provide recommendations for policy or practice, whilst

in contrast systematic reviews can be used as such (31).

Considering the objectives of this review, a scoping review was selected as the appropriate methodological approach to systematically identify and map the evidence, across a wide range

of sources, relating to SDEC. This will assist in clarifying the evidence base

and identify key characteristics and/or factors relating to SDEC, as well as

identifying and analysing gaps in knowledge to support future research

initiatives.

The guidance provided by the JBI Manual for Evidence Synthesis, Chapter 11: Scoping Reviews (32) offers a robust, structured framework, that builds on and refines previous iterations of scoping review frameworks (31). This guidance recommends that an a

priori protocol is required to support a systematic scoping review, that established

methodological guidance should be followed and that reporting standards, such

as the Preferred Reporting Items for Systematic Reviews and Meta-analyses

extension for scoping review (PRISMA-ScR) guidelines, should be utilised (31, 33,

34).

In accordance with the JBI methodology for scoping reviews (32) this methods section follows the recommended structure of: Search strategy; Study/Source of Evidence selection; Data Extraction; Data Analysis and Presentation.

Search Strategy

The search strategy will aim to locate both published and unpublished studies. An

initial limited search of MEDLINE and CINAHL, via EBSCOhost, was undertaken to

identify articles on the topic. The words contained in the titles and abstracts

of relevant articles were used to develop a full search strategy. The search strategy, including all identified keywords, will be adapted for each database and/or information source. The reference lists of all included sources of evidence will be screened for additional studies (32).

Studies published in English will be included, as this review focuses on UK SDEC services. Studies published in the past five years will be included, due to the recent initiation of the SDEC model, the

specific focus on SDEC, and the wide-ranging differences between the former

heterogenous AEC services. The introductory section of the scoping

review will consider the wider context of papers beyond 5 years, as will the

ensuing discussion section of the paper, but the scoping review itself will

focus on up to 5 years, as that is the general timeline for operation of SDEC

services.

Inclusion criteria: English

language, within the last 5 years, full text available, UK only, Adults (over 18), acute medicine specialty.

Exclusion criteria: Foreign language, older than 5 years, no full text available, non-UK papers,

paediatrics (under 18), specialties other than acute medicine.

The databases to be searched will include EMBASE, MEDLINE and CINAHL, via EBSCOhost. Sources of unpublished studies, policies and grey literature will include Google Scholar, the Cochrane

Library, TRIP database, ProQuest Dissertations and Theses Open, and the Health

Management Information Consortium. Planned search dates will be in August 2023.

Study/Source of Evidence selection n

Following the search, all identified citations will be collated and uploaded into EndNote Web

(35) and duplicates removed. Titles and abstracts will be screened against the inclusion criteria, by one reviewer. Potentially relevant papers will be retrieved in full. The full text of

selected papers will be assessed, against the inclusion criteria, by two

reviewers. Reasons for exclusion of papers, at the full text stage, that do not

meet the inclusion criteria will be recorded and reported (32). The results of the search, and

the study inclusion process, will be reported in the final scoping review and

presented in a PRISMA flow diagram, as the consensus reporting tool for scoping

reviews (34).

Data Extraction

Data will be independently extracted from papers included in the scoping review by two reviewers, using a data extraction tool based on the JBI data tool (32). The data extracted will

include specific details about the participants, concept, context, study

methods, and key findings relevant to the review question. Information on the

case-mix, staffing and capability of SDEC services will be extracted where

available. Any differences of opinion will be discussed until consensus is

reached. If the need arises, a third reviewer will be asked to join the review

team to achieve consensus.

According to Peters et al. (32), critical appraisal of individual sources of evidence is generally not required for scoping reviews that map the evidence base, hence no critique, assessment of study quality, or risk of bias, will be offered in the final review.

The PRISMA-ScR checklist will be used to guide reporting (34), providing a comprehensive report structure, as per the JBI guidance.

DATA ANALYSIS AND PRESENTATION

Data from the extraction tool will be summarised and presented in tabular form. Types of papers and key categories or themes will be identified a priori, using an iterative approach, and presented

in graphical form, to map the type of publications, and key themes identified

within them. There is limited guidance on how scoping review data analysis and

presentation should be conducted, beyond the use of frequency counts,

tabular/graphical presentation, and basic qualitative content analysis to

identify key factors or issues (36).

A narrative summary will accompany the presented results and describe, through the use of themes,

how the results relate to the review objective. Gaps in the literature will be

identified and recommendations for future research will be made.

STRENGTHS AND LIMITATIONS OF THIS STUDY

A significant strength of the JBI scoping review methodology is that it provides a structured and systematic approach for conducting scoping reviews, which utilises the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews checklist (PRISMA-ScR) as a reporting framework.

Scoping reviews as a form of evidence synthesis address broad research questions and map evidence from a variety of sources to examine practice, policy and research, and to highlight gaps in the evidence base to inform future research.

Critical appraisal and risk of bias assessments are not required in scoping reviews; some methodologists suggest that this is a limitation.

Evidence from the previous iteration of SDEC, ambulatory care, may offer developmental insights into the preliminary commencement of SDEC services, but other than informing the introduction to the topic, papers over 5 years old have been excluded from this planned scoping review as SDEC is a new innovation in healthcare delivery incepted over the past 5 years. This may be a limitation.