STALLED: What works to improve SafeTy, pAtient experience, outcomes and costs related to deLayed ambulance handovers at Emergency Departments? A whole systems approach

Emergency Departments (ED) sometimes become unable to manage the flow of patients, and close their doors to new patients arriving by ambulance. In some areas this is rare, in others it is common. When patients are held in ambulances in a queue, they are not receiving full ED care and ambulances are unavailable to attend other patients, so there are ‘knock-on’ effects throughout the system. We aim to provide evidence about what works to reduce harms related to ambulance queuing. We will 1. Describe what is known about the nature and effectiveness of initiatives aimed at reducing ambulance queuing and related harms 2. Identify initiatives currently in use in the UK to reduce handover delays 3. Understand what policies and practices are being used in hospitals where ambulance queuing is rare 4. Assess impact of successful handover management on patient outcomes, safety, experience and costs 5. Predict wider impacts of initiatives on patient flow through emergency care 6. Produce guidance about what works to reduce delayed handovers Methods: We will review existing evidence about initiatives to reduce delayed handovers at ED and survey 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 within ambulances; paramedic care within 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 agree criteria for selecting sites to include in more in-depth work at a stakeholder event. We will then select and collect data from four sites where ambulance queues are rare (Group 1) and four sites where queues are more frequent (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 groups, including: deaths, 999 ambulance attendance, conveyance rates, admissions and waiting times. We will investigate, in particular, effects within vulnerable groups, including the very elderly, 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 and views and do the same with stakeholders from across the emergency care system, including ED, hospital staff, ambulance clinicians, call takers, healthcare managers and commissioners. Finally, we will hold stakeholder workshops towards the end of the study to interpret findings. We will make recommendations about how to reduce harms related to 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. We will recruit public contributors to the independent Study Steering Group. Our research team includes clinical, academic and policy specialists. We have a strong track record of delivering studies in emergency care and making our research inclusive. We will maximise impact by publishing findings widely.