Understanding how clinical decisions are made in Emergency Multidisciplinary Units (EMUs) in Oxfordshire to improve training and decision making to improve patient safety: What are the factors that influence decision making? How does the day-unit environment of EMUs influence decisions?

Who?

Clinical staff working in the Emergency Multidisciplinary Units (EMUs) in Oxfordshire.

What?

Emergency Multidisciplinary Units are day units treating older patients with complex medical and social needs, without keeping them in a hospital bed overnight. This is called ‘Ambulatory Care’.

Aims

  • To understand how clinical decisions are made by staff working in the Emergency Multidisciplinary Units (EMUs) in Oxfordshire.
  • To learn what factors influence how staff makes decisions in the EMUs and how the day unit environment might affect this process.

Why this is important

The EMUs are based in local community hospitals, allowing patients to be treated closer to their home. They typically treat frail older patients with health and social care needs.  During a visit to an EMU, patients are treated by a multidisciplinary team made of a doctor, nurse, physiotherapist, occupational therapist and social worker. This allows each person to be assessed as a whole so that a personalised treatment plan can be made.

Medical care at the EMU is different to a normal hospital visit because patients are treated in the day and return to their homes overnight. Patients often prefer staying in their own bed overnight, and carers also often prefer that the patient is treated closer to home.

However, as patients are at home overnight, they are away from their care team between their treatments. Because of this, it is vital for patient safety that the correct decisions are made about which patients are suitable for ambulatory care, and which may need to be treated in a hospital bed overnight.

Doctors and nurses need to be able to judge who would be suitable for this type of medical care. Making sure that staff are properly trained to be able to undertake this complex work is vital for both patient safety and the future of the EMUs.

By understanding the factors that influence decision making, we plan to improve the training that doctors and nurses need to work in the EMUs and other similar ambulatory care centres.  

Methods

To investigate clinical decision making, in real-life ambulatory care, we will observe clinicians at work using a case study approach, to see the factors that influence their decision-making behaviours. This will be done across both the Abingdon and Witney EMU sites, as well as the ambulatory care areas within the John Radcliffe Hospital.

These case studies will include both observations and interviews with clinicians to explore and understand how and why they made different decisions, the factors they feel influenced their choices, and any educational needs they feel they might have.

These observations will be used to identify the different features of clinical decision-making and the factors which influence it. This will include whether we see any examples of previously described decision-making behaviours, how these behaviours can vary within and between clinicians, and how the ambulatory environment might affect those decisions.

The final stage will use the information that we have gained to improve training for doctors and nurses working in ambulatory care centres such as the EMU. We plan a conference style day where local and national stakeholders from academic, clinical and educational fields participate in a series of workshops to discuss the key findings. We will discuss how to best train and support the future workforce in ambulatory care and address any barriers to staff recruitment and retention. 

How this could benefit patients

The King’s Fund estimate that 1 in 6 emergency medical admissions is an ambulatory care sensitive condition, which could have been treated without the need of a hospital bed overnight in an acute hospital. The development of ambulatory care is seen as one way to help reduce the pressures on acute hospitals from the increasing numbers of emergency hospital admissions. The King’s Fund estimate that between £96-238 million could be saved by reducing these hospital admissions.

The EMUs provide an example of how ambulatory care can be used to reduce hospital admissions for frail older adults.

A trained workforce is needed in the EMUs and other similar ambulatory care centres to support patients being treated in this way. It is essential for patient safety that doctors and nurses working in ambulatory care are trained to decide which patients are suitable for ambulatory care. This study aims to understand the training needs of the ambulatory care workforce to support them to provide safe effective patient care in this new environment.

Emergency Multidisciplinary Units (EMUs)

Patients visiting EMUs are typically elderly, with an average age of 80 years.

A patient at the EMU would usually have long-term medical problems, such as diabetes or COPD, that their GP usually manages at home. They often have difficulties with mobility or other disabilities which they need help with, for example, using a walking frame to manage with leg weakness after a stroke.

EMU patients usually live at home with either their spouse who cares for them, or alone with carers visiting. These patients are then referred into the EMU when an acute illness such as pneumonia or urine infection causes illness and compromises their ability to manage at home. At this point, the patient would usually be referred to hospital, but the EMU is able to use a combination of medical, nursing, rehabilitation and increased social care provision (e.g. increased carers visiting) to allow them to be cared for in the EMU day unit.

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