The need for change - rcem.ac.uk

1 Diagnosis The need for change Meaningless diagnoses Currently only about half of emergency In 2013 the Health Select Committee looked The SNOMED CT system currently used care patients have a diagnosis' entered: at the reasons for the repeated failures in in many Emergency Departments was Emergency Care and reported: designed to be used by expert coders The system cannot accurately analyse the who are not time-pressured and offers cause of the problem, still less resolve it, if an almost unlimited range of options. This it continues to fly blind'. More accurate does not work well when presented to information about the causes of rising service untrained time-poor ED trainee doctors. What is ECDS? pressures is not simply a management convenience; it is fundamental to the delivery Items submitted as a diagnosis' include of high quality care.

2 '. The Emergency Care Data Set (ECDS) is the new national data set for urgent and Boxing ring emergency care. Key components of ECDS House fire Faeces quantity Reason for attendance But most of these diagnoses' are not ECDS will be implemented in consultant- Mushroom diagnoses at all. led 24hr (Type 1) Emergency Departments Currently only about 5% of ED patients Condom and specialist (Type 2) Emergency have a meaningful reason recorded for The data from the pilot sites (below) Dutch Shepherd dog breed Departments by October 2017. their attendance. This data vacuum allows showed that prior to ECDS implementation: Tropical medicine department unhelpful myths to develop. Brassica napus ECDS will be implemented in Minor Injury 74% of the top ten diagnoses by volume Units/ Urgent Care Centres and Walk- Coughed sputum specimen were vague / symptoms (see table).

3 In Centres (Types 3 & 4 respectively) In total, these non-diagnosis codes Emergency Departments by October 2018. 41 of the top 100 diagnoses by volume account for 16% of all codes submitted were vague / symptoms. by these centres. There is interest in adapting the ECDS. template for use in Ambulatory Emergency Even then, the data is of questionable quality nearly 2% of all pregnancy ECDS limits the choice to real' diagnosis Care and Ambulance services. codes to ensure that time is not wasted related problems occur in males, if current data are to be believed. searching through hundreds of codes to find the right one. ECDS overcomes these issues by having a limited list of approximately 750 diagnoses. The ECDS diagnosis list is derived from the The diagnosis term is combined with RCEM work that has been succesfully Chief Complaint a qualifier': confirmed diagnosis' or used to code millions of patient episodes In ECDS every patient will have their chief suspected diagnosis'.

4 With high accuracy and data quality. complaint' (and acuity') recorded by a clinician at initial assessment. ECDS Diagnosis data quality The list of 138 items is based on a well- Data from the ECDS pilot sites : the top ten codes by volume Pre ECDS vs Post ECDS. validated Canadian list of presenting Prior to ECDS, 74% of all diagnoses' were invalid (in red) - Post ECDS all diagnoses are valid. complaints, and has been used successfully in several centres in the UK. This will enable optimised pathways based Why do we need ECDS? on these presenting complaints. The current Accident and Emergency data Acuity set was developed in the late 1970s. Currently there is no national measure of At that time the work of the Casualty acuity, and Emergency Departments use Department' was largely minor injuries and many different measures triage, NEWS.

5 Occasional major trauma. ECDS specifies that acuity must be There has been a rapid and sustained measured on a five point scale. increase in the volume, scope and complexity of emergency care. The data If acuity is not formally assessed, it will we have been collecting has not kept be inferred from the intended physical pace with the changes, so the reasons destination of the patient minors /. emergency care fails are not clear. majors / resuscitation. Benefits of ECDS Healthcare analysis Communication with GPs and patients Many healthcare analysts use ED data. When that data is absent or of poor quality, General Practitioners have long the advice they provide to commissioners complained about the quality of at all levels (including governmental) will information from Emergency Departments.

6 Be correspondingly poor - the old adage: ECDS data will populate a standard letter rubbish in = rubbish out template, developed in parallel with ECDS. ECDS ensures that the quality of information All patients should receive a copy of the available will be meaningful and GP letter on discharge as this minimises comprehensive. This will encourage much miscommunication and complaints. better policy decisions that will benefit patients, staff and the NHS. Communication with commissioners Research and audit Many misunderstandings occur because commissioners have poor quality data from Research and audit in Emergency Emergency Care, and this may lead to Medicine are hampered by incomplete misguided commissioning decisions. / meaningless data, and the difficulty of monitoring / co-ordinating trials across Consistent, high quality data allows multiple centres.

7 ECDS introduces a specific commissioners to compare data apples research field to record participation. with apples'. Better tariffs for Emergency Care Better data will ensure that the services commissioned are ones that patients Emergency Medicine is the only hospital will use, and that provide definitive cost- specialty where the tariffs (the money effective care that is safe and of good earned for the hospital) is not linked to quality. diagnosis. This has been because the diagnosis data was so poor, but with ECDS. Understanding vulnerable patients this will no longer be the case. When data is not collected on patients, it tends to be the patients in whom data is While the ECDS will in no way guarantee difficult to collect an increase in tariffs for emergency care, it will allow the budget to be divided in a fair people who do not speak English and transparent manner that recognises homeless people people with mental illness the value that Emergency Medicine brings people with dementia to the NHS.

8 People who leave without being seen RCEM is already working with NHS Digital This creates bias when data regarding on ways of using ECDS to create tariffs that Emergency Care is analysed. Only by better reward emergency care that adds collecting meaningful clinical data on all value keeping patients out of hospital. patients will this be avoided. Public Health Safeguarding information collection is integrated into ECDS and will allow staff to Injury is the largest preventable cause of communicate concerns to the GP. years of life lost. While there is good data on the most serious injuries, there is very Workforce, training and revalidation little data available about the vast majority There will be a clear record of which of injuries that cause significant morbidity clinicians have provided treatment and and financial loss to the community.

9 Reviewed the treatment plan, and this ECDS incorporates injury data collection will be very useful in workforce planning. performed by clerical staff. April 2017. Royal College of Emergency Medicine. All data / figures from NHS Digital. SNOMED CT (Systematic Nomenclature Of MEDicine Clinical Terms). For more information: To contact the ECDS team please email.