Using the WHO Hospital Emergency Unit Assessment Tool to assess changes in Emergency Care Capacity in a United Kingdom Major Trauma Centre

Using the WHO Hospital Emergency Unit Assessment Tool to assess changes in Emergency Care Capacity in a United Kingdom Major Trauma Centre | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Using the WHO Hospital Emergency Unit Assessment Tool to assess changes in Emergency Care Capacity in a United Kingdom Major Trauma Centre Zosia Bredow, Ahmed E O Ali, Fiona Lecky This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8733892/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background: We reviewed a Major Trauma Centre (MTC) in the UK over an Emergency Department (ED) transition using the World Health Organization (WHO) Hospital Emergency Unit Assessment Tool (HEAT). HEAT has previously been used in low- and middle-income countries. This is the first time it has been used to explore resource constraints and predict potential barriers to emergency care capacity in a higher-income country. Our primary outcome was to find any difference in emergency care capacity with a change in emergency care resources. Secondary outcomes included a series of observations on the appropriateness of the tool itself and its use in a higher-resourced system. Methods: All areas of the MTC that impact emergency care capacity were studied, with multiple key informants (KIs) in each area interviewed. The HEAT-adjusted Emergency Care Capacity Score (HEAT-ECCS) was used for quantitative analysis of the MTC’s emergency care capacity. Qualitative data was collected for analysis of barriers to availability of emergency care. Data collection was between May and September 2024, over an ED transition in July 2024, with the extension to the original ED of an additional 12-cubicle resuscitation unit and associated infrastructure. Results: The HEAT-ECCS showed higher availability ratings both overall, and in each of the 5 parameters: Infrastructure; Diagnostics; Human Resources; Clinical Services and Signal Functions. KI comments on the applicability of HEAT to this setting fell into 4 themes: 1. Equipment / process in this context 2. Skill in this context 3. Question clarity 4. Streaming Conclusions: This study provides context to barriers to availability of emergency care and suggests some solutions may be found through similar ED transitions. By exploring emergency care systems from a global health perspective, using tools such as HEAT, we believe that learning can be shared between higher and lower-resourced systems, and strategies found to strengthen them. Trial Registration: This study received local Research and Innovation approval, and registered as a health improvement project (reference 24HIP31) to hold interviews, store and analyse anonymised KI responses and disseminate findings through publication and conference presentation. Emergency Medicine Emergency care systems Global health Emergency department management Background The benefits of improved emergency care are well recognised; the Disease Control Priorities Project estimates that more than 50% of annual mortality in low- and middle-income countries (LMIC) can be addressed with emergency care improvements ( 1 ). Resource constraints in emergency care are increasingly becoming an international priority. The World Health Organization (WHO) has created an Emergency Care Toolkit to assess and support improvements in capacity, with tools such as WHO’s Hospital Emergency Unit Assessment Tool (HEAT) ( 2 ). HEAT incorporates the views of various Emergency Department (ED) and hospital staff through Key Informant (KI) interviews to determine the availability of essential ED structures and functions. These WHO tools, including HEAT, have been primarily utilised to appraise emergency care systems in LMICs, and they have not previously been used to explore the resource challenges and barriers to capacity in a high-income country (HIC). The HEAT was chosen to review an ED transition within an urban Major Trauma Centre (MTC) teaching hospital in the Northwest of England. This was informed by the investigators' (ZB, AA) involvement in previous applications of the WHO Emergency Care Toolkit in LMICs such as Sudan and Sierra Leone ( 3 ). It is felt that these tools can be of use in HICs, such as the United Kingdom (UK), given that access to emergency care through long waits, corridor care and overcrowding has been the subject of national concern ( 4 ) ( 5 ) ( 6 ). It is hoped that this study adds insight and assessment data to existing review and evaluation frameworks. By sharing learning from lower-resourced systems and from the tools used to support them, this study may provide an opportunity to find practical solutions to the current resource pressures and capacity issues that are now seen in many HIC emergency care systems Methods HEAT is a standardised assessment of a hospital’s capacity to deliver effective emergency care at a single timepoint [HEAT is included in Appendix A]. HEAT forms part of the WHO’s Emergency Care Toolkit (2). It has been used across the globe both for individual facility reviews and as part of larger national emergency care systems assessments(3) (7) (8). The development of HEAT was informed by earlier tools that were also developed with resource-constrained settings, such as Emergency Obstetric Care assessment (EmOC), the African Federation for Emergency Medicine’s Emergency Care Assessment Tool (ECAT), the WHO Emergency Care System Framework, the WHO Guidelines for Essential Trauma Care, and the WHO Tool for the Situational Analysis of Emergency and Essential Surgical Care (1) (10) (11) (12). The HEAT assessment is completed via interviews with KIs: stakeholders in the facility’s emergency care system who are best able to give an accurate understanding of the availability of resources and service capacity. Each interview requires KIs to give availability ratings for certain key functions needed for emergency care: 1 ‘generally unavailable’; 2 ‘some availability’; or 3 ‘adequate availability’. This rating is then further explained by free-text comments based around barriers to availability (e.g. ‘infrastructure’; ‘absent equipment’; ‘training’ etc). HEAT recommends triangulation of responses with multiple KIs to improve the accuracy of the results and suggests that parallel interviews can be rationalised via a consensus process (2). The HEAT is a standardised assessment that does not involve patients nor members of the public, exclusively relying on KI interview for data collection. Therefore, to conform to these set standards, the authors did not involve patients nor members of the public in this study. The authors have chosen to use the term Emergency Department (ED) in this study rather than the WHO’s term Emergency Unit (EU), as ED is the more common term used in the UK. Both terms are used with the same meaning, defined in HEAT as ‘any dedicated intake area for acutely ill and injured patients’ (2). An ED transition at the UK MTC occurred over May and June of 2024. This involved an extension to the original 30-cubicle ED, with an additional12-cubicle resuscitation unit and associated additional infrastructure, including imaging facilities (Xray, CT and MRI scanners) and additional theatres and wards for trauma and resus patients (13). Data collection for the initial HEAT assessment took place between May and June 2024, examining the period preceding the opening of the new extension. Data collection for the second HEAT assessment took place in September 2024, with the aim of capturing any change in ED capacity. No patient-identifying data was collected in any form. As context, the ED had received a ‘needs improvement rating’ in the most recent Care Quality Commission (CQC) inspection in 2022 as part of a multi-acute hospital NHS Trust. It was previously rated ‘good’ in 2018 and ‘outstanding’ in 2015 as part of a single acute hospital NHS Trust. The study involved all areas of the MTC that impact emergency care, and a range of KI job roles were interviewed as per HEAT guidance. All interviews were completed by the authors of this paper, who, although all work as clinicians in the studied ED, did not offer opinions or responses to HEAT questions. Interviews were conducted in person or by videocall. Each individual interview took 45 minutes to 1 hour to complete, followed by consensus interviews panels which took 2 hours. The KIs were recruited by email to departmental leads of all services pertinent to HEAT, requesting that either the lead or a ‘better suited informant’ attend both individual and consensus interviews pre- and post-transition to ‘provide insight into how [the MTC’s] emergency care is organised’. A total of 10 KIs were interviewed separately, including multiple laboratory staff, speciality clinicians such as radiologists and a haematologist, multiple managerial staff, and pharmacy and clinical staff working in the ED. A full breakdown of the roles of the KIs is included in Appendix B. After individual KI interviews, two consensus meetings were held (one pre- and one post-ED transition), as suggested by the HEAT guidance, to ensure a single answer for each HEAT question was agreed upon. The same KIs were invited for pre- and post- transition interviews and consensus meetings, and outcome summaries of comments were confirmed by KIs in writing after analysis. KIs who could not attend the consensus meeting were offered to review the written meeting report and to provide their feedback. The HEAT-adjusted Emergency Care Capacity Score (HEAT-ECCS) was used for quantitative analysis of the MTC’s emergency care capacity (3). The HEAT-ECCS is a composite score created in a previous open-access study by mapping the WHO's HEAT questions to the 5 Emergency Care Capacity Score domains: 1. Infrastructure 2. Diagnostics Services 3. Human Resources 4. Clinical Services (incorporating systems and guidelines) 5. Signal Function Performance (incorporating training, drugs, and equipment) Mean HEAT-ECCS scores were calculated for each domain and a total score for the ED. Each domain is weighted equally. Scores are expressed as percentages. Qualitative data were collected for analysis of barriers to the availability of emergency care. This study’s primary outcome was to find any difference in emergency care capacity in this MTC ED with this change in resource availability. Secondary outcomes included a series of observations on the appropriateness of the use of the HEAT in a high-resourced setting, and reviewing the perceived quality of the emergency care services provided by the ED as contextualised by other contemporaneous data sources. HEAT has not been previously used to review emergency care capacity in the UK. This study is the first use of the tool in an ED from a high-income country that aims to provide universal health coverage free at the point of need. Therefore, data collection was extended to include comments and reflections from KIs on the applicability of the tool to this setting. Furthermore, results were contextualised using the latest data from the publicly available Getting It Right First Time (GIRFT) programme. The study received local Research and Innovation approval, and registered as a health improvement project (reference 24HIP31) to hold interviews, store and analyse anonymised KI responses and disseminate findings through publication and conference presentation. Results Quantitative data were analysed with the HEAT-ECCS. Results are reported in line with HEAT domains. Mean HEAT-ECCS scores were calculated for each domain from consensus interviews, and a total score was calculated. The data from the second HEAT assessment showed higher availability ratings both overall, and in each of the 5 domains (Table 1). Table 1. HEAT-ECCS Initial HEAT Assessment Second HEAT Assessment Infrastructure 83% 93% Emergency Diagnostic Services 83% 85% Human Resources 61% 72% Clinical Services 71% 76% Signal Function Performance 85% 90% Overall 77% 83% Examples of these findings under each domain are presented in Table 2; full qualitative data are explored further in Appendix C under each HEAT-ECCS domain. Table 2. Example Data from each Domain HEAT-ECCS Domain Example Question Initial HEAT Assessment Comments Consensus 1 Availability Rating Second HEAT Assessment Comments Consensus 2 Availability Rating Infrastructure 1.3.10 Designated resuscitation area Noted that the resus area was often overfilled, and that there was no decent flow out of resus. 2 ED transition at the UK MTC involved an extension to the original ED, with an additional 12-cubicle resuscitation unit and associated additional infrastructure. 3 Emergency Diagnostic Services 1.4.23 CT scan The CT scanner for the ED was ‘meant to be replaced after 10 years and was now 14 years old’… The provision generally did not meet demand. 2 The speed to scan has improved with the ED extension opening and the provision of 2 new CT scanners. 3 Human Resources 2.2.1 General surgery Patients waiting more than 12 hours for review, with the expectation that the ED will frontload patients and do scans prior to consult. 2 3 Clinical Services 3.3.22 Handover protocols when transferring patient care to another provider No written protocols or agreed pathways, transfers on a case-by-case basis - especially for paediatrics. 1 1 Signal Function Performance 4.7.13 Relevant antidote administration No stock of antivenom as recommended by the Royal College of Emergency Medicine (RCEM), and the antidotes not kept in the same location as per RCEM recommendation. 2 The antidote cupboard was moved to the ED extension and has improved 3 Secondary outcomes included recording in detail the KI comments on the use of the HEAT; this was planned prior to interviews. This reporter data was checked in detail at consensus. KI comments on the HEAT itself can be categorised under 4 themes: Equipment / Process in this context Skill in this context Streaming comments KIs felt question needed clarity Examples of these HEAT-specific comments are presented in Table 3; full data on this secondary outcome are found in the supplementary material at Appendix D. Table 3. Example Key Informant comments on use of HEAT tool for this context Comment Theme HEAT Question Example KI Comments Equipment / Process in this context 1.3.24 Oxygen is supplied by oxygen concentrator stored on this unit Data fields for oxygen concentrator were felt to be not required in this setting. 1.4.17 Availability of Malaria Rapid Diagnostic Tests within the emergency unit Not an ED priority in areas of the world where malaria is not endemic, such as the UK. KIs suggested that the question could be extended to reflect global variance of disease patterns to inform emergency care pertinent to the region (e.g. EDs in the UK will have COVID, Flu and RSV point of care tests to enable flow and appropriate treatments). Skill in this context 4.4.4 Venous cutdown Venous cutdown no longer recommended as superseded by technologies such as intraosseous (IO) access and ultrasound. 4.6.1 Pericardiocentesis, 4.8.3 Diagnostic paracentesis, 4.8.4 Surgical source control, 4.9.3 Fasciotomy or escharotomy for compartment syndrome KIs agreed that speciality doctors would be called to the ED or patients moved elsewhere for these procedures. Streaming comments In higher-income systems, ED waiting rooms may encompass multiple 'external streams' including clinics, General Practice and minor injuries areas. These are led by consulting services such as Emergency Nurse Practitioners, physiotherapists and doctors alongside the ED footprint in an attempt to reduce crowding. Low-acuity patients are streamed to these external services after ED triage, a concept that is common and encouraged in overcrowded, resource-restricted high-income systems, and therefore not captured by HEAT. The impact of flow limitations and capacity mitigations such as corridor care are not captured by HEAT. KIs felt question needed clarity 3.3.8 Protocol for neonatal resuscitation KIs commented that the Signal Functions section of HEAT did not reflect emergency paediatrics and noted although HEAT has a neonatal resus question (3.3.8) there is no question for Acute Paediatric Life Support (APLS), and a lack of HEAT questions on emergency paediatrics overall The publicly available GIRFT data table is shown in Table 4. This gives performance values for the whole of the Trust which contains 3 EDs and 1 Acute Care Centre across 4 hospitals in the area including the urban MTC where this study was conducted. Therefore, this data remains relevant for the urban MTC studied, but has incorporated and therefore is affected by data on the performance of the other 3 facilities within the same Trust. Performance for Type 1 ED attendances (patient attending with complaints requiring a general ED who are seen and receive all ED care within 4 hours of arrival) remains static at 55-56% throughout the study period. However, the percentage of patients requiring a stay in ED of greater than 12 hours fell from a peak of 4.3% in June 2024 to below 2.5% in August and September 2024, as illustrated in Table 5. Table 4. GIRFT Performance values for Trust Region: North West - ICB : NHS Greater Manchester Integrated Care Board - Organisation : Northern Care Alliance NHS Foundation Trust 2024 Month Attendances Breaches Performance Type 1 attendances Type 1 breaches Type 1 performance Emergency admissions Emergency admissions via A&E 4+ hour delays from decision to admit 12+ hour delays from decision to admit September 33,047 11,291 65.8% 24,649 10,994 55.4% 9,146 7,421 2,555 583 August 31,500 10,392 67.0% 23,316 10,163 56.4% 8,716 6,989 4,303 496 July 35,090 11,788 66.4% 25,778 11,400 55.8% 9,107 7,317 2,540 791 June 33,753 11,285 66.6% 25,044 10,980 56.2% 8,803 7,236 2,331 1,066 May 35,809 12,134 66.1% 26,332 11,839 55.0% 9,387 7,663 2,086 901 Grand Total 169,199 56,890 66.4% 125,119 55,376 55.7% 45,159 36,626 13,815 3,837 Table 5. Patients requiring a stay in ED of greater than 12 hours 2024 Month Patients requiring a stay in ED of greater than 12 hours (%) Patients requiring a stay in ED of greater than 12 hours (Total) September 2.4% 583 August 2.1% 496 July 3.0% 791 June 4.3% 1066 May 3.4% 901 Discussion In this single-centre analysis of emergency care capacity of a UK MTC over an ED transition, the study team found significant improvement to availability ratings of emergency care capacity in all domains, as reflected in the HEAT-ECCS. The GIRFT quantitative data summaries for the Trust, although an indirect measure for this ED, support this assessment over the period of study. This is the first study to describe the resource challenges and emergency care capacity of a high-income system using the WHO HEAT assessment. The study team believe that these data add depth to the quantitative measures more usually relied upon for ED care capacity and performance in systems such as the UK, as the data from this study are based on structured in-person interviews. The GIRFT Emergency Medicine Index (GEMI) is a proxy performance metric based on inflow, throughput and exit block data ( 14 ). The GEMI published for the same time period as this study ranks the site nationally: in May 2024, the month of the department transition, the GEMI was at 75 out of all of the trusts in England, June was similarly ranked at 73, whereas in July the GEMI improved to 51 nationally. A 2022 Care Quality Commission 4 hour target (CQC 4HT) review also found similar data in Emergency Care, rating safety in urgent and emergency services as ‘inadequate’, and ‘requiring improvement’ for effective care ( 15 ). The comments specific to HEAT that we collected from the KIs at both initial and consensus interviews have been useful in contextualising the tool in this high-resource setting. KIs felt that some areas of the HEAT were not applicable in EM or laboratory practice in their setting, with regards to certain diagnostic tests, clinical procedures and skills. Their comments and observations on the appropriateness of the use of the HEAT in this high-resourced setting have been summarised in Table 3 , with full data on this secondary outcome in the supplementary material at Appendix D. All comments and observations have been shared with the WHO team for ongoing development. It was notable that the KIs were positive in their feedback on the use of a WHO tool, and there was noted a readiness to incorporate change in practice based on HEAT questions, for example with malaria screening. The study has certain limitations. Firstly, as HEAT has previously been used to assess resource-constrained settings, high-income emergency care systems such as this have not previously been reviewed with such tools. The study team found that the interviews and data collection were therefore limited by the constraints of the tool as illustrated by the KIs comments on HEAT assessment questions themselves and the HEAT’s overall appropriateness to this setting. HEAT has been used as an assessment at a single point in time. The authors have tried to give a fuller picture of the capacity of this system by repeating the assessment after a significant change. However, to mitigate against transient or chance fluctuations and capture longer trends, repeated assessments would need to be completed over a longer period. The study team addressed the limitations in the data scope by interviewing a range of KIs in-person. However, as HEAT aims to evaluate the structure and key functions of an ED via the process of KI interview, any data collected and therefore wider conclusions made was limited by the knowledge and experience of those KIs that were interviewed. Consensus was reached in the second meeting, and views not captured in the numerical data were therefore reflected qualitatively in comment form. Conclusions This study provides context to the challenges facing emergency care systems in high-income settings such as this large MTC in the UK. The authors hope that it offers some insight into common barriers to the availability of emergency care and suggests some solutions may be found through similar Emergency Department transitions to the one studied here. We believe that by exploring emergency care systems from the perspective of global health, using validated global tools such as the WHO’s HEAT, learning can be shared and exchanged between systems with different levels of resources. We are all facing resource issues that challenge the provision of the emergency care that we bring to our patients each day. Through studying these systems, we aim to find and share strategies to strengthen them. Declarations Ethics approval and consent to participate The study received review and approval from the Institutional Review Board and registered as a health improvement project (reference 24HIP31) with the Research Management Team at Northern Care Alliance NHS Foundation Trust. According to the NHS Health Research Authority (HRA) Research Ethics Service, this study did not require further NHS Research Ethics Committee review as informed consent was obtained from all respondents and no patient-identifying data was collected in any form. Consent for publication The study received local Research and Innovation approval and registered as a health improvement project (reference 24HIP31) to hold interviews, store and analyse anonymised Key Informant responses and disseminate findings through publication and conference presentation. Availability of data and materials Further data including HEAT Emergency unit Assessment Tool (Aug 2020 version), List of Key Informants by Role and Speciality, Qualitative data under each HEAT-ECCS domain and Full Key Informant comments on use of HEAT tool for this context, as shared with WHOare attached in appendices A-D; the datasets used and analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study did not receive any specific funding. Authors' contributions All authors contributed equally to this work. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Reynolds T, Sawe H, Rubiano A, Shin S, Wallis L et al. Strengthening Health Systems to Provide Emergency Care. [ed.] Jamison D T, Gelband H, Horton S, Jha P, Laxminara. Disease Control Priorities (third edition): Improving Health and Reducing Poverty. Washington, DC: World Bank, pp. 247–265. World Health Organization. WHO Tools for strengthening emergency care systems. Tools for Strengthening Emergency Care Systems. [Online] 2019. [Cited: 15 June 2023.] https://www.who.int/publications/m/item/who-tools-for-strengthening-emergency-care-systems Emergency care capacity in Sierra Leone: A multicentre analysis. Bredow, Z. et al. s l : AfJEM, 2024, 14, pp. 58–64. Dummigan G. February. Thousands wait more than day in A&E for beds. BBC News. [Online] 12 2025. [Cited: 8 April 2025.] Therrien A. 'Corridors were lined with patients on trolleys': Your stories of NHS pressures as flu cases rise. BBC News [Online] 9 January 2025. [Cited: 8 April 2025.] Quinn C. Long waits outside EDs causing deaths - ambulance chief. BBC News NI. [Online] 10 January 2025. [Cited: 8 April 2025.] www. bbc.co.uk/news/articles/c360nw0dx0eo Evaluating capacity at three government referral hospital emergency units in the kingdom of Eswatini using the WHO Hospital Emergency Unit Assessment Tool. Pigoga, J L, et al. 20 (1), May 2020, BMC Emerg Med., Vol. 6, p. 33. PMID: 28228178. Shayo M, Sakita F, Wilhelms FM, Moshi D, Frankiewicz B. Emergency unit capacity in Northern Tanzania: a cross-sectional survey. Ardsby. P et al s l : BMJ Open. 2023;13:e068484. Teri A, Reynolds H, Sawe AndrésM, Rubiano SD, Shin L, Wallis. and Charles N. Mock. Ch. 13: Strengthening Health Systems to Provide Emergency Care. [book auth.] Susan Horton, Ramanan Laxminarayan Dean T. Jamison. Hellen Gelband. Disease Control Priorities 3: Improving Health and Reducing Poverty. s.l.: World Bank Publications, 2017. Evaluating emergency care capacity in Africa: an iterative, multicountry refinement of the Emergency Care Assessment Tool. Bae, C, et al. 5, s.l.: BMJ Global Health, October 2018, BMJ Glob Health., Vol. 3, p. e001138. PMID: 30364370. World Health Organization Team Clinical Services. Guidelines for essential trauma care. [Online] 2012. [Cited: 15 June 2023.] https://www.who.int/publications/i/item/guidelines-for-essential-trauma-care World Health Organization. Tool for Situational Analysis to Assess Emergency and Essential Surgical Care. [Online] 2010. [Cited: 15 June 2023.] https://www.who.int/docs/default-source/integrated-health-services-(ihs)/csy/gieesc/whotoolsituationalanalysiseesc.pdf?sfvrsn=fccb6814_5 Northern Care Alliance NHS Foundation Trust. Greater Manchester Trauma Hospital. Northern Care Alliance. [Online] 2024. [Cited: 1 April 2025.] https://www.northerncarealliance.nhs.uk/about-us/new-hospital-developments/Greater-Manchester-Major-Trauma-Hospital NHS England Getting It Right First Time. Accident and Emergency Monthly Performance Dashboard. NHS England GIRFT Analytics Hub. [Online] May - Sept 2024. [Cited: 19th April 2025.] https://apps.model.nhs.uk/report/AEMonthly Care Quality Commission. Northern Care Alliance NHS Foundation Trust Inspection Report 2022. s.l. Care Quality Commission; 2022. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8733892","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":588517687,"identity":"31dbe311-9eda-41c0-8043-0d4cf98bc396","order_by":0,"name":"Zosia Bredow","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEElEQVRIiWNgGAWjYJCCA4wNIJKB8QEPijgPVtUoWpgNgIokiNLCANXCJkGUFvn29ocHfu64J8d3vMes4k2FXR2/9PEHDB/31DIYnDmA3YKeMwYHe88UG0ueOWN2c86ZZAnJvhwDxhnPjjMYnG3AqoVZIofhAG9bQuKGG7nbbvO2HZAwOMPDwMxz4BiDwXnsDmOTSH9w8G9bQj1ISzFEC/sDvFp4JBIMDgNtSTAAamGGaGEwAGqpwekwCZ4zBodlzyQYzjxz/rMk0C+SM3t4DA7OOHCARxKH94Eh9vjj2x0J8nzH2xI/AEOMn5+H/eGDDwfq5PjOJGB3GVYANP4wvojEDupI1jEKRsEoGAXDFgAAe4hmrOtgo4sAAAAASUVORK5CYII=","orcid":"","institution":"Northern Care Alliance NHS Foundation Trust","correspondingAuthor":true,"prefix":"","firstName":"Zosia","middleName":"","lastName":"Bredow","suffix":""},{"id":588517688,"identity":"e9e92433-ea6a-4fcc-b8a1-f6db3871b613","order_by":1,"name":"Ahmed E O Ali","email":"","orcid":"","institution":"Northern Care Alliance NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"E O","lastName":"Ali","suffix":""},{"id":588517689,"identity":"ff9b8f0d-7c3e-426d-b737-00da2d70ce01","order_by":2,"name":"Fiona Lecky","email":"","orcid":"","institution":"The University of Sheffield","correspondingAuthor":false,"prefix":"","firstName":"Fiona","middleName":"","lastName":"Lecky","suffix":""}],"badges":[],"createdAt":"2026-01-29 16:53:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8733892/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8733892/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102746837,"identity":"d7237641-e417-4dca-8ec3-72f84e99172e","added_by":"auto","created_at":"2026-02-16 09:01:56","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":896850,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8733892/v1/175141eb-f136-4c1e-8b6d-a77ae6569497.pdf"},{"id":102537382,"identity":"5cb291c2-5698-40fb-b2e5-4f08f367d87e","added_by":"auto","created_at":"2026-02-12 17:52:42","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":2956855,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-8733892/v1/33ad93a8c9ea19b2a7040512.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Using the WHO Hospital Emergency Unit Assessment Tool to assess changes in Emergency Care Capacity in a United Kingdom Major Trauma Centre","fulltext":[{"header":"Background","content":"\u003cp\u003eThe benefits of improved emergency care are well recognised; the Disease Control Priorities Project estimates that more than 50% of annual mortality in low- and middle-income countries (LMIC) can be addressed with emergency care improvements (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Resource constraints in emergency care are increasingly becoming an international priority. The World Health Organization (WHO) has created an Emergency Care Toolkit to assess and support improvements in capacity, with tools such as WHO\u0026rsquo;s Hospital Emergency Unit Assessment Tool (HEAT) (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). HEAT incorporates the views of various Emergency Department (ED) and hospital staff through Key Informant (KI) interviews to determine the availability of essential ED structures and functions. These WHO tools, including HEAT, have been primarily utilised to appraise emergency care systems in LMICs, and they have not previously been used to explore the resource challenges and barriers to capacity in a high-income country (HIC).\u003c/p\u003e \u003cp\u003eThe HEAT was chosen to review an ED transition within an urban Major Trauma Centre (MTC) teaching hospital in the Northwest of England. This was informed by the investigators' (ZB, AA) involvement in previous applications of the WHO Emergency Care Toolkit in LMICs such as Sudan and Sierra Leone (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). It is felt that these tools can be of use in HICs, such as the United Kingdom (UK), given that access to emergency care through long waits, corridor care and overcrowding has been the subject of national concern (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). It is hoped that this study adds insight and assessment data to existing review and evaluation frameworks. By sharing learning from lower-resourced systems and from the tools used to support them, this study may provide an opportunity to find practical solutions to the current resource pressures and capacity issues that are now seen in many HIC emergency care systems\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eHEAT is a standardised assessment of a hospital\u0026rsquo;s capacity to deliver effective emergency care at a single timepoint [HEAT is included in Appendix A]. HEAT forms part of the WHO\u0026rsquo;s Emergency Care Toolkit (2). It has been used across the globe both for individual facility reviews and as part of larger national emergency care systems assessments(3) (7) (8). The development of HEAT was informed by earlier tools that were also developed with resource-constrained settings, such as Emergency Obstetric Care assessment (EmOC), the African Federation for Emergency Medicine\u0026rsquo;s Emergency Care Assessment Tool (ECAT), the WHO Emergency Care System Framework, the WHO Guidelines for Essential Trauma Care, and the WHO Tool for the Situational Analysis of Emergency and Essential Surgical Care (1) (10) (11) (12).\u003c/p\u003e\n\u003cp\u003eThe HEAT assessment is completed via interviews with KIs: stakeholders in the facility\u0026rsquo;s emergency care system who are best able to give an accurate understanding of the availability of resources and service capacity. Each interview requires KIs to give availability ratings for certain key functions needed for emergency care: 1 \u0026lsquo;generally unavailable\u0026rsquo;; 2 \u0026lsquo;some availability\u0026rsquo;; or 3 \u0026lsquo;adequate availability\u0026rsquo;. This rating is then further explained by free-text comments based around barriers to availability (e.g. \u0026lsquo;infrastructure\u0026rsquo;; \u0026lsquo;absent equipment\u0026rsquo;; \u0026lsquo;training\u0026rsquo; etc). HEAT recommends triangulation of responses with multiple KIs to improve the accuracy of the results and suggests that parallel interviews can be rationalised via a consensus process (2). The HEAT is a standardised assessment that does not involve patients nor members of the public, exclusively relying on KI interview for data collection. Therefore, to conform to these set standards, the authors did not involve patients nor members of the public in this study.\u003c/p\u003e\n\u003cp\u003eThe authors have chosen to use the term Emergency Department (ED) in this study rather than the WHO\u0026rsquo;s term Emergency Unit (EU), as ED is the more common term used in the UK. Both terms are used with the same meaning, defined in HEAT as \u0026lsquo;any dedicated intake area for acutely ill and injured patients\u0026rsquo; (2).\u003c/p\u003e\n\u003cp\u003eAn ED transition at the UK MTC occurred over May and June of 2024. This involved an extension to the original 30-cubicle ED, with an additional12-cubicle resuscitation unit and associated additional infrastructure, including imaging facilities (Xray, CT and MRI scanners) and additional theatres and wards for trauma and resus patients (13). Data collection for the initial HEAT assessment took place between May and June 2024, examining the period preceding the opening of the new extension. Data collection for the second HEAT assessment took place in September 2024, with the aim of capturing any change in ED capacity. No patient-identifying data was collected in any form. As context, the ED had received a \u0026lsquo;needs improvement rating\u0026rsquo; in the most recent Care Quality Commission (CQC) inspection in 2022 as part of a multi-acute hospital NHS Trust. It was previously rated \u0026lsquo;good\u0026rsquo; in 2018 and \u0026lsquo;outstanding\u0026rsquo; in 2015 as part of a single acute hospital NHS Trust.\u003c/p\u003e\n\u003cp\u003eThe study involved all areas of the MTC that impact emergency care, and a range of KI job roles were interviewed as per HEAT guidance. All interviews were completed by the authors of this paper, who, although all work as clinicians in the studied ED, did not offer opinions or responses to HEAT questions. Interviews were conducted in person or by videocall. Each individual interview took 45 minutes to 1 hour to complete, followed by consensus interviews panels which took 2 hours. The KIs were recruited by email to departmental leads of all services pertinent to HEAT, requesting that either the lead or a \u0026lsquo;better suited informant\u0026rsquo; attend both individual and consensus interviews pre- and post-transition to \u0026lsquo;provide insight into how [the MTC\u0026rsquo;s] emergency care is organised\u0026rsquo;. A total of 10 KIs were interviewed separately, including multiple laboratory staff, speciality clinicians such as radiologists and a haematologist, multiple managerial staff, and pharmacy and clinical staff working in the ED. A full breakdown of the roles of the KIs is included in Appendix B. After individual KI interviews, two consensus meetings were held (one pre- and one post-ED transition), as suggested by the HEAT guidance, to ensure a single answer for each HEAT question was agreed upon. The same KIs were invited for pre- and post- transition interviews and consensus meetings, and outcome summaries of comments were confirmed by KIs in writing after analysis. KIs who could not attend the consensus meeting were offered to review the written meeting report and to provide their feedback. The HEAT-adjusted Emergency Care Capacity Score (HEAT-ECCS) was used for quantitative analysis of the MTC\u0026rsquo;s emergency care capacity (3). The HEAT-ECCS is a composite score created in a previous open-access study by mapping the WHO\u0026apos;s HEAT questions to the 5 Emergency Care Capacity Score domains:\u003c/p\u003e\n\u003cp\u003e1. Infrastructure\u003c/p\u003e\n\u003cp\u003e2. Diagnostics Services\u003c/p\u003e\n\u003cp\u003e3. Human Resources\u003c/p\u003e\n\u003cp\u003e4. Clinical Services (incorporating systems and guidelines)\u003c/p\u003e\n\u003cp\u003e5. Signal Function Performance (incorporating training, drugs, and equipment)\u003c/p\u003e\n\u003cp\u003eMean HEAT-ECCS scores were calculated for each domain and a total score for the ED. Each domain is weighted equally. Scores are expressed as percentages. Qualitative data were collected for analysis of barriers to the availability of emergency care.\u003c/p\u003e\n\u003cp\u003eThis study\u0026rsquo;s primary outcome was to find any difference in emergency care capacity in this MTC ED with this change in resource availability. Secondary outcomes included a series of observations on the appropriateness of the use of the HEAT in a high-resourced setting, and reviewing the perceived quality of the emergency care services provided by the ED as contextualised by other contemporaneous data sources.\u003c/p\u003e\n\u003cp\u003eHEAT has not been previously used to review emergency care capacity in the UK. This study is the first use of the tool in an ED from a high-income country that aims to provide universal health coverage free at the point of need. Therefore, data collection was extended to include comments and reflections from KIs on the applicability of the tool to this setting. Furthermore, results were contextualised using the latest data from the publicly available Getting It Right First Time (GIRFT) programme.\u003c/p\u003e\n\u003cp\u003eThe study received local Research and Innovation approval, and registered as a health improvement project (reference 24HIP31) to hold interviews, store and analyse anonymised KI responses and disseminate findings through publication and conference presentation.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eQuantitative data were analysed with the HEAT-ECCS. Results are reported in line with HEAT domains. Mean HEAT-ECCS scores were calculated for each domain from consensus interviews, and a total score was calculated. The data from the second HEAT assessment showed higher availability ratings both overall, and in each of the 5 domains (Table 1).\u003c/p\u003e\n\u003cp\u003eTable 1.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" title=\"Table 1.\" width=\"652\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 263px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHEAT-ECCS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 182px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInitial HEAT Assessment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSecond HEAT Assessment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 263px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInfrastructure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 182px;\"\u003e\n \u003cp\u003e83%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e93%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 263px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmergency Diagnostic Services\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 182px;\"\u003e\n \u003cp\u003e83%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e85%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 263px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHuman Resources\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 182px;\"\u003e\n \u003cp\u003e61%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e72%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 263px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical Services\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 182px;\"\u003e\n \u003cp\u003e71%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e76%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 263px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSignal Function Performance\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 182px;\"\u003e\n \u003cp\u003e85%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e90%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 263px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 182px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 263px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 182px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e77%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e83%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eExamples of these findings under each domain are presented in Table 2; full qualitative data are explored further in Appendix C under each HEAT-ECCS domain.\u003c/p\u003e\n\u003cp\u003eTable 2. Example Data from each Domain\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" title=\"Table 2.\" width=\"694\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHEAT-ECCS Domain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExample Question\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInitial HEAT Assessment Comments\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConsensus 1 Availability Rating\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSecond HEAT Assessment Comments\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConsensus 2 Availability Rating\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInfrastructure\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1.3.10 Designated resuscitation area\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003eNoted that the resus area was often overfilled, and that there was no decent flow out of resus.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eED transition at the UK MTC involved an extension to the original ED, with an additional 12-cubicle resuscitation unit and associated additional infrastructure.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmergency Diagnostic Services\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e1.4.23 CT scan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003eThe CT scanner for the ED was \u0026lsquo;meant to be replaced after 10 years and was now 14 years old\u0026rsquo;\u0026hellip; The provision generally did not meet demand.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eThe speed to scan has improved with the ED extension opening and the provision of 2 new CT scanners.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHuman Resources\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e2.2.1 General surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003ePatients waiting more than 12 hours for review, with the expectation that the ED will frontload patients and do scans prior to consult.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical Services\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e3.3.22 Handover protocols when transferring patient care to another provider\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003eNo written protocols or agreed pathways, transfers on a case-by-case basis - especially for paediatrics.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSignal Function Performance\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e4.7.13 Relevant antidote administration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 188px;\"\u003e\n \u003cp\u003eNo stock of antivenom as recommended by the Royal College of Emergency Medicine (RCEM), and the antidotes not kept in the same location as per RCEM recommendation.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eThe antidote cupboard was moved to the ED extension and has improved\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSecondary outcomes included recording in detail the KI comments on the use of the HEAT; this was planned prior to interviews. This reporter data was checked in detail at consensus.\u003c/p\u003e\n\u003cp\u003eKI comments on the HEAT itself can be categorised under 4 themes:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u003cstrong\u003eEquipment / Process in this context\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSkill in this context\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eStreaming comments\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eKIs felt question needed clarity\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eExamples of these HEAT-specific comments are presented in Table 3; full data on this secondary outcome are found in the supplementary material at Appendix D.\u003c/p\u003e\n\u003cp\u003eTable 3. Example Key Informant comments on use of HEAT tool for this context\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" title=\"Table 1.\" width=\"652\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComment Theme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHEAT Question\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExample KI Comments\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEquipment / Process in this context\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e1.3.24 Oxygen is supplied by oxygen concentrator stored on this unit\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eData fields for oxygen concentrator were felt to be not required in this setting.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e1.4.17 Availability of Malaria Rapid Diagnostic Tests within the emergency unit\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eNot an ED priority in areas of the world where malaria is not endemic, such as the UK. KIs suggested that the question could be extended to reflect global variance of disease patterns to inform emergency care pertinent to the region (e.g. EDs in the UK will have COVID, Flu and RSV point of care tests to enable flow and appropriate treatments).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSkill in this context\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e4.4.4 Venous cutdown\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eVenous cutdown no longer recommended as superseded by technologies such as intraosseous (IO) access and ultrasound.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e4.6.1 Pericardiocentesis,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.8.3 Diagnostic paracentesis,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.8.4 Surgical source control,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.9.3 Fasciotomy or escharotomy for compartment syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eKIs agreed that speciality doctors would be called to the ED or patients moved elsewhere for these procedures.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStreaming comments\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 435px;\"\u003e\n \u003cp\u003eIn higher-income systems, ED waiting rooms may encompass multiple \u0026apos;external streams\u0026apos; including clinics, General Practice and minor injuries areas. These are led by consulting services such as Emergency Nurse Practitioners, physiotherapists and doctors alongside the ED footprint in an attempt to reduce crowding. Low-acuity patients are streamed to these external services after ED triage, a concept that is common and encouraged in overcrowded, resource-restricted high-income systems, and therefore not captured by HEAT. The impact of flow limitations and capacity mitigations such as corridor care are not captured by HEAT.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKIs felt question needed clarity\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e3.3.8 Protocol for neonatal resuscitation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003eKIs commented that\u0026nbsp;the Signal Functions section of HEAT did not reflect emergency paediatrics and noted although HEAT has a neonatal resus question (3.3.8) there is no question for Acute Paediatric Life Support (APLS), and a lack of HEAT questions on emergency paediatrics overall\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThe publicly available GIRFT data table is shown in Table 4. This gives performance values for the whole of the Trust which contains 3 EDs and 1 Acute Care Centre across 4 hospitals in the area including the urban MTC where this study was conducted. Therefore, this data remains relevant for the urban MTC studied, but has incorporated and therefore is affected by data on the performance of the other 3 facilities within the same Trust. Performance for Type 1 ED attendances (patient attending with complaints requiring a general ED who are seen and receive all ED care within 4 hours of arrival) remains static at 55-56% throughout the study period. However, the percentage of patients requiring a stay in ED of greater than 12 hours fell from a peak of 4.3% in June 2024 to below 2.5% in August and September 2024, as illustrated in Table 5.\u003c/p\u003e\n\u003cp\u003eTable 4. GIRFT Performance values for Trust\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"708\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\" valign=\"bottom\" style=\"width: 708px;\"\u003e\n \u003cp\u003eRegion: North West - ICB : NHS Greater Manchester Integrated Care Board - Organisation : \u0026nbsp; \u0026nbsp; Northern Care Alliance NHS Foundation Trust\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2024 Month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAttendances\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBreaches\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerformance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType 1 attendances\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType 1 breaches\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType 1 performance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmergency admissions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmergency admissions via A\u0026amp;E\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4+ hour delays from decision to admit\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e12+ hour delays from decision to admit\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 57px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 57px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeptember\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e33,047\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e11,291\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e65.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e24,649\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e10,994\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e55.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e9,146\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e7,421\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2,555\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 57px;\"\u003e\n \u003cp\u003e583\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAugust\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e31,500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e10,392\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e67.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e23,316\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e10,163\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e56.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e8,716\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e6,989\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 57px;\"\u003e\n \u003cp\u003e4,303\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 57px;\"\u003e\n \u003cp\u003e496\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eJuly\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e35,090\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e11,788\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e66.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e25,778\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e11,400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e55.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e9,107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e7,317\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2,540\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 57px;\"\u003e\n \u003cp\u003e791\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eJune\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e33,753\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e11,285\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e66.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e25,044\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e10,980\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e56.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e8,803\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e7,236\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2,331\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1,066\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMay\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e35,809\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e12,134\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e66.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e26,332\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e11,839\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e55.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e9,387\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e7,663\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2,086\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 57px;\"\u003e\n \u003cp\u003e901\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrand Total\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e169,199\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e56,890\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 71px;\"\u003e\n \u003cp\u003e66.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e125,119\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 55px;\"\u003e\n \u003cp\u003e55,376\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 85px;\"\u003e\n \u003cp\u003e55.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e45,159\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 64px;\"\u003e\n \u003cp\u003e36,626\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 57px;\"\u003e\n \u003cp\u003e13,815\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3,837\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 5. Patients requiring a stay in ED of greater than 12 hours\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" title=\"Table 1.\" width=\"662\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2024 Month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 274px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients requiring a stay in ED of greater than 12 hours (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 283px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients requiring a stay in ED of greater than 12 hours (Total)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 272px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeptember\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 106px;\"\u003e\n \u003cp\u003e2.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 283px;\"\u003e\n \u003cp\u003e583\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 272px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAugust\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 106px;\"\u003e\n \u003cp\u003e2.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 283px;\"\u003e\n \u003cp\u003e496\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 272px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eJuly\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 106px;\"\u003e\n \u003cp\u003e3.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 283px;\"\u003e\n \u003cp\u003e791\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 272px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eJune\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 106px;\"\u003e\n \u003cp\u003e4.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 283px;\"\u003e\n \u003cp\u003e1066\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 272px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMay\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 106px;\"\u003e\n \u003cp\u003e3.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 283px;\"\u003e\n \u003cp\u003e901\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this single-centre analysis of emergency care capacity of a UK MTC over an ED transition, the study team found significant improvement to availability ratings of emergency care capacity in all domains, as reflected in the HEAT-ECCS. The GIRFT quantitative data summaries for the Trust, although an indirect measure for this ED, support this assessment over the period of study.\u003c/p\u003e \u003cp\u003eThis is the first study to describe the resource challenges and emergency care capacity of a high-income system using the WHO HEAT assessment. The study team believe that these data add depth to the quantitative measures more usually relied upon for ED care capacity and performance in systems such as the UK, as the data from this study are based on structured in-person interviews. The GIRFT Emergency Medicine Index (GEMI) is a proxy performance metric based on inflow, throughput and exit block data (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The GEMI published for the same time period as this study ranks the site nationally: in May 2024, the month of the department transition, the GEMI was at 75 out of all of the trusts in England, June was similarly ranked at 73, whereas in July the GEMI improved to 51 nationally. A 2022 Care Quality Commission 4 hour target (CQC 4HT) review also found similar data in Emergency Care, rating safety in urgent and emergency services as \u0026lsquo;inadequate\u0026rsquo;, and \u0026lsquo;requiring improvement\u0026rsquo; for effective care (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe comments specific to HEAT that we collected from the KIs at both initial and consensus interviews have been useful in contextualising the tool in this high-resource setting. KIs felt that some areas of the HEAT were not applicable in EM or laboratory practice in their setting, with regards to certain diagnostic tests, clinical procedures and skills. Their comments and observations on the appropriateness of the use of the HEAT in this high-resourced setting have been summarised in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e, with full data on this secondary outcome in the supplementary material at Appendix D. All comments and observations have been shared with the WHO team for ongoing development.\u003c/p\u003e \u003cp\u003eIt was notable that the KIs were positive in their feedback on the use of a WHO tool, and there was noted a readiness to incorporate change in practice based on HEAT questions, for example with malaria screening.\u003c/p\u003e \u003cp\u003eThe study has certain limitations. Firstly, as HEAT has previously been used to assess resource-constrained settings, high-income emergency care systems such as this have not previously been reviewed with such tools. The study team found that the interviews and data collection were therefore limited by the constraints of the tool as illustrated by the KIs comments on HEAT assessment questions themselves and the HEAT\u0026rsquo;s overall appropriateness to this setting.\u003c/p\u003e \u003cp\u003eHEAT has been used as an assessment at a single point in time. The authors have tried to give a fuller picture of the capacity of this system by repeating the assessment after a significant change. However, to mitigate against transient or chance fluctuations and capture longer trends, repeated assessments would need to be completed over a longer period.\u003c/p\u003e \u003cp\u003eThe study team addressed the limitations in the data scope by interviewing a range of KIs in-person. However, as HEAT aims to evaluate the structure and key functions of an ED via the process of KI interview, any data collected and therefore wider conclusions made was limited by the knowledge and experience of those KIs that were interviewed. Consensus was reached in the second meeting, and views not captured in the numerical data were therefore reflected qualitatively in comment form.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study provides context to the challenges facing emergency care systems in high-income settings such as this large MTC in the UK. The authors hope that it offers some insight into common barriers to the availability of emergency care and suggests some solutions may be found through similar Emergency Department transitions to the one studied here.\u003c/p\u003e \u003cp\u003eWe believe that by exploring emergency care systems from the perspective of global health, using validated global tools such as the WHO\u0026rsquo;s HEAT, learning can be shared and exchanged between systems with different levels of resources. We are all facing resource issues that challenge the provision of the emergency care that we bring to our patients each day. Through studying these systems, we aim to find and share strategies to strengthen them.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThe study received review and approval from the Institutional Review Board and registered as a health improvement project (reference 24HIP31) with the Research Management Team at Northern Care Alliance NHS Foundation Trust. According to the NHS Health Research Authority (HRA) Research Ethics Service, this study did not require further NHS Research Ethics Committee review as informed consent was obtained from all respondents and no patient-identifying data was collected in any form.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eThe study received local Research and Innovation approval and registered as a health improvement project (reference 24HIP31) to hold interviews, store and analyse anonymised Key Informant responses and disseminate findings through publication and conference presentation.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eFurther data including HEAT Emergency unit Assessment Tool (Aug 2020 version), List of Key Informants by Role and Speciality, Qualitative data under each HEAT-ECCS domain and\u0026nbsp;Full Key Informant comments on use of HEAT tool for this context, as shared with WHOare attached in appendices A-D; the datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis study did not receive any specific funding.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eAll authors contributed equally to this work. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eReynolds T, Sawe H, Rubiano A, Shin S, Wallis L et al. Strengthening Health Systems to Provide Emergency Care. [ed.] Jamison D T, Gelband H, Horton S, Jha P, Laxminara. \u003cem\u003eDisease Control Priorities (third edition): Improving Health and Reducing Poverty.\u003c/em\u003e Washington, DC: World Bank, pp. 247\u0026ndash;265.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. WHO Tools for strengthening emergency care systems. \u003cem\u003eTools for Strengthening Emergency Care Systems.\u003c/em\u003e [Online] 2019. [Cited: 15 June 2023.] \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/m/item/who-tools-for-strengthening-emergency-care-systems\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/m/item/who-tools-for-strengthening-emergency-care-systems\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cem\u003eEmergency care capacity in Sierra Leone: A multicentre analysis.\u003c/em\u003e Bredow, Z. et al. s l : AfJEM, 2024, 14, pp. 58\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDummigan G. February. Thousands wait more than day in A\u0026amp;E for beds. \u003cem\u003eBBC News.\u003c/em\u003e [Online] 12 2025. 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[Cited: 8 April 2025.] www.\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ebbc.co.uk/news/articles/c360nw0dx0eo\u003c/span\u003e\u003cspan address=\"http://bbc.co.uk/news/articles/c360nw0dx0eo\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cem\u003eEvaluating capacity at three government referral hospital emergency units in the kingdom of Eswatini using the WHO Hospital Emergency Unit Assessment Tool.\u003c/em\u003e Pigoga, J L, et al. 20 (1), May 2020, BMC Emerg Med., Vol. 6, p. 33. PMID: 28228178.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShayo M, Sakita F, Wilhelms FM, Moshi D, Frankiewicz B. \u003cem\u003eEmergency unit capacity in Northern Tanzania: a cross-sectional survey.\u003c/em\u003e Ardsby. P et al s l : BMJ Open. 2023;13:e068484.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTeri A, Reynolds H, Sawe Andr\u0026eacute;sM, Rubiano SD, Shin L, Wallis. and Charles N. Mock. Ch. 13: Strengthening Health Systems to Provide Emergency Care. [book auth.] Susan Horton, Ramanan Laxminarayan Dean T. Jamison. Hellen Gelband. \u003cem\u003eDisease Control Priorities 3: Improving Health and Reducing Poverty.\u003c/em\u003e s.l.: World Bank Publications, 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cem\u003eEvaluating emergency care capacity in Africa: an iterative, multicountry refinement of the Emergency Care Assessment Tool.\u003c/em\u003e Bae, C, et al. 5, s.l.: BMJ Global Health, October 2018, BMJ Glob Health., Vol. 3, p. e001138. PMID: 30364370.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization Team Clinical Services. \u003cem\u003eGuidelines for essential trauma care.\u003c/em\u003e [Online] 2012. [Cited: 15 June 2023.] \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/publications/i/item/guidelines-for-essential-trauma-care\u003c/span\u003e\u003cspan address=\"https://www.who.int/publications/i/item/guidelines-for-essential-trauma-care\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. \u003cem\u003eTool for Situational Analysis to Assess Emergency and Essential Surgical Care.\u003c/em\u003e [Online] 2010. [Cited: 15 June 2023.] \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/docs/default-source/integrated-health-services-(ihs)/csy/gieesc/whotoolsituationalanalysiseesc.pdf?sfvrsn=fccb6814_5\u003c/span\u003e\u003cspan address=\"https://www.who.int/docs/default-source/integrated-health-services-(ihs)/csy/gieesc/whotoolsituationalanalysiseesc.pdf?sfvrsn=fccb6814_5\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNorthern Care Alliance NHS Foundation Trust. Greater Manchester Trauma Hospital. \u003cem\u003eNorthern Care Alliance.\u003c/em\u003e [Online] 2024. [Cited: 1 April 2025.] \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.northerncarealliance.nhs.uk/about-us/new-hospital-developments/Greater-Manchester-Major-Trauma-Hospital\u003c/span\u003e\u003cspan address=\"https://www.northerncarealliance.nhs.uk/about-us/new-hospital-developments/Greater-Manchester-Major-Trauma-Hospital\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNHS England Getting It Right First Time. Accident and Emergency Monthly Performance Dashboard. \u003cem\u003eNHS England GIRFT Analytics Hub.\u003c/em\u003e [Online] May - Sept 2024. [Cited: 19th April 2025.] \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://apps.model.nhs.uk/report/AEMonthly\u003c/span\u003e\u003cspan address=\"https://apps.model.nhs.uk/report/AEMonthly\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCare Quality Commission. \u003cem\u003eNorthern Care Alliance NHS Foundation Trust Inspection Report 2022.\u003c/em\u003e s.l. Care Quality Commission; 2022.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Emergency Medicine, Emergency care systems, Global health, Emergency department management","lastPublishedDoi":"10.21203/rs.3.rs-8733892/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8733892/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe reviewed a Major Trauma Centre (MTC) in the UK over an Emergency Department (ED) transition using the World Health Organization (WHO) Hospital Emergency Unit Assessment Tool (HEAT). HEAT has previously been used in low- and middle-income countries. This is the first time it has been used to explore resource constraints and predict potential barriers to emergency care capacity in a higher-income country.\u003c/p\u003e\n\u003cp\u003eOur primary outcome was to find any difference in emergency care capacity with a change in emergency care resources. Secondary outcomes included a series of observations on the appropriateness of the tool itself and its use in a higher-resourced system.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll areas of the MTC that impact emergency care capacity were studied, with multiple key informants (KIs) in each area interviewed. The HEAT-adjusted Emergency Care Capacity Score (HEAT-ECCS) was used for quantitative analysis of the MTC’s emergency care capacity. Qualitative data was collected for analysis of barriers to availability of emergency care.\u003c/p\u003e\n\u003cp\u003eData collection was between May and September 2024, over an ED transition in July 2024, with the extension to the original ED of an additional 12-cubicle resuscitation unit and associated infrastructure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe HEAT-ECCS showed higher availability ratings both overall, and in each of the 5 parameters: Infrastructure; Diagnostics; Human Resources; Clinical Services and Signal Functions.\u003c/p\u003e\n\u003cp\u003eKI comments on the applicability of HEAT to this setting fell into 4 themes:\u003c/p\u003e\n\u003cp\u003e1. Equipment / process in this context\u003c/p\u003e\n\u003cp\u003e2. Skill in this context\u003c/p\u003e\n\u003cp\u003e3. Question clarity\u003c/p\u003e\n\u003cp\u003e4. Streaming\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study provides context to barriers to availability of emergency care and suggests some solutions may be found through similar ED transitions. By exploring emergency care systems from a global health perspective, using tools such as HEAT, we believe that learning can be shared between higher and lower-resourced systems, and strategies found to strengthen them.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received local Research and Innovation approval, and registered as a health improvement project (reference 24HIP31) to hold interviews, store and analyse anonymised KI responses and disseminate findings through publication and conference presentation.\u003c/p\u003e","manuscriptTitle":"Using the WHO Hospital Emergency Unit Assessment Tool to assess changes in Emergency Care Capacity in a United Kingdom Major Trauma Centre","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-12 17:52:37","doi":"10.21203/rs.3.rs-8733892/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-17T04:51:38+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-13T13:29:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"165741167437833377201028816444750676374","date":"2026-03-31T20:52:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"62666786579003864632669936789954190131","date":"2026-02-28T12:08:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-26T13:33:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"84581741186642245920124134604564310818","date":"2026-02-22T09:42:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"237895271164854134062178785472071423926","date":"2026-02-09T18:55:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-09T17:01:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-04T13:15:16+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-04T05:05:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-02T16:56:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Emergency Medicine","date":"2026-02-02T16:45:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cab88fec-567e-4ab4-b9f1-1552bd8e21a2","owner":[],"postedDate":"February 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-30T18:38:42+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-12 17:52:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8733892","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8733892","identity":"rs-8733892","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}