Improving early identification of emergency department patients who need time-critical treatment

Development work questions: What is the current evidence base for emergency department (ED) initial assessment tools intended to identify patients needing time-critical treatment? Can clinicians, patients, and the public work with researchers using an appropriate framework to develop initial assessment tools? Can we reliably measure patient need for time-critical treatment (acuity) across different settings? What are the characteristics of patients needing time-critical treatment across different settings? Background ED crowding can delay time-critical treatment and lead to avoidable death and disability. Initial assessment by ED and ambulance clinicians aims to identify and prioritise patients needing time-critical treatment. Many initial assessment tools have been developed to assist clinicians, such as early warning scores and triage tools, but with little evidence that they accurately identify patients needing time-critical treatment. Studies have not followed methodological guidance for developing complex interventions, input from clinicians and patients has been limited, and external validation has often been omitted. Predictive accuracy has focussed on mortality and other measures that may not reflect need for time-critical treatment. We have developed an outcome measure to evaluate predictive accuracy for time-critical treatment that was reliable (kappa=0.89) and usable in the setting in which it was developed, and could be used to develop and evaluate initial assessment tools. Aims and Objectives We plan a research programme to develop and evaluate an initial assessment tool or toolkit for identifying adults needing time-critical treatment. The Programme Development Grant will support preparatory work to review existing initial assessment tools, build our team and intervention co-production group (with patient and public involvement), test our outcome measure in other settings, and collect outcome data to inform programme study design. Development work plan We will undertake three concurrent work packages: Initial assessment tool review: We will undertake an umbrella review of ED and prehospital initial assessment tools to provide an overview of the supporting evidence and a scoping review of any primary studies that specifically evaluate accuracy for predicting receipt of time-critical intervention. Intervention co-production group: We will create a group of 10-20 ED and ambulance service clinicians to review initial assessment tools, develop the research programme, and ultimately co-produce the intervention with the research team. A patient and public involvement group consisting of 10-20 patient or public representatives (including those from under-researched populations) will convene alongside the co-production group to review the developing programme, ensuring that public values are included and the needs of specific groups are addressed. Outcome measurement and characterisation: We will undertake a retrospective observational study of hospital records from 4000 adults attending four diverse EDs with diverse populations to test the reliability of our outcome measure (need for time-critical treatment) and characterise patients needing time-critical treatment. Timelines for delivery 15 months from 01/05/2025 to 31/07/2026 Anticipated Impact and Dissemination The project will lead to an application for a Programme Grant for Applied Research aimed at developing tools and/or a toolkit to improve early identification of time-critical emergencies, ultimately reducing avoidable harm due to ED crowding.