Developing indicators for failure or delays in recognising clinical deterioration and escalation of care across primary care

Date of ISAC Approval: 
Lay Summary: 
Failures or delays in general practitioners (GP) recognising patients' health getting worse (clinical deterioration) is a key driver for patients experiencing harm during their care and can result in serious consequences such as requiring a hospital admission. As 90% of all patients' contacts with healthcare professionals occur at the GP surgery, it is important to understand factors relating to these potential failures or delays. We propose to study the patient journeys of clinically deteriorating patients who end up in hospital as an emergency. Using information from the Clinical Practice Research Datalink, linked to hospital data, we will compare those patients who visit their GP with those who go straight to A&E prior to an emergency admission. We will explore what factors, recorded in the patients' electronic records, relate to a GP referring the patient to hospital or not. As well as gaining an overall picture, we will also focus on particular conditions that show rapid deterioration and are commonly missed by the GP (e.g. sepsis). This study will contribute to development of real time monitoring, flagging patient deterioration or delays in care. Such information will help clinicians and managers, resulting in fewer patients experiencing harm throughout their patient journeys.
Technical Summary: 
Research suggests that one main cause of safety incidents in primary care is the general practitioner's (GP) failure to recognise signs of a patient's clinical deterioration. Our objective is to investigate healthcare contacts in deteriorating patients and determine the risk factors associated with GPs not referring deteriorating patients for secondary care compared with those patients who are referred. We will obtain data from Clinical Practice Research Datalink, linked with Hospital Episode Statistics data on patients who had an emergency hospital admission (their health has deteriorated) between 2014 and 2017. Using individual patient's electronic health records, we will interrogate health contacts of deteriorating patients (we hypothesise this is within 3 days prior to emergency admission), to determine recorded factors such as behaviour (contact at GP or A&E), symptoms, referrals or comorbidities. We will use logistic regression to determine factors associated with a potentially missed deterioration (a GP contact which does not result in referral to hospital). We will investigate all conditions and then focus on specific conditions that are reported as commonly missed in primary care (e.g. sepsis). Our study will contribute to future risk prediction modelling and the development of potential indicators of clinical deterioration within the primary care setting.
Health Outcomes to be Measured: 
Primary - A&E unplanned admission Secondary - Mortality - GP Consultations - Emergency department visits - GP referrals

Elizabeth Cecil - Chief Investigator - Imperial College London
Alex Bottle - Collaborator - Imperial College London
Professor Azeem Majeed - Collaborator - Imperial College London
Elizabeth Cecil - Corresponding Applicant - Imperial College London
Paul Aylin - Collaborator - Imperial College London

HES A&E;HES Admitted;ONS;Patient IMD