Protocol

The open access protocol has been published in …

Abstract

There has been a problem in the UK and other countries for many years, that at busy times Emergency Departments (ED) become unable to manage the flow of patients. Patients may remain in the ambulance, sometimes for several hours. In some areas, this practice is rare; in others, it is common. When ambulances are queuing, there are ‘knock-on’ effects throughout the emergency care system – patients at the ED may not be receiving full ED care, while queued ambulances are unavailable to attend other patients in the wider community. We aim to provide evidence about what works to improve safety, patient experience, outcomes and costs related to ambulance queuing. 

Our objectives are to:   
1. Describe what is already published about initiatives aimed at reducing ambulance queuing, delayed handovers and related harms 
2. Identify and describe initiatives currently in use across the UK to reduce handover delays and related harms 
3. Identify EDs where ambulance queuing is rare and understand what policies and practices are being used in those hospitals to avoid ambulance queuing 
4. Assess impact of successful queue management on patient flows, safety, experience, health outcomes and costs 
5. Predict wider impacts of initiatives on patient flow through the urgent and emergency care system  
6. Produce guidance about what works to reduce delayed handovers.  

In this study, we will use a mix of methods to answer our questions. We will carry out an initial mapping exercise to identify relevant stakeholders and run online workshops to promote engagement within and beyond the study. We will look for existing evidence about initiatives to reduce delayed handovers at ED and carry out a survey of ambulance services (with follow up at EDs) about what initiatives exist within their areas. We will group initiatives into categories of similar types e.g. ED clinician care provided on ambulances; paramedic care within the ED; or use of additional space. We will analyse existing data to identify sites that rarely queue ambulances and sites that do this more frequently. We will present findings at a stakeholder event with participants from across the Urgent and Emergency Care system, including providers, users and commissioners of care where we will agree on criteria for selecting sites to include in more in-depth work. We will then select four sites where ambulance queues are relatively rare – and ambulance hours lost to delays are low (Group 1) and four sites where queues are more frequently seen – and ambulance hours lost to delays are higher (Group 2). We will carry out qualitative work at these sites to understand what makes a difference to their performance. We will compare important patient outcomes between patients who called 999 or attended ED in the two groups, including: 30-day mortality (primary outcome); 999 ambulance attendance; conveyance rates to ED; hospital admissions; and waiting times. We will investigate effects within vulnerable subgroups of the population, including the very elderly, people in ethnic minorities and people who make high use of emergency care. We will send questionnaires to a sample of patients to gather their experiences, quality of life, use of non-NHS services and safety concerns. We will carry out clinical case note reviews to compare safety issues between groups and will construct in-depth descriptions of complex cases. We will use patient flow data to determine initiatives that may be most beneficial to the NHS. We will conduct interviews with patients to find out more about their experiences. We will interview stakeholders from across the emergency care system, including ED and hospital staff, ambulance clinicians and call takers, healthcare managers and commissioners about their experiences and views. Finally, we will hold stakeholder workshops towards the end of the study to help us interpret findings. and will make recommendations about how to reduce ambulance queuing. 

We have worked with public contributors to develop this proposal and will include them throughout the study as members of the Research Management Group and in the Public Advisory Panels, to be appointed. We will recruit public contributors to the Independent Study Steering Group. Our research team includes clinical, academic and policy specialists.