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BackgroundIn recent years, a number of emergency departments (EDs) have closed or have been replaced by another facility such as an urgent care centre. With further reorganisation of EDs expected, this study aimed to provide research evidence to inform the public, the NHS and policy-makers when considering local closures.ObjectiveTo understand the impact of ED closures/downgrades on populations and emergency care providers.DesignA controlled interrupted time series of monthly data to assess changes in the patterns of mortality in local populations and changes in local emergency care service activity and performance, following the closure of type 1 EDs.SettingThe populations of interest were in the resident catchment areas of five EDs that closed between 2009 and 2011 (in Newark, Hemel Hempstead, Bishop Auckland, Hartlepool and Rochdale) and of five control areas.Main outcome measuresThe primary outcome measures were ambulance service incident volumes and times, the number of emergency and urgent care attendances at EDs, the number of emergency hospital admissions, mortality, and case fatality ratios.Data sourcesData were sourced from the Office for National Statistics, Hospital Episode Statistics (HES) accident and emergency, HES admitted patient care and ambulance service computer-aided dispatch records.ResultsThere was significant heterogeneity among sites in the results for most of the outcome measures, but the overall findings were as follows: there is evidence of an increase, on average, in the total number of incidents attended by an ambulance following 999 calls, and those categorised as potentially serious emergency incidents; there is no statistically reliable evidence of changes in the number of attendances at emergency or urgent care services or emergency hospital admissions; there is no statistically reliable evidence of any change in the number of deaths from a set of emergency conditions following the ED closure in any site, although, on average, there was a small increase in an indicator of the ‘risk of death’ in the closure areas compared with the control areas.LimitationsUnavailable or unreliable data hindered some of the analysis regarding ED and ambulance service performance.ConclusionsOverall, across the five areas studied, there was no statistically reliable evidence that the reorganisation of emergency care was associated with an increase in population mortality. This suggests that any negative effects caused by increased journey time to the ED can be offset by other factors; for example, if other new services are introduced and care becomes more effective than it used to be, or if the care received at the now-nearest hospital is more effective than that provided at the hospital where the ED closed. However, there may be implications of reorganisation for NHS emergency care providers, with ambulance services appearing to experience a greater burden.Future workUnderstanding why effects vary between sites is necessary. It is also necessary to understand the impact on patient experience. Economic evaluation to understand the cost implications of such reorganisation is also desirable.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Background Paramedics make important and increasingly complex decisions at scene about patient care. Patient safety implications of influences on decision making in the pre-hospital setting were previously under-researched. Cutting edge perspectives advocate exploring the whole system rather than individual influences on patient safety. Ethnography (the study of people and cultures) has been acknowledged as a suitable method for identifying health care issues as they occur within the natural context. In this paper we compare multiple methods used in a multi-site, qualitative study that aimed to identify system influences on decision making. Methods The study was conducted in three NHS Ambulance Trusts in England and involved researchers from each Trust working alongside academic researchers. Exploratory interviews with key informants e.g. managers (n = 16) and document review provided contextual information. Between October 2012 and July 2013 researchers observed 34 paramedic shifts and ten paramedics provided additional accounts via audio-recorded ‘digital diaries’ (155 events). Three staff focus groups (total n = 21) and three service user focus groups (total n = 23) explored a range of experiences and perceptions. Data collection and analysis was carried out by academic and ambulance service researchers as well as service users. Workshops were held at each site to elicit feedback on the findings and facilitate prioritisation of issues identified. Results The use of a multi-method qualitative approach allowed cross-validation of important issues for ambulance service staff and service users. A key factor in successful implementation of the study was establishing good working relationships with academic and ambulance service teams. Enrolling at least one research lead at each site facilitated the recruitment process as well as study progress. Active involvement with the study allowed ambulance service researchers and service users to gain a better understanding of the research process. Feedback workshops allowed stakeholders to discuss and prioritise findings as well as identify new research areas. Conclusion Combining multiple qualitative methods with a collaborative research approach can facilitate exploration of system influences on patient safety in under-researched settings. The paper highlights empirical issues, strengths and limitations for this approach. Feedback workshops were effective for verifying findings and prioritising areas for future intervention and research.

BackgroundIn recent years a number of Emergency Departments (EDs) in England have closed, or been replaced by a lower acuity facility such as an Urgent Care Centre. With further re-organisation of EDs expected, the ‘closED’ study aimed to provide research evidence to inform the public, NHS, and policymakers when considering future closures. Our aim was to understand the impact of ED closure on populations and emergency care providers, the first study to do so in England. In this session I will focus on the impact on the ambulance service.MethodsWe undertook a controlled interrupted time series analysis assessing changes in ambulance service activity, following the closure of Type 1 EDs in England. Data was sourced data from Ambulance service computer-assisted dispatch (CAD) records. The resident catchment populations of five EDs, closed between 2009 and 2011, were selected for analysis. Five control areas were also selected. The primary ambulance outcome measures were: ambulance service incident volumes and mean ‘call to destination’ time.ResultsThere was some evidence of a large increase of 13.9% [95% confidence interval (CI) 3.5% to 24.4%] in the total number of emergency ambulance incidents compared with the control areas. There was an increase of 3.9 minutes (95% CI 2.2 to 5.6 minutes) in the meantime taken from a 999 ‘red’ call being answered to a patient arriving at hospital.ConclusionsGiven such major reorganisation of emergency and urgent care we might expect some changes in emergency and urgency care activity. Our study found some changes in the ambulance service measures. The increase in emergency ambulance incidents, over and above the increase in the control area, suggests that the closure of the EDs in our study may have contributed to an additional increase in workload within the ambulance services in these areas.

Decisions made by ambulance staff are often time-critical and based on limited information. Wrong decisions could have serious consequences for patients but little is known about areas of risk associated with decisions about patient care. We aimed to examine system influences on decision making in the ambulance service setting focusing on paramedic roles.