Emergency department opening hours

National Guideline Centre (UK)

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National Guideline Centre (UK). Emergency and acute medical care in over 16s: service delivery and organisation. London: National Institute for Health and Care Excellence (NICE); 2018 Mar. (NICE Guideline, No. 94.)

Emergency and acute medical care in over 16s: service delivery and organisation.

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Chapter 16Emergency department opening hours

16. Emergency department opening hours

16.1. Introduction

Emergency Departments are usually open 24 hours a day, but in recent years there is an increasing trend to close some at nights. Often in quieter, more rural units this is because there is very little demand at night; but it may also happen as part of service consolidation to assure patient safety.

The effect of limiting ED opening times may be minimal. It maybe that the demand is swept up elsewhere (for example, in other hospitals or by other healthcare providers, for example, GPs or other community carers); however, this maybe at the expense of longer journey times and possible worsening of the patient’s condition. There could be further knock on effects to the ambulance service with vehicles being used for longer journeys not being able to respond to other emergency calls. However, the cost of keeping a 24 hour unit in all acute hospitals may be hugely expensive.

Therefore, closing ED’s at night should only be considered if clinically safe and cost effective to the whole healthcare economy. The guideline committee wanted to know if any work had been done in this area to assure this, and in what circumstances this had been shown.

16.2. Review question: Is 24-hour open access to ED more clinically and cost effective compared with limited opening times to ED?

For full details see review protocol in Appendix A.

Table 1

PICO characteristics of review question.

16.3. Clinical evidence

Four studies were included in the review; 1 controlled before-after study and 3 cohort studies,⁷^–⁹^,¹¹ these are summarised in Table 2 below. Evidence from these studies is summarised in the clinical evidence summaries below (Table 3 – Table 7). See also the study selection flow chart in Appendix B, forest plots in Appendix C, study evidence tables in Appendix D, GRADE tables in Appendix F and excluded studies list in Appendix G.

Table 2

Summary of studies included in the review.

Table 3

Clinical evidence summary: Day-time only ED versus 24 hour ED access.

Table 7

Clinical evidence summary: Increased driving time to ED versus no increase in driving time to the ED.

Table 4

Clinical evidence summary: ED closure versus 24 hour ED access.

Table 5

Clinical evidence summary: local ED closure versus no ED closure.

Table 6

Clinical evidence summary: Increased driving time to ED versus no increase in driving time to the ED.

16.4. Economic evidence

Published literature

No relevant health economic studies were identified.

The economic article selection protocol and flow chart for the whole guideline can found in the guideline’s Appendix 41A and Appendix 41B.

In the absence of economic evidence, unit costs were presented to the committee – see Chapter 41 Appendix I.

16.5. Evidence statements

Clinical

Restricted and closure of ED versus 24 hour ED access

One study conducted in Denmark reported gender stratified healthcare utilisation rates on in-person GP consultations, telephone GP consultations, home visits by GPs, ED visits and hospital admission. The evidence suggested that there was no difference in outcomes when ED hours were restricted (very low quality). When the ED was closed, the evidence suggested a reduction in GP telephone consultations, in-person consultation rates and home consultation rates amongst female patients, but not males. The evidence suggested there was no effect on ED visit rate or admission rat (very low quality).

Local ED closure versus no ED closure

One study set in the USA suggested a possible increase in mortality with ED closure compared to no ED closure (very low quality).

Increased driving time to ED versus no increase in driving time to the ED

One study set in the USA suggested a possible increase in mortality amongst patients with time-sensitive conditions when driving time to nearest ED was increased (very low quality). One study set in the USA suggested a possible increase in mortality amongst patients with time sensitive conditions when driving time to the nearest ED was increased more than 30 minutes (very low quality).

Economic

No relevant economic evaluations were identified.

16.6. Recommendations and link to evidence

Recommendations	-
Research recommendation	RR8. What is the clinical and cost effectiveness of limiting emergency department opening hours, and what effect does this have on local healthcare provision and outcomes for people with medical emergencies?
Relative values of different outcomes	Mortality, quality of life, avoidable adverse events, impact on other services and patient and/or carer satisfaction were considered by the committee to be critical outcomes. Ambulance transfer times and number of ED presentations were considered important outcomes.
Trade-off between benefits and harms	A total of 4 observational studies were identified. The evidence for restriction of ED opening hours was mixed. One study set in USA suggested a possible increase in mortality with ED closure compared to no ED closure. One study set in the USA suggested a possible increase in mortality amongst patients with time-sensitive conditions when driving time to nearest ED was increased (very low quality). Another study set in the USA suggested a possible increase in mortality amongst patients with time sensitive conditions when driving time to the nearest ED was increased more than 30 minutes (very low quality). Evidence from 1 study conducted in Denmark reported gender-stratified healthcare utilisation rates of in-person GP consultations, telephone GP consultations, home visits by GPs, ED visits and hospital admissions. Data were collected only from the sample population, and therefore the evidence did not take into account any overall impact on the services. The evidence suggested that there was no difference in outcomes when ED hours were restricted. However, after the ED was closed the evidence suggested a reduction in GP telephone consultations, in-person consultation rates and home consultation rates amongst female patients. The evidence suggested there was no effect on ED attendances or admission rates. No evidence was identified for avoidable adverse events, quality of life, patient and/or carer satisfaction, and ambulance transfer times. A positive or permissive recommendation to limit ED opening hours would require evidence showing that patient outcomes would not worsen and that health care utilisation would be reduced. The direction and quality of evidence currently identified would not permit such a recommendation, particularly as it was not directly applicable to the UK health system. The committee noted that a research protocol which fulfilled the requirements for the review question was currently being developed within the UK. Therefore, the committee considered a research recommendation would be the most appropriate until this evidence from this research was available.
Trade-off between net effects and costs	No economic studies were included. Unit costs of ED visits and alternative care services were provided to aid cost-effectiveness considerations (Chapter 14 Appendix I). Further economic analysis could not be undertaken due to the quality of the evidence. Although 1 included study reported healthcare utilisation from a patient perspective, the study did not explore the impact on other EDs that would need to absorb the additional patients. Therefore, the full economic and resource impact could not be considered based on the outcomes of this study. Reducing the hours of or closing an ED could be cost-saving if it reduces overall healthcare utilisation. This includes the impact on other EDs, alternative urgent care services and other emergency care resources such as ambulance services. This would only be cost-effective if it is clinically safe and those services that treat the redirected patients have the capacity to do so without a negative impact on their current service. The committee concluded that more research was needed to assess the cost impact and cost-effectiveness of limited ED opening hours.
Quality of evidence	The evidence was graded at very low quality. All evidence was downgraded for study design, whilst all but one was further downgraded for risk of bias. Three of the 4 studies were downgraded for indirectness as the evidence was combined for ED restriction, ED closure and full hospital closure. There were no economic studies included in the review.
Other considerations	The committee noted that there are very different reasons for ED closure and ED restriction. For example, in the UK, restriction in ED hours usually occurs when there is little demand for the service, such as overnight in smaller rural EDs. Closures typically occur in EDs when there is a consolidation of services in an area, such as in urban areas. However, overnight closures in EDs may also be due to workforce shortages. Closures would not normally occur where this would lead to an absence of ED provision in an area, as ED provision is an essential service. Often the closed EDs have been replaced by another facility such as an Urgent Care Centre. Currently, there is little research evidence to inform decision making about these closures. Distance to an ED is an important factor in acute medical emergencies and the committee discussed the importance of the first hour (the ‘golden hour’) when, in certain acute conditions, access to curative interventions is most likely to be effective (for example, stroke). The committee noted that an NIHR –funded trial is underway. This study is a large controlled interrupted time series study which aims to analyse both ED closure and restriction in ED hours. Furthermore, this study includes both healthcare utilisation outcomes and patient safety outcomes and would be directly applicable to the UK population.

References

1.: Impact of closing Emergency Departments in England (closED). Health Technology Assessment, 2015. Available from: http://www.nets.nihr.ac.uk/__data/assets/pdf_file/0013/133033/PRO-13-10-42.pdf
2.: Congdon P. The development of gravity models for hospital patient flows under system change: a Bayesian modelling approach. Health Care Management Science. 2001; 4(4):289–304 [PubMed: 11718461]
3.: Curtis L. Unit costs of health and social care 2014. Canterbury: Personal Social Services Research Unit, University of Kent; 2014. Available from: http://www.pssru.ac.uk/project-pages/unit-costs/2014/index.php
4.: Department of Health. NHS reference costs 2013-14. 2014. Available from: http://www.gov.uk/government/publications/nhs-reference-costs-2013-to-2014 [Last accessed: 12 March 2015]
5.: El Sayed M, Mitchell PM, White LF, Rubin-Smith JE, Maciejko TM, Obendorfer DT et al. Impact of an emergency department closure on the local emergency medical services system. Prehospital Emergency Care. 2012; 16(2):198–203 [PubMed: 22191683]
6.: Fisher K, Bonalumi N. Lessons learned from the merger of two emergency departments. Journal of Nursing Administration. 2000; 30(12):577–579 [PubMed: 11132344]
7.: Hansen KS, Enemark U, Foldspang A. Health services use associated with emergency department closure. Journal of Health Services Research and Policy. 2011; 16(3):161–166 [PubMed: 21389061]
8.: Hsia RY, Kanzaria HK, Srebotnjak T, Maselli J, McCulloch C, Auerbach AD. Is emergency department closure resulting in increased distance to the nearest emergency department associated with increased inpatient mortality? Annals of Emergency Medicine. 2012; 60(6):707–715 [PMC free article: PMC4096136] [PubMed: 23026784]
9.: Liu C, Srebotnjak T, Hsia RY. California emergency department closures are associated with increased inpatient mortality at nearby hospitals. Health Affairs. 2014; 33(8):1323–1329 [PMC free article: PMC4214135] [PubMed: 25092832]
10.: Mitchell A, Krmpotic D. What happens when a hospital closes its emergency department: our experience. Journal of Emergency Nursing. 2008; 34(2):126–129 [PubMed: 18358350]
11.: Shen YC, Hsia RY. Does decreased access to emergency departments affect patient outcomes? Analysis of acute myocardial infarction population 1996-2005. Health Services Research. 2012; 47(1 Pt 1):188–210 [PMC free article: PMC3258371] [PubMed: 22091922]
12.: Sun BC, Mohanty SA, Weiss R, Tadeo R, Hasbrouck M, Koenig W et al. Effects of hospital closures and hospital characteristics on emergency department ambulance diversion, Los Angeles County, 1998 to 2004. Annals of Emergency Medicine. 2006; 47(4):309–316 [PubMed: 16546614]
13.: Teljeur C, Barry J, Kelly A. The potential impact on travel times of closure and redistribution of A&E units in Ireland. Irish Medical Journal. 2004; 97(6):173–175 [PubMed: 15305619]

Appendices

Appendix A. Review protocol

Table 8Review protocol: ED opening hours

Review question	Is 24-hour open access to ED more clinically and cost effective compared with limited opening times to ED?
Guideline condition and its definition	Acute Medical Emergencies. Definition: people with suspected or confirmed acute medical emergencies or at risk of an acute medical emergency.
Review population	Adults and young people (16 years and over) with a suspected or confirmed AME.
	Adults and young people (16 years and over).
	Line of therapy not an inclusion criterion.
Interventions and comparators: generic/class; specific/drug (All interventions will be compared with each other, unless otherwise stated)	Access to ED; 24 hour access to ED. Access to ED; undefined ‘usual’ access to ED. Reduced access to ED; restricted access with pre-planned diversion to other services. Reduced access to ED; restricted access without pre-planned diversion. Reduced access to ED; ED closure (without hospital closure).
Outcomes	- Impact on other services as defined by the paper during the study period (Dichotomous) CRITICAL - Quality of life during the study period (Continuous) CRITICAL - Patient/carer satisfaction during the study period (Dichotomous) CRITICAL - Mortality during the study period (Dichotomous) CRITICAL - Avoidable adverse events during the study period (Dichotomous) CRITICAL - Number of ED presentations during the study period (Dichotomous) IMPORTANT
Study design	Systematic reviews (SRs) of RCTs, RCTs, observational studies only to be included if no relevant SRs or RCTs are identified.
Unit of randomisation	Patient. Hospital.
Crossover study	Not permitted.
Minimum duration of study	Not defined.
Other exclusions	Major trauma centres. Walk in centres. Minor injury units. Urgent care centres co-located in EDs, unless an unselected population presenting with emergencies can access the service. Whole hospital closing. Non-OECD country.
Population stratification	Unselected population. Severely ill patients. Non-severely ill patients.
Reasons for stratification	If a population is selected in the study in may be that severely ill patients (such as those with acute myocardial infarction) will be affected by a restriction in ED opening hours to a greater degree. Trauma patients are excluded from the scope so studies which purposely select them will be excluded.
Subgroup analyses if there is heterogeneity	- UK versus non-UK (UK; Non-UK); effects may be different in this subgroup. - Rural versus urban (Rural; Urban); effects may be different in this subgroup. - Planned diversion to other hospital versus non-planned diversion for example, straight to AMU (Planned diversion; Non-planned diversion); effects may be different in this subgroup.
Search criteria	Databases: Medline, Embase, the Cochrane Library. Date limits for search: 1990. Language: English.

Appendix B. Clinical article selection

Figure 1Flow chart of clinical article selection for the review of ED opening hours