Title: Can a practice based approach using Significant Event Audit identify key factors that might reduce avoidable non-elective hospital admissions? A feasibility study
Funder: Department of Health (England)

Abstract: Background Non-elective admissions are defined as admissions by pathways other than a waiting list, and these are increasing by 2.4% each year in England.6 7 Patients do not like being admitted as this can cause distress, depression and loss of independence.8 It is thought that many admissions could be avoided and there is a policy aim to reduce these.7 9-11 There is no agreed definition of the term ‘avoidable admission’.7 9 10 12 Research into interventions to reduce non-elective hospital admissions has identified only limited evidence of success.9 This includes case management in nursing homes;13 telemedicine in heart failure (assessment of the patient’s problems by sources receiving data at a distance);14 pharmacy review (to identify potentially risky prescribing),15 and ‘integrated’ care –arrangements for shared responsibility for a patient across different agencies.13 16-18 One study found that feedback and training reduced non-elective admissions in asthma.19 We will investigate whether the intervention of ‘significant event audit’ (SEA) is a suitable tool to analyse non-elective hospital admissions. SEA is a complex intervention20 which has the advantage that it is widely used in other areas of primary care to analyse unexpected outcomes, critical incidents, deaths, new cancer diagnoses and complaints, and is designed to examine all clinical presentations.21 Aims We aim to Determine the acceptability to staff and patients of SEA as an approach to examine and reduce non-elective admissions. Fine tune SEA when used for this purpose if stage 1 finds changes are needed. Provide information needed for a sample size calculation for a future cluster-randomised trial. This study will inform the design of a future definitive study to test the hypothesis that practices which regularly perform SEA of non-elective admissions from their practice will have lower subsequent rates of non-elective admissions. Plan of investigation Phase 1 (recruitment) will inform aims 1 and 3; we will select 20 practices and provide training in performing SEAs on patients records subsequent to a non-elective admission. Phase 2 (intervention) will also inform aims 1 and 3; Practices will perform SEAs on records of patients who have had a non-elective admission. We will use the consensus opinion of practices using SEA to determine the likelihood of an admission being avoidable. Practices will estimate the potential for avoiding admission, and summarise these findings in a report. Phase 3 (evaluation) will inform aims 1, 2 and 3; we will run two focus groups for practice staff and one focus group of patients to determine the acceptability of SEA in this setting. We will use data collected on recruitment rates and we will assess SEA reports for quality with a peer review instrument to inform aim 2. We will collect survey data in phases 1 and 3 to inform aim 1. Potential benefit to the NHS This research is into an area of high priority and is included in the NHS Institute for Innovation and Improvement performance indicators. This feasibility study will test the acceptability of SEA in this setting, fine-tune SEA, and collect data to inform a subsequent cluster RCT to examine whether this approach will lead to a reduction in non-elective admissions, and whether this is cost-effective. This is important for patients as they prefer treatment outside the hospital setting if it is feasible.8 SEA is expected to provide a greater understanding of changes in practice including clinical pathways which may reduce non-elective admissions. This could inform local and national policy making in the development of pathways of care to reduce avoidable non-elective admissions.


Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING
Health categories: GENERIC HEALTH RELEVANCE