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Changes in admission thresholds in English emergency departments
  1. Steven Wyatt1,
  2. Kieran Child1,
  3. Andrew Hood1,
  4. Matthew Cooke2,
  5. Mohammed A Mohammed3
  1. 1 Strategy Unit, NHS Midlands and Lancashire Commissioning Support Unit, West Bromwich, UK
  2. 2 Warwick Medical School, University of Warwick, Coventry, UK
  3. 3 Faculty of Health Studies, University of Bradford, Bradford, UK
  1. Correspondence to Steven Wyatt, Strategy Unit - NHS Midlands and Lancashire Commissioning Support Unit Kingston House 438-450 High Street West Bromwich B70 9LD UK; swyatt{at}


Background The most common route to a hospital bed in an emergency is via an Emergency Department (ED). Many recent initiatives and interventions have the objective of reducing the number of unnecessary emergency admissions. We aimed to assess whether ED admission thresholds had changed over time taking account of the casemix of patients arriving at ED.

Methods We conducted a retrospective cross-sectional analysis of more than 20 million attendances at 47 consultant-led EDs in England between April 2010 and March 2015. We used mixed-effects logistic regression to estimate the odds of a patient being admitted to hospital and the impact of a range of potential explanatory variables. Models were developed and validated for four attendance subgroups: ambulance-conveyed children, walk-in children, ambulance-conveyed adults and walk-in adults.

Results 23.8% of attendances were for children aged under 18 years, 49.7% were female and 30.0% were conveyed by ambulance. The number of ED attendances increased by 1.8% per annum between April 2010–March 2011 (year 1) and April 2014–March 2015 (year 5). The proportion of these attendances that were admitted to hospital changed negligiblybetween year 1 (27.0%) and year 5 (27.5%). However, after adjusting for patient and attendance characteristics, the odds of admission over the 5-year period had reduced by 15.2% (95% CI 13.4% to 17.0%) for ambulance-conveyed children, 22.6% (95% CI 21.7% to 23.5%) for walk-in children, 20.9% (95% CI 20.4% to 21.5%) for ambulance conveyed adults and 22.9% (95% CI 22.4% to 23.5%) for walk-in adults.

Conclusions The casemix-adjusted odds of admission via ED to NHS hospitals in England have decreased since April 2010. EDs are admitting a similar proportion of patients to hospital despite increases in the complexity and acuity of presenting patients. Without these threshold changes, the number of emergency admissions would have been 11.9% higher than was the case in year 5.

  • emergency department utilisation
  • emergency care systems
  • admission avoidance
  • hospitalisations

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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  • Contributors SW and AH conceived the work. KC conducted and AH supervised the preliminary data analysis. SW conducted the final data analysis and wrote the first draft of the paper. MAM provided methodological and statistical advice. MC provided clinical and operational interpretation of the findings. All authors commented on draft versions and approved the final version of the article.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All data used are published.

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