We have undertaken a host of projects in the Centre for Urgent and Emergency Care Research.
- Safety INdEx of Prehospital On Scene Triage (SINEPOST)
The derivation and validation of a risk prediction model to support ambulance clinical transport decisions on scene.
With Emergency Departments becoming increasingly crowded, it is vital paramedics are supported to make complex decisions on-scene to ensure the patients get to the right place; first time. This project aims to develop and validate a risk prediction model to help Paramedics decide if their patient will have a clear benefit if they got transported to hospital.
- Project Lead - Jamie Miles, Yorkshire Ambulance Service and University of Sheffield, email@example.com
- Primary Supervision - Suzanne Mason, University of Sheffield, firstname.lastname@example.org
- Statistical supervision - Richard Jacques, University of Sheffield, email@example.com
- Ambulance policy and design supervision - Janette Turner, University of Sheffield firstname.lastname@example.org
- Clinical supervision - Julia Williams, South East Coast Ambulance Service Julia.Williams@secamb.nhs.uk
This research is supporting paramedics to make more appropriate and effective decisions for patients who may not require the level of care provided by a hospital. It is important as it is aiming to navigate care decisions that will safely provide patients with the right care, first time. If a paramedic can see the likelihood that their patient may have an avoidable attendance, it opens up an opportunity to explore community options. It also empowers the patient to be an active partner in developing a self-care plan
The aim of this project is to design a tool that can be automatically calculated for paramedics to use on scene, which will inform them their patient might not need the Emergency Department.
To build classification models deriving risk predictions using prehospital clinical data as input variables, and ED experience as the output variable.
- Internally validate the model and apply to a retrospective cohort of non-conveyed patients.
- Compare the different classification models for most accurate and feasible to embed in practice.
Phase 1 will start by creating a dataset of all patients who called an ambulance and got transported to the Emergency Department in Yorkshire. Each episode in the dataset will contain clinical information from both the ambulance service and ED.
Different mathematical models will be applied to the dataset to try and predict an avoidable attendance at ED (primary outcome measure). Phase 1 will end when the models have been created.
Phase 2 will use statistical methods to internally validate the models. The models will also be applied to random samples of patients who were not conveyed to the ED. Phase 2 will end when the most accurate model has been identified and selected.
This project is funded by the National Institute of Health Research and Health Education England as part of a Clinical Doctoral Research Fellowship. For more information on these awards, please click the following link: https://www.nihr.ac.uk/explore-nihr/academy-programmes/hee-nihr-integrated-clinical-academic-programme.htm
- NHS 111 Online Evaluation
An Evaluation of the impact of online NHS11 on the NHS111 telephone service and potential effects on the urgent care system.
The study will improve our understanding of the online system, and how it impacts on other services operating within the emergency and urgent care system. A mixed methods approach will be adopted which will include an evidence review, analysis of routine data, user surveys and interviews, staff and stakeholder interviews, and assessment of cost consequences.
Background: The NHS 111 telephone service is used to direct patients to appropriate services, or provide self care advice. It is being used increasingly by people who need help deciding which urgent care services to use when they need help quickly. Recently, an alternative online NHS 111 service has been introduced across England to improve access to services and reduce the impact of growing demand for the NHS 111 telephone services. This is particularly important as demand for urgent care services continues to rise each year and difficulties in recruiting and retaining NHS staff make it even more difficult to meet this demand.
The online NHS 111 service was tested initially within 4 pilot sites in 2017. Since then, the service has expanded rapidly and became available to the whole population of England by the end of 2018. We have been funding to evaluate this new service and to assess the current and potential future impact of an online NHS111 service on the NHS 111 telephone service. It is hoped that this research will help to support decisions about how future services can be developed and improved.
Aim: The aim of this study is to evaluate the impact of an online NHS111 service on the existing NHS111 telephone service and the wider EUCS. The main questions we will address are:
- What impact does an online system have on the demand for the associated telephone service and other services both now and in the future?
- Are there differences in the people who use the online and telephone services?
- What are the experiences of people who use the online service?
- What are the workforce implications of two different access points in to the urgent care system?
- What are the cost implications for the NHS?
Design: We will address these questions using 5 separate research activities:
- We will review the current published evidence about telephone and online services to help access urgent care.
- We will measure the number of calls to the 111 telephone services and contacts with the online service over a four year period in 9 sites. We will use statistical analysis to measure any shift from the telephone service to the online service and estimate likely future demand for each service.
- We will use detailed online and telephone service routine data to understand who uses the service and how they may use other health services in future. We will also use the data from NHS 111 user surveys and carry out detailed interviews with online NHS 111 users to understand how they felt about how the service worked and how easy it was to use.
- We will carry out detailed interviews with a range of staff and other stakeholders to understand how the new online service affects their workload and whether it has had any impact on the work and workload of the people who work at the NHS 111 telephone service. We will also explore whether there are any lessons for how services can be developed and improved.
- Estimate the cost consequences of the introduction of an online service on the telephone service and wider system.
By combining the results from the different research tasks we hope to be able to identify where online NHS 111 works well and whether changes are needed to improve the advice provided to people who use it, in order to make the service easier to access and use. We also hope to provide a broader picture of the overall impact on other urgent care services and assess how this might affect the future provision of NHS111 in terms of activity, service use and costs.
Project timetable: 16 month funded research programme
- Initial set up: Ethical and research governance permissions; Identification of routine data sources and data specifications; update of existing systematic review; development of surveys (4 months March – June 2019)
- Routine data acquisition; quantitative time series analysis of NHS111 telephone and online service activity and processes; user surveys; online service detailed pathway analysis; qualitative interviews (9 months July 2019 – March 2020)
- Economic analysis : (4 months – April 2020)
- Data triangulation and write-up (4 months March – June 2020).
Our Research Team
- Janette Turner (Chief Investigator)
- Fiona Sampson
- Emma Knowles
- Jo Coster
- Simon Dixon
- Richard Jacques
- Jon Nicholl
- Peter Bath
- Peter Cudd
- Kat Noble (NW Ambulance Service)
- Dan Fall (PPI)
- Marc Chattle (Project Administrator)
Funding: NIHR Health Services & Delivery Research Programme, project reference NIHR127655
- Emergency and Urgent Care System Demand in Yorkshire and Humber
A retrospective analysis of routine data. Addressing the long term rise in demand in urgent and emergency care (UEC) services is a key focus for the NHS. The Collaboration and Leadership in Applied Health and Care Yorkshire and Humber (CLAHRC YH) are undertaking a detailed population analysis to identify patients who present to the ED or who are admitted to hospital as an emergency who may be amenable to alternative management in the EUC system.
Background: Addressing the long term rise in demand in urgent and emergency care (UEC) services is a key focus for the NHS. The Collaboration and Leadership in Applied Health and Care Yorkshire and Humber (CLAHRC YH) are undertaking a detailed population analysis to identify patients who present to the ED or who are admitted to hospital as an emergency who may be amenable to alternative management in the EUC system.
This research project involves the processing of Hospital Episode Statistics (HES) data collected from NHS Digital for the period 2011-2014. The project team is bound by the regulations set out in the General Data Protection Regulation (EU 2016/679) and Data Protection Act 2018. More information about how patient information is processed and how we protect the data of patients is contained in the privacy notice accessed in the link below.
Aims: To use routinely collected, pseudo-anonymised Hospital Episode Statistics (HES) to describe a detailed profile of all emergency department attendances and admissions in Yorkshire and Humber over the three-year period, specifically to examine:
- Trends in ED attendances and emergency hospital admissions over time
- ED attendance and emergency hospital admissions assessed by case mix of the population
- Identify explanatory factors affecting emergency hospital services including factors modifiable by services (such as availability of services eg acute wards)
Progress: The data was collected in 2015 and a number of analyses have been completed to identify key population groups who could receive alternative care in the UEC system, including non-urgent attenders to the ED. Work is ongoing to identify patients who meet a process-based definition of an avoidable admission.
The project is due to complete in September 2019.
- O'Keeffe, C., Mason, S., Jacques, R. M., & Nicholl, J. (2018). Characterising non-urgent users of the emergency department (ED): A retrospective analysis of routine ED data. PLoS ONE, 13(2). doi:10.1371/journal.pone.0192855
Download the privacy notice (PDF: 275kb)
- Pre-alerts study
Exploring the use of pre-hospital pre-alerts and their impact on patients, ambulance service and Emergency Department staff.
Ambulance Clinicians use pre-alert calls to inform receiving Emergency Departments (EDs) of the arrival of a critically unwell or rapidly deteriorating patient who they believe requires senior clinical review and time-critical treatment immediately upon arrival. By enabling EDs to prepare for the patient’s arrival, pre-alerts can lead to earlier initiation of time-critical treatment, improved processes and better clinical outcomes for patients (James et al, 2019, Kelleher et al, 2014). However, over- or inappropriate use of pre-alerts can lead to EDs diverting resources from other critically ill ED patients, which has important risks for patient safety. There is currently a lack of evidence about the impact of pre-alerts on patients, ED staff or ambulance clinicians. In particular, there is limited guidance about how pre-alerts should be undertaken, delivered and communicated with EDs, in order to optimise their use for patient benefit.
Aims and objectives
This study aims to understand how pre-alert decisions are made and implemented by pre-hospital staff, and the impact of these on receiving EDs and patients, in order to identify principles of good practice, areas of uncertainty and areas for improvement.
- To map current pre-alert practice in terms of volume and types of pre-alerts and explore potential reasons for variation in practice by reviewing existing Ambulance Service patient records and mapping to local guidance. (WP1)
- To explore and understand pre-alert decision-making by undertaking semi-structured interviews with Ambulance Clinicians from three Ambulance Services and a national survey of Ambulance Clinicians to identify key areas of uncertainty where further guidance would be useful. (WP2)
- To identify how pre-alert decisions are communicated, and what information needs to be communicated in order to improve patient care, by interviewing pre-hospital and ED staff. (WP2 & 3)
- To understand how pre-alerts influence patient care in the ED, including potential benefits and unintended consequences, by observing pre-alert processes and responses to them within two EDs in each of 3 Ambulance Service areas/regions. (WP3)
- To explore whether there are specific conditions or patient groups for whom pre-alerts are most likely to lead to action, or for whom action is unlikely to provide benefit, and explore factors that affect whether action is taken within the ED. (WP3)
- To understand service user experience of pre-alerts by interviewing patients and/or carers. (WP4)
- To identify good pre-alert practice, areas where further guidance is needed and co-produce information to inform the development of pre-alert guidance with research participants and other key stakeholders. (WP5)
- Avoiding Attendances and Admissions
This is a theme within the Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Yorkshire and Humber. It is the only CLAHRC theme in the country focused on addressing the challenges facing the emergency and urgent care system. The theme has collected, linked and analysed routine patient data from the ambulance service, NHS 111 and emergency departments to record the patient journey from ‘time of call to discharge from hospital’. Analyses of this data will identify key patients and parts of the system to target interventions at to improve system performance and patient care.
NIHR Collaboration for Leadership in Applied Health Research and Care Yorkshire and Humber (CLAHRC YH)
Background: Avoiding Attendances and Admissions is a theme within the Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Yorkshire and Humber. The theme is a five-year programme of work (January 2014-December 2018) addressing avoidable hospital (ED) attendances and emergency hospital admissions in key patient groups (including those with long term conditions), which is a major priority for the NHS.
- Establish close collaboration with stakeholders in emergency and urgent care in Yorkshire and Humber to develop high quality evidence to answer key local NHS and user priorities
- Use large routine NHS datasets to Identify key patient groups amenable to care outside of hospital
- Evaluate interventions to reduce avoidable attendances and unplanned admissions for patients with long-term conditions.
- Completion of the region’s first emergency and urgent care routine linked dataset linking Yorkshire Ambulance Service call data (999 and NHS 111) and hospital data from all 13 acute hospital NHS trusts in Yorkshire and Humber
- Using large Hospital Episode Statistics (HES) Data to define and identify non-urgent attenders to the emergency department (ED)
- Early evaluation of interventions to improve care (Senior Doctor Triage and GP-collocation)
- Further separate analyses underway to identify alternative care pathways for older people, people of working age and patients with mental health problems.
- March 2018: Completion of analysis of large routine datasets.
- December 2018: Completion of project evidence reports.
- The ideal Urgent and Emergency Care system: Public and healthcare staff perspectives
Background: Our urgent and emergency care services such as the ambulance service, minor injuries units, GP out-of-hours and emergency departments are under more pressure than ever to deliver fast, good quality care, in an environment with fewer resources (e.g. money and staff).
How we use these services has changed over time but have the services changed to keep up with how we live today?
What we aimed to do: This was a small-scale exploratory study which involved inviting members of the public and healthcare staff to attend a small-group workshop where they were asked to design their ideal UEC system.
The objectives of the overall study were:
- To identify from the public and healthcare staff perspective what their ideal UEC system(s) would look like.
- To identify the key priorities of the ideal UEC system(s) from the public and healthcare staff perspective.
- To explore how the public and healthcare staff come up with their ideal UEC system.
- To test the ideal UEC system(s) using ‘real-life’ scenarios.
The study recruited members of the public who had been in contact with an Emergency Department, an ambulance, NHS 111, GP out-of-hours, walk-in centre, or a minor injuries unit within 12 months (of the recruitment date) and who fell into any of the following categories:
- 18-45 years
- 75 years and older
- Adults with young children
- Adults with long term conditions
Additionally, healthcare staff were recruited who were working in the Emergency Department, Yorkshire Ambulance Service, NHS 111, GP out-of-hours, walk-in centre, or a minor injuries unit.
Recruitment for this study is now closed (January 2019) and no further workshops will be taking place.
A short report summarising the results of this study is now available.
The team have also published the results in the Emergency Medicine Journal in January 2020.
If you would like further information then please contact Maxine Kuczawski on +44 114 222 2981 or email email@example.com.
The study was organised by the University of Sheffield, and was funded by Connected Yorkshire (part of the Connected Health Cities Programme) and CLAHRC Yorkshire and the Humber.
- TiLLI: Thromboprophylaxis in Lower Limb Immobilisation
People who have their leg immobilised in a plaster cast or brace following an injury are at risk of developing a blood clot. Sometimes the clot can break up and lodge in the lungs, which can make the person seriously ill. Drugs that thin the blood (anticoagulants) can reduce the risk of blood clots, but they carry a small risk of serious bleeding. This study analysed all published trials of anticoagulants for people with leg immobilisation and found that, without treatment, there was a 1–2% risk of a serious blood clot. This risk was roughly halved by using anticoagulant treatment. These estimates were used in a simulation model of patient treatment and it was found that the benefit of anticoagulants in reducing blood clots (in terms of length and quality of life) outweighed the risks of bleeding.
Next, all published studies of risk assessment tools were analysed. Risk assessment tools can be used to predict who is most likely to get a blood clot. There were only a few studies and they had significant weaknesses. The risk assessment tools in the simulation model were evaluated and it was found that the most cost-effective approach was to use a risk assessment tool to select approximately half of the patients for treatment (those at higher risk), while not treating those at lower risk. Treating only the higher-risk patients would be a cost-effective use of NHS resources, compared with treating nobody. Treating everybody, compared with just treating higher-risk patients, would improve outcomes for some patients but would not be a cost-effective use of NHS resources.
Key message: Anticoagulant drugs are an effective and potentially cost-effective way of preventing blood clots in people with leg immobilisation due to injury. Research is needed to determine whether or not risk assessment tools can accurately predict who needs anticoagulant drugs and who does not.
- Different strategies for pharmacological thromboprophylaxis for lower-limb immobilisation after injury: systematic review and economic evaluation. Health Technol Assess 2019.www.journalslibrary.nihr.ac.uk/hta/hta23630#/abstract
- Thromboprophylaxis in lower limb immobilisation after injury (TiLLI). Emerg Med J 2019.emj.bmj.com/content/early/2019/11/06/emermed-2019-208944
- Pharmacological thromboprophylaxis to prevent venous thromboembolism in patients with temporary lower limb immobilization after injury: systematic review and network meta‐analysis. J Thromb Haemost. 2019. onlinelibrary.wiley.com/doi/abs/10.1111/jth.14666
- Individual risk factors predictive of venous thromboembolism in patients with temporary lower limb immobilization due to injury: a systematic review. J Thromb Haemost 2019.onlinelibrary.wiley.com/doi/full/10.1111/jth.14367
- Decision‐analysis modelling of the effects of thromboprophylaxis for people with lower limb immobilisation for injury. Br J Haematol 2019.onlinelibrary.wiley.com/doi/full/10.1111/bjh.15748
This study was funded by the United Kingdom National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme (project number 15/187/06). The views and opinions expressed in any outputs are those of the authors and do not necessarily reflect those of the Health Technology Assessment Programme, NIHR, NHS or the UK Department of Health.
- Safety for Patients through Quality Review (SPQR)
We aim to determine how Medical Examiner (ME) assessment of death certification and retrospective cases record review (RCRR) can best work together to identify potentially avoidable deaths due to shortcomings in care. We also aim to use the ME assessments and RCRR recorded in this study to identify features or patterns related to problems in care that might be addressed to improve quality of care.
- Estimate the sensitivity and specificity of ME assessment for identifying potentially avoidable deaths compared to a reference standard of RCRR and determine whether the ‘miss rate’ of ME assessment (the proportion of potentially avoidable deaths among cases screened out by ME assessment or 1 minus the negative predictive value) is low enough to allow ME assessment to be used to ‘pre-screen’ deaths for RCRR.
- Examine discordant judgements between ME assessment and RCRR (i.e. potentially avoidable deaths missed by either ME assessment or RCRR) to determine how ME assessment and RCRR might be improved and how they could work alongside each other to identify problems in care and potentially avoidable deaths.
- Identify themes in the problems in care revealed by ME assessment and RCRR, such as the nature of harms and the patients or processes involved, thus providing insights to improve quality of care.
- Increase understanding of the ME role in identifying potentially avoidable deaths, particularly through interaction with relatives, and explore how the role can be developed to maximise learning opportunities alongside RCRR.
- Explore the impact of implementing systems combining ME assessment and RCRR.
- June – September 2017 Obtain study research approvals (ethics, HRA etc)
- September – November 2017 Reviewer training
- September – November 2017 Qualitative interviews with medical examiners
- January 2018 – June 2018 Participating Trusts review records
Impact of the new medical examiner role on patient safety. BMJ 2018;363:k5166 https://doi.org/10.1136/bmj.k5166
- The ACUTE (Ambulance CPAP: Use, Treatment effect and Economics) feasibility study
A pilot randomised controlled trial of prehospital CPAP for acute respiratory failure.
Background: Acute respiratory failure (ARF) is a common and life-threatening medical emergency that often results in long hospital stays or expensive intensive care admissions. It occurs when heart or lung disease suddenly develops or worsens and leads to the patient being unable to maintain oxygen levels in their blood. When this happens the patient may be at high risk of death and needs emergency treatment.
Paramedics currently provide oxygen delivered at normal pressure by a loose fitting face mask. Continuous positive airway pressure (CPAP) is a potentially useful treatment that could be delivered by paramedics in an ambulance. It involves delivering oxygen under increased pressure through a close-fitting facemask. Its use in hospital can reduce the risk of death in people with lung disease and improve breathing in people with heart disease. Small studies undertaken outside the UK have suggested that using CPAP in an ambulance may save more lives than delaying its use until arrival at hospital. However, it is uncertain whether this treatment could work effectively in NHS ambulance services, and if it represents value for money.
Aim: The purpose of this study is to see whether it is possible and worthwhile to undertake a full-scale study comparing CPAP and standard oxygen treatment delivered by paramedics for acute respiratory failure, and if so, how we should do it.
Methods: Paramedics will identify adults with ARF when attending 999 emergency calls. One hundred and twenty such patients will be included in the study. Half will be randomly assigned to a group that will receive CPAP, while the other half will be treated with standard oxygen therapy. All the patients will then undergo normal hospital treatment and be followed up for a month to see if they survive. We will also measure each patient’s quality of life, need for admission to intensive care, length of stay in hospital, and health service use.
Additionally, we will look at how many adults are attended with ARF, how many are entered into study, the number who correctly receive CPAP treatment, and how many patients we can follow up to the end of the study. Paramedics will also be surveyed to understand their experience of delivering CPAP and being involved in the research. Together these results will tell us whether it is feasible and affordable to conduct a full -scale trial evaluating CPAP for acute respiratory failure, and will also inform us how to design such a study.
Oversight: The proposed study will be designed and conducted in accordance with Good Clinical Practice (GCP), an international standard that ensures medical research is safe and ethical. The main ethical issue is that the trial will involve patients who are severely ill and potentially unable to decide whether they wish to participate. In these circumstances patients can be recruited to the trial and their consent sought later, provided important legal safeguards are followed. All research procedures will be reviewed by an independent NHS ethics committee and overseen by committees of independent statisticians and clinical experts in the field. Additionally, the research will conform to University of Sheffield Clinical Trials and Research Unit (CTRU) standard operating procedures. We will publish our results in scientific journals and publicise our findings through the Study website and on social media.
If you would like more information about the trial, please contact Dr Samuel Keating on firstname.lastname@example.org.
- Dr Gordon Fuller
- Prof Steve Goodacre
- Dr Sam Keating
- Prof Cindy Cooper
- Mike Bradburn
- Sarah Gonzalez
- Prof Gavin Perkins
- Prof Tim Harris
- Dr Praveen Thokala
- Matt Ward
- Dr Andy Carson
- Andy Rosser
- Imogen Gunson
- Joshua Miller
Downloads and links
- Evaluating the Diversion of Alcohol-Related Attendances (EDARA)
This project will evaluate the effectiveness, cost-effectiveness, efficiency and acceptability of Alcohol Intoxication Management Services (AIMS) in managing alcohol-related Emergency Departments’ attendances. AIMS are designed to receive, treat and monitor intoxicated patients who would normally attend Emergency Departments and to lessen the burden that alcohol-misuse places on unscheduled care.
They are usually located close to areas characterised by excessive intoxication and are open at times when levels of intoxication peak (e.g. Friday and Saturday evenings). AIMS therefore offer the potential to mitigate some of the pressures on Emergency Departments as well as ambulance services and the police at times when there is a sustained increase in demand.
999EMS forum Advancing patient care: taking research to the front line (1-2 April 2019)
The project aims to:
- Explore barriers and facilitators of AIMS implementation from the perspective of frontline staff by examining the impact of AIMS on the frontline work setting and on practitioners’ working lives
- Identify the key ingredients required for successful implementation of AIMS in order to lead on the co-production of guidance on AIMS development and implementation
- Establish the acceptability of AIMS to users
- Investigate how the implementation of AIMS affect Emergency Departments users’ experience
- Determine the effect of AIMS implementation on key performance indicators across health and ambulance services
- Consider secondary effects of AIMS implementation such as ambulance response times and reduction in violent assaults through increased police presence
- Identify set-up and running costs for AIMS, resolve costs by sector (health, ambulance and police), before, during and after AIMS setup, and quantify AIMS benefits in order to establish the cost-effectiveness of AIMS
The project is funded by National Institute for Health Research Health Services and Delivery Research Programme. It started in January 2016 and will run for 30 months with £925,000 funding.
- Professor Simon Moore, School of Dentistry, Cardiff University
- Professor Davina Allen, School of Healthcare Sciences, Cardiff University
- Professor Petra Meier, School of Health and Related Research, University of Sheffield
- Professor Steve Goodacre, School of Health and Related Research, University of Sheffield
- Professor Alan Brennan, School of Health and Related Research, University of Sheffield
- Professor Alicia O’Cathain, School of Health and Related Research, University of Sheffield
- Dr Vaseekaran Sivarajasingam, School of Dentistry, Cardiff University
- Professor Jonathan Shepherd, School of Dentistry, Cardiff University
- Dr Tracey Young, School of Health and Related Research, University of Sheffield
- Andy Irving, School of Health and Related Research, University of Sheffield
- Dr Penny F Buykx, School of Health and Related Research, University of Sheffield
- Andy Irving, School of Health and Related Research, University of Sheffield
- Dr Yu-Chiao Wang, School of Dentistry, Cardiff University
- Clare Olson, Administrative Assistant, School of Dentistry, Cardiff University
- Joanne Blake, Research Associate, School of Healthcare Sciences, Cardiff University
Professor Simon Moore, School of Dentistry, Cardiff University
Telephone: +44 (0)29 2074 4246
EDARA 999EMS Forum 2019 poster (PDF: 321kb)
EDARA ED survey instruction manual v4.9, 5.7.17 (Word: 1.3mb)
EDARA ED Survey 2017, v3.1, 10.11.16 (Word: 76kb)
EDARA ED Survey reminder letter, v3.1, 10.11.16 (Word: 43kb)
- CUREd Research Database
There is increased demand on emergency departments (ED) across the UK. The services are becoming stretched and as a result waiting times are increasing and patient care is suffering. By linking together patient data from different hospitals and services across Yorkshire, researchers are able to build a more complete picture of how emergency and urgent care (UEC) services in the region function. This picture will help researchers understand the flow of patients through EUC services, to understand what the most common health issues are and to better plan community services in the future. The anonymous data can help scientists understand EUC services across an entire region and suggest improvements in a much more synchronised way.
The CUREd Research Database collates routine NHS data from a number of UEC service providers in Yorkshire and the Humber region from 2011-2017 including the Yorkshire Ambulance Service (YAS), NHS111 and acute NHS trusts, in addition to other health service providers. Individual patient records have been linked to form this large unique research database, containing over 15 million patient episodes. This rich data source allows the EUC services to be viewed as a whole system, enabling demand on the system by patients to be analysed as well as the flow of patients through the system.
The patient identifiable data has been obtained from the UEC service providers, checked and cleaned. Data linkage has been completed and is in the final stages of validation.
Following completion of the validation of the data linkage process, patient identifiers will be deleted from the CUREd Research Database and a unique identifier assigned to each record. Due to delays in this process, it is now expected that validation will be fully complete by the end of March 2020.
The project team are also working with a number of stakeholders to develop further research questions that may be answered using the CUREd Research Database, these include:-
- University of York
- Sheffield Teaching Hospitals NHS Trust
- Bradford Institute for Health Research
External researchers can request data extracts from the CUREd Research Database to be used in research studies focusing on urgent and emergency care within the UK. Researchers will need to go through an application process to obtain data and if successful, will only be supplied with data that does not contain patient identifiers. Strict processes are in place to ensure all project data released is governed correctly and will be used for research purposes only.
Information about the CUREd Research Database including data processing, data governance and how to apply for data extracts is available here.
The CUREd Research Database is managed by The University of Sheffield. It was developed with funding from Connected Yorkshire – part of the Connected Health Cities (CHC) programme which ended in December 2019. The NIHR Applied Research Collaboration in Yorkshire and Humber is providing on-going support to thethe CUREd Research Database.
Ethical review and legal permissions
The “Connected Health Cities: Data linkage of urgent care data” study (known as the “CUREd research database”) has approval from a NHS Research and Ethics Committee (REC), overseen by the NHS Health Research Authority’s Research Ethics Service, and from the NHS Health Research Authority (HRA), directly, to receive health and social care data without patient consent for patients of emergency and urgent care services in Yorkshire and Humber. The Leeds East REC granted approval (18/YH/0234) and, subsequent to receiving a recommendation to approve from the Confidentiality Advisory Group (18/CAG/0126, previously 17/CAG/0024), the NHS HRA provided approval for English health and care providers to supply identifiable patient data to the study. The study complies with the common law of duty of confidentiality owed by health professionals in regard to information provided by patients in the course of clinical care; the General Data Protection Regulation as enacted in the UK by the Data Protection Act 2018; and, where applicable, the Statistics and Registration Service Act 2007. The NHS HRA’s approval additionally provides the study with the authority to afford other researchers access to anonymised data subject to approval by the study’s Data Release Committee. A release register of all data extracts provided to external researchers is available here.
Contact email: email@example.com
- Professor Suzanne Mason, Professor of Emergency Medicine and Chief Investigator
- Maxine kuczawski, Study Manager and Researcher
Clinical (primary / secondary care):
- Dr Brad Wilson, Emergency Medicine Consultant, Bradford Teaching Hospitals
- Dr Susan Croft, Emergency Medicine Consultant, Sheffield Teaching Hospitals
- Dr Richard Jacques, Lecturer in Medical Statistics
- Dr Rebecca Simpson, Lecturer in Medical Statistics
- Jen Lewis, Medical Statistician
To oversee and ensure that particular tasks and activities relating to the management of the CUREd Research Database are undertaken, there is a CUREd Data Release Committee (DRC). Further information about this can be viewed on the CUREd DRC page.
Externally, The UOS team also works closely with other partners and organisations in the Yorkshire and Humber region, including:
- Bradford Institute for Health Research
- Bradford Teaching Hospitals NHS Foundation Trust
- Leeds Teaching Hospitals NHS Foundation Trust
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC)
- Sheffield Emergency Care Forum (PPI group)
- Sheffield Teaching Hospitals NHS Foundation Trust
- University of Leeds
- University of York
- Yorkshire Ambulance Service
Further information and documentation about the CUREd Research Database can be found below. Alternatively, please contact The UOS team via firstname.lastname@example.org
Information about the NIHR ARC Yorkshire and Humber, which is providing support and funding for the research database can be found here.
Project overview (v3.2)
- The AHEAD Study: monitoring anticoagulated patients who suffer head injury
Existing practice in emergency departments (ED) in the UK for managing patients taking warfarin after a blunt head injury is variable with little research that supports the most appropriate way to manage these patients.
We aimed to undertake research in order to understand the range and frequency of outcomes following head injury in this group of patients and to develop robust clinical guidance for how they should be optimally managed in the future.
The AHEAD Study was a prospective observational study which enrolled patients taking warfarin who attended 33 ED’s in England and Scotland after blunt head injury.
Over an 18-month period from October 2011, ED attendance data was collected from each site as well as information from patient questionnaires about the care they received and the status of their health 6 weeks after the injury.
Patients who died due to their head injury, experienced surgery due to their injury, had a change identified on a CT scan or re-attended the ED with a clear head injury complication were defined as experiencing a poor outcome. Information such as the patients’ conscious state (GCS), level of clotting in their blood (INR) and symptoms were investigated as predictors of a poor outcome.
A mathematical model was used to estimate the most cost-effective strategy assuming published NICE thresholds for cost per quality adjusted life year (QALY).
- Identify and determine incidence of clinically significant outcomes
- Identify predictors of adverse outcomes
- Identify cost-effectiveness of different models of care
- Develop robust clinical guidance to reduce risk of complication and death
A total of 3566 patients were enrolled in The AHEAD Study; the age range was 18 to 101 yrs (mean 79yrs) and 49% were men. Most patients were generally well on arrival in the ED and only 1/3 reported any symptoms (amnesia, vomiting, loss of consciousness or headache).
The average level of clotting in the blood tended to fall in the ‘normal range’ (mean INR 2.7). Imaging of the head was performed in 2/3 patients with 1 in 10 patients having a change identified in the result. Only a small number of patients underwent surgery (19) and 42 patients died of a head injury-related death.
A poor outcome was identified in 6.1% of the patient group. After further data analysis, a reduced conscious state, vomiting and loss of consciousness were found to predict a poor outcome.
The most cost-effective strategy appeared to be that employed in the real world, compared with the strategy of CT imaging for all patients taking account of patient benefit and costs.
These results will help to inform ED clinicians and other health professionals how to manage this group of patients most effectively, improving patient care and hopefully help to reduce poor outcomes.
The study was funded by a National Institute for Health (NIHR) Research for Patient Benefit (RfPB) grant, Ref: PB-PG-0808-17148 (£249,000). It started in July 2011 and closed in March 2014 following a 9-month extension.
- Senior Doctor Triage in the emergency department
A collaboration between The University Of Sheffield and the Yorkshire and Humber Academic Health Science Network (AHSN) Improvement Academy.
With the increasing problem of poor flow and crowding in emergency departments (ED), there is a growing interest in whether senior doctor triage (SDT) can improve flow and departmental performance.
This improvement project aimed to develop and test a senior doctor led triage process for patients arriving by ambulance to the ED that would reduce the time from arrival to triage for patients and consequently reduce the time to treatment and overall time spent in the ED.
Develop and share best practice recommendations for the process of Senior Doctor Triage within emergency departments through evaluation of existing services in the Yorkshire and Humber region and bringing together a collaboration of up to 3 emergency departments.
Undertake a regional survey of all EDs in the Yorkshire and Humber region in relation to how patients are triaged on arrival at the department. The survey will identify many different strategies especially in relation to the use of senior doctors to triage patients on arrival, and potential emergency departments to work in the collaboration for further evaluation. Feedback the regional survey results in a short report to all hospital sites in the region.
Build a collaboration of up to 3 EDs with a view to gathering more detailed information on the Senior Doctor Triage employed in their emergency departments and how it links with pre- and post-hospital emergency care services. A comprehensive assessment using a mixed methods approach (quantitative and qualitative) will be employed enabling the clinical effectiveness and cost-effectiveness to be evaluated as well as how the different triage strategies work for those involved i.e. staff and patients.
The collaborative will generate a set of recommendations for best practice to be shared and disseminated throughout the region. An ED within the collaborative will incorporate one or more of the recommendations, using hospital metrics to measure improvements. Undertake a number of ‘information sharing’ events where the results of the survey and good practice recommendations can be shared and discussed
Re-organising staff and utilising a small additional resource (computer, scanner and mobile phone) in a single ED to deliver senior doctor triage significantly reduced the time to decision-making and the overall time patients arriving by ambulance spent in the ED.
This improvement project was funded by the Yorkshire and Humber AHSN Improvement Academy as part of the Communities of Improvement programme (£193,000). It started in August 2014 and closed in July 2016.
Abdulwahid MA, Booth A, Kuczawski M & Mason SM (2016) The impact of senior doctor assessment at triage on emergency department performance measures: systematic review and meta-analysis of comparative studies. Emergency Medicine Journal, 33(7), 504-513.
The project operated in 2 phases. During the first phase the project team visited each ED in the Yorkshire and Humber region to complete a survey and observe how the ED and staff worked, whilst also forming relationships with senior ED clinicians.
This was collated into a report detailing existing ED resources, facilties and processes in each ED and presented at a regional workshop generating new and sharing existing ideas for improving the speed and appropriateness of care for patients arriving in the ED.
The second phase of the project involved working with staff in an acute NHS hospital based in England to support staff in identifying and implementing improvements to their existing triage process. An SDT process was developed using existing resources over 6 months (September to March 2016), and tested during an implementation week (25th to 29th April 2016).
Patients arriving by ambulance to the ED between 10:00 and 16:00, Monday to Friday during the implementation week were included. Anonymised routine hospital ED data was collected and compared with 6 control weeks where standard nurse triage operated (4 pre- and 2 post-implementation week).
Median times in the ED were significantly reduced for ambulance patients during the implementation week, time to triage (3 min v 10 min, p<0.001), to decision to admit (80 min v 133 min, p<0.001), and total time in ED (127 min v 224 min, p<0.001). More ambulance patients were admitted or discharged within 4 hours during implementation week (94% [97/103] v 64% [147/228]).
Patients arriving by other modes also experienced a reduction in the median total time spent in the ED (134 min v 137 min, p=0.066).
Project lead: Professor Suzanne Mason
Project manager: Maxine Kuczawski
- DiPEP: Diagnosis of Pulmonary Embolism in Pregnancy
- The PAINTED Study (Pandemic Influenza Triage in the Emergency Department)
NB: PAINTED 2009 is now completed.
Funded by the National Institute for Health Research. PAINTED was part of the NIHR clinical research network portfolio.
- Professor Steve Goodacre (Lead Investigator), Health Services Research, ScHARR, University of Sheffield
- Professor Jon Nicholl (Co-Investigator), MCRU, ScHARR, University of Sheffield
- Professor Mike campbell (Co-Investigator), Health Services Research, ScHARR, University of Sheffield
- Dr Mark Strong (Co-Investigator), Public Health Section, ScHARR, University of Sheffield
- Dr Kirsty Challen (Co-Investigator), Health Services Research, ScHARR, University of Sheffield
- Mr Darren Walter (Co-Investigator), University Hospitals of South Manchester NHS Trust
- Dr Andrew Bentley (Co-Investigator), University Hospitals of South Manchester NHS Trust
- Dr Emad Elmalek, Consultant in Emergency Medicine, Pennine Acute Hospitals NHS Trust
- Dr Chris Fitzsimmons, Consultant in Paediatric Emergency Medicine, Sheffield Children's Hospital NHS Trust
- Richard Wilson (Project Manager), Health Services Research, ScHARR, University of Sheffield
- Martina Santarelli (Research Nurse), Health Services Research, ScHARR, University of Sheffield
- Susan Proctor (Clerical Assistant), Health Services Research, ScHARR, University of Sheffield
- Participating Trusts
- Sheffield Teaching Hospitals NHS Trust
- Sheffield Children's Hospital NHS Trust
- Pennine Acute Hospitals NHS Trust
- University Hospitals of South Manchester NHS Trust
- Pre-hospital Outcomes for Evidence Based Evaluation (PhOEBE)
The PhOEBE project is a programme of research designed to develop new ways of measuring the impact of ambulance service care that can be used to monitor performance, measure quality improvement and evaluate service innovation.
The PhOEBE project will help ambulance services to keep improving so they can provide high quality care.
The PhOEBE animation
This short, entertaining and information animation developed with the help of patient and public represetntatives tell the story of the PhOEBE project.
Ambulance Response Programme
The Ambulance Response Programme (ARP) aims to improve response times to critically ill patients. It will make sure that the best, high quality, most appropriate response is provided for each patient first time.
Patient and Public Involvement (PPI) in PhOEBE
PPI input at all stages of a research project, from initial conception to dissemination, is a prerequisite of good quality research.
PhOEBE PPI Reference Group
The role of the reference group is to give a lay perspective on, and influence the research that is being carried out as part of the PhOEBE programme and provide support to the delivery of specific PPI components.
"My interest in influencing policy and practice and ‘PCPIE’ (Patient, Carer, Public Involvement and Engagement) activities stems from 28 plus years as an incomplete spinal cord injured person following a Road Traffic Accident in 1986. My family and I have had much experience of using all manner of services over time, especially health services. Following studies in Social Policy (York, 1992) and Health Education (York St John, 1994), post 16/Adults Teaching/Training and a 5 year semi professional career as a British Paralympic level Wheelchair Tennis athlete (Atlanta 1996), I have run my own part time freelance disability consultancy, 'Dispel', based in York since 1998. I have experience of working in the voluntary, public and private sectors nationally and regionally and focused latterly in "expert patient" and patient experience/quality focused work. Key roles currently include ‘Expert Patient/Advisor’ with Yorkshire Ambulance Service; Lay Review work for NIHR (Research for Patient Benefit Prog)., member of PURSUN (Pressure Ulcer Research Service User Network) c/o University of Leeds, Lay Member to Yorkshire and Humber PPI Forum Research Design Service c/o University of Sheffield and other freelance work as a PPI/Lay Rep. to various research projects. I have an active interest in self management/self care, user led and peer support approaches and I'm passionate about ‘patient partnership’ and ‘service user/consumer’ involvement as a means of securing safe, efficient improvements in services and practices, including research, which are truly patient/service user/consumer centred."
"I am a retired primary teacher. My father was a GP. I became interested in medical research when my late husband developed heart problems and I was invited to take part in various research projects. I have become more interested in patient care and experience as have taken part in further research projects to do with emergency care.I am a member of Sheffield Emergency Care Forum PPI group (See SECF)"
"I currently work in the IT and exhibition industries running two small businesses. I previously worked as a researcher on studies about the Ambulance service as well as a wide range of odd jobs including coach driving. I am participating within the PPI group for this project to provide a view from the middle aged working man and generally to be involved in the research process from a public perspective. I am a member of Sheffield Emergency Care Forum PPI group." (See Sheffield Emergency Care Forum (SECF)).
- The Global EMergency CAre Research Network (GEM-CARN); Harnessing collaborative inter-disciplinary research to improve Emergency Care in Low and Middle Income Countries
University of Sheffield Health Services Research, School of Health and Related Research
- Professor Fiona Lecky, email@example.com
- Olubukola Otesile, firstname.lastname@example.org
- Janette Turner, email@example.com
- Prof Steve Goodacre, firstname.lastname@example.org
- Dr Gordon Fuller, email@example.com
- Dr Ian Sammy, firstname.lastname@example.org
University of Sheffield , Public Health, School of health and Related Research
- Professor Lee Wallis, university of Cape town (Emergency Medicine), Republic of South Africa
- Professor Sujan Marahatta, Manmohan Memorial Institute of Health Sciences, Kathmandu (Epidemiology), Nepal
- Dr Teri Reynolds, World Health Organisation (Department for Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention (NVI)), Tanzania, Uganda
- Professor Mohamed El-Shinawi, Ain Shams University, Cairo (General Surgery) Egypt
- Dr Ishtar Govia, University of the West Indies Mona Campus (Caribbean Institute for Health Research), Jamaica
Globally 80% of healthcare emergencies in children and working age adults occur in low- and middle income countries (LMICs). While prevention is ideal, not all emergencies can be prevented. The World Bank Disease Control Priorities project estimates that over half of deaths in LMICs could be impacted by emergency care. For example, research has shown that people with similar injuries are nearly twice as likely to die in LMICs than in high income countries. A recent draft World Health Assembly Resolution aims to extend Universal Health Coverage to a further 1 billion people by 2023, but there is a lack of research evidence to suggest which emergency interventions and care systems should be prioritised for development.
We propose to address this by establishing a Global Network of Emergency care researchers
– bringing together researchers from many different disciplines and countries to establish the best way to improve Emergency Care in low resource settings.
We aim to improve awareness and understanding of the challenges of Emergency Care in LMICs by creating a website and academy, and by planning new emergency care research studies. Our research priorities will be based on evidence reviews, gap analyses and early data from WHO initiatives in Africa – using the WHO Emergency Care Toolkit. These will help us design large studies to evaluate which medicines, procedures and Emergency Care System elements will best reduce premature deaths in the poorest billion of the World’s population.
This proposal builds on established collaboration between ScHARR Investigators and the Universities of Cape Town (UCT), Ain Shams Cairo, Manmohan Memorial Institute of Health Sciences, Nepal, University of the West Indies, World Health Organisation Emergency Acute Care and Surgery Programme and draws upon the collaboration of WHO and UCT with the Universities of Makerere (Uganda) and Muhimbili (Tanzania).
The overarching theme is to develop a network of researchers with the capacity to conduct studies leading to improved Emergency Care for people in LMICs. The aim is to bring together researchers from several disciplines including Emergency Medicine, Pre-hospital Care, Health Services Research, Public Health, Disaster Management and Defence Emergency Care. The proposal seeks to build on the National Institute of Health Fogarty Center’s strategic initiative for emergency care research in LMICs (“CLEER”) through a scientific forum of networked researchers addressing the following key questions:
- What is the impact of recent emergency care initiatives on patient outcomes in LMICs?
- Which are the most important research questions for improving emergency care in LMICS?
- Which research designs will deliver reliable evidence to inform future emergency care initiatives?
- Which study outcomes should evaluate initiatives such as the WHO Emergency Care Development Toolkit?
The University’s four flagship institutes bring together our key strengths to tackle global issues, turning interdisciplinary and translational research into real-world solutions.